Your SlideShare is downloading. ×
From testing to spread: Sharing the knowledge and learning from organisations spreading the winning principles - case studies
From testing to spread: Sharing the knowledge and learning from organisations spreading the winning principles - case studies
From testing to spread: Sharing the knowledge and learning from organisations spreading the winning principles - case studies
From testing to spread: Sharing the knowledge and learning from organisations spreading the winning principles - case studies
From testing to spread: Sharing the knowledge and learning from organisations spreading the winning principles - case studies
From testing to spread: Sharing the knowledge and learning from organisations spreading the winning principles - case studies
From testing to spread: Sharing the knowledge and learning from organisations spreading the winning principles - case studies
From testing to spread: Sharing the knowledge and learning from organisations spreading the winning principles - case studies
From testing to spread: Sharing the knowledge and learning from organisations spreading the winning principles - case studies
From testing to spread: Sharing the knowledge and learning from organisations spreading the winning principles - case studies
From testing to spread: Sharing the knowledge and learning from organisations spreading the winning principles - case studies
From testing to spread: Sharing the knowledge and learning from organisations spreading the winning principles - case studies
From testing to spread: Sharing the knowledge and learning from organisations spreading the winning principles - case studies
From testing to spread: Sharing the knowledge and learning from organisations spreading the winning principles - case studies
From testing to spread: Sharing the knowledge and learning from organisations spreading the winning principles - case studies
From testing to spread: Sharing the knowledge and learning from organisations spreading the winning principles - case studies
From testing to spread: Sharing the knowledge and learning from organisations spreading the winning principles - case studies
From testing to spread: Sharing the knowledge and learning from organisations spreading the winning principles - case studies
From testing to spread: Sharing the knowledge and learning from organisations spreading the winning principles - case studies
From testing to spread: Sharing the knowledge and learning from organisations spreading the winning principles - case studies
From testing to spread: Sharing the knowledge and learning from organisations spreading the winning principles - case studies
From testing to spread: Sharing the knowledge and learning from organisations spreading the winning principles - case studies
From testing to spread: Sharing the knowledge and learning from organisations spreading the winning principles - case studies
From testing to spread: Sharing the knowledge and learning from organisations spreading the winning principles - case studies
From testing to spread: Sharing the knowledge and learning from organisations spreading the winning principles - case studies
From testing to spread: Sharing the knowledge and learning from organisations spreading the winning principles - case studies
From testing to spread: Sharing the knowledge and learning from organisations spreading the winning principles - case studies
From testing to spread: Sharing the knowledge and learning from organisations spreading the winning principles - case studies
From testing to spread: Sharing the knowledge and learning from organisations spreading the winning principles - case studies
From testing to spread: Sharing the knowledge and learning from organisations spreading the winning principles - case studies
From testing to spread: Sharing the knowledge and learning from organisations spreading the winning principles - case studies
From testing to spread: Sharing the knowledge and learning from organisations spreading the winning principles - case studies
From testing to spread: Sharing the knowledge and learning from organisations spreading the winning principles - case studies
From testing to spread: Sharing the knowledge and learning from organisations spreading the winning principles - case studies
From testing to spread: Sharing the knowledge and learning from organisations spreading the winning principles - case studies
From testing to spread: Sharing the knowledge and learning from organisations spreading the winning principles - case studies
From testing to spread: Sharing the knowledge and learning from organisations spreading the winning principles - case studies
From testing to spread: Sharing the knowledge and learning from organisations spreading the winning principles - case studies
From testing to spread: Sharing the knowledge and learning from organisations spreading the winning principles - case studies
From testing to spread: Sharing the knowledge and learning from organisations spreading the winning principles - case studies
From testing to spread: Sharing the knowledge and learning from organisations spreading the winning principles - case studies
From testing to spread: Sharing the knowledge and learning from organisations spreading the winning principles - case studies
From testing to spread: Sharing the knowledge and learning from organisations spreading the winning principles - case studies
From testing to spread: Sharing the knowledge and learning from organisations spreading the winning principles - case studies
From testing to spread: Sharing the knowledge and learning from organisations spreading the winning principles - case studies
From testing to spread: Sharing the knowledge and learning from organisations spreading the winning principles - case studies
From testing to spread: Sharing the knowledge and learning from organisations spreading the winning principles - case studies
From testing to spread: Sharing the knowledge and learning from organisations spreading the winning principles - case studies
Upcoming SlideShare
Loading in...5
×

Thanks for flagging this SlideShare!

Oops! An error has occurred.

×
Saving this for later? Get the SlideShare app to save on your phone or tablet. Read anywhere, anytime – even offline.
Text the download link to your phone
Standard text messaging rates apply

From testing to spread: Sharing the knowledge and learning from organisations spreading the winning principles - case studies

437

Published on

From testing to spread:Sharing the knowledge and learning from organisations spreading the Winning Principles - case studies …

From testing to spread:Sharing the knowledge and learning from organisations spreading the Winning Principles - case studies
The spread case studies illustrate many of these factors and provide an opportunity for sharing ‘working’ knowledge and learning experiences with the intention to promote further spread, adoption and action of good practice across the country and benefit more patients (Published July 2010).

Published in: Health & Medicine
0 Comments
0 Likes
Statistics
Notes
  • Be the first to comment

  • Be the first to like this

No Downloads
Views
Total Views
437
On Slideshare
0
From Embeds
0
Number of Embeds
0
Actions
Shares
0
Downloads
1
Comments
0
Likes
0
Embeds 0
No embeds

Report content
Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

Cancel
No notes for slide

Transcript

  • 1. NHSCANCER NHS ImprovementDIAGNOSTICSHEARTLUNGSTROKETransforming Inpatient Care ProgrammeFrom testing to spread:Sharing the knowledge and learning fromorganisations spreading the WinningPrinciples - case studies
  • 2. ContentsIntroduction 3Winning Principle 1Electronic alerts for emergency admissions: How the learningwas spread from Sherwood Forest Hospitals NHS FoundationTrust and United Lincolnshire Hospitals NHS Trust 4Emergency admissions, the exception rather than the norm 9Patient Electronic Alert to Key-worker System (PEAKS) 14Pan Birmingham Network wide spread of neutropenicsepsis pathway improvements 16Commissioning and cost benefits of acute oncology:Supporting spread across the Anglia Cancer Network 19Winning Principle 2Spreading the enhanced recovery principles in patientsundergoing colorectal, liver and upper GI surgery 21Shifting care and reducing length of stay: Ambulatorycare beds in the haematology inpatient ward 23Adopting the 23 hour model for mastectomy patients 24Enhanced Recovery Programme (ERP): Integratedcare pathway for elective colorectal surgery 27Spreading Enhanced Recovery from one testproject to a network wide programme 29Delivering care in appropriate settings 34Enhanced Recovery: Colorectal cancer 36Breast inpatient care: Valuing patient time 38Winning Principle 3Protocol for patients admitted with clinical diagnosis of malignantbowel obstruction secondary to gynaecological cancer 39Winning Principle 4The ‘FAB’ Programme: Fatigue, anxiety breathlessnessprogramme for patients with lung cancer and their carers 42Acknowledgements and references 46
  • 3. From testing to spread: Sharing the knowledge and learning from organisations spreading the Winning Principles | 3IntroductionThere has been good progress in patients with cancer or its symptoms, and totransforming cancer inpatient care. More be seen by the right person, with appropriateorganisations and clinical teams are adopting expertise. The Winning Principles underpinthe Winning Principles and adapting the new these improvements.models of care, but there is still more to bedone and the pace of spread needs to be Spread and adoption is not easy and requiresaccelerated (Consolidation Report: From Testing using a multi-level of methods, levers and factorsto Spread (2009) - published July 2010). to create, inspire and make the connections with people and organisations within the currentThe new levers supporting spread such as Quality, nature of the changing health landscape. TheInnovation, Productivity and Prevention (QIPP), spread case studies within this publicationGP commissioning and a patient led NHS will illustrate many of these factors and provide ancontinue to support the drive for improvement opportunity for sharing ‘working’ knowledge andand encourage further adoption of good practice. learning experiences with the intention toThe recent revised Operating Framework promote further spread, adoption and action(2010/11) highlighted the importance to continue of good practice across the country and benefitto deliver improvements in access and quality for more patients. The Winning Principles 1. Unscheduled (emergency) patients should be assessed prior to the decision to admit. Emergency admission should be the exception not the norm. 2. All patients should be on a defined inpatient pathways based on their tumour type and reasons for admission. 3. Clinical decisions should be made on a daily basis to promote proactive case management. 4. Patient and carers need to know about their condition and symptoms to encourage self-management and to know who to contact when needed.
  • 4. 4 | From testing to spread: Sharing the knowledge and learning from organisations spreading the Winning Principles Winning Principle 1 Unscheduled (emergency) patients should be assessed prior to the decision to admit. Emergency admission should be the exception not the norm. Sandwell and West Birmingham Hospitals NHS Trust Electronic alerts for emergency admissions: How the learning was spread from Sherwood Forest Hospitals NHS Foundation Trust and United Lincolnshire Hospitals NHS Trust Background For the period 2007-2008 the figures the benchmark data. It appeared that The colorectal team at Sandwell and highlighted that 64% of all bed days patients were not under the care of West Birmingham Hospitals NHS Trust (3975) followed an emergency colorectal MDT members or (SWBH) and the Pan Birmingham admittance. A simple trend indicates interacting with the colorectal CNS Cancer Network (PBCN) have been that by 2010 emergency bed days will following an emergency admission working to improve patient account for 70% of colorectal and this required further investigation. experience, outcomes and reduce inpatient spells. At Sandwell General length of stay (LOS) for emergency Hospital (SGH) and City Hospital (City) The wider MDT is used to identify admissions of colorectal cancer almost 55% of emergency admissions healthcare professionals who would patients. ended without a specific surgical be reasonably expected to be involved intervention (surgery, invasive in patients with colorectal cancer. For Baseline data collection demonstrated diagnostics, or an invasive procedure). an analysis of Finished Consultant that SWBH colorectal services mirrored Episodes (FCE) as well as colorectal the national landscape. The service It was important to place the baseline surgeons clinicians from the had the largest number of emergency data into an operational context, the specialities of upper GI surgery, bed days and longest average LOS three years of data was analysed and gastroenterology, medical and clinical when compared with all other tumour used to identify a cohort of 250 oncology were also included. An FCE sites at the trust. patients for a review of the healthcare is only recorded when a patient is records (notes review). The review was passed into the care of a consultant designed to record patient journey and will not identify any discussion from arrival at A&E through to between colleagues concerning discharge noting any interactions or patients but as the HES data has only diagnostics of significance. patients with colorectal cancer Interactions include those by Allied recorded in their diagnosis the Health Professionals (AHP) and expectation is that the majority of specialist services but exclude ward patients have an FCE with a member rounds and observations where no of the wider MDT. further actions or decisions were made. The review also investigated if At SGH, 224 of 380 patients admitted admitted patients were brought to the as colorectal emergencies did not attention of the Clinical Nurse interact with a member of the wider Specialist (CNS) or multidisciplinary MDT. If patients with a short stay of team (MDT) during each stay and if up to four days are excluded (84) that any provisional discharge dates were leaves 160 (70%) patients with a stay decided as part of the patients of five days and greater who have not recorded management plan. The seen a member of the wider MDT. notes review validated the findings ofWINNING PRINCIPLE 1 the Hospital Episodes Statistics (HES) At City, 60 of the182 patients data review. admitted as colorectal emergencies did not interact with a member of the The notes review covered 20% of wider MDT. Excluding short stay colorectal cancer emergency patients (30) leaves 30 (50%) patients admissions for a two year period and with a stay of five days and greater provided context and granularity to who have not seen a member of the
  • 5. CFrom testing to spread: Sharing the knowledge and learning from organisations spreading the Winning Principles | 5wider MDT. At City there were 29stays of 16 days and greater that did Emergency Admissions - Health Record Audit - Health Care Role Interactionsnot have any interaction from the 100wider MDT until at least day six. 90 80The wider MDT interactions were Percentage of patients seencomparable with the interactions 70abstracted from the notes review 60were, for instance, documented 50CNS attendance is 18%. 40 30The data also demonstrated that just 20over 50% of patients admitted as an 10emergency did not have a procedureor intervention that could be coded 0 CNS Physiotherapist Dietician Social Pain Outreach Palliative Case Discharge US/MRI/with OPCS4 and that half of patients Services Management Team Care Team Manager Liaison CT/XRadmitted presented with symptoms of Healthcare Role Patients seen Patients not seenabdominal pain, nausea and vomiting.A report was presented to thecolorectal team, cancer services andcancer operational team, summarising Emergency Admissions - Presenting symptomsthe findings with a data appendixcontaining in depth analysis of ICD10 9 10codes, FCEs, co-morbidity etc as a 8whole trust and by individual site (Cityand SGH). Following discussions with 13the clinical director, management, the 7clinical team and the CNS’s it wasagreed that the emergency pathway 6 5 11would benefit from service 1 12improvement and that PBCN would 4provide a service improvementfacilitator (SIF) to support this work. 3 2Delays to progress 1. Pain and vomiting (50%) 8. Other (15%)The service improvement work had 2. Acute abdomen obstruction (4%) 9. Temperature >36C (1%)been authorised but the colorectal 3. Anaemia (4%) 10. Temperature >38C (3%) 4. Bleeding (10%) 11. Pain and vomiting 13%)service at SWBH were in a transitional 5. Constipation and diestension (1%) 12. Vomiting (10%) 6. Deep vein thrombosis (3%) 13. Pain (27%)state with a reconfiguration exercise 7. Generally unwell (9%)to integrate the service on a singlesite, adoption of bowel screening andtaking on the care of gynae-oncologysingle and dual stoma patients. Inaddition, the long standing Clinical were suggested and attempted on The City CNSs had reviewed theDirector was stepping down and it several occasions but it became clear findings and the graphicalwas uncertain who would be his that the opening steps of any representations of the patients timereplacement and the SGH site was improvement ideas would have to be spent in hospital. They commented ondeveloping a fast track elective small and local until some of the the fact that sometimes they werepathway whilst City were transitional issues had resolved only aware of a patients admittance ifimplementing enhanced recovery. themselves. they saw them on the ward or aService improvement methodologies relative phoned.
  • 6. 6 | From testing to spread: Sharing the knowledge and learning from organisations spreading the Winning Principles They also recognised that the data showed that once they were involved Electronic Emergency Alert Model in a patient’s care that patient journeys became more ordered and Mail/SMS alert CNS attends Patient Speedy sent to CNS patient to receives discharge for the patient was brought to the when patient resolve timely patient attention of the wider MDT and arrives in A&E colorectal treatment received the appropriate clinical care or ward issues and referrals to allied health professionals (AHPs). The CNSs felt that if they were made aware of a patient being admitted that they could visit the patient earlier Using data for the period April 2007 - The median and mean LOS for the 19 and bring there skills and expertise to May 2009 and City MDT lists each patients who could reasonably expect bear in addition to the reassurance month there was circa 650 known to be colorectal emergency the LOS that having a known face (keyworker) colorectal cancer patients who would are as follows: visiting the patient would bring. The potentially trigger an alert for A&E Service Improvement Facilitator (SIF) attendance or and inpatient Mean 3.2 and Median1 with CNS shared the learning gained from admittance. Additions were also attendance 68%. Sherwood Forest Hospitals NHS added following each MDT. Foundation Trust and United (Caveat this is a small data set and for Lincolnshire Hospitals NHS Trust of The alert system utilised the existing City only patients but the mean is how successful their emergency Lorenzo IPM interface and the Health suggestive in relation to the increased communication alert system had been Care Professional flag on the patient CNS attendance). and the CNSs agreed that if a local PDS screen. Other than internal solution could be found they were interface team time there were no As well as the overall reduction in prepared to test it. additional costs associated with the IT median LOS there was also a interface. significant increase in the percentage On contacting the SWBH electronic of patients who stayed in hospital for patient record development team the Impact 0 to 5 days to 79%. The increase in SIF found that a similar system was The baseline data from April 2007 to CNS attendance may explain this shift being used by the infection control March 2009 identified 243 emergency as there are examples of potential team and with a little re-designing for admissions with a median LOS of 13 admissions to the wards being shifted operational fit e-mails and text days and a mean LOS of 20 days to the Surgical Admission Unit (SAU) messages could be sent to a for washouts, enemas and outpatient smartphone when a known colorectal The team were hoping that they could appointments which resulted in the cancer patient was admitted. reduce median LOS from 13 days to patients leaving hospital in less than 11 and aim for CNS contact with 70% four hours. Attendance of a known On 14 September 2009, an electronic of patients. patient with a fractured femur emergency alert test cycle was highlighted two missed follow up CT commenced at City Hospital to Test cycle preliminary results scans for which outpatient appoints ascertain if early CNS attendance and The results reflect the patient have been made. intervention would have an impact on population of City Hospital who are patient LOS using the model. generally in a fitter state than those of It also appears that early CNS Sandwell. There has been a response provides the junior doctors reconfiguration of the colorectal with a colleague who has a clinical service with the majority of surgery knowledge of the patient and this moving to Sandwell. may stop diagnostics test and unnecessary treatment being Alerts in total 45 undertaken. Alerts perceived to be colorectal 19 Actual colorectal related alerts 16
  • 7. From testing to spread: Sharing the knowledge and learning from organisations spreading the Winning Principles | 7As the colorectal team had moved Emergency alerts: Internal What is the impact of thethrough their transitional phase these spread at SWBH incremental spreadindicative test cycle results helped Upper GI The emergency alert flags for Upperwith the consolidation of the project In April 2010, when it became clear GI have been populated using theboard and a commitment to test that there were delays in the second MDT outcomes from April 2010 andelectronic emergency alerts colorectal test cycle it opened a even with a small alert populationconcurrently on both sites for six window of opportunity to offer during the period the 1 May 2010 tomonths with the final three months emergency alerts to the upper GI 10 June 2006 they have receivedbeing used to test the impact of CNS team. The CNS were already seven emergency alerts for patientsfacilitated discharge. experiencing difficulty with knowing admitted as an emergency. when their patients were admitted.The second stage of the test cycle was The preliminary results meant that the Off those seven alerts, three patientsdue to start in March 2010 when it upper GI CNS could test the are still inpatients. However, thewas intended that an additional CNS opportunities this system offered results have been very encouragingwould commence in post. them. The SIF added the flags to the and match those of the trial with City system from ongoing MDT outcomes colorectal patients and the Upper GIUnfortunately, the new CNS will not and on the 1 May 2010 a test cycle CNS confirmed the following.be in post until after June 2010 and began. The upper GI CNS have readythat has delayed the test cycle start access to emails throughout the daydate. so preferred not to use a smart phone. Extract of Emergency Alerts - Upper GI
  • 8. 8 | From testing to spread: Sharing the knowledge and learning from organisations spreading the Winning Principles These are early results and the Incremental spread – What has The spread still continues expected LOS represents best clinical been learned? The chemotherapy unit manager from experience as baseline data is still It was challenging to engage and City Hospital has enquired how she being validated and analysed. keep momentum with the colorectal could set up her own alert system to services but once the service ensure patients on active As encouraging as the preliminary improvement project was authorised chemotherapy who are admitted as data is, it is as encouraging that the and a clear need to alert the CNS had elective inpatients for all disease CNS has found the alerts very useful. been identified the Winning Principles groups don’t have their care In the past they would have been case studies provided a documented compromised. unaware of these patient admissions solution that could be shared with the and they are conscious that many of team and adapt to work locally. Cancer services at SWBH will approve their patients are on palliative care the roll out of electronic emergency plans more suited to management at It is useful to have the Colorectal alerts to all tumour groups if the data their place of choice, mostly their Project Board structure as it has from haematology and oncology, home. They have used the alerts to delivered the implementation of upper GI and colorectal can proactively manage the patient electronic emergency alerts and as demonstrate a reduction in LOS, pathways to ensure that patients word gets around the Trust other readmissions and unnecessary tests spend the minimum time in an acute teams are willing to accept the and diagnostics. setting receiving the most appropriate concept knowing that it has been treatment and medicines using accepted clinically by their peers. outpatient services for urgent referrals where required. The teams that you work with need to be aware of the value of Haematology and oncology benchmarked data and aim for a local The haematology and oncology team measurable target that can be were looking for a solution to the assessed against the benchmarked challenges of identification of patients data. who were admitted with potential neutropenic sepsis and delivery of the It is important to let the various teams one hour ‘door to needle’ time. find an operational fit for their own Flagging the patients has been service and needs and if its successful relatively easy but the alert has had to the message will spread and the roll be tailored to prevent false positives. out will follow. For chemotherapy patients the alert is only sent if it is an A&E or Emergency Ownership is key to spreading the Admission Unit (EAU) admission. learning. The colorectal CNS are spreading the message across the The alert however was only part of network with other cancer nurses the solution and it requires the through presentations and by word emergency admissions team to receive of mouth. refresher training and to adopt the HEAT campaign. In addition junior doctors on rotation and induction also require specific training. It is expected that in late June 2010, the Neutropenic Sepsis Alerts will go live to support the delivery of antibiotics within one hour of presenting at the trust.
  • 9. From testing to spread: Sharing the knowledge and learning from organisations spreading the Winning Principles | 9 Winning Principle 1 Unscheduled (emergency) patients should be assessed prior to the decision to admit. Emergency admission should be the exception not the norm.Cambridge University Hospitals NHS Foundation TrustEmergency admissions, the exceptionrather than the normBackground • National End of Life Care Strategy – Problems identifiedCambridge University Hospitals NHS Advanced care planning and High frequency of emergencyFoundation Trust (CUHFT) is a large avoidance of inappropriate inpatient admission of cancer patients toteaching hospital located in South admissions CUHFT and the corresponding impactCambridge. The hospital has a • Chemotherapy Services in England: on bed days meant initialcatchment population of 500,000 but Ensuring Quality and Safety (NCAG) investigations and testing was focusedas a specialist tertiary centre serves a – Acute Oncology Service around Winning Principle 1 –wider patient group. Currently, CUHFT • The Quality and Productivity assessment prior to admission. Ashas 1,188 beds accommodating Challenge – which asks: How CUHFT has 69 inpatient beds within65,000 inpatient admissions each quality of care can be improved its cancer division, it was felt that ityear. Expansion plans for the trust whilst also improving productivity. would be appropriate to look first atover the next 20 years will see the the emergency pathways (seecapacity for clinical services increase in Local drivers pathway diagram) into this divisionsize by 50%. The hospital has an • Towards the best, together – East of and see whether any serviceaverage length of stay of 5.4 days and England SHA ten year strategy improvements could be applied herecurrently runs at an average capacity • CUHFT Effective Patient Care to make emergency admission theof 97%, both these figures are higher programme – reducing length of exception for these patients ratherthan the recommended national stay than the norm.averages and the local standards the • CUHFT Trust Values – Kind, Safe andtrust are aiming for of; 3.4 days and Excellent85% capacity respectively. • CUHFT Releasing Capacity – striving to reduce emergency departmentIn the March 2009, the Anglia Cancer and inpatient capacity.Network (ACN) provided funding for aService Improvement Facilitator post CUHFT Cancer Patient Statistics (February 2008 – January 2009)at CUHFT. The post was established tosupport CUHFTs inclusion in the Trust-wide 22,000 patients with a diagnosis of cancer attended CUHFTTransforming Inpatients programme statistics 6,100 inpatient admissions (38,300 bed days)being led by NHS Improvement. 3,100 emergency inpatient admissions (28,000 bed days)Strategic contexts warranting CUHFT Cancer division 14,500 patients attended the cancer divisiondesire to be involved with the statistics 2,350 inpatient admissions (15,835 bed days)programme: 1,600 emergency inpatient admissions (12,160 bed days)National drivers• Cancer Reform Strategy - 20% reduction in cancer inpatient bed days for each SHA• Our Health, Our Care, Our Say – Patient choice and care closer to home
  • 10. 10 | From testing to spread: Sharing the knowledge and learning from organisations spreading the Winning Principles Baseline data Data Analysis (February 2008 – January 2009) To understand the current assessment processes for emergency admission Referral source Accounting for % of admissions patients admitted to the cancer division, The CUHFT Transforming 1. Self referral / Direct to ward 30% Inpatient Cancer Care project team 2. Emergency Department 25% conducted: 3. GP referral 15% • High level data analysis using PAS data 4. Outpatient Clinic 10% • Retrospective clinical notes audit 5. Oncology / Haematology Day Unit 10% • Patient satisfaction/experience 6. Inter-hospital transfer 10% questionnaire • Staff interviews and service evaluation questionnaire. Patient satisfaction and experience • Slow response times of Cancer The outcome of emergency questionnaire specialists to the ED attendance, i.e. admission or 274 questionnaires were sent out to • Lack of resources to carry out discharge following assessment, varies patients who experienced an thorough assessments depending on what route in to the emergency attendance / admission to • Too many emergency routes in to hospital the patient has taken. Those the cancer division between the hospital for patients admitted to patients who go directly to the ward November 2008 – February 2009; we the cancer division or to the Emergency Department (ED) received 103 responses, 31 of these • Professionals making decision to for an assessment have a 95% chance patients went through the ED and 73 admit tend to be recently qualified of admission after assessment, via the other emergency routes, and doctors with limited experience of compared to those who were showed the following: assessment and risk aversive assessed in either of the day units attitude to avoiding admission who have a 45% chance of admission • Patients want more information • Admitting patients appears to be following assessment. Except for a around symptom management at easier than considering alternatives small number of very poorly patients home, what to expect and who to to admission. who attended the ED, there was no contact in an emergency obvious difference in the acuity of the • 70 patients had a specific contact Objectives patients who came through the number to ring in an emergency; From the information we discovered different emergency routes. within this, there were 21 different through our comprehensive baseline people/places analysis, we set the following Retrospective clinical notes audit • High level of reliance remains with objectives: A clinical notes audit was undertaken the GP as first point of contact in an • Reduce unnecessary emergency on 51/147 emergency admissions to emergency admissions the Cancer division in January 2009, • Patients who attended a specialist • Reduce number of pathways and showed the following: area for assessment were more currently used by patients admitted satisfied with their experience than in to the cancer division • Documentation is poor and difficult those admitted via other routes. • Improve patient experience to track route from initial referral to • Have a reliable single point of assessment to admission Staff service evaluation contact to be used for advice by • 25% of emergency admissions interviews and survey patients and professionals could have been planned for or Staff interviews were carried out with • Improve recording of information predicted a wide range of multi-disciplinary • Embed a culture that views • 33% of the patients could have professionals who may be involved in emergency admission as a last been cared for elsewhere (i.e. in the the emergency admission pathway for resort. community, hospice or district patients admitted in to the cancer general hospital) division. To compliment the • 30% of patients admitted were in interviews, two short surveys were their last month of life. sent out to staff working the in the ED and cancer division, and showed the following:
  • 11. From testing to spread: Sharing the knowledge and learning from organisations spreading the Winning Principles | 11Models for testing Cancer Assessment Unit Outcomes from testingThe results from the base lining The CAU was located in a four The CAU had 36 attendances, 28 ofprocess were presented to a bedded bay and staffed by an these were oncology patients andmultidisciplinary steering group, which Oncology Specialist Registrar, two eight were haematology patients.included both CUHFT staff and Oncology Clinical Nurse Specialistsexternal professionals. Internal staff and one Haematology Clinical Nurse This test increased the capacity forincluded; consultants, specialist Specialist. The pilot ran for two weeks assessment in a specialist area andregistrars and senior nurses from the and the assessment unit was open maintained the low admission rateemergency department, oncology Monday to Friday 08:00-17:00. Staff which was identified in the day unitsteam, haematology team and in the assessment unit also manned in the base lining exercise.palliative care team and there was the SPC and there was one SPC forinternal administrative representation Oncology and one SPC for Additional benefitsfrom the associate director and Haematology. • Assessment procedure andoperational manager of the cancer development of treatment plansdivision. External staff invited on to All areas within CUHFT which were was rapidthe group included the NHS identified as taking calls from patients • Improvements reported in recordingimprovement lead, lead commissioner or professionals seeking specialist of clinical informationfrom the PCT, a local GP, and cancer advice were given the bleep • Useful having one pathway forrepresentatives from the cancer numbers for the SPC and were told to emergency admission both for thenetwork. divert all calls during the two weeks to patient but also for the staff in the professionals carrying these terms of tracking admissions andThe steering group considered the bleeps. Advice given to patients were decision making processesvarious themes identified from the recorded on the electronic telephone • Staff reported that working withinbase line work and decided to test record form which was then faxed to the unit was rewarding andthree service improvement initiatives: the patients GP. interesting.i) Cancer Assessment Unit (CAU)ii) Single Point of Contact (SPC)iii) Electronic telephone triage system. Percentage of patients admitted following testing in three clinical areas during testing periodNB: During the five weeks preparationbefore the pilot it was felt that ii) and 100iii) would be more appropriate if they Percentage of patients admitted 14were combined into one work stream. 22 80By time of launching the pilot theelectronic telephone triage system had 60not been developed; however a newelectronic method of recording 40telephone advice was introduced to 36support those staff managing the 20single point of contact. 0 ED Ward CAU Clinical Area
  • 12. 12 | From testing to spread: Sharing the knowledge and learning from organisations spreading the Winning Principles Single Point of Contact SPC The SPC was contacted 156 times, Patient Experience Results 118 of these contacts were oncology Single point of access: Wait to Current experience compared with enquiries and 38 were haematology speak to appropriate person previous experience of telephone enquiries. access Additional benefits 13% 13% 13% • Information and advice given over the phone to patients was much better recorded 13% • Time available for follow-up phone 25% calls allowed for safer practice and 54% continuity of care 20% 49% • Only 11 out of the 156 calls were redirected to the patients consulting team • 100% of GPs who received a copy of the electronic telephone record 0 to 5 mins 6 to 10 mins Much better Better form said that the seeing the 11 to 15 mins Not recorded Similar Not recorded emergency advice given to the patient was useful • 73% of GPs said that having a reliable SPC would help them to manage cancer patients safely from the practice/community rather than Benefits of these services ‘I was treated very well- as always. But sending them to the acute trust. The CAU and SPC have wide reaching I had the same nurse look after me implications in terms of service from coming in from home to being Financial Implications delivery and quality of care and would admitted on to the ward. Really quick • 833 emergency inpatient admissions benefit not only the trust and patients and it was nice to have her follow me August 2008 – July 2009; Monday - but also the commissioners and through.’ Friday 8am to 10pm primary care partners: One pathway • 202 of these admissions came through a specialist area would reduce Lessons learned through the day units which provide the rate of unnecessary admissions, • Engagement of all stakeholders the same level of specialist take pressure off the ED and inpatient from the outset of the project and assessment as the CAU ward areas and offer patients ensuring that the group plays a key • The extra 631 patients were continuity of care during anxious role in directing the project. admitted as inpatients via the ED or times. By offering a specialist Arranging short informal meetings went directly to the ward. assessment prior to admission in a individually with steering group specialist environment we have shown members in between formal Assuming that the extra 631 patients that admission can become the steering group meetings also had been assessed in the CAU where exception and not the norm. ensures they remain up-to-date with the 41% admission rate could be developments and their opinions are applied: Patient’s thoughts on their being constantly reviewed and • 259 patients admitted experience discussed. • 372 admissions averted (59%). ‘The pre-admission advice and contact • Clinical champions who bought in • 2,760 bed days or £1,023,960 prior to my admission via the doctor to the idea and were able to potentially could be saved. was second to none. I was constantly encourage colleagues to view the informed of the steps being taken to pilot positively. The most effective ensure my safety; including knowing a champions were those clinicians CT scan was being booked for the engaged on the ground floor who following day, so I felt more informed were already directly involved in and involved with my own treatment.’ assessments; clinical nurse specialists and special registrars.
  • 13. From testing to spread: Sharing the knowledge and learning from organisations spreading the Winning Principles | 13• Patients at the centre of all Challenges became very evident. Also, the developments and service redesign • The pilot was limited because we environment was not ideal; the four options engages clinicians and helps also used staff from our existing beds were in close proximity to each to channel the direction of the human resource. This meant that and separated by curtains which project. we were unable extend the opening raise questions regarding its• Alignment with national, local and hours later than 5pm and as such compliance with single sex organisational priorities is key to get missed out on applying this model accommodation, there was not a engagement from stakeholders. to patients who attended the specified area for clinical Reminding people of this alignment hospital for emergency assessment preparation and only a small desk as often as possible helps to embed in the evening. for the staff to work on. the necessity of change and • Resources required to successfully • Identifying a single model of encourage a sense of urgency implement this service were initially emergency assessment which meets within the project. underestimated. During the pilot, the diverse needs of oncology and the need for increased access to haematology patients. both computers and telephones Emergency admissions pathway – pre testing Medical secretary Inpatient ward (95% admission On call SpR/SHO Oncology rate) On call SpR/SHO Haematology Emergency dep’t (95% Admission Consultant admission GP rate) Discharge Day units Day unit Other hospitals On call (40% Inpatient ward SpR/SHO admission Oncology rate) Patient Main hospital switchboard On call SpR/SHO GP liaison team Haematology Clinical nurse specialist Emergency admissions pathway – post testing GP Other hospitals Cancer Admission Patient Assessment Unit (41% admission rate) Discharge CUH Emergency Department GP liaison
  • 14. 14 | From testing to spread: Sharing the knowledge and learning from organisations spreading the Winning Principles Winning Principle 1 Unscheduled (emergency) patients should be assessed prior to the decision to admit. Emergency admission should be the exception not the norm. Doncaster and Bassetlaw Hospitals NHS Foundation Trust Patient Electronic Alert to Key-worker System (PEAKS) Background The PEAKS Alert for cancer patients Patient Electronic Alert to Key-worker System (PEAKS) How it works went live at Doncaster and Bassetlaw Patient attends Hospitals (DBH) in September 2009, A&E/Emergency Admission initially rolled out by the lung multi- IT SYSTEM disciplinary team (MDT) and Information trigger PEAKS database Patient subsequently across every tumour attendance input of patients linked to specialist into PAS/EMIS group. The alert is now live across all treatment Patient live on four of the hospital sites in nine PEAKS updated tumour groups and the Specialist Key worker calls via CNS or MDT Palliative Care team. ward to check reason for Email and SMS message sent admission to key worker The alert meets the requirements of QIPP, showing: Key worker visits receiving areas (A&E, MAU, Patient/carer feel supported by key • Quality of care for patients and ward) Staff to inform of patient treatment plan/ worker awareness of visit carers is improved pathway/preferences • Innovation of ‘pull’ style alert • Productivity increase of the OUTCOMES Improved patient experience reduction in length of stay Reduced length of stay Reduced inappropriate • Prevention of inappropriate admissions admissions and treatments. The idea of the cancer alert came from a review of similar alerts implemented at both Sherwood Forest registered key worker informing them If the patient is admitted, the key- Hospitals NHS Foundation Trust and of the patient attendance and current worker gets additional alerts as they United Lincolnshire Hospitals NHS location. are transferred onto a ward, and so Trust. Both schemes were based on are again able to make contact with the RAPA (Recurring Admission This then enables the key-worker to the ward staff to ensure that they are Patient Alert) project work detailed in make contact with the clinical staff fully aware of the patient’s current Transforming Inpatient Care currently treating the patient initially diagnosis, treatment plan and Programme for Cancer Patients – The to understand whether the preferred place of care. Winning Principles. attendance is cancer related and then to ensure that the team are fully Funding The alert also met requirements for aware of the patient’s current DBH decided to develop the IT DBH to meet local End of Life Strategy diagnosis, treatment plan and functionality of the alert system after (2008) requirements and Cancer preferred place of care. considering the purchase of a bespoke Reform Strategy (2007) initiatives. If appropriate, the key-worker can visit system from an external supplier, as the patient and carers to provide this was felt to provide best flexibility How the PEAKS alert works additional support. In this way some and value for money. Additional costs When a diagnosed cancer patient emergency admissions have been included one off payments for mobile attends hospital as an emergency, the avoided, although it is acknowledged phone hardware and clinical audit registration (on PAS or eMIS) triggers that particularly for patients on End of support and regular costs for mobile the PEAKS system, which sends an Life pathways attending A&E out of phone messaging and calls and MDT alert in the form of a simultaneous hours, hospital admission may be administrative support. SMS text message and email to the appropriate.
  • 15. From testing to spread: Sharing the knowledge and learning from organisations spreading the Winning Principles | 15BenefitsAfter the initial implementation, anevaluation demonstrated:-• Improved patient and carer experience (through collection of ‘good news’ stories)• Reduction in LOS for these patients (via Information department data)• Anticipated release of capacity in other areas as a result of patients not undergoing unnecessary diagnostic tests, treatment and medication.Additionally, feedback from theClinical Nurse Specialists (CNS), whoare the key-workers receiving the alertat DBH, suggests that while the alertis an additional activity to manage, ithas brought an increase in jobsatisfaction through seeing animproved delivery of appropriate carefor their patients and an improvedpatient experience.ChallengesThe key workers who receive thealerts work standard hours, sopatients attending out of hours (OOH)saw a delay in response time.However, part of the project alsoinvolved the circulation of detailedOOH guidance for the treatment ofcancer patients attending with variouscomplaints. Additionally the auditingof the project is currently aiming toidentify the reasons for OOHadmissions and inform work by othercommunity teams on improvingservices for these patients outside ofnormal working hours. It is an ongoing task to ensure that In conclusion, the overall feedback fromThe auditing process itself was an the ‘right’ patients are on PEAKS. the cancer MDTs is that PEAKS is aadditional burden on the key workers Initially, this means deciding how long positive initiative and good news storiesduring the initial six months of the ago a patient cancer diagnosis would and initial evaluations support this.implementation, but brought essential still be relevant in impacting on theirinformation and evidence to the likelihood of emergency attendance. After excellent initial success, theevaluation of the project roll out In addition, in order to maintain the Doncaster locality are already lookingregarding number and timing of accuracy of the patients on PEAKS, at the benefits of roll-out of thealerts, nature of attendance and there is a regular administrative PEAKS alert to bring benefits to theresponse times. Subsequently some requirement to update PEAKS with wider health community, for example,teams have retained the audit newly diagnosed patients for each patients undergoing chemotherapy orpaperwork to use to support their tumour group, which is currently with other long term conditions,own systems for patient monitoring. being undertaken by MDT staff. known infections or those on an End of Life Pathway.
  • 16. 16 | From testing to spread: Sharing the knowledge and learning from organisations spreading the Winning Principles Winning Principle 1 Unscheduled (emergency) patients should be assessed prior to the decision to admit. Emergency admission should be the exception not the norm. Pan Birmingham Cancer Network Pan Birmingham Network wide spread of neutropenic sepsis pathway improvements A review of the neutropenic sepsis • A raised temperature may be the The review found the following: pathway identified that within hours only sign of infection in a • Lack of awareness of the pathway the team were able to deliver neutropenic patient. Conversely a and the neutropenic sepsis guideline antibiotics within one hour. Out of patient may be septic and not have • Difficulty in accessing the electronic hours (OOH) the pathway was not a raised temperature guideline able to achieve the recommendation. • Neutropenic sepsis is a medical • Lack of formal condition and central A 50% improvement and a three-day emergency requiring line management training reduction in length of stay have been commencement of intravenous • Poor symptom and condition achieved in the ‘door to needle’ OOH antibiotics. awareness neutropenic sepsis pathway at • Poor communication between in Birmingham Heartlands Hospital. The National Chemotherapy Advisory patient ward and acute ward Learning from PDSA cycles has been Group (NCAG) report, August 2009, • Poor awareness of key resources shared and spread to other trusts to recommends that the delivery of such as the triage bleep holder and improve Network wide delivery of the antibiotics ‘door to needle time’ patient alert cards ‘one hour door to needle’ should occur within one hour of • Variation in place of patient recommendation. presenting with neutropenic sepsis. presentation • Absence or poor availability of Network spread In January 2009, the PBCN intravenous antibiotics appropriate The testing work initially commenced commenced a three month audit to for the treatment of neutropenic with the OOH pathway at Birmingham capture ‘door to needle’ performance sepsis. Heartlands Hospital. This work has of trusts. Audit results highlighted subsequently spread to Good Hope variation in pathways and trusts ability Despite the availability of a pathway Hospital, and Solihull Hospital, the to deliver antibiotics within one hour. and tools to support delivery, there three acute sites which make up Heart remained barriers to staff using these of England NHS Foundation Trusts Birmingham Heartlands Hospital audit tools effectively in order to provide (HEFT). Improvements achieved at results highlighted that out of hours treatment in a timely manner. A (HEFT) have been shared and spread patients would present at A&E or the number of improvements were tested throughout trusts within the Pan Acute Medical Unit (AMU). In addition and measured to determine benefit. Birmingham Cancer Network (PBCN). the pathway was not delivering timely treatment. A project team consisting One point of access Background of senior nurses, haematologists, Previously, patients presented at A&E The PBCN guidelines for the matrons and a service improvement or AMU. Multiple access points management of Febrile Neutropenia facilitator (SIF) was convened and they impacted on the length of delay state that: agreed a period of service review. The experienced by patients. In addition • Neutropenia a neutrophil count of focus of the review was to gain a patients with neutropenic sepsis may <1.0 x109/l baseline through audit and an or may not have a temperature and • Febrile neutropenia is any fever of understanding of the OOH pathway. they can appear well. Without an 38 °C or more maintained for over In reality this meant meeting with understanding of the symptoms these an hour or > 38.3°C on one urgent care medical and nursing patients are at risk of not being occasion leads, a group of clinicians who are prioritised as requiring urgent outside the common groups of intervention. clinicians that the Network usually works with.
  • 17. From testing to spread: Sharing the knowledge and learning from organisations spreading the Winning Principles | 17Clinical service leads agreed and Development of electroniccommitted to AMU as the designated patient alerts Benefits of training staffpoint of access for patients. A period An electronic flag is now attached to • Improved knowledge andof training for AMU staff to support the patient electronic record and it skills of nursingdelivery was also instigated. There was highlights the need for urgent • Increased likelihood of staffalso agreement to educate and treatment. The electronic flag was recognising the symptomssignpost patients to AMU. A by produced through partnership of neutropenic sepsisproduct of the project has been working between nursing and IT staff. • Supporting ‘right person,improved communication between It uses existing capabilities of right time’ thinkingteams and a breakdown of silo electronic patient record system, and • Increasing the liklihood ofworking. so did not incur any additional the delivery of timely care financial outlay. It also includes the • Terms such as ‘neutropenicPatient alert card redesigned alert card and guideline information. sepsis suspected’ orThe original patient alert card antibiotics given as perprovided patients with a 24 hour Future developments are planned policy’ are documentedtelephone contact number to access which will enable the system to be more frequentlythe haematology/oncology triage more proactive. It will be able to • Training providesbleep holder. The role of the triage communicate with a bleep or pager to coordinated way of raisingbleep holder is to provide the patient inform a nominated staff member of condition awareness andwith advice and support. Before the patient’s presentation to hospital. management which is intesting if urgent treatment was This would enable the individual to line with trust policy.required, patients were advised to provide timely support or administerpresent with their card at the antibiotics. The benefit of utilising anemergency department. alert system has been shared with various trusts within the Network. this update is 51% of patientsA survey identified 71% (28/44) of receiving antibiotics with an hour andacute staff had not seen a Delivery of competency a 72% within 1½ hours.neutropenic sepsis alert card, based trainingpotentially due to patients not The staff survey identified 68% Improving condition awarenessshowing the card to staff. Additionally (30/44) of staff surveyed had not read and management based on trustthe card did not promote urgent the guideline. In addition, 75% policy and guidancemedical treatment. (33/44) of staff had not had any A survey of acute staff identified that formal training in the management of 32% (14/44), do not know where toThe alert card was redesigned and is neutropenia. find the guideline and morenow visually alerting as it is red as significantly 45% (20/44) did notopposed to the original white. It The Haematology CNS now provides know there was a guideline.highlights the life threatening nature competency based training to acuteof the condition and provides patients staff which is aligned with policy. She Before testing electronic access to theand staff with a checklist of also provides nursing staff with guideline was not intuitive, it took tensymptoms. Staff members have readily practical skills to identify the steps and several minutes to access it,available guidance on how to treat condition, manage central lines and as it was not located in the trustthe patient and also directions on how facilitate the delivery of timely care. intranet policy section. Improvementsto access the electronic guideline on have been made so that access to thethe trust intranet. The impact of training has been policy takes three steps, it takes less shared with other trusts with in the than a minute and it is also linked toThe alert card is now used for all network. an electronic alert. Finally it is locatedhaematology and some oncology in the policy section of the intranet.patients on all three HEFT sites. For example at University Hospitals Birmingham Foundation Trust (UHBFT) Ensuring that trusts have an accessibleThe improvements in the HEFT alert the project team updated oncology policy or guideline in place whichcard have been shared with other nursing staff on how to manage supports staff in the delivery oftrusts within the network that are patients with suspected neutropenic treatment is the main principle beingadopting or adapting the alert card to sepsis. UHBFT report the impact of spread throughout the network.suit the needs of their patients.
  • 18. 18 | From testing to spread: Sharing the knowledge and learning from organisations spreading the Winning Principles Reducing delays through Patient Group Directives (PGD) The OOH process from presentation to hospital The longest pathway delay exists from the point of medic assessment to the STEP 1 STEP 2 STEP 3 STEP 4 STEP 5 time the antibiotic is prescribed. Patient Patient Medic Nurse Patient Baseline data showed 36% (5/11) of triaged is assessed prescribes administers admitted patients experienced an average delay by a nurse by a medic antibiotics antibiotics to hospital of 134 minutes at this point. A PGD is being developed which will enable specific nursing staff to prescribe and administer a stat dose of antibiotics. Once ratified the PGD will eliminate Improving communication Conclusion duplication, reduce hand offs and lead between teams to support co Underlying the improvements and to a decrease in delay to treatment. production learning achieved is a clear A survey highlighted that 61% (27/44) understanding of the pathway in Development of the PGD has been of acute staff did not know that there conjunction with hard work and drive challenging, primarily due to the was a triage bleep holder on Ward 19. of staff members at all levels of the number of teams involved in its In addition 66% (29/44) acute staff organisation to improving the development. Additional support for had not been contacted by the triage provision of care for patients with the PGD was gained by sharing bleep holder. This indicated that the neutropenic sepsis. pathway data on the OOH pathway communication between teams was performance and the impact of the not supporting co production. PGD at Blackpool, Fylde and Wyre Hospitals NHS Foundation Trust where Improvements and benefits it provided a 69% improvement in achieved door to antibiotics time. AMU staff receive a verbal hand over from the triage bleep holder prior to Development of an antibiotics box the patient presenting at their unit. to improve access to treatment The verbal handover enables AMU to Access to the right antibiotics has prepare for the patient’s arrival. been achieved through the development of an antibiotics drug The double sided triage form has been box. The box is secure and lockable. replaced by the single sided UKONS It contains appropriate antibiotics, form. Staff find this easier to complete medical supplies required for the and understand. The completed form treatment of neutropenic sepsis and a is faxed to AMU providing timely paper version of the guideline. information supported by the verbal hand over. Once used the box is swopped with a fully stocked replacement box situated Reducing barriers to effective on the haematology/ oncology ward. communication between teams has In conjunction with the PGD the box improved the flow of information and will reduce the barriers faced by patients in the pathway. Improved nursing staff to deliver the one hour communication has also promoted co door to needle target. production as teams now support each other in care delivery.
  • 19. From testing to spread: Sharing the knowledge and learning from organisations spreading the Winning Principles | 19 Winning Principle 1 Unscheduled (emergency) patients should be assessed prior to the decision to admit. Emergency admission should be the exception not the norm.Anglia Cancer NetworkCommissioning and cost benefits of acute oncology:Supporting spread across the Anglia Cancer NetworkCommissioners and trusts now have NHS Improvement as being associated There is a good case for establishingaccess to comparative information with these projects. Gross savings of network wide cost reporting on aabout costs of treating cancer patients £5.5m per annum in inpatients costs regular basis, harnessing the PbR datain the network, enabling rates of have been identified as realisable as a which is already being collectedemergency and planned admissions, result of implementing CRS continuously by PCTs, and in somelengths of stay and Payments by recommendations for these four cases by the SHA or its contractors, inResults (PbR) costs to be identified and projects, most of which occurs in order to monitor benefits realisation.compared for different tumour sites, acute oncology. This approach is being adopted acrossproviders and PCTs. This will help in the network to support the spread ofbuilding business cases for Programme Budgeting gives a good the Winning Principles.implementing nationally indicator of total cancer care costs perrecommended improvements, as well PCT, but does not provideas identifying inefficiencies in opportunities to analyse cost at levelstreatment practice within the lower than PCT.network. PbR data readily available in all PCTs,Published Programme Budgeting (PB) covering all surgical admissions anddata suggests the cost of treating many non-surgical treatments, can becancer in the Network is c£250m pa, combined across the Network givingand Cancer Reform Strategy (CRS) important comparative data. Thisdata suggests that about 50% of this work requires financial and IT skills tois Inpatient cost. Variations in PB cost be shared across the network and arelative to incidence suggest gross shared commitment to informationsavings of £30m pa across the exchange.network are possible if the cost percase of the three lowest cost PCTs Interest in using the tool which haswere applied to the three highest cost been developed, and interest inPCTs. Specialist resources were increasing awareness of costs, is veryconsequently commissioned to study high throughout the network.detailed Payment by Results inpatientdata for cancer spells in the network, Existing contractual and financialat a cost of c£40k. arrangements for cancer treatment are not widely understood by cancerPCTs have already reported savings of commissioners, especially in the non-over £1m pa as a result of this PbR areas of chemotherapy andanalysis. These and future consequent radiotherapy, where availability ofproductivity savings will enable activity and cost information differprojects to be implemented in the potentially for each provider. There isareas of acute oncology, 23 hour no consistent standard for whether tobreast, enhanced recovery and day treat chemotherapy treatment ascase chemotherapy, providing all of inpatient activity or not, or on how tothe benefits identified by the CRS and report it.
  • 20. 20 | From testing to spread: Sharing the knowledge and learning from organisations spreading the Winning Principles Anglia Cancer Network - Potential savings per project
  • 21. From testing to spread: Sharing the knowledge and learning from organisations spreading the Winning Principles | 21 Winning Principle 2 All patients should be on defined inpatient pathways based on their tumour type and reasons for admission.Aintree University Hospitals NHS Foundation TrustSpreading the enhanced recovery principles in patientsundergoing colorectal, liver and upper GI surgeryThe t rust is part of the Enhanced The project aimed to reduce length of LOS data collected through the DHRecovery Partnership Programme. stay by the following: database for each patient is beingEnhanced Recovery pathways have used in Statistical Control Charts tobeen introduced for patients • Liver pathway – reduce LOS for feedback improvement data to theundergoing colorectal and liver 50% of patients to ≤ five days teams. The mean LOS has gone fromsurgery. A pathway will also be • Colorectal pathway – reduce LOS 12.64 days to eight days following theintroduced for patients undergoing for 80% of patients ≤ five days launch of ERP (Source: Data submittedupper GI surgery. The two aims of the • Upper GI pathway – reduce LOS for to the DH database for each patientwork are to improve the quality of 80% of patients ≤ nine days. admitted to ward 10 from 12/12/2009care for patients and to reduce length to 13/04/2010).of stay. The impact is being measured through monitoring length of stay, readmission rates and patient satisfaction surveys. Reduction in length of stay has supported the closure of five beds on the enhanced recovery ward 50 40 ERP Commenced 30 Length of Stay 20 10 0 -10 -20 Patients Length of Stay The Mean (average) Upper Control Limit Lower Control Limit WINNING PRINCIPLE 2
  • 22. 22 | From testing to spread: Sharing the knowledge and learning from organisations spreading the Winning Principles Achievements and impact Lessons learned • Dedicated time from a member of • Developed multidisciplinary • Process mapping the patient the service transformation team Integrated Care Pathways for major pathway with the MDT allows the provided support for the project colorectal surgery and liver surgery team to understand what happens lead who had a day job, allowed for that are initiated during the pre now, helps define scope, and forms development of governance operative stage the basis of the pathway structures for reporting and • Set up a ‘patient school’ to provide • Involving the whole team in the monitoring of the project, and opportunity for patients to become process of pathway development practical help in terms of the familiar with the Enhanced Recovery helped develop team working, and application of service improvement programme prior to admission ensured that everyone was aware of tools and techniques • Developed patient information what was happening; bringing • Key challenges remain ongoing booklets/diary that set out the everyone along at the same time engagement of the three primary expected care trajectory and what • The pathway work enabled personal and three social care organisations patients can do to help themselves development opportunities for the that are linked to Aintree. A pilot • Introduced a rolling programme of nursing and AHP staff on the ward referral from pre op to social work staff education to train all staff in who undertook responsibilities for with one of the social care the department on the principles of specific aspects of the project to organisations is being tested, and Enhanced Recovery progress improvements to the two of the PCTs have agreed in • Hosted a ‘stakeholder event’ with organisation of care principle to test systems from GP colleagues from primary and social • Bringing the team together to talk surgeries to improve optimisation of care to raise awareness of the ERP about the patient pathway, out of patients prior to admission work at Aintree and to explore how the normal ward routine, allowed • Core leadership for each of the to improve the referral and for productive discussions and pathways, have dedicated time for discharge processes between provided a supportive environment project management and a pre primary and secondary care in which to challenge any defined timeline for the project, and • Launched ward 10 as the Enhanced assumptions raised relating to the committed executive level support. Recovery ward on 8 March 2010 delivery of care • Improved team working and • Identifying the matron as project communication between nurses and lead was key; it brought the benefit medics of pre- established positive working • Patients are better informed about relationships with the doctors, their care and discharge nurses and AHPs; an in-depth arrangements knowledge of local systems, • Positive feedback from patients including specific cultural traits • Patients are more proactive in their within each department; and care and spend less time in bed knowledge of who to contact to • More effective use of physiotherapy problem solve issues relating to team’s time (patients are dressed pathway development and estates and sitting by the side of the bed issues. This knowledge was when the physiotherapist arrives) invaluable in progressing the project • Stoma nurses providing Saturday • Being involved in the national morning service to facilitate programme set the pace for change, weekend discharges which has and support from the ADO of impacted on LOS surgery ensured that pace was kept • Ward day room is being converted up back into a dining area for patients • The consultant colorectal surgeon to eat away from the bedside and and liver surgeon were visible in encourages mobility terms of support for the project and • A dedicated area for patient articulating the evidence base for education/counselling has been changes in clinical practice to established colleagues, and the rest of the • Some patients have been team discharged significantly earlier than they would have been traditionally.
  • 23. From testing to spread: Sharing the knowledge and learning from organisations spreading the Winning Principles | 23 Winning Principle 2 All patients should be on defined inpatient pathways based on their tumour type and reasons for admission.East Kent Hospitals NHS Foundation TrustsKent and Canterbury HospitalShifting care and reducing length of stay: Ambulatorycare beds in the haematology inpatient wardWe currently have a 14 bed inpatient The first phase recently commenced inhaematology ward with eight single June 2010, six inpatient beds werebedded rooms. closed and in place three ambulatory care chairs were opened. This is in theBaseline evidence showed that up to early days of implementation and thethree haematology inpatient beds a impact of this change on patients andday are utilised by non specialty capacity is being monitored. If thispatients and a number of patients phase is successful the intention is totreated on the haematology pathway move to six ambulatory chairs furtherwere often well enough to go home releasing haematology day patientsin the evening, returning the from the Chemotherapy Day Units forfollowing day and some patients have non-cancer related patients e.g.weekend leave, such as patients rheumatology patients requiringundergoing blood product support monocional drug treatment.and diagnostic work up.• The predominant use by the haematologist of the inpatient beds is for remission, induction and consolidation chemotherapy for acute leukemia, usually acute myloid leukaemia (AMC) although acute lymphoblastic leukemia (ALL) is also treated• It was agreed that these patients would ideally support an ambulatory care pathway• The consultant champion helped to influence this change.
  • 24. 24 | From testing to spread: Sharing the knowledge and learning from organisations spreading the Winning Principles Winning Principle 2 All patients should be on defined inpatient pathways based on their tumour type and reasons for admission. Derby City Hospital NHS Foundation Trust Adopting the 23 hour model for mastectomy patients Introduction The Derby Hospitals NHS Foundation Inpatient stay - January to June 2008 Trust consists of two sites, the London Road Community Hospital and the 40 Royal Derby Hospital, which is a 35 Cancer Centre. The trust has a Number of patients 30 catchment population of around 600,000 patients in Southern 25 Derbyshire. 20 15 The breast team at the Royal Derby Hospital consists of four consultants 10 who undertake around 230 5 mastectomies per annum. The team decided to look specifically at the 0 1 2 3 4 5 Plus mastectomy patient pathway with a Length of Stay - Days view to improving the patient’s experience and valuing patients’ time by giving suitable patients the chance to be discharged from hospital earlier following their surgery. The team was What we did • Engagement - Training events for interested in looking at the 23 hour • Reviewed existing pathway community nurses - enhanced model that had been adopted by the • Identified variance in length of stay working relationships with Pan Birmingham Cancer Network • Created new mastectomy inpatient PCT/provider colleagues (PBCN) very successfully. Contact was pathway for testing • Patient’s expectations - patients made with Birmingham so that we • Inclusion criteria proforma were advised at the outset that if could learn first hand from them developed for 23 hour breast they were medically fit and the about their experience. model patient was in agreement discharge • Suitable patients were identified would take place around 24 hours The length of stay for mastectomy from October 2008 after their operation patients compared favourably with • Questionnaire – adapted from • Pre-operative assessment breast the rest of the country, but we felt we PBCN care nurses (BCN) were in could still improve this. The data from • One consultant agreed to use a low attendance at the pre assessment the first six months of 2008 showed vacuum drain and were able to further identify that 95 patients had been treated and • Discharge information reviewed and patients who would be suitable approximately 8.6% of these patients information sheets created for the • Patient satisfaction questionnaires were discharged the day after their different types of drains used completed. operation. The length of stay ranged • Engagement – Breast 23 hour from one day to 21 days, with 76% of model standing agenda item at these patients being discharged Breast Network Site Specific between days two to four. Group (NSSG)
  • 25. From testing to spread: Sharing the knowledge and learning from organisations spreading the Winning Principles | 25Breast Pathway - Pre and Post Testing Pathway July 2008 Pathway since early 2009 Patients seen in clinic Patients seen in clinic with results with results (Date given Breast care nurse also present 23 hour length for surgery and pre (Date give for surgery and pre of stay discussed assessment clinic) assessment clinic) Nurse led pre Nurse led pre assessment clinic Length of stay assessment clinic Patients will also see physio and re-iterated Patients will also see physio breast care nurse, ocassionally surgeon and breast care nurse, ocassionally surgeon Admission Day of surgery Confirm consent/patient information KTC admission clinic and meet anaesthetist Confirm consent/patient information and meet anaesthetist Nuclear medicine for Sentinel Node Biopsy Attend nuclear medicine for Sentinel Node Biopsy Day case admission lounge Kings Treatment Centre Consultant identifies On occasion visit ward 311 those patients suitable Surgery for nurse led discharge Surgery Breast Care Nurse visits Admit post op to ward 311 all patients on ward before discharge Admit post op to ward 311 Patients discharged following day Verbal and written information leaflet Patients discharged given to patients about days 2-4 (some nurse their drains All patients discharged into care led discharge but of district nurse team - referrrals predominantly consultant faxed Community team led) contact all patients day after discharge and visits for wound check, Patients discharged into support and drain care of district nurse removal team - referrrals faxed Some visits take place 24-48 hours post discharge - not all patients visited
  • 26. 26 | From testing to spread: Sharing the knowledge and learning from organisations spreading the Winning Principles Early Progress - Spread to other consultants Challenge Solution The testing ran from October 2008 to February 2009. It was agreed to Patient expectation - patients If patients were medically fit and include the first 25 patients in the enquired why other patients were agreed they were also discharged testing of the new pathway that were being discharged sooner than them after 23 hours. treated by one consultant but it was when they had had their operation soon realised that this would take to on the same day long to recruit this number of Applying a standardised pathway – The option of the 23 hour discharge patients, so the other three nurses raised concerns if patients was mentioned to ALL patients at consultants agreed to identify were not aware they could go diagnosis and pre-operative suitable patients. home after 23 hours assessment clinic Results A low number of questionnaires Once a patient had been identified During testing we have reduced our returned, so unable to measure how as suitable, SIF sent the LOS, and we have also continued to the patients felt about 23 hour questionnaire out improve on this since implementation discharge - it was felt that this may and the improvement in LOS is being be because patients are given so sustained. This is demonstrating a much information at pre-operative quality driven service that is valuing assessment patient’s time. Breast care nurses unable to attend Robust follow up procedure for Patient experience patient on the ward before patients introduced – BCN time discharge freed up by the introduction on an administrator ‘They were very good at the hospital, before and after the operation. Also the district Comparison of mean length of stay - pre, during and nurses were very caring too.’ post implementation of the 23 hour Breast Model 3 ‘No criticisms – felt consulted 2.5 2.85 yet advised professionally.’ 2.53 2 Conclusions 1.98 • The 23 hour stay model is now 1.5 firmly embedded in the trust 1 • The results of the patient satisfaction questionnaires show 0.5 that patients are very happy with the new service. 0 • Communication and relationships Pre test - up to Testing phase Post test Sept 08 Oct 08 - Feb 09 Mar 09 - May 10 between the hospital trust and the community teams has improved significantly • Continued reduction in length of stay • The percentage of patients who were discharged after 23 hours had increased to 61% for the months July to December 2009.
  • 27. From testing to spread: Sharing the knowledge and learning from organisations spreading the Winning Principles | 27 Winning Principle 2 All patients should be on defined inpatient pathways based on their tumour type and reasons for admission.Whipps Cross University Hospital NHS TrustEnhanced Recovery Programme (ERP): Integratedcare pathway for elective colorectal surgeryWhat is ERP? Staff: • Attendance of ERP course by StThe programme is based on the work • Improve multidisciplinary experience Marks and other training events e.g.of Professor Henrik Kehlet. It is often • Team building opportunities National Awareness Eventsreferred to as rapid or accelerated • Educating and training • Develop shared vision between therecovery. • Recognition for achieving multidisciplinary team improvements in quality and • Creation of a steering groupThis is a multimodal and evidence patient. • Evidence explored throughbased approach to patient’s pathway education literature review andof care. Current practice at Whipps Cross baseline study University Hospital • Developed a dedicated pathway ofIt is comprehensive multistep and Current trend of care follows the care by each lead discipline and themultidisciplinary which optimises traditional pre-operative and post- development of approvedpatient organ function and recovery. operative model of care where integrated pathway of care patients undergoing major colorectal • Developed process map of patientsAim of ERP surgery were experiencing long and journeyThe implementation of the ERP variable length of stay (LOS). • Case analysisthrough Integrated Care Pathway • Lack of shared vision on patient’s • Collaborative problem solving(ICP) is to provide pre, intra and post- pathway • Delivering of an in-house rollingoperative patient’s care with the aim • Lack of communication between training programme for staff andto: the multidisciplinary team junior doctors• Reduce mortality • Fragmentation of care • On going monthly meetings to• Reduce morbidity • No established audit and evaluation update and monitor• Reducing length of hospital stay. of care experience (DOH 2010). • Auditing results of first phase of ERP• Reducing physiological and and comparison with previous psychological stress. Whipps Cross University Hospital studies approach to ERP • Submission to clinical governanceBenefits of ERP • The steering group was established and approvedFor the patient: in February 2009. The core group • External bodies: NHS improvement• Improve patient experience comprised of: team, NHS for London• Empowered as a partner in his/her • Surgeon (lead for ERP) • Audit and pilot on LOS and patient care • Anaesthetist satisfaction survey.• Planned earlier rehabilitation / return • Pain team to work • Physiotherapist/occupational• Reduce exposure to hospital therapist infection • Pre-admission team• Fewer complications. • Ward nurses • DieticianQuality: • Specialist nurses• Improve clinical outcome with • Discharge coordinator and social decreased mortality and morbidity worker• Quality Standards met e.g. CQC, cancer standards, NICE guidelines• Operational standards met e.g. 18 weeks, cancer pathway.
  • 28. 28 | From testing to spread: Sharing the knowledge and learning from organisations spreading the Winning Principles Results The tables show that length of stay Whipps Cross University Hospital ERP colorectal audit 2010 has been reduced from an average of 11.6 days to 6.1 days. 14 13 Length of Stay (post op) Days 12 The future for ERP at Whipps Cross 11 University Hospital 10 9 • Confirming decrease mortality and 8 morbidity through audit 7 • Focusing on other teams e.g. 6 5 urology, gynaecology to embrace 4 the Enhanced Recovery programme 3 2 • Dedicated bay on the surgical ward 1 for patients on ERP 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 • Closer working partnerships with Patient Reference local health community and help Expected length of stay (days) Actual length of stay (days) developing ERP in other trusts. Sustaining change • Patient prospective audit performance and patient Whipps Cross University Hospital ERP colorectal audit 2010 satisfaction • Case base discussion 14 • Study compliance 12 • Continued in-house training for Number of patients staff and junior doctors. 10 8 6 4 2 0 Whipps Cross National Database HES ERP Implemented Inpatient Audit 2008/09 2008/09 20009/10
  • 29. From testing to spread: Sharing the knowledge and learning from organisations spreading the Winning Principles | 29 Winning Principle 2 All patients should be on defined inpatient pathways based on their tumour type and reasons for admission.Pan Birmingham Cancer NetworkSpreading Enhanced Recovery from one testproject to a network wide programmeSummaryThe Colorectal Surgery Team at City Main Test Site Colorectal Service, City Hospital, Sandwell and WestHospital agreed to test the use of an Birmingham NHS TrustEnhanced Recovery approach as part Colorectal Service, Walsall Hospitals NHS Trust Spread Sitesof the National Transforming Colorectal Service, Sandwell Hospital, Sandwell Phase 1Inpatients Programme. After initial and West Birmingham NHS Trusttesting showed positive results they Colorectal Service, Heart of England NHSwent on to adopt the process Foundation Trustpermanently. Learning from their Colorectal Service, University Hospital Birminghamexperiences the Pan Birmingham NHS Foundation TrustCancer Network has supported thespread of Enhanced Recovery, first to Spread Sites Gynaecology Service, Sandwell Hospital, Sandwell andthe other colorectal services in the Phase 2 West Birmingham NHS Trustnetwork and then to other specialties. Gynaecology Service, City Hospital, Sandwell and WestWork to complete adoption into all Birmingham NHS Trustrelevant specialties is ongoing but the Urology Service, University Hospital Birminghamnetwork is already seeing substantial NHS Foundation Trustreductions in average length ofpatient stay, with positive patient Winning All patients should be on a defined inpatient pathwayexperiences and no increase in Principle 2 based on their tumour type and reasons for admissionreadmission rates.Testing Enhanced Recoveryat City Hospital As part of the National TransformingColorectal surgery patients have Inpatients Programme, the teamhistorically had long and variable agreed to test a pathway involving thelengths of stay in hospital. Research following:into a number of different practices • Reduced fasting for six hours pre-ophas shown that it is possible to with fluids allowed up to two hoursdramatically reduce length of stay and beforehandimprove outcomes by adopting a • No bowel preparationdefined patient pathway following the • Avoiding opiate based analgesiaprinciples of Enhanced Recovery. • Limited IV fluids post operativelyThese principles focus on optimising • Early oral fluids and foodthe patients’ physical condition before • Early mobilisation from the day ofsurgery, minimising the impact of the surgery.surgery and then returning the patientto their pre-surgical state as quickly aspossible. Patients are also given clearinformation about what to expect andthe part they need to play in theirown recovery.
  • 30. 30 | From testing to spread: Sharing the knowledge and learning from organisations spreading the Winning Principles Results of testing Figure 1 The pathway was tested on a small number of patients to represent each Procedure Current Predicted Test Patient Potential type of procedure with the following average length of stay actual length difference in results (figure 1). length of stay on test of stay length of stay pathway per patient These positive initial results were enough to increase the confidence of Colectomy 12 Days 4 Days 5 Days 7 Days the staff to implement these changes on a wider scale and as a result Colectomy patients at City Hospital now with stoma 16 Days 6 Days 6 Days 10 Days experience a very different pathway to formation that of only a couple of years ago (figure 2). Colostomy 12 Days 4 Days 2 Days 10 Days reversal Lessons learned Patient’s expectation of their recovery Figure 2 is a key factor in the success of the programme. They need clear information leaflets and to have the Day Traditional Pathway Enhanced Recovery Pathway message consistently reinforced by all the staff they come into contact with. 0 Surgery Performed Surgery Performed This was a big cultural change for Drip, Fluids, Drain, NG Tube Drip, Fluids, Drain and Catheter many staff and they need time to fully and Catheter in in NG Tube removed after surgery understand the process and become Epidural for pain relief confident applying the principles. Drinking in recovery Formal training is particularly useful Sitting out in chair for this but staff have also benefited from hearing about the experiences of 1 Nil by mouth Eating normally colleagues. Sit out in chair if able Catheter out Regular walks around ward A particular aspect of the programme Begin oral pain relief may not be suitable for a patient but this should not preclude them from 2 Sips Epidural down participating in the rest of the Short walk Drip down pathway. Each aspect makes its own contribution to their recovery and we 3 Sips Patient independent should aim to apply as many as are NG tube down if flatus passed Showered and dressed appropriate for each patient. 4 Oral Fluids Discharge Changes are made to the patient’s Short walks pathway at every step so interdisciplinary working is required to 5 Drip down make sure these changes are practical Drain out for each affected staff group. Key members of the team are surgeons 6 Soft diet and ward nurses but many other people should be involved including 7 Diet if tolerated anaesthetics, pain management, Walking more discharge liaison, physiotherapy, dietetics and pre-assessment. 8 Wound clips removed 9 Patient Independent 10 Discharge at discretion of consultant
  • 31. From testing to spread: Sharing the knowledge and learning from organisations spreading the Winning Principles | 31Spread Phase 1 – Colorectal Development of network wide things staff can do to help theirservices across the Network resources patients recover quickerAfter the success of the City Hospital Part of the networks strategy to • A patient held record andpilot it was agreed that Enhanced support spread was to monitor what information leaflet – a bookletRecovery Programmes would be resources the individual trusts needed which combined all the informationdeveloped for all the colorectal and to produce some of these the patient should be receiving atservices with in the Pan Birmingham centrally to avoid duplication of work the pre-assessment appointmentCancer Network. This would focus and ensure consistency across the with a daily journal sectioninitially on City Hospital’s sister site, region. As a result the network has reiterating the milestones for thatSandwell General Hospital and Walsall worked with representatives from the day and allowing them to record theHospital as these two teams were trusts to produce a number of actions they have takenparticularly keen to proceed. Work resources including: • Training sessions – different types ofwould then commence at Heart of • A patient information card – a training sessions were developed toEngland NHS Foundation Trust and business card sized list of the make them accessible to all staff.University Hospital Birmingham NHS milestones for each day of a These could be for small groups onFoundation Trust. patients recovery, encouraging them the ward, one to one for key staff or to play an active role in meeting more formal study days withFrom the beginning the aim was to those goals on the road to recovery speakers from leading organisationssupport each team progressing • A staff education poster – a poster and the national partnershipindividually while sharing resources to aimed at ward staff and junior programme.avoid duplication of work. The doctors which explains the nine keynetwork developed a set ofstandardised ‘work packages’ toensure each of the projects wereaddressing the key issues and alsoproduced resources to be used acrossthe network including educationposters and patient information cards.The network has also taken on therole of gathering and analysing lengthof stay data.Development of standardisedwork packagesAfter reviewing the relevant literatureand in consultation with the clinicalteams the following list of workpackages was agreed. It was felt thatthis covered all the essential aspects ofEnhanced Recovery and encouragedthe teams to embark on discretepieces of work rather than trying tochange everything at once. Each trustnominates a lead for each workpackage ensuring that the work isshared our amongst the team ratherthan always falling to the EnhancedRecovery lead, who was then freed upto act as a coordinator of all the workpackages.
  • 32. 32 | From testing to spread: Sharing the knowledge and learning from organisations spreading the Winning Principles Standardised work packages Work Area Objective Pre-assessment Train pre-assessment staff to manage patient expectation and hand out ‘pre-op’ drinks and information leaflets. Patient Information Manage patient expectation and support their recovery by producing a Pre-assessment comprehensive patient information booklet and an interim leaflet. Pre-op Drinks Provide patients with a set number of carbohydrate loading drinks to reduce the impact of fasting and the consequent insulin resistance. Pathway Notes Produce pathway paperwork to support staff in delivering the components of the programme. Admission to Ward Patients to be admitted on day of surgery except where there is a clinical reason for earlier admission. Anaesthetics Ensure that anaesthetic practice is in line with the principles of Enhanced Recovery, including short acting anaesthetics, no pre-med and restricted fluids. Peri-operative Surgery Ensure that clinical practice is in line with the principles of Enhanced Recovery, including transverse incisions and reduced bowel prep. Recovery Ensure that recovery procedures are in line with the principles of Enhanced Recovery, including removing NG tubes, allowing oral fluids and restricting IV fluids Mobilising on Ward Patients to be out of bed after surgery and walking regularly from the following day. On the Ward Eating on Ward Patients to be eating and drinking after surgery and returning to a normal diet quickly. Pain Management Development of a protocol that manages the patient’s pain with out compromising their recovery. Discharge Processes Develop discharge criteria and consider nurse led discharge. Plan discharge processes such as arranging TTOs to prevent delays. At Discharge Follow Up Calls Senior nurse to contact patients 24 hours after discharge to troubleshoot and prevent readmission. Primary Care Info Ensure GPs are aware of the new processes. GPs to manage patient’s comorbidities preoperatively and set expectations.
  • 33. From testing to spread: Sharing the knowledge and learning from organisations spreading the Winning Principles | 33 Figure 3: Average length of stay 2009/10 16 Trust 1 Trust 2 Trust 3 Aim 15 14 13 12 Days 11 10 9 8 7 6 Q1 Q2 Q3 Q4 QuarterResults so farThree of the four trusts have been How Enhanced Recovery is spreading across Birminghamable to provide robust length of staydata which covers all elective Sandwell & West Birmingham NHScolorectal surgery patients showing Trust - Sandwell Site Colorectaleach achieving a substantial reduction Walsall Hospitals Sandwell & West Birmingham NHS NHS Trustover the course of the year. Provisional Colorectal Trust - Sandwell Site Gynaecologydata for the first quarter of 2010/11indicates this trend is continuing, with Sandwell & Westall trusts moving towards their aim of Birmingham NHS University Hospitals Trust - City Site Sandwell & Westa 6.5 day average (figure 3). Birmingham NHS Colorectal Birmingham NHS Foundation Trust Trust - City Site Urology GynaecologyThe aim of 6.5 days has been agreedas while it was felt that ‘straightforward’ enhanced recovery cases University Hospitals Heart of Birmingham NHS England NHSshould have a four or five day stay, Foundation Trust Foundation Trustthe teams felt strongly that no patient Colorectal Colorectalshould be considered ‘off thepathway’ and that all patients should Work completed Work nearing completion Work ongoing Work in early stagesbe included regardless ofcomorbidities or social problems. The6.5 day average was therefore arrivedat to make an allowance for a small Spread Phase 2 – Other specialties work that has gone on already. Thisnumber of patients who could As interest in Enhanced Recovery has spread process will not only apply thereasonably expect a longer length spread and other teams have heard knowledge we have gained with theof stay. about the success achieved by there early adopters but can also easily colorectal colleagues, the Network has adapt the resources that were had contact with a number of other developed for the colorectal teams to teams wanting to embark on similar suit the other specialties. Due to this projects. As a result work is now big advantage we anticipate that beginning with two gynaecology these new projects should be able to teams and a urology team. These demonstrate results within a much teams will really benefit from all the shorter time frame.
  • 34. 34 | From testing to spread: Sharing the knowledge and learning from organisations spreading the Winning Principles Winning Principle 2 All patients should be on defined inpatient pathways based on their tumour type and reasons for admission. Queens Centre for Oncology and Haematology Hull and East Yorkshire Hospitals NHS Trust Delivering care in appropriate settings Hull and East Yorkshire Hospitals NHS LoS is being used as a key metric for Looking at the four month period of Trust has recently seen a significant measuring improvement, however, it November, December, January and development in its cancer services must also be stated that there has February (2009-10) there were 404 following relocation into the new been a significant improvement in regimes of Cisplatin delivered. Again Queens Centre for Oncology and patient experience and valuing the removing the top ten percent of long Haematology. This development patients time, as they spend less time stays to account for patients that provided an facility to deliver in an acute hospital setting. would have needed inpatient care significant changes in working This improvement has been achieved regardless has shown that on average practice and released capacity. One within existing staffing resource and 0.9 in patient bed days are used per change was the transfer of delivery of delivered with a change of working patient as represented below with some chemotherapy regimens from practice. 70% of patients having no inpatient the inpatient to outpatient setting. stay displayed below. Transferring the delivery of Cisplatin By moving the Cisplatin regimen to regimens (where clinically appropriate) out patient delivery there has been a This has had a significant impact upon to the day unit has made a significant significant reduction in the number of patient experience and bed reduction in inpatient length of stay inpatient bed days used for this management within the cancer (LoS). This change supports the pathway. centre. NCAG guidelines (2009) and the Transforming Inpatients Programme drive to improve quality and ‘save a 70% of patients have no inpatient stay million bed days’ (NHS Improvement 2009). 350 A new network protocol for delivery Total of Cisplatin in the outpatient setting 300 was agreed by the Humber and Yorkshire Cancer Network 250 Number of Patients Chemobiological Group. When reviewing the delivery of the Cisplatin 200 inpatient regimes it was necessary to 150 remove from calculations the top 10% of long stays as this assumes a 100 group of patients that are in clinical need of an inpatient stay. Looking at 50 the delivery of the Cisplatin regimen in October 2009 there were 45 0 patients identified as a sample of 0 1 2 3 4 5 6 7 8 9 10 14 16 18 19 22 26 36 inpatient stay LoS to set a base line for Number of Days improvement (after removing the 10%). This in turn showed that 101 bed days were used in delivery of the Cisplatin regime showing an average of 2.2 days LoS per regimen delivery.
  • 35. From testing to spread: Sharing the knowledge and learning from organisations spreading the Winning Principles | 35Delivery of the service as anoutpatient led appointment hasallowed reduction of average LoSfrom 2.2 to 0.9 days; providing asaving in the region of 1500 beddays per year within the centre.This has allowed for an improvementin access to the centres wards and byreleasing bed capacity for patientsthat would have previously beentreated within other specialities in thetrust.The NCAG recommendations (2009),and the increasing demands oninpatient capacity acted as the majordrivers for change. The ability to utiliseday unit facilities that were availablefrom moving to a new unit providedthe catalyst for change.The clinicians were champions of thenew network protocol as they couldsee benefits for both patients and theservice. The key challenge was theredesign of pathways so that longeroutpatient regimens could bedelivered. Staffing levels wereadjusted to enable 8am to 6pm coverfor the day unit. Staff were consultedand involved in the redesigning of theservice.
  • 36. 36 | From testing to spread: Sharing the knowledge and learning from organisations spreading the Winning Principles Winning Principle 2 All patients should be on defined inpatient pathways based on their tumour type and reasons for admission. Hinchingbrooke Healthcare NHS Trust Enhanced Recovery: Colorectal cancer Although good average length of stay Consultants Out-patient A collaborative care plan (CCP) was was identified at Hinchingbrooke staff developed which all disciplines have hospital, there was considerable Patients and carers Dietitians signed up to. This is a multi- variation. disciplinary document that identifies Pre-op assessment PALS the key nursing, physiotherapy, • Average LoS = 8 days for patients Cancer management Ward nurses medical and other interventions having an elective anterior resection. Pharmacy Physio needed each day. • Average LoS = 12 days for patients GPs OOH GP have an elective hemicolectomy. services Outcomes Quality and productivity Colorectal Nurse With the advances in surgical We have successfully; improved Specialist Stoma Nurse techniques and feedback from other quality and productivity: sites, we decided to look at our Theatres Recovery • Reduced length of stay (LoS). Please pathways and attempt to standardise Anaesthetists note: LoS did not immediately our length of stay. We also wanted to reduce and there was a ‘chaotic’ offer the best care for patients, reduce Setting patient expectations period initially after the change was waiting times and achieve clinically for surgery first introduced. This soon settled and financially sustainable services. We provide patient information to and LoS was reduced as follows: The primary resource and investment assist with managing patient • Average LoS = was 8 days for we used was staff time. Initially, we expectations of surgery and recovery patients having an elective discussed ideas at a clinical and this empowers patients as anterior resection. Now 4-5 governance meeting. We had the partners in the process and aids their days backing of colleagues, management understanding of what is expected of • Average LoS = was 12 days for and the SHA. Meetings were held them. patients have an elective with key stakeholders to discuss and hemicolectomy. Now 8-9 days identify key players including the Information is provided at different • Risks involved with hepatic arterial involvement of colleagues in points in the pathway, both written infusion (HAI) have been reduced Community Care Service (Providers) and verbal, during clinic, pre-op • Multi-disciplinary notes have and NHS Cambridgeshire assessment, ward and at discharge. improved (Commissioners). This gave us the The feedback that patients provide to • There is an agreed plan of care opportunity for a joined up and us, for example, on written between disciplines. This can be seamless care pathway. A half day information is used to help re-draft used as an educational tool for event was held involving and ensure we meet the needs of the students and newly qualified staff the following stakeholders in patients. This is an iterative process. • The amount of nursing paperwork identifying the issues and action to be written has been reduced so planning. Changing practice this allows increased time for direct Pre-op optimisation of the patient is patient care. done, especially nutrition. Early nutritional assessment is conducted, With the standardisation of care, best which must be scored in the clinic practice is adopted and variation (supplements are given if required). (depending on experience/knowledge) We are reducing the fasting period is reduced or eliminated. and glucose loading prior to surgery.
  • 37. From testing to spread: Sharing the knowledge and learning from organisations spreading the Winning Principles | 37Challenges in changing theservice included:• Differing opinions on the best dietary management in the peri-op phase between different sites and different disciplines still exist• Managing patient expectations from the outset• Managing staff expectations and the change process• Managing changes in documentation (CCP)• Pain management, which needs to be effective but should not hamper early mobility.Next stepsThis is an iterative process and we arealways looking to improve. We arecontinually looking for furtherrefinements of the CCP as newevidence comes to light.Further investigation is being doneinto new pain managementtechniques to promote earliermobilisation and removal of lines,catheters etc. which can hampermobility.Tighter fluid management peri-operatively is also being looked into.
  • 38. 38 | From testing to spread: Sharing the knowledge and learning from organisations spreading the Winning Principles Winning Principle 2 All patients should be on defined inpatient pathways based on their tumour type and reasons for admission. West Suffolk Hospital, Bury St Edmunds Breast inpatient care: Valuing patient time The West Suffolk Hospital (WSH), Drains are not used routinely, which The majority of the patients are now wanted to improve the breast service. supports early discharge. There are two discharged between one to two days. Changes in the breast service were not consultants at WSH, one who does not Some patients are discharged on the implemented as a specific project but use drains at all and one who does use same day and some lists are done in the have evolved over time since 2004. The drains for axillary node clearances but day surgery unit. If patients are not primary investment has been staff time these patients are discharged with their discharged on the same day, patients and commitment. The most important drains if necessary and possible. are normally discharged the next and challenging issue was changing and morning. It is all done on an individual managing expectations of both staff Post-op information is given to the patient basis. and patients. patient, including follow up information, and the patient is A three month audit was recently The team regularly look at continuously discharged with all the information conducted which covered the period improving the service they provide via: which includes: from January – March 2010. Out of 100 • Weekly breast care nurse meetings • Discharge letter (including follow up breast operations performed: • Breast cancer patient experience appointment details) • Nine in day surgery unit (DSU) questionnaires to every patient three • Details of support services • One was plastics months after diagnosis date • Post-operative information, including • 74 were cancers • Bi-monthly breast unit business a care plan from the ward. • 91 patients were discharged within 24 meetings hours • Annual breast cancer audit day and The patient is asked to contact the • Seven discharged within two days service improvement day. practice nurse three days after the • Two discharged within three days. operation for a wound check. Managing patient expectations Therefore, 91% of patients were Patient expectations and understanding For patients who are discharged with discharged within 24 hours, 98% were has evolved through easier access to drains: discharged within two days and 100% information on the internet etc. Patients • On the day of discharge the district of patients were discharged within three are now informed at the very beginning nurse is contacted to confirm the days. of the service what is provided and the discharge arrangements and patients The key to the success of this expected length of stay. Pre assessment condition. change has been: is conducted one week before • Patients are discharged with a district • Changing and managing expectations admission. nurse letter, dressings and - patients, surgeons, nurses and all medications. other involved staff. Key changes in practice • If they need additional drainage • Dynamics of the team - team working • Admission on day of surgery equipment, the patient is seen at the and a collaborative approach, with the • Surgical technique – flap suturing – WSH. This is very rare. breast care nurses being essential to which reduces the need for drains • The district nurse then contacts the the smooth running of the service. • Glue is used to seal incisions so no patient, on the day they are dressings are required discharged, to confirm a visit to the The team now regularly review the • No Patient Controlled Analgesia (PCA) patient at home the next day. service to consider ways of improving it is used • The district nurse then visits the and it has become part of the culture • Nurse-led discharge is in place. patient daily whilst the drain is in and mindset of the whole team. place. The district nurse removes the drain on the fifth day after surgery or when drainage <50 mls per day.
  • 39. From testing to spread: Sharing the knowledge and learning from organisations spreading the Winning Principles | 39 Winning Principle 3 Clinical decisions should be made on a daily basis to promote proactive case management.Royal Cornwall Hospital NHS TrustProtocol for patients admitted with clinical diagnosisof malignant bowel obstruction secondary togynaecological cancerWe have centralised the care of The prognosis for these women is The results of the audit andwomen suspected of intestinal often poor and their management is management will be evaluated afterobstruction due to gynaecological usually haphazard resulting in long six months.cancer to the gynaecology ward. The stays in hospital. The protocol aims topatients are seen daily by the provide a definitive plan of Lessons learnedgynaecological oncology and palliative management within a week reducing Development of the protocol was acare teams and managed according to the stay in an acute hospital collaboration between thethe protocol. This provides a environment. gynaecological oncological andstructured approach to their care, palliative care team. It was presentedassessing the role of surgery and if We estimate that up to 30% of at the surgical directorate clinicalinappropriate, attempts to manage women with ovarian cancer will governance meeting as many of thesethe symptoms medically. Medication present with intestinal obstruction as women are admitted under theis adjusted daily as required and a part of recurrent disease. surgeons. The current problem isjoint review is made on the sixth day Management is audited against the maintaining a multidisciplinaryto formulate ongoing care. protocol using forms produced by the approach over the weekends. The hospital audit department. Laminated evidence base involved an extensive copies of the protocol are kept in the review of the medical literature related ward and placed temporarily in the to the management of intestinal patients being managed. The obstruction in gynaecological cancers. development of the protocol involved the gynaecological oncology and Spread and adoption palliative care teams as well as a lead Although in its infancy, the protocol nurse form the ward and the Trust has centralised the management of audit team. these patients across the hospital and has been supported by the general Achievements and impact surgeons who are now transferring The protocol commenced on the these patients early in their 1 March 2010, with five patients management. They are also managed to date. Two have gone on considering the use of the protocol in to surgery and further chemotherapy, non gynaecological cancer cases. two have resolved with medical There have been requests from management and one has been clinicians in Leeds and London for managed palliatively. Structured copies of the protocol. quality of life has not been assessed but we are intending to use the EORTC QOL questionnaires. The management has been more proactive WINNING PRINCIPLE 3 and decisions made earlier than in the past.
  • 40. 40 | From testing to spread: Sharing the knowledge and learning from organisations spreading the Winning Principles Protocol for Patients Admitted with Clinical Diagnosis of Malignant Bowel Obstruction Secondary to Gynaecological Cancer Initial Audit Protocol – prospective from (01.03.2010) Clinical diagnosis = abdominal distension, pain, nausea and vomiting +/- constipation or absence of PR flatus, which may occur later. Admission: Refer to Gynaecology Oncology, and Hospital Palliative Care Teams Treatment Algorithm (Medical) IV fluids. Nil by mouth. NG tube placement, IF ACCEPTABLE TO PATIENT Colicky pain present Pain present but not colicky Hyoscine butylbromide 60 – 80 mgs via Cyclizine 150 mgs + syring Haloperidol 3 mgs driver over Diamorphine/other opioid +/- 24 hrs Diamorphine/other opioid (Haloperidol used if pain present In addition: Transfer patient to Specialist palliative care and as cyclizine may precipitate with Wheal Agar Ward ASAP gynaecology review hyoscine butylbromide) Investigations: • Face to face review within 24 hours Abdominal x-ray ideally (or telephone review if If opioid naïve, start at 10-15mg over Abdominal CT with contrast ASAP. unavailable). 24 hours, or 5-10mg over 24 hours if • Daily review both teams after. frail / low body weight (10mg UNLESS: Diamorphine = 30mg oral morphine). • Clearly unfit for any surgical or A decision to proceed to surgery procedural intervention may be taken at any point if If already on opioids, • Patient refuses to consider any deemed appropriate by senior Diamorphine/opioid dose to be surgery or procedure review. discussed with hospital palliative care • Senior gynaecological surgical Criteria may include: team – Monday – Friday 0900 – 1630 decision NOT for surgery (exclusion • Radiology suggesting high or Specialist Palliative Care Advice criteria may include: previous probability of single-site obstruction Line, 01736 757707 to access laparotomy precluding success, (e.g. post-op adhesion or single discussion with Consultant on-call. abdominal carcinomatosis evidenced discrete neoplastic mass) by diffuse palpable tumours, • Low tumour bulk on imaging If considering use of oxycodone as massive ascites with rapid re- • Patient fit for surgery. injectable opioid, beware accumulation after drainage). precipitation with cyclizine in syringe driver.
  • 41. From testing to spread: Sharing the knowledge and learning from organisations spreading the Winning Principles | 41Day 2: Treatment algorithm Day 3: Repeat assessments as per Day 6:(medical) day 2 PLUS Joint or same day gynae/oncologyIf NG tube in place: Parenteral fluid: surgical and specialist palliative care Consider removal of NG tube if • If symptoms have become well review:• Nausea and vomiting controlled in last 24 hours, allow • Final decision regarding any surgical controlled/significantly improved, clear fluids by mouth and review or interventional options of care and volume of NG drainage need for iv/sc fluids after further 24 • Definitive decision regarding <500mls previous 24 hours hours ongoing place of care if not made• Patient would prefer no NG tube. • Stop parenteral fluids if tolerating earlier and no possible surgical oral fluids. optionsParenteral fluid • If NOT for surgery, ongoing Review need for intravenous fluid : Symptom Control Review responsibility of care between• May be appropriate to change to • If high volume vomiting/NG tube gynaecology and specialist palliative subcut fluids drainage greater than 1000 mls in care until moved out of acute trust,• May be appropriate to stop all 24 hours despite previous measures: or death of patient if unfit to be parenteral fluids if patient clearly • Stop Hyoscine butylbromide and moved. deteriorating rapidly add Octreotide 300 micrograms • Consider PEG.• If symptoms well controlled, allow per 24 hours in syringe driver clear fluids by mouth and review • Adjust opioid and anti-emetic doses need for iv/sc fluids after 24 hours. as needed.Symptom control review: Day 4: Repeat assessments as per• If nausea and vomiting remain day 2 and 3 PLUS uncontrolled consider change of Symptom Control Review anti-emetic to Levomepromazine • If high volume vomiting/NG 6.25 to 12.5 mgs per 24 hours in drainage tube drainage greater than syringe driver 1000 mls in 24 hours despite• If high volume vomiting/NG tube previous measures : drainage more than 1000 mls in 24 • Increase Octreotide to 600 hours despite nil by mouth and anti- microgms/24 hours in syringe driver emetics: • Adjust opioid and anti-emetic doses • Add or increase Hyoscine as needed. butylbromide to 120-160 mgs/24 hours (do not mix with Cyclizine, Day 5: Repeat assessments as per if patient previously on Cyclizine, day 2, 3 and 4 PLUS anti-emetics should be changed to Symptom Control Review Levomepromazine as above) • If high volume vomiting/NG• Adjust opioid for pain relief as drainage tube drainage greater than appropriate 1000 mls in 24 hours despite• If high small bowel obstruction plus previous measures: gastric dilation confirmed, consider • Increase Octreotide to 900 adding proton pump inhibitor. microgms/24 hours in syringe driver.Gynaecological review re surgicalintervention using exclusion / Consider appropriate place of care –suitability criteria as end page 1, discussion with patient and family ifinitial section page 2 appropriate.Consider appropriate place of care –discussion with patient and family ifappropriate.
  • 42. 42 | From testing to spread: Sharing the knowledge and learning from organisations spreading the Winning Principles Winning Principle 4 Patient and carers need to know about their condition and symptoms to encourage self-management and to know who to contact when needed. Burton Hospitals NHS Foundation Trust, Queens Hospital The ‘FAB’ Programme: Fatigue, anxiety and breathlessness programme for patients with lung cancer and their carers The trust tested a multidisciplinary • Reduce emergency admissions for Measuring improvement care approach to Fatigue, Anxiety and patients with lung cancer due to The following evaluation methods Breathlessness (FAB) for patients with problems related to the symptoms were used to measure the impact of lung cancer and their carers. The of fatigue, anxiety and the FAB programme: multidisciplinary team included a breathlessness, where appropriate. • An Assessment Toolkit completed by Respiratory Physician, Physiotherapist, • To provide patients and carers with the patient pre and post programme two Occupational Therapists, Lung the knowledge and skills to which includes: Clinical Nurse Specialist (CNS), effectively manage symptoms at • Hospital Anxiety & Depression Dietician, Clinical Aroma therapist and home, to avoid inappropriate (HAD) Scales a Fixed Term Therapy Assistant. emergency visits and/or admissions • Fatigue Severity Scales to hospital. • Breathlessness Scales The FAB programmes aim supports • Provide access to high quality care • Goal Planning the spread of Winning Principle 4 to: from a wide range of health care • Patient and carer experience surveys • Empower patients and carers to professionals • Review of the patient pathways for take control of their symptoms and • Increase the patient and carers’ patients to compare the number of manage their own health needs. ability to effectively self-manage non-elective admissions and length symptoms associated with a lung of stay for patients who do and do cancer diagnosis in the patient’s not attend a FAB programme. own home. Resource and investment Baseline A bid for £10K was submitted to the An audit of 25 randomly selected East Midlands Cancer Network in patients with lung cancer accessing February 2009, for non-recurrent Burton Cancer Services was Service Improvement funding to completed to look at non-elective support the initial local testing and the admissions and to explore the reasons implementation of 4 x 6 week for emergency visits and hospital Breathlessness Management admissions. The results showed that, Programmes for patients with lung • 13 (20%) of the 64 non-elective cancer and their carers. The funding admissions were due to supported: breathlessness. • Sessional staff costs for two • Average length of stay eight days. occupational therapists and a physiotherapist • The fixed term appointment of a therapy assistant • External venue hire to run the programme away the hospital site,WINNING PRINCIPLE 4 in order to reduce feelings of anxiety associated with attending the hospital for appointments and treatment • Patient transport.
  • 43. From testing to spread: Sharing the knowledge and learning from organisations spreading the Winning Principles | 43Results Patient responses Carer responsesTo date, three ‘FAB’ programmes havebeen run. The first two have been Have you found the FAB clinic useful? Do you feel that the FAB clinic hasevaluated from a patient’s perspective. • “Yes - Useful to hear other peoples helped you to cope better with any attitudes towards their condition.” symptoms/problems you have been• The final FAB programme is due to • “Yes - Joining in a group and being experiencing? begin in September 2010 and aims able to talk to other people. Also • “Helped me not to be over to include targeted chemotherapy talking to therapist involved.” protective.” awareness and inform carers about the signs and symptoms of Did the FAB clinic meet your Do you feel that the FAB clinic has chemotherapy related problems. expectations? helped you to feel better able to cope• Efficiency savings have been made • “Yes - Opportunity to share views in a crisis? through the provision of patient and learn basic techniques.” • “To know the crisis is recognised education around self management • “Yes - Informative & helpful.” and how to cope with it emotionally techniques in a group setting. and physically.” Compared to providing support to Do you feel that the FAB clinic has patients and their carers/relatives on helped you to cope better with any Is there anything that you will do a one to one basis, group sessions symptoms/problems you have been differently as a result of attending the ensure that both the patients, carers experiencing? FAB clinic? and staff time is valued. • “I do feel I will cope much better • How to help my partner as she faces with my problems. Relaxing and the problems of FAB.‘The support and knowledge breathing control especially.” • “Yes - both for information & General commentsof other patients and their practical support.” • “As the partner of a patient, I feelpartners was invaluable.’ better able to support my husband Do you feel that the FAB Clinic has through his experiences of acute• Patient/carer experience surveys helped you to feel better able to cope breathlessness, anxiety and general evaluated the programme positively. in a crisis? fatigue.” Questions are asked to discover the • “Yes - Anxiety being my main usefulness of the programme, what problem.” their expectations of the • “Yes - Relaxation techniques programme were and if they were practised.” realised, and how they intend to use the information and techniques that Is there anything that you will do are covered within the programme differently as a result of attending the to help the patients and carers feel FAB clinic? better equip to manage their own • “Not so inclined to panic.” care at home.
  • 44. 44 | From testing to spread: Sharing the knowledge and learning from organisations spreading the Winning Principles Outline of the FAB Programme Figure 1: Planned goals for patients attending FAB Programme 1 Goal planning During week one, patients are asked 12 to consider specific problems, identify personal goals and to formulate an 10 action plan. This allows each patient to identify what is important to them. Number of Patients 8 In addition it means that the staff are able to identify what support each 6 individual needs to improve their 4 quality of life. 2 Figure 1 opposite, illustrates the type of goals patients who attended the 0 first FAB programme (FAB Programme FAB related Emotions Lifestyle & Independence Preparations for others Body Image 1) set themselves. Goal Theme Outlined below (figure 2) are some of the examples which illustrate each of the themes opposite. FAB related Figure 2: Goal planning actions achieved • “To learn how to remain calm and through the FAB Programme used controlled breathing.” • “To have more energy to do things.” 12 • “To learn to relax and to talk to 10 others to relieve stress.” Number of Patients Emotions 8 • “To find ways to deal with 6 aggression by talking and addressing worries.” 4 • “To learn to accept help from others and to recognise good friends.” 2 Lifestyle and independence 0 • “To manage the train journey or FAB related Emotions Lifestyle & Independence Preparations for others Body Image flight to Lyon.” Goal Theme • “To be to play football etc. with grandsons.” • “To be able to attend hospital and medical centres independently.” The goal planning element has been of the FAB programme, the patients Preparation for others proven to demonstrate improvements are asked to review their personal • “To prepare the relevant paperwork in patient experience and self goals and action plan and then and to ensure family understands management from the end of comment on any progress they have my wishes.” programme review. During week six made towards achieving them. • “To find a residential placement for my mother.” Body image • “To stabilise weight.”
  • 45. From testing to spread: Sharing the knowledge and learning from organisations spreading the Winning Principles | 45Comments and outcomes stated by Advise to others Evidence basethe patients which illustrate each of Following service improvement Researchers (Corner et al, 1996;the themes identified: techniques were useful in planning, Bredin et al, 1999; Syrett & Taylor, implementation and development of 2003) have found that lung cancerFollow advice given on course the FAB programme, around: patients can benefit from a• “Easier to plan ahead appropriately, • Effective clinical engagement multidisciplinary, non-pharmacological use relaxation techniques.” • Risk assessment breathlessness intervention through• “Have benefited from taking to • Action planning an increased functional level and others in the same situation, use • Options appraisal ability to perform activities of daily relaxation techniques.” • Experience surveys living. In addition patients reported a• “Feel much calmer, breathing • Patient pathways. reduction in feelings of anxiety and settling into a routine, coping better levels of perceived breathlessness. with walking and managing the Top tips stairs.” • Ensure all key stakeholders are The next stage of the FAB programme• “More controlled eating plan.” involved and kept up to date with is to evaluate from a productivity the progress perspective and to quantify the impactTo use techniques learned • Plan to use PDSA cycles to test each on reducing emergency admissionsat the group programme through empowering patients.• “Have learned to pace myself and to • Be flexible to develop programme conserve energy, I now set accordingly. achievable tasks for myself.”• “The write up in the FAB handout Key challenges was good and it has helped but also • Identifying performance measures talking as a group and practicing to assess the impact of the FAB breathing exercises.” programme.• “I now set two to three jobs a day • Reduced attendance in the second and do them in the morning taking programme. short breaks in between with coffee • Poor experience survey and and biscuits.” assessment toolkit return for the second FAB programme.Signposting and referral toother services Discussions have taken place with the• “To address blue badge parking FAB multidisciplinary team members with the authorities.” to explore the reasons for the latter two challenges. An options appraisalAdvanced care planning was put together to outline strategies• “To source instructions, contacts, that could be explored to address the required forms etc.” challenges.• “To liaise with Social Services.”
  • 46. 46 | From testing to spread: Sharing the knowledge and learning from organisations spreading the Winning Principles Acknowledgements and references With thanks to the staff and Further reading NHS Improvement Transforming patients at: Inpatient Care Programme Team NHS Improvement - Transforming • Anglia Cancer Network Inpatient Care Programme An Celia Ingham Clark • Aintree University Hospitals NHS Integrated Approach: The National Clinical Lead Transforming Foundation Trust Transferability of the Winning Inpatient Care Programme • Burton Hospitals NHS Foundation Principles - Sharing the Learning Trust (July 2010). Ann Driver • Cambridge University Hospitals Director, NHS Foundation Trust NHS Improvement - Transforming NHS Improvement • Derby City Hospital NHS Inpatient Care Programme ann.driver@improvement.nhs.uk Foundation Trust Consolidation Report (2009): From • Doncaster & Bassetlaw Hospitals Testing to Spread (July 2010). Angie Robinson NHS Foundation Trust National Improvement Lead, • East Kent and Canterbury Hospital NHS Improvement - Transforming NHS Improvement • Hinchingbrooke Healthcare NHS Care for Cancer Patients – Spreading angie.robinson@improvement.nhs.uk Trust the Winning Principles and Good • Hull & East Yorkshire Hospitals Practice (July 2009). Marie Tarplee NHS Trust National Improvement Lead, • Pan Birmingham Cancer Network NHS Improvement - Meeting the NHS Improvement • Royal Cornwall Hospital NHS Trust challenge together – delivering care in maire.tarplee@improvement.nhs.uk • Sandwell & West Birmingham the most appropriate setting (October Hospital NHS Trust 2008). Catherine Strong • West Suffolk Hospital PA Transforming Inpatient Care • Whipps Cross University Hospital NHS Improvement - The Winning Programme, NHS Improvement NHS Trust. Principles – Transforming Inpatient catherine.strong@improvement.nhs.uk Care Programme for Cancer Patients (July 2008). SHARING AND SPREADING YOUR SUCCESS TO IMPROVE PATIENT CARE www.improvement.nhs.uk Further details relating to the information and case studies in this publication are available on our website at www.improvement.nhs.uk/cancer/inpatients
  • 47. NHSCANCER NHS ImprovementDIAGNOSTICSHEARTLUNGSTROKE NHS Improvement With over ten years practical service improvement experience in cancer, diagnostics and heart, NHS Improvement aims to achieve sustainable effective pathways and systems, share improvement resources and learning, increase impact and ensure value for money to improve the efficiency and quality of NHS services. Working with clinical networks and NHS organisations across England, NHS Improvement helps to transform, deliver and build sustainable improvements across the entire pathway of care in cancer, diagnostics, heart, lung and stroke services. 3rd Floor | St John’s House | East Street | Leicester | LE1 6NB Telephone: 0116 222 5184 | Fax: 0116 222 5101 www.improvement.nhs.uk ©NHS Improvement 2010 | All Rights Reserved | July 2010 Delivering tomorrow’s improvement agenda for the NHS

×