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The winning principles - transforming inpatient care programme for cancer patients
The winning principles - transforming inpatient care programme for cancer patients
The winning principles - transforming inpatient care programme for cancer patients
The winning principles - transforming inpatient care programme for cancer patients
The winning principles - transforming inpatient care programme for cancer patients
The winning principles - transforming inpatient care programme for cancer patients
The winning principles - transforming inpatient care programme for cancer patients
The winning principles - transforming inpatient care programme for cancer patients
The winning principles - transforming inpatient care programme for cancer patients
The winning principles - transforming inpatient care programme for cancer patients
The winning principles - transforming inpatient care programme for cancer patients
The winning principles - transforming inpatient care programme for cancer patients
The winning principles - transforming inpatient care programme for cancer patients
The winning principles - transforming inpatient care programme for cancer patients
The winning principles - transforming inpatient care programme for cancer patients
The winning principles - transforming inpatient care programme for cancer patients
The winning principles - transforming inpatient care programme for cancer patients
The winning principles - transforming inpatient care programme for cancer patients
The winning principles - transforming inpatient care programme for cancer patients
The winning principles - transforming inpatient care programme for cancer patients
The winning principles - transforming inpatient care programme for cancer patients
The winning principles - transforming inpatient care programme for cancer patients
The winning principles - transforming inpatient care programme for cancer patients
The winning principles - transforming inpatient care programme for cancer patients
The winning principles - transforming inpatient care programme for cancer patients
The winning principles - transforming inpatient care programme for cancer patients
The winning principles - transforming inpatient care programme for cancer patients
The winning principles - transforming inpatient care programme for cancer patients
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The winning principles - transforming inpatient care programme for cancer patients

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The Winning Principles- Transforming Inpatient Care Programme for Cancer Patients. (July 2008) By bringing together all the test sites experience and learning, FOUR WINNING PRINCIPLES have been …

The Winning Principles- Transforming Inpatient Care Programme for Cancer Patients. (July 2008) By bringing together all the test sites experience and learning, FOUR WINNING PRINCIPLES have been identified that if applied can make a significant difference to the management and experience of the inpatient pathway.

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  • 1. NHS NHS Improvement Assessment prior to admission Defined inpatient pathwaysDaily decision making Transforming Inpatient Care Programme for Cancer Patients The Winning PrinciplesEncourage self management
  • 2. Transforming Inpatient Care Programme for Cancer Patients - The Winning Principles 3ContentsForeword 4Acknowledgements 5Introduction 6Winning Principle 1: Unscheduled (emergency) patients should be 7assessed prior to the decision to admit - emergency admission shouldbe the exception not the normWinning Principle 2: All patients should be on a defined inpatient 12pathway based on their tumour type and reasons for admissionWinning Principle 3: Clinical decisions should be made on a daily 18basis to promote proactive case managementWinning Principle 4: Patient and carers need to know about their 22condition and symptoms to encourage self-management, choice andto know who, where and what to access first timeTest Sites 26Case Studies CD-Rom 27 www.improvement.nhs.uk/cancer
  • 3. 4 Transforming Inpatient Care Programme for Cancer Patients - The Winning Principles Foreword Inpatient care for patients with cancer The four approaches set out here are based accounts for around 12% of all inpatient bed on the actual experiences of local NHS days and for more than half of the total hospitals caring for their cancer patients. The expenditure on cancer in England. work of NHS Improvement and the pilot sites Furthermore, inpatient admissions for cancer as summarised here clearly shows how have risen by around 25% in the past eight different approaches to inpatient cancer care years with emergency admissions rising by can deliver major improvements, and make a nearly 50%. A large proportion of these real and positive difference to patients’ emergency admissions are managed by experience of inpatient care. physicians in general medicine or geriatricians. The case studies in this publication serve as Over the past 18 months the Cancer Services excellent examples for other NHS trusts as Collaborative ‘Improvement Partnership’ (now they consider how they can improve delivery part of NHS Improvement) and the Cancer of inpatient care to ensure their patients have Action Team have been looking at ways to access to the best cancer care. avoid unnecessary admissions and to reduce length of stay. It has become very clear that major improvements can be made, with Ann Keen benefits both for patients and for the NHS. Parliamentary Under Secretary of State for Health Services Some of the approaches to streamlining inpatient care pathways that have been tested by trusts across the country are set out in this ‘Winning Principles’ report. I strongly commend these approaches to commissioners and to service providers. The task now is to ensure that the Winning Principles are embedded across the NHS. Mike Richards National Cancer Directorwww.improvement.nhs.uk/cancer
  • 4. Transforming Inpatient Care Programme for Cancer Patients - The Winning Principles 5AcknowledgementNHS Improvement would like to thank allthe test sites for their support and input intothis challenging area of work. Theircontribution and co-operation identified thehuge potential for improving the cancerinpatient pathway and also identified thatthe task is not always easy.Many of the sites are continuing to take thiswork further into implementation and sharetheir learning both nationally and locallythrough the cancer networks. www.improvement.nhs.uk/cancer
  • 5. 6 Transforming Inpatient Care Programme for Cancer Patients - The Winning Principles Introduction One of the major commitments in the Cancer By bringing together all the test sites experience Reform Strategy is to shift care from an inpatient and learning, FOUR WINNING PRINCIPLES to an ambulatory care setting. Pilot schemes have been identified that if applied can make a have shown that there is considerable potential significant difference to the management and to avoid unnecessary emergency admissions and experience of the inpatient pathway. to reduce lengths of stay, both for elective and emergency admissions. Making this happen will 1. Unscheduled (emergency) be a major task for cancer networks, PCTs and patients should be assessed acute trusts. Assessment prior to the decision to admit. prior to admission Emergency admission should This document provides a summary of the be the exception not the norm. learning drawn from pilot sites across England and aims to support the organisations that are embarking on this challenging task and provides 2. All patients should be on a a basis upon which the cancer inpatient defined inpatient pathways programme (Cancer Reform Strategy 2007) can Defined based on their tumour type build upon. inpatient pathways and reasons for admission. The Transforming Inpatient Care Programme is the next stage. This will be supported by NHS 3. Clinical decisions should Improvement, the Cancer Action Team along be made on a daily basis with key organisations, charities and professional to promote proactive bodies. This new and exciting work will include Daily decision making case management. further testing and spreading of new models of care in primary and secondary care settings, focusing on shifting care into the community 4. Patient and carers need to where appropriate and learning to transform know about their condition inpatient care for cancer patients. and symptoms to encourage Encourage self management self-management and to know All test sites included in this document, working who to contact when needed. in collaboration with NHS Improvement (CSC’IP’) have tried and tested different approaches in order to reduce length of stay, avert unnecessary Detailed case studies of the testing work to date admissions, shift care to appropriate care can be found on the accompanying CD and on settings, provide value for money, efficiency and www.improvement.nhs.uk. This is ongoing work most importantly value the patient’s time and and will be updated as further learning emerges experience. from the testing, spreading and implementation.www.improvement.nhs.uk/cancer
  • 6. Transforming Inpatient Care Programme for Cancer Patients - The Winning Principles 7 Assessment prior to admissionWinning Principle 1Unscheduled (emergency)patients should beassessed prior to thedecision to admit -emergency admissionshould be the exceptionnot the norm www.improvement.nhs.uk/cancer
  • 7. 8 Transforming Inpatient Care Programme for Cancer Patients - The Winning Principles Unscheduled (emergency) patients should be assessed prior to the decision to admit. Emergency admission should be the exception not the norm. Different approaches have been tried and tested that have successfully supported the above R - Right care principles and realised the following benefits: A - A friendly face • Aversion of inappropriate/unnecessary emergency admissions. P - Patient satisfaction • Improved clinical decision making and assessment A - Appropriate place • Proactive length of stay management. • Getting the patient onto the right pathway first time. • Reductions in length of stay and re-admissions United Lincolnshire Hospitals NHS Trust • Enabling improvements in supporting patient Tested the transferability of the Recurring choice and preferred place of care. Admissions Patient Alerts approach in urology (180 patients) and upper GI (77patients) for Sherwood Forest Hospitals emergency readmissions and reduced length of NHS Foundation Trust stay by three days per patient in urology and Reduced length of stay by 25% for lung cancer two days per patient in upper GI. patients by developing and testing a Recurring Admission Patient Alert System (RAPA), and Analysis of the emergency admissions showed identified the potential of releasing 560 bed that for urology 50% presented during working days per annum. The success of this approach hours and 50% outside. For upper GI 64% has now been implemented across the whole presented out of hours and 36% during. This hospital and won the 2007 Medical Innovation has led to the next stage of testing to prevent Futures Award. emergency admissions involving one out of hours pathway for cancer patients with one ‘ single point of access. RAPA is a simple Further analysis of urology emergency communication solution admissions identified a high number of referrals to A&E for acute urine retention and an that ensures that everyone undefined patient pathway for follow up care. knows their patient is there. Working in collaboration with primary care, a primary care pathway for patients with acute It has worked successfully urinary retention has been developed and is at in cancer for known and the early stages of testing. unknown patients and now the idea is used across ’ other specialities. Jeffrey Worrell Chief Executive, Sherwood Forest NHS Foundation Trustwww.improvement.nhs.uk/cancer
  • 8. Transforming Inpatient Care Programme for Cancer Patients - The Winning Principles 9Stage 1 Testing: Primary care pathway for male patientswith acute urine retention tested in LincolnStage 2 Testing: Primary care pathway forpatients with acute urine retention www.improvement.nhs.uk/cancer
  • 9. 10 Transforming Inpatient Care Programme for Cancer Patients - The Winning Principles ‘ The acute urinary retention pathway promotes partnership working to provide a seamless University Hospitals of Morecambe Bay NHS Trust Tested in collaboration with primary care and the ambulance service an emergency care pathway for palliative patients following a baseline review service for patients. It aims that identified 23 patients out of 30 admissions may have been avoided, potentially releasing to move care to a more £93,778 funding to deliver care in the home appropriate setting and avert environment. unnecessary admissions. It The Christie Hospital NHS Foundation Trust and Manchester Primary Care Trust also aims to improve quality The baseline showed that 78% of hospital ’ and safety. deaths were emergency admissions. This led to testing the potential of an alert system and Mr Nazeer Dahar protocols focusing on supporting the dying Lead Cancer Clinician patient and identifying preferred priorities for United Lincolnshire Hospitals NHS Trust care. During three months testing 76 bed days were saved, 22 admissions averted and 69% of ‘ patients died in their preferred place of care. The acute urinary retention Manchester Primary Care Trust pathway will ensure Nurse led walk-in centre, early intervention to accessibility to a service that prevent admission crisis. Nurse-led walk-in centres across the UK have played a crucial role is delivered closer to the in appropriately streaming patients to primary care, alleviating the pressure on the A&E four- patient’s home. It will ensure hour wait target and developing the skills of safe care is provided outside nurses. of the hospital setting with Barts and the London NHS Trust access to acute services when Averted 50% of cancer emergency inpatients admissions per week and reduced length of stay necessary. This is the first from 18.1 days to 13 days by testing an emergency pathway for cancer patients involving stage in testing the impact of early oncology decision making at A&E. This moving particular clinical testing is ongoing and working in collaboration with Tower Hamlets PCT to identify further services from acute care to testing earlier in the emergency pathway. primary care. Mrs Sarah Furley Cancer & Palliative Care Planning Manager Lincolnshire County Teaching Primary Care Trustwww.improvement.nhs.uk/cancer
  • 10. Transforming Inpatient Care Programme for Cancer Patients - The Winning Principles 11The Hillingdon Hospital NHS TrustThe development of a palliative care patientpathway for acute admissions. Proposed provsional palliative care patient pathway for acute cancer admissions to the Hillingdon Hospital NHS TrustAimTo optimise appropriateness of admissions, placeof admissions, management and length of stay. www.improvement.nhs.uk/cancer
  • 11. 12 Transforming Inpatient Care Programme for Cancer Patients - The Winning Principles Defined inpatient pathways Winning Principle 2 All patients should be on a defined inpatient pathway based on their tumour type and reasons for admissionwww.improvement.nhs.uk/cancer
  • 12. Transforming Inpatient Care Programme for Cancer Patients - The Winning Principles 13 All patients should be on a defined inpatient pathway based on their tumour type and reasons for admission Benefits • Promotes length of stay management in contrast to bed management • Values patient’s time and sets patient expectations ‘ This new early discharge pathway enhances recovery time, as patients recover at • Effective and efficient use of bed capacity home in their own • Reduces length of stay to match the appropriate stay required for treatment and environment. All of the care patients have been satisfied • Shifts care to alternative appropriate care ’ settings with the pathway. • Supports changes in clinical practice and clinical decision making Luna Vishwanath • Reduction in the duplication of tests Breast Consultant, Sandwell & • Reduction of inappropriate diagnostic tests. West Birmingham Hospital NHS Trust Breast Heart of England NHS Foundation Trust Reduce length of stay for breast patients from 2.6 days to 1.7 days by streamlining the elective Sandwell & West Birmingham breast pathway and drain insertion becoming Hospital NHS Trust the exception rather than the norm. This Reduced length of stay for breast patient’s potentially can release 849 bed days per year for (including mastectomy patients) from 6.6 days to the trust. The long term aim is to achieve 80% 23 hours. Approximately 300 patients a year of breast cancer patients to be admitted under will benefit. All breast patients are now treated the 23 hour model of care and have no drains in the treatment centre. Changes in clinical with no increase in seroma rates. practice have supported this with robust pre- operative screening and wound drains are not University Hospital Birmingham NHS inserted. Current medical audit of this has Foundation Trust shown a reduction in hospital acquired infection Reduced length of stay from 4.6 days to an and patient’s satisfaction with this new model of average of 12-23 hours. Testing included a no care has been very positive. wound drain policy without adverse event. This‘ proved to be successful and is now offered to all suitable patients. There has been no The 23 hour stay was readmissions and patient satisfaction is high. universally popular with This practice is now being embedded. patients from all ’ backgrounds. If the 23 hour model for breast care was spread across the West Midlands SHA and all breast providers reduced length Hamish Brown of stay to 1.9 day average, this could Breast Consultant, Sandwell & have the potential of releasing 14,396 West Birmingham Hospital NHS Trust bed days per annum (10.5%). www.improvement.nhs.uk/cancer
  • 13. 14 Transforming Inpatient Care Programme for Cancer Patients - The Winning Principles Colorectal Queen Mary’s Sidcup NHS Trust Baseline of the traditional pathway identified that the average total length of stay was 21.3 ‘ The biggest challenge to introducing enhanced recovery to our team was days. Length of stay from the date of surgery for trying to change their deeply colorectal patients was found to be 16.6 days held ideas about patient and the average stay in the intensive care unit was 6.3 days. Readmission rate (within four recovery. The Cancer Services weeks) was found to be 11.6%. Testing of an integrated care pathway supporting enhanced Collaborative ‘Improvement recovery after surgery for colorectal patients Partnership’ brought with reduced the length of stay to 8.2 days average. Readmission rates have remained stable. them energy, vigour and a Sandwell & West Birmingham motivating influence which Hospital NHS Trust was instrumental in changing ’ Patients undergoing major colorectal surgery were experiencing long variable lengths of stay. the culture of our team. Testing the principles of enhanced recovery in colorectal identified that length of stay could be Satish Bhalerao reduced significantly. Consultant, Sandwell & West Birmingham Hospital NHS Trust Procedure Baseline LOS Test Pathway (average) Colectomy 16 days 6 days Colostomy 12 days 5 days formation Colostomy 12 days 2 days closurewww.improvement.nhs.uk/cancer
  • 14. Transforming Inpatient Care Programme for Cancer Patients - The Winning Principles 15NeurologyNorth London Cancer Network, TheNational Hospital and Norwich ParkHospitalSince its inception in February 2008 this projecthas succeeded in significantly reducing thepre-admission and post operative repatriationand discharge waiting times. In total, the timetaken from referral to repatriation - the entirecare pathway has been reduced by a mean of76% (60% reduction for pre-admission wait and84% for repatriation). This has been achievedby agreeing the length of stay and confirmingdischarge dates prior to transfer. The patientsare tracked through a trigger pathway thatcommences at the time of referral. Mean Wait No. of Pilot Mean Wait Days Saved Reduction Baseline Patients Pilot % Referral to 2.5 21 1.1 1.4 56.4 Admission Awaiting 5.5 14 0.8 4.7 85.6 Discharge Total 8 1.9 6.1 76.5This testing clearly demonstrated the need forhospitals to improve their collaboration andcommunication when transferring patients fortreatment. As a result of this work the NationalHospital for Neurology and Neuro-surgery isimplementing the strategy as a Service LevelAgreement (SLA) with all tertiary referringhospitals. www.improvement.nhs.uk/cancer
  • 15. 16 Transforming Inpatient Care Programme for Cancer Patients - The Winning Principles Shifting procedures from inpatient to day case Barking, Havering and Redbridge The diagram below shows a diary comparing the Hospitals NHS Trust same patient admitted for intravenous Analysis showed that 65% of inpatient referrals antibiotics to the haematology oncology ward in for tests and procedures came from the April 2007 (baseline data) compared to day unit consultant outpatient clinics. Many patients bed in May 2007 testing period. spent hours waiting for procedures to be carried out. Patients having a computerised tomography (CT) guided biopsy waited on average four days for the test to be performed and a further day to be discharged. The trusts aim was to avert inpatient admissions for procedures for all tumour groups by 50%. The outcome of testing indicated improved inpatient bed utilisation by 80% by identifying the procedures that could be conducted as a day case as timed procedures. Testing results suggest: • Inpatient admission avoidance for 80% of patients • Access to specialist nurse advice during assessment/treatments • Enhanced continuity of care. Inpatient assessment bed hours compared to outpatient assessment bed hourswww.improvement.nhs.uk/cancer
  • 16. Transforming Inpatient Care Programme for Cancer Patients - The Winning Principles 17Carcinoma of Unknown Primary:Inpatient Pathways (Elective andEmergency)St Helens & Knowsley Hospitals NHS Trust ‘ Early assessment by specialist services is essential if further progress is to be made in thisA retrospective audit covering a 15 month often complex area ofperiod showed delays in referral to appropriatespecialists, inappropriate lengths of stay, lack of diagnosis and management.coordination and inappropriate investigations All cases of suspected cancerwith poor understanding of results andmanagement. should be referred at theA joint Unknown Pathway was tested that earliest opportunity andinvolved a multidisciplinary approach, radiology before extensive and oftenalerts and improved clinical decision making ’within 24 hours of referral. unhelpful investigation.The impact of this approach has resulted in a Ernie Marshallreduction in unecessary investigations and Macmillan Consultant in Medical Oncologyreduction in length of stay by 20%. Test Period Pathway www.improvement.nhs.uk/cancer
  • 17. 18 Transforming Inpatient Care Programme for Cancer Patients - The Winning Principles Daily decision making Winning Principle 3 Clinical decisions should be made on a daily basis to promote proactive case managementwww.improvement.nhs.uk/cancer
  • 18. Transforming Inpatient Care Programme for Cancer Patients - The Winning Principles 19Clinical decisions should be made on a daily basis topromote proactive case managementBenefits Total length of stay• Reduction in length of stay• Proactive clinical decision making• Effective use of bed capacity• Valuing patient’s time• Enhance clinical governance and risk management.Royal Berkshire NHS Foundation TrustBaseline of emergency admission comparingtime from admission to being seen by a doctorhighlighted a significant difference betweenhaematology and oncology.Time of admission to first seen by Average length of stay Haematology = 88hoursoncologlist (range 72-120hours) Average length of stay Oncology = 185 hours (range 72-360 hours) Operating a haematologist of the week system, where by a consultant is freed from clinical commitments in order to carry out daily ward- rounds significantly reduces length of stay. Building upon the same concept different models have been tested in oncology and further work is underway, early indication is that the medical consultant model as used in haematology offers potentially more benefit. ‘Average time for Haematology = 23hours(range 12 to 46)Average time for Oncology = 41 hours Ensuring that patients with(range 1-72) cancer are reviewed by an appropriate specialist on a daily basis is an important step in improving the quality and efficiency of the care we ’ offer to our patients. Dr Jane Barrett Consultant, Royal Berkshire NHS Foundation Trust www.improvement.nhs.uk/cancer
  • 19. 20 Transforming Inpatient Care Programme for Cancer Patients - The Winning Principles Milton Keynes Hospital NHS Foundation Trust Tested the following hypothesis: Can the referral of patients with new or suspected cancer disease recurrence to an advanced nurse practitioner at the point of emergency admission reduce length of stay for these patients? The real problem identified was that patients were being admitted through various emergency routes resulting in poor co-ordination, communication and decision-making. Early intervention by an advanced nurse practitioner (ANP) at the point of entry resulted in a reduction in the length of stay (baseline 23.8 days to eight days). The ANP also provided added value to the patient’s journey and experience by reducing repeated tests, administrative duplication and a central point of contact. A number of initiatives as resulted from this work including the development of a supportive care integrated pathway for all (cancer and non cancer) emergency palliative care patients. Milton Keynes Supportive Care Integrated Pathway (MKSCIP) Patient is referred to the trust and is assessed by the Advanced Nurse Practitioner and referred into the most appropriate stage of the MKSCIP, based on clinical complexity and patient consent using a combination of assessment approaches. Stage 1 Stage 2 Stage 3 Stage 4 New/suspected Confirmed disease Palliative Care Liverpool Care disease recurrence recurrence with Pathway complications/ exacerbationwww.improvement.nhs.uk/cancer
  • 20. Transforming Inpatient Care Programme for Cancer Patients - The Winning Principles 21Brighton & Sussex UniversityHospitals NHS TrustThis testing site became one of the winners ofthe 2008 South East Coast Best of HealthWinners in the improving access category for re-designing, developing and instigated a new styleadmissions policy balancing the needs ofemergency and elective patients, by improvingclinical decision, the better utilisation of bedsand management of length of stay. Area of Performance Baseline Results of Testing % of all elective patients admitted 50% 81% on their original planned date Actual length of stay compared 29% exceeded planned 5% exceeded discharge with required/anticipated discharge date date % of priority elective (new primary 64% 93% curative) patients admitted on original planned dateThe results indicate a significant improvementin the management of elective stays. Withapproximately 500 elective admissions per yearat the same level of improvement this has thepotential of releasing up to 250 bed days. ‘ We are absolutely delighted the implementation of our timely clinical decision makingThree key improvements have led to this strategies made such ansuccess. impact. It certainly made the• Developing an admissions priority table most efficient use of staff• Daily ‘paper ward rounds’• Weekly inpatient review meetings. time, but also undoubtedlyThe pleasing aspect of this work is that the improved the experience for ’improvements have been implemented the patient.seamlessly into ‘business as usual’ and they arenow accepted working practice. The next stage Angus Robinsonof this work is to investigate the emergency Consultant Oncologistpathway and the use of RAPA alert systemswhich has been successfully tested atSherwood Forest NHS Foundation Trust. www.improvement.nhs.uk/cancer
  • 21. 22 Transforming Inpatient Care Programme for Cancer Patients - The Winning Principles Encourage self management Winning Principle 4 Patient and carers need to know about their condition and symptoms to encourage self-management, choice and to know who, where and what to access first timewww.improvement.nhs.uk/cancer
  • 22. Transforming Inpatient Care Programme for Cancer Patients - The Winning Principles 23Patient and carers need to know about their condition and symptoms toencourage self-management, choice and to know who, where and whatto access first time.The above principle was identified by Hull and East Yorkshire Hospitals NHS Trustpatients and carers drawing upon their Palliative care rapid response clinics avoided 63experiences, advice and requirements inpatient admissions, released 208 Bed days during the testing period and reduced length ofBenefits stay from 23.7 days – to average 7.7 days an• Reduced emergency admission and average saving per patient of 26 days. length of stay• Enhanced patient choice, awareness and Northampton General Hospital NHS Trust self-management. Tested the impact on length of stay for• Increase patient confidence in own emergency lung patients by taking a staged decision making approach that include:• Right pathway, right person, first time• Identified symptom pathways enhancing • A strategy for the non-pharmacological proactive prevention and care. management of breathlessness in the community with the aim of empoweringBlackpool, Fylde and Wyre Hospitals patients and carers to manage their symptomsNHS Foundation Trust at home where appropriate. Working inTested multiple approaches involving patients collaboration with the PCT using agreedand clinicians to reduce mortality and length of criteria for assessment unnecessary admissionsstay through developing an emergency pathway have been avoided.for the management of emergency patients with • Alert system for reducing emergency lungneutropenic sepsis (see diagram on opposite cancer patients.page). Winner of the 2007 Blackpool, Fylde andWyre Innovation Award. Applying the principle of a communication alert system for known lung patients reduced lengthSwindon and Marlborough NHS Trust of stay from 12.5 average to 9.7 days.Base lining identified that only 36% of patientswere treated with IV antibiotics within the firsthour of admission for neutropenic sepsis. Duringtesting, 78% were given Tazocin within onehour and 60% of those patients confirmedneutropenic were given Gentamicin within twohours.East Sussex Hospitals NHS TrustInpatient paracentesis length of stay rangedfrom one to six days, testing involved carryingout the paracentesis procedure in the hospiceenvironment. This testing proved to besuccessful in enhancing patient choice, preferredplace of care and avoiding unnecessaryadmissions.Further areas are being now explored includingParacentesis in radiology outpatients. www.improvement.nhs.uk/cancer
  • 23. 24 Transforming Inpatient Care Programme for Cancer Patients - The Winning Principles Blackpool, Fylde and Wyre Hospitals NHS NHS Foundation Trust Neutopenic Sepsis - Reduce mortality - Reduce length of stay (LOS) Late emergency Aim Tested solutions Impact presentation Improve patient Promote self management and Cancer Partnership Group awareness/promote confidence in the system undergoing audit of patient High risk of early presentation, views - positive feedback mortality self management and • Patient held alert card patient’s confidence • 24 hour help line Divisional audit on • Patient experience DVD neutropenic sepsis to Save lives created by patients for patients include presentation times Multiple Aim Tested solutions Impact emergency access Right place, first time • One entry point 100% admitted went to points • Direct admission to ward designated ward Improve patient, • Awareness campaign to GPs Only 42% of primary and secondary • Press release patients go to the care awareness • Direct admission policy right place first • Neutropenic sepsis time management policy Delay in Aim Tested solutions Impact treatment Improve door to • Patient group directive for 55% of patient’s received treatment time for antibiotics given at point antibiotics within an hour Only 8% of 100% of patients of entry by nurse of arrival admissions received antibiotics within • No deaths an hour of admission The approach to improving the emergency pathway for patients with Neutropenic Sepsis is underpinned by an agreed Neutropenic Sepsis Management Policy, listening and using the views of our patients. This DVD is a good idea verbal information and leaflets donít really sink in because it is such a difficult time. You can’t take it all in itís a bit to much, but I think the DVD will stick in peoples minds. Husband of a patient Thanks for the DVD which I found very powerful. Every patient on chemo should have a copy. Diana’s statement that ‘I didn’t want to be any trouble, because they are so busy’ rang very true to me and it could have been my late wife speaking. Husband of a patient I do think it is important that itís patients that feature on the DVD. I thought I knew better and didn’t follow all the written advice but that’s what patients need to do. Patient The patient’s stories in the DVD are very powerful and makes much more impact on other patients and carers understanding of the importance of presenting early. Lead cancer nursewww.improvement.nhs.uk/cancer
  • 24. Transforming Inpatient Care Programme for Cancer Patients - The Winning Principles 25Further case studies, details and examples of Would you like to become involvedthe tools used and lessons learned can be in this work?found in the detailed case studies foundon the accompanying CD or at: For further information contact:www.improvement.nhs.uk Ann DriverThis is ongoing work and all the studies are Director, NHS Improvement.reflecting the learning and stage of testing to Email: ann.driver@improvement.nhs.ukdate. Angie Robinson National Improvement Lead 1. Unscheduled (emergency) Email: angie.robinson@improvement.nhs.uk patients should be assessed Assessment prior to the decision to admit. prior to admission Emergency admission should be the exception not the norm. www.improvement.nhs.uk 2. All patients should be on a defined inpatient pathways Defined based on their tumour type inpatient pathways and reasons for admission. 3. Clinical decisions should be made on a daily basis to promote proactive Daily decision making case management. 4. Patient and carers need to know about their condition and symptoms to encourage Encourage self management self-management and to know who to contact when needed. www.improvement.nhs.uk/cancer
  • 25. 26 Transforming Inpatient Care Programme for Cancer Patients - The Winning Principles Assessment Defined prior to inpatient Daily decision Encourage self admission pathways making managementWinning Principle 1 Winning Principle 2 Winning Principle 3 Winning Principle 4Sherwood Forest Hospitals Sandwell & West Royal Berkshire NHS Blackpool, Fylde andNHS Foundation Trust Birmingham Hospital Foundation Trust Wyre Hospitals NHS NHS Trust (Breast) Foundation TrustUnited Lincolnshire Hospitals Milton Keynes HospitalNHS Trust Heart of England NHS NHS Foundation Trust Swindon and Foundation Trust Marlborough NHS TrustUniversity Hospitals of Brighton & SussexMorecambe Bay NHS Trust University Hospital University Hospitals East Sussex Hospitals Birmingham NHS NHS Trust NHS TrustThe Christie Hospital NHS Foundation TrustFoundation Trust Hull and East Yorkshire Queen Mary’s Sidcup Hospitals NHS TrustManchester Primary Care NHS TrustTrust Northampton General Sandwell & West Hospital NHS TrustBarts and the London NHS Birmingham HospitalTrust & Tower Hamlets PCT NHS Trust (Colorectal)Nottinghamshire County North London CancerTeaching Primary Care Trust Network, The National Hospital and Norwich ParkOxford Radcliffe Hospitals HospitalNHS Trust Barking, Havering andUnited Lincolnshire Hospitals Redbridge HospitalsNHS Trusts/Lincolnshire NHS TrustCounty Teaching PrimaryCare Trust, Sherwood Forest St Helens & KnowsleyHospitals NHS Foundation Hospitals NHS TrustTrust and NottinghamshireCounty Teaching Primary Kings College Hospital NHSCare Trust (New ways of Foundation Trust*working with theAmbulance Service to avert Scarborough and Northadmissions) East Yorkshire Healthcare NHS Trust*Sherwood Forest HospitalsNHS Foundation Trust St Mark’s Hospital*(Management of UnknownPrimary) Queen Elizabeth The Queen Mother Hospital, Margate,Whipps Cross University Kent*Hospital NHS Trust Aptium - Focus onThe Hillingdon Hospital Oncology and HaematologyNHS Trust Wards** These trusts were not part of the testing work, but provided evidenceof good practice that supported and advised the areas of testing.www.improvement.nhs.uk/cancer www.improvement.nhs.uk/cancer
  • 26. NHS NHS ImprovementCANCERDIAGNOSTICSHEARTSTROKE NHS Improvement Formed in April 2008, NHS Improvement brings together the Cancer Services Collaborative ‘Improvement Partnership’, Diagnostics Service Improvement, NHS Heart Improvement Programme and Stroke Improvement into one improvement programme. With over eight 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 and stroke services. NHS Improvement 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 2008 | All Rights Reserved Publication Ref: IMP/cancer0001

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