Making Best Use of Inpatient Beds Project - National Priority Projects 07/08 Summary Document


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Making Best Use of Inpatient Beds Project - National Priority Projects 07/08 Summary Document
This summary document include descriptions, supporting information and key learning from the project. Details of each project site are available in the summary document, and are linked to the priority project online resource – an interactive tool that shares the learning across all project areas (Published June 2008).

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Making Best Use of Inpatient Beds Project - National Priority Projects 07/08 Summary Document

  1. 1. NHS NHS ImprovementCANCERDIAGNOSTICS Heart ImprovementHEART Making Best UseSTROKE of Inpatient Beds National Priority Project
  2. 2. Making Best Use of Inpatient Beds is a national priority project of the Heart ImprovementProgramme focusing on a variety of approaches to reducing avoidable inpatient bed days.The project ran over the period June 2007 to March 2008.Key learning from the project is available in the following formats:1. Project summaryThis document includes a description of the national project, supporting informationgained throughout the period and key learning from the project.Project summaries include issues to address, actions taken and key outcomes from eachof the 12 projects participating in this work.Contact details are included to provide additional information with regular updatesavailable on the website.2. Presentations at National Conference 8 May 2008Copies of presentations from the speakers at the conference are available on the Web based resourcesProject team members found this a very useful opportunity to share learning across thedifferent project areas. These are now available to share on the improvement website are categorised into four chapters:1. Admission avoidance and timely readmission2. Improving inpatient stay3. Hospital/community interface4. End of Life CareContent includes:• Case studies and improvement stories• Protocols, procedures• Operational policies• Job descriptions• Business cases• Vox pops and video clipsAdditional information will be included as it becomes available and existing materialsregularly updated.Further information and updates email:
  3. 3. Making Best Use of Inpatient Beds 3ContentsIntroduction 4Key Findings 6Project Summaries 11Plymouth Clinical Assessment Service (PCAS) 12Heart Failure - Rotherham 13Central Manchester Left Ventricular Systolic Dysfunction 15Project in Primary CareWest Hertfordshire Brain Natriuretic Peptides (BNP) in 17Secondary Care ProjectReducing Length of Inpatient Stay for Myocardial Infarction 18and Acute Coronary Syndrome Patients - LancashireCardiac Surgery Inter-hospital Transfer Project - North West London 20Continuing Development of Cardiac Services in North Bristol 21NHS Trust – Southmead Hospital and Frenchay HospitalReducing Non-elective Arrhythmia Inter-hospital Transfer Waits Through 22the Implementation of an Internet-based Referral and TransferManagement System - North Central LondonHeart Failure Early Discharge - North West London 24Reducing Avoidable Hospital Admissions by Providing Community 26Support for Patients Referred Through the Single Contact AccessNomination (SCAN) - SheffieldIntegrated Heart Failure Service Across All Organisational 27Boundaries - SurreyMaking Best Use of Inpatient Beds - Sussex 28Project Teams and Participating Sites 29
  4. 4. 4 Making Best Use of Inpatient Beds Introduction Admission to hospital is essential for To improve health outcomes for patients requiring surgery, some invasive investigations and stabilisation of medical conditions. Following on from the work on interhospital transfers1 there are still some patients waiting for unnecessarily long ? people with long-term conditions by March 2008 offering a personalised care plan for the most at risk vulnerable people; and to reduce overall emergency periods as an inpatient for surgery and bed days by 5% by 2008, electrophysiological procedures. This is both through improved care clinically suboptimal for the patients and in primary care and community inefficient in terms of avoidable bed days. settings for people with Waiting unnecessarily long periods for long-term conditions. inpatient procedures and regular admissions to hospital can be demoralising and stressful for patients, their families and the staff who care for them. PSA12a3: Emergency bed days The NHS Heart Improvement Programme ? established a national project to work The recent NICE Commissioning Guide with a number of local project teams. highlights evidence to support effective multidisciplinary specialist services for The aims of this work were: people with chronic heart failure. These can have a positive effect on patients’ life • To reduce the number of avoidable expectancy and quality of life and help to emergency bed days reduce recurrent hospital stays by 30–50%2. • To reduce overall length of stay The Operating Framework requires • To develop alternative models organisations to reduce these avoidable bed of care. days by putting systems in place to support Twelve projects across the country took people with long term conditions in the part in this work and from the outset we community. recognised that many of the issues were complex and that there was no single solution. 1 Making moves Heart Improvement Programme April 2006 2 Commissioning a heart failure service for the management of chronic heart failure 3 Operating Framework 2007/
  5. 5. Making Best Use of Inpatient Beds 5The areas of work broadly divided into thefollowing:• Prevention of admissions by improved detection and management in the community• Redesign of the inpatient pathway• Reduction in the frequency and urgency of readmissions• End of life care.
  6. 6. 6 Making Best Use of Inpatient Beds Key
  7. 7. Making Best Use of Inpatient Beds 7Key FindingsAll 12 projects had very different approaches to Inter-hospital transfersmaking best use of inpatient beds and, as such, • Treat and return policy implementation led towere able to look at a variety of ways to achieve a reduction of an average by eight days staytheir results. The three areas addressed can for ACS patients awaiting angiographybroadly be defined as cardiology services, heart • Prioritisation and risk stratification agreementfailure services and inter-hospital transfers. The reached for targets that form part of thefindings include:- commissioning framework with a resultant reduction in mean length of stay admission toCardiology services surgical transfer of 3.3 days per patient, and• GPSI triage of cardiology referrals to effectively from work-up to surgical transfer of 7.25 per manage patients led to a 66% reduction in patient the referrals requiring cardiologist input in • Implementation of a web-based transfer secondary care management system for electrophysiology• Diagnostic testing performed and reported on patients showed a 55% reduction in total days in less than ten working days using ‘Choose & waiting from the baseline. Book’• Transferring services from two hospitals to one Challenges led to an average reduction in length of stay This work started in June 2007 and was (LoS) for myocardial infarction (MI) and acute ambitious from the outset. Below are some of coronary syndrome (ACS) patients of four the key challenges: days. • The complexity of the issues presenting atHeart failure services local level required good information to• BNP testing used to rule out heart failure understand fully the issues that face service reduced inappropriate medication and providers. Robust systems of data collection requests for echo tests. Referral to and analysis were required and the initiation cardiologists dropped by 30% of such systems was slower than originally• BNP testing increased the percentage of anticipated. people discharged from hospital with a • A variety of approaches to patient experience diagnosis of heart failure confirmed by echo across the projects included surveys, patient from 22% to 75% diaries and discovery interviews. The uptake of• Electronic reporting of results reduced various methods was encouraging; however duplication of tests achieving meaningful patient involvement• Re-configuration of services enabled a continues to provide a challenge and will be a reduction of heart failure admissions from 65 key element of future work. to 21 per month and reduced length of stay • Demonstrating return on investment at a time from 8.59 days to 4.5 days of early implementation of payment by results• An audit indicated that optimal prescribing and development of the Improvement System and titration of beta blockers could reduce gives added impetus to ensure that baseline admissions by 142 per year. This equates to a data and methods of data collection and 16% reduction. The guidelines have been analysis are in place at the time of project circulated to all GPs in one PCT inception. The nine month timeline• A whole system integrated approach to heart attributable to the projects has largely been failure cut admissions by more than 50% able to go some way to highlight and deliver for people with heart failure in primary return on investment and it is anticipated diagnosis position. The length of stay reduced that this will gain momentum in future by four days from 11 to seven, which months and years. represents a nearly 40% decrease and a 20% • Re-configuration at local level proved reduction in the number of days waiting for challenging at times with competing agendas. echo.
  8. 8. 8 Making Best Use of Inpatient Beds Return on Investment (ROI) The indicative savings shown may accrue to a The development of NHS tariffs is ongoing and hospital provider but are not reflected in a where possible projects have been encouraged reduction of cost to the commissioner through to show ROI as an outcome measure. However, the tariff or contract mechanisms as they the limited unbundling of diagnostics and the currently exist. Calculation of future tariffs will relative insensitivity of tariffs at this stage of reflect changes in patient care. their development to the effect of reducing lengths of stay has been a limiting factor in These calculations are offered as an indicative clearly identifying financial savings. short term saving and one which may be used to stimulate local dialogue with the aim of The following table sets out an example of ROI developing appropriate arrangements to re- from one of the projects. The project aim was to invest savings as appropriate to improve care of focus on emergency admissions and to identify patients along the whole pathway. This is and reduce avoidable aspects of the patient stay premised on the understanding that the and thereby to reduce the overall length of development of tariffs is not designed to prevent hospital stay. A calculated cost per bed day of improvements in care from being realised. £101 was based on the average of each non elective spell tariff for heart failure (E18 and E19) The Heart Improvement Programme urges you divided by their respective non elective stay trim to learn from this important work and discuss point days to demonstrate an indicative return locally how you might apply some of the on investment for each bed day saved against solutions to your own environment for the the project baseline. benefit of local cardiac patients. Mean LOS Admissions ROI £ Baseline: April 8.59 65 May 8.81 66 June 5.36 64 Average 7.59 65 Project Reduction Bed days saved Bed day cost £ July 4.3 75 3.29 122 August 5.44 58 2.15 54 September 3.15 20 4.44 89 October 6.61 23 0.98 22 November 4.17 23 3.42 79 December 7.08 30 0.51 13 January 6.92 24 0.67 16 February 4.52 21 3.07 64 Total bed days saved 623 101
  9. 9. Making Best Use of Inpatient Beds 9Key learning Other aspects includes:With a range of clinical presentations, including • Good understanding of the complexity of allheart failure, acute coronary syndrome and the issues, through effective base-liningthose awaiting surgical and electrical procedures, activities and ongoing data analysis isby far the largest gain and the most challenging essentialwas the heart failure group. Project team • Achieving earlier diagnosis ensures thatcommitment has been impressive with feedback patients are on the right pathway of care athighlighting the positive effects of peer support an earlier stage to achieve improved clinicaland national steerage. outcomes • Increasing effective, appropriate and earlyOf crucial importance is having an integrated medication, up-titrating and achievingapproach across the pathway of care. For cardiac maintenance dose, promotes symptom controlsurgery patients explicit communication is and prevents emergency admission,required, particularly between cardiology and particularly for heart failure patientscardiac surgery departments, and between • Supporting partnership between patients andsecondary and tertiary care. Heart failure services health professionals, and where appropriaterequire collaborative approaches particularly patient self management is necessary, tobetween community and secondary care, achieve patient centred careespecially between nursing staff, and elderly • Using a systematic approach for booking andmedicine and cardiology. This underpins the transfer of patients helps reduce avoidableopportunity for a co-ordinated and team based delays in the systemmanagement style promoting a smoother • To help patients shape future services andtransition across organisations, departments and choice, their involvement is necessary from theservice providers for patients. outset • Trust between organisations needs to beThe development of a supportive infrastructure developed to help avoid unnecessaryin primary care is essential when addressing duplication of diagnostic tests, particularlyadmission avoidance, early discharge and when a patient needs to move betweenreduction in readmissions. Commissioning service providersexpertise within the national team and locally • Education and training are crucial to thehas been beneficial to participating projects in implementation of changethis regard. • Greater flexibility of workforce and changing roles can increase capacity and effectiveness of service provision • A greater focus on good working relationships across the organisational interface will lead to a reduction in frequency of admissions and readmissions and will promote seamless care.
  10. 10. 10 Making Best Use of Inpatient Beds Moving forward/next steps Before discussing the specific projects it is The online resource has been set up to important to acknowledge the huge encapsulate useful information. This is a dynamic reductions in inpatient bed days realised to tool for accessing a huge variety of useful date, for example through reducing resources that will be continually developing unnecessary waits for urgent interhospital following this initial launch and will provide an transfers for acute coronary syndrome and opportunity for fast tracking innovative working. pathway redesign to meet elective targets. Generally speaking the remaining work is The next round of priority projects will include more challenging due to the competing heart failure and surgery and will start in the pressures on elective and non elective services summer of 2008 until 2010. and the increasing co-morbidity of patients. Heart failure The NHS Heart Improvement Programme Some of the projects above will continue acknowledge that NHS staff want systems to through to the next stage of their work plan work seamlessly to help them provide the best whilst other new projects will be recruited possible care for patients and that NHS through the process of application. In particular, organisations need efficient and effective we intend to work with networks and processes to make the best use of available organisations on the issues below: beds. • Prevalence and incidence For more information and to get involved • Diagnosis please contact • Treatment • Maintenance • Supportive and palliative care. Underpinning the applications, we are particularly interested to look at issues affecting equity and access, information, audit and coding, patient experience and workforce. Surgery Surgical work will focus on the whole pathway of care including elective and non elective management. This will bring together learning from the 18 week pathway, making best use of inpatient beds and the interhospital transfer
  11. 11. Making Best Use of Inpatient Beds 11Project Summaries
  12. 12. 12 Making Best Use of Inpatient Beds Plymouth Clinical Assessment Service (PCAS) Plymouth NHS Hospital Trust, Plymouth Teaching Primary Care Trust, Private provider: Express Diagnostics Peninsula Cardiac Managed Clinical Network (PCMCN) Issues to address Key results/outcomes General Practitioners’ with a Specialist Interest A pilot scheme was implemented (September (GPSI) in Coronary Heart Disease (CHD) to triage 2007) of the Plymouth clinical assessment service all cardiology referrals in order to ‘stem the flow’ (PCAS) which showed: of referrals into the acute sector by sharing and diversifying pathways, and provide more services • Only 34% of patients actually required in the community e.g. NT Pro Brain Natriuretic referral to a cardiologist Peptides (NT Pro BNP) to: • All patients are booked through Choose & Book and all diagnostic tests are • Increase choice of provider, with quicker access performed and reported on in less than to diagnostic tests and a quicker diagnosis of 10 working days the disease • Results and reports are sent electronically to • Enter the patient on the right pathway for the GPSIs and are available to cardiologists their care, see the most appropriate person for • Those requiring clinical assessment from their their care and be given medicines test result are booked into a community management therapies much sooner to cardiology service and offered either a improve their prognosis medicine management plan, referral to the • Agree clearer pathways across organisational heart failure nurse or are referred back to their boundaries GP for follow up. • Set processes up electronically to ensure a paperless trail to inform the referral to BNP - NT pro BNP has been used to rule out treatment time for the 18 week pathway heart failure since April 07. A total of 400 • Ensure speedy access to cardiologists for patients have been assessed using the test and urgent cases from CHD GPSIs. found that: Actions taken • 30% of patients were identified as not • GPSIs were approached to ensure their having heart failure reducing agreement and a small scale triage study was inappropriate medication, request for instigated to determine additional GPSI ECHO tests and referral to cardiologists capacity required for triaging referral letters • early diagnosis has ensured patients are (one hour of additional capacity per week was given appropriate medicines management required for the GPSIs to perform a turn therapies which may translate into better around time of less than five days). outcomes. • Clear outcomes and priorities of these meetings were established, delivered and All Plymouth GPs now use Choose & Book for all evaluated by an inclusive PCAS project group. cardiology referrals and thus capture the • Cardiologists met monthly with the GPSIs for Plymouth population within the Clinical tutorials which also enabled speedier access Assessment Service. This will significantly for urgent referrals. increase current referral figures and capacity planning is underway to meet the demand. Contact information Chrissie Bennett Email:
  13. 13. Making Best Use of Inpatient Beds 13Heart FailureRotherham PCT and Rotherham Hospital NHS Foundation TrustNorth Trent Network of Cardiac CareIssues to address 2007 to identify the scope for training andRotherham has a higher than national incidence developing primary care teams, to optimise theirof heart failure (HF) coupled with a high rate of prescribing practice and reduce the need foremergency admissions and readmissions for hospital admissions. This highlighted significantpeople with a primary diagnosis of HF. The main variation between primary care practices with anaim of this project was to achieve a 5% overall low incidence of HF patients on betareduction in bed days for HF patients and to blockers licensed for HF and on the appropriatedevelop a care package for people with three dose.or more admissions per annum. As a result of this work, titration guidelines have• Avoidance of emergency admissions for been developed and disseminated widely to patients with heart failure – one of the highest primary care teams. These are also available on causes of admissions in Rotherham the PCT intranet.• Getting patients onto the appropriate pathway of care A series of protected learning time events aimed• To ensure that admissions are timely and at GPs, practice nurses and other primary care appropriate staff were held. This forms part of a rolling• Education of staff in both secondary and programme of training and education. primary care• Support and joint working between secondary The beta blocker prescribing audit was and primary care to improve the patient presented at the cardiovascular local pathway implementation team (CVD LIT) meeting, and• Improved communication across the whole also to primary care staff at the Protected patient pathway Learning Time events in January 2008.• Reduction in bed days for heart failure patients. The main finding was that an indicated 142 admissions per year could be avoided byActions taken optimal prescribing and titration of betaA time limited multidisciplinary project group blockers. This equates to a 16% reductionwas established to oversee the project. in HF admissions.An admissions audit was performed from patient A six month telemedicine pilot for heart failurerecords to identify patients with three or more patients will be completed in August 2008 whenadmissions. A readmission evaluation form was a full evaluation will be carried out by Sheffielddeveloped including admission source, University. The pilot will compare the effectsmedication on admission and noting changes and outcomes of 30 patients, trained andmade, diagnostic tests performed and discharge equipped to download vital signs data daily viadetails. This baseline audit, carried out on 2006 the telephone line to a health care provider whodata, identified 53 patients in this category. will alert the GP or nurse when changes are detected, with those of a control group. The aimBeta blocker prescribing rates were recognised is to encourage patient self management andas a significant indicator of successful patient reduce readmission rates and the number ofcare and a correlation was identified from visits by specialist HF nurses.research evidence between the increased use ofbeta blockers in HF patients and a correspondingreduction in hospital admissions. An audit ofbeta blocker prescribing was carried out across39 practices using practice registers in April
  14. 14. 14 Making Best Use of Inpatient Beds Key results/outcomes • Two GP practices are due to commence a pilot looking at ‘Enhancing the use of beta blockers in heart failure patients – preventing non- elective admissions and out patient referrals to secondary care.’ It will be reviewed by the PCT in October 2008. • The titration guidelines are currently being printed into booklet format and each GP will receive a copy. • Protected learning time events were organised for GPs, focused on CVD, and many of the workshops were targeted at heart failure. • GP practice and community staff are being kept up to date with evidence based education and training • This is part of a rolling programme of work for patients with heart failure and will continue on completion of the project. Contact information Ann Baines Email:
  15. 15. Making Best Use of Inpatient Beds 15Central Manchester Left Ventricular Systolic Dysfunction Project in Primary CareManchester Primary Care TrustGreater Manchester and Cheshire Cardiac NetworkIssues to address Key results/outcomesThe aim of the project was to establish a local 1. Audit of practice registersenhanced service (LES) in primary care for people Out of the 41 GP practices in the central hub ofwith left ventricular dysfunction (LVSD) to assess Manchester PCT, 29 practices responded.impact on hospital admissions, length of stayand patient experience. Below highlights some of the key results:A staged approach was agreed to: Confirm the diagnosis of those patients with read code G58• Identify patients on practice systems with an • 66% of patients have their diagnosis accurate diagnosis of LVSD confirmed by echocardiography• Design and implement an education •12% of patients are awaiting an programme for primary care clinicians to echocardiogram to confirm their diagnosis ensure a high level of knowledge and skill amongst participating practices Establish how many of these currently being• Fully implement a LES to support specialist followed up in secondary care could be services for people with LVSD and to raise the managed in the practice level of care delivered to them in primary care. •There are potentially another 100 patients from the practices that responded that could haveActions taken their follow up in primary care• As part of the LES, all 41 practices within Central Manchester were asked to audit their Identify the number of new patients diagnosed practice registers for patients with LVSD in the last year and consequently require up-• Data was collected from all practices within titration of their medication Central Manchester as well as practices • Last year there were 95 new patients participating in the LES using the Tactical identified with a further 12 awaiting Information System (TIS). This included length cardiology assessment of stay (LoS) and admission/readmission rates • Out of these, only nine were followed up and• Development of a training programme for the up-titrated in primary care, potentially leaving enhanced service for LVSD to provide a possible 98 patients that could have been participants with the knowledge & skills base treated in primary care. sufficient to provide an enhanced service to these patients 2. Data collection from Tactical Information• A key component of the education System (TIS) - Data at the end of ten programme focused on patient and public months involvement. A pack was provided to staff Due to the two month time lag between activity with useful references to follow up and teams and data collection, the March ‘08 data was not proceeded with their chosen methodology available at time of publication. over the course of the project, targeting people appropriately from their heart failure This data will be incorporated onto the Greater registers and utilising the cardiac network for Manchester and Cheshire website at support. in May 2008.
  16. 16. 16 Making Best Use of Inpatient Beds 3. Educational programme for the enhanced service for left ventricular systolic dysfunction The content for this programme was developed by GPSI working closely with the Professor of Cardiology from the local tertiary centre and his team. 4. Patient involvement Two practices are using ‘Discovery Interviews’ to gain insight into the patient experience. This is being utilised to shape future developments as per local and national guidelines. Other practices will be required to involve patients and this is being followed up. Contact information Caroline Hewitt Email:
  17. 17. Making Best Use of Inpatient Beds 17West Hertfordshire Brain Natriuretic Peptides (BNP) in Secondary Care ProjectWest Herts Hospital TrustBedfordshire and Hertfordshire Heart and Stroke NetworkOrganisations involved Key results/outcomes• Hemel Hempstead General Hospital (HHGH)• Watford General Hospital (WGH) Before introduction After introduction of BNP of BNP in HHGHIssues to addressAssessing the effect of introducing urgent Brain Mean LoS for heart Mean Los for heartNatriuretic Peptides (BNP) testing at one site failure primary failure primary(Hemel Hempstead General Hospital) and diagnosis in the diagnosis first 3comparing this to a neighbouring site which three months prior months with BNP atdoes not perform BNP (Watford General to BNP: HHGH:Hospital): • HHGH 6.8 days • HHGH: 4.6 days• Identifying patients with suspected heart • WGH 5.4 days (down 2.2 days) failure • WGH: 5.6 days• Confirming diagnosis earlier (up 0.2 days)• Getting on to heart failure pathway (or other) Median LoS for Median LoS for earlier heart failure primary heart failure• Reducing in-patient echocardiograms diagnosis in the primary diagnosis in• Increasing percentage of patients with primary three months prior the three months heart failure discharge diagnosis confirmed by to BNP: with BNP in HHGH: echo• Reducing length of stay (LoS). • HHGH 2 days HHGH: 1.6 days • WGH 4.3 days (down 0.4 days)Actions taken with BNPAt Hemel Hempstead General Hospital (HHGH): WGH: 5.1 days• Negotiated with the pathology lab to do (up 0.8 days) urgent BNPs (result within 2 hours) for Number of IP echoes Number of IP echoes breathless patients being admitted with a in HHGH: 48 in HHGH Feb 08: 68 query cardiac or definite cardiac cause for their breathlessness Percentage of patients Percentage of patients• Informed consultants and trained junior with HF diagnosis on with HF diagnosis on doctors in the use of BNP discharge with discharge with• BNP available from November 2007 diagnosis confirmed by diagnosis confirmed• Organised for Pathology to send copies of BNP echo: 22% by echo: 75% results to heart failure specialist nurse for her to visit all patients with a positive result to ensure echo and cardiology follow up This interim report demonstrates a reduction in• Monitored BNP usage. both mean and median length of stay at Hemel Hempstead General Hospital (HHGH), and aAt both Hemel Hempstead General Hospital slight increase at the neighbouring hospital site,(HHGH) and Watford General Hospital (WGH) although the statistical significance has not yet• Organised for data collections through IT been assessed. The results so far indicate that• Baseline audits in Sept/Oct this has not reduced the number of inpatient• Follow up audit in February 2008 and echos at this site, however the number of collected/analysed data in March 2008. patients discharged with a diagnosis of heart failure on discharge confirmed by echo has increased from 22% to 75%. Contact information Candy Jeffries: Email:
  18. 18. 18 Making Best Use of Inpatient Beds Reducing Length of Inpatient Stay for Myocardial Infarction (MI) and Acute Coronary Syndrome (ACS) Patients East Lancashire Hospitals NHS Trust Lancashire and South Cumbria Cardiac Network Issues to address Actions taken East Lancashire Hospitals Trust consisted of two • Mapping of MI and ACS care pathways main District General Hospital sites 15 miles • Baseline information for the previous 12 apart, serving a population of 500 000 people. months of MI and ACS data was obtained The trust had a disparate cardiology service, from healthcare resource groups (HRG). consisting of 45 dedicated cardiac ward beds Prospectively, data was analysed and 12 coronary care beds split across the two monthly in relation to length of stay, sites, with two cardiologists at Burnley, and two readmission rate and bed days at Blackburn, one of whom was a locum who • A flow tool that measured throughput worked solely in the cardiac catheter lab. There through beds was obtained from critical care. was no cardiology on call service, and the The flow tool was implemented on coronary coronary care unit did not come under the care at both sites one month prior to the management auspices of the cardiologists. move, and then was used to monitor activity until 31 December Patients who attended with MI were admitted • All cardiology inpatient services centralised on onto a ward under the general physician of the to one site day, rather than a cardiologist; and some • Treat and return policy instigated with tertiary patients with ACS would complete their care centre for acute ACS patients. This inpatient stay without seeing a cardiologist at meant that patients needing urgent all. The catheter lab, based at the Blackburn site, angiography were identified to the tertiary only performed procedures on ‘cold’ elective centre, taken for the procedure in a dedicated patients. Acute ACS patients were referred to cardiac vehicle once the slot was available, and the tertiary centre, remaining as in patients until returned to point of origin afterwards, without the angiography had been done. The average becoming a tertiary centre inpatient. A web wait for transfer to the tertiary centre was 15 based ‘whiteboard’ referral system was days, but on occasion the wait could be as long created to facilitate this process as 21 days. • Three interventional cardiologists recruited (making a total of six cardiologists in total) • Instigated 24/7 cardiology on call service • Daily consultant ward rounds on cardiology wards, coronary care and medical admissions unit (MAU). MAU referral guidelines were created by the cardiologists to identify and accelerate referral of appropriate patients • Instigated a pacemaker implantation service • Catheter lab activity expanded to include low risk inpatients. Balloon pump policy created, training instigated, and ‘dummy run’ transfers
  19. 19. Making Best Use of Inpatient Beds 19Key results/outcomes Number of Beds Average LOS MI/ACS LOS ACS patients awaiting CCU Ward inpatients (days) angiography (days) Baseline position 12 45 10 15 Position after 10 26 6 7 implementation Notes 19 cardiology Average length of stay Average length of stay beds removed reduced by 4 days reduced by 8 daysContact informationJennifer WattsEmail:
  20. 20. 20 Making Best Use of Inpatient Beds Cardiac Surgery Inter-hospital Transfer Project Ealing Hospital NHS Trust Imperial Healthcare NHS Trust (incorporating Hammersmith and St Mary’s sites) The Royal Brompton and Harefield NHS Trust North West London Cardiac Network Issues to address Key results/outcomes In July 2007 it became apparent that significant Transfer targets delays were occurring for inpatients requiring Meetings have taken place and agreement urgent transfer from a District General Hospital reached that the targets listed below will form (DGH) into a tertiary centre for a surgical part of the commissioning framework for North procedure. The reasons behind these delays West London. This is a significant step towards were complex and varied, and related to bed ensuring that the aims of the project are met, pressures, access to diagnostics and also to and that urgent surgical patients waiting for work-up procedures. In July 2007, the web- transfer can go to the centre with the shortest based Inter-Hospital Transfer (IHT) system waiting time. showed that the average wait from admission to transfer for an urgent inpatient surgical referral The targets agreed state that: in North West London was 18 days. The project 1. 100% of high risk patients needing was designed to address these issues and cardiac surgery should have been focussed on Ealing NHS Trust and the tertiary transferred, and received their surgery, centres it refers patients into (see above). within five days of the request for a fully ‘worked-up’ patient to be transferred Actions taken 2. For intermediate risk patients, 90% The project team looked at the entire patient should be transferred and have their pathway for urgent surgical inpatients and surgery within five days identified bottlenecks and agreed actions to 3. The risk scoring system devised and take to address these issues. These bottlenecks approved by the North West London fell into three main areas: Cardiac Network should be utilised 4. The North West London Cardiac 1. Pre-operative work-up Network’s web-based transfer system 2. Patient referral/tertiary care delays should be fully utilised by all trusts in 3. Clinical prioritisation and risk scoring North West London to monitor this target Three project meetings were held at which aims, 5. The web-based transfer system will be approaches and actions were agreed. Actions used to flag the patient for transfer to were undertaken outside the meeting in various another trust within North West London areas: if a patient cannot be transferred and operated on within five days. • Development of a protocol for cardiothoracic surgical work-up for patients to improve Transfer times from Ealing: interhospital transfer to a tertiary care centre - A comparison of eight week audit data collected Ealing NHS Trust at the beginning and end of the project shows • Definition and agreement of standardised that the following savings are being made: surgical work-up criteria • Clinical prioritisation and risk scoring Mean wait from 3.3 days saved • Audit of tertiary care bottlenecks and delays admission to per patient • IHT system amended to facilitate cardiac surgical transfer surgery work-up criteria. Mean wait from 7.25 days saved The network board was regularly updated on work-up complete per patient the project’s progress and key issues were to surgical transfer agreed there as appropriate. Contact information Jason Antrobus. Email:
  21. 21. Making Best Use of Inpatient Beds 21Continuing Development of Cardiac Services in North Bristol NHS Trust –Southmead Hospital and Frenchay HospitalAvon, Gloucestershire, Wiltshire and Somerset Cardiac and Stroke NetworkIssues to address Key results/outcomesSouthmead and Frenchay Hospitals serve the Unfortunately, an outbreak of Noraviruspopulation of Bristol and the surrounding area, infection resulted in ward closures during thesupported by the Royal Bristol Hospital Tertiary course of the project, which had an impact onCentre which is only a few miles away. There are the performance of the cardiology service.currently two inpatient wards that receive However, despite this, the figures show that thecardiac patients, supported by a coronary care improvements that had been made in theunit. It became apparent that patients admitted system managed to prevent the performance ofwith a primary cardiac diagnosis were subject to the service from deteriorating significantly froma prolonged length of stay; that once admitted baseline levels.patients transfer to a cardiac ward was delayed;and that less than 60% were transferred to the In its first month, the catheter lab has seen andcare of a cardiologist. In addition, targets for the treated 100 patients. Further developments andtransfer of appropriate patients to the tertiary the continuation of this work are expected tocentre were not being achieved, and it was produce significant positive impacts on thebelieved that opportunities to prevent patient current situation.readmission after discharge were not being met. Contact informationAt the same time, there was a need to develop Nicola Hughesappropriate pathways and guidelines for the Email: Nicola.Hughes@nbt.nhs.ukimminent opening of a new catheter lab at theFrenchay site.Actions taken• Developed and piloted a cardiac support nurse role which actively pulled cardiac patients on to the cardiac wards• Developed a patient journal for cardiac inpatients to records their thoughts regarding their stay• Operational policy and guidelines for the new catheter lab were formulated• Staff were very kindly supported and trained by national specialist units• Patient tracking system implemented• Catheter lab opened on 18 February 2008, providing angiography for low risk ACS inpatients, a pacemaker insertion service and PCI• A second catheter lab is due to be opened imminently• A further cardiology consultant is due to join the team in May• Preparing for BCIS accreditation.
  22. 22. 22 Making Best Use of Inpatient Beds Reducing Non-elective Arrhythmia Inter-hospital Transfer Waits Through the Implementation of an Internet-based Referral and Transfer Management System The Heart Hospital (University College London Hospital), Barnet Hospital, Chase Farm Hospital, North Middlesex Hospital, Royal Free Hampstead Hospital, Whittington Hospital and North Central London Cardiac Network Issues to address Actions taken Patients who required treatment for a non- • A retrospective audit of time from admission elective arrhythmia were referred by five North to referral, and from referral to IHT was Central London (NCL) hospitals to the tertiary established (25 patients) centre at University College London Hospital • Implementation of on-line IHT referral and (UCLH). The referral was faxed from the acute transfer management system (Web Based hospital to the catheter lab co-ordinator, and an Transfer System) at the end of August 2007 in inter hospital transfer (IHT) arranged. Every stage the referring and receiving hospitals across the of this process required lengthy medical North Central London sector. This incorporated supervision. Anecdotally, long waits were a WBTS also a tracking and audit tool reported but no robust audit system existed. • Initial training of the main users at all centres during the month preceding going-live date • Successful introduction of the web-based • Dedicated user support during office hours for transfer system (WBTS) a further month • Reduced length of stay for arrhythmia inter- • Further user training delivered between hospital transfer (IHT) patients within North October and December 2007 for user change- Central London over (mainly junior doctors) • Improved communication between referring • In-house WBTS training and administration and receiving centres as well as between staff functions given back to each hospital. and patients Implementation of in-house WBTS champion • Transparency of IHT wait, through on-line • Feedback lines of communication through waiting lists WBTS champions • Easily accessible length of stay data for all key • Cross-organisational team building and stakeholders. problem solving through regular ‘Learn and Share Events’ • Daily dedicated permanent pacemaker slots at UCLH • After implementation of WBTS a prospective audit of waiting times was performed, matching types and number of procedures of baseline audit (25 patients) • WTBS user satisfaction questionnaires used to determine staff response to changes. Key results/outcomes The key results are shown in the table below: Admission to Referral to transfer Admission to referral (total days) (total days) transfer (total days) Baseline 193 155 348 WBTS cohort 87 140 227 Reduction from 55% 10% 35% baseline in
  23. 23. Making Best Use of Inpatient Beds 23The user satisfaction questionnaires weredistributed to WBTS users including ward sisters,receivers (personnel organising transfers atreceiving centres) and referring consultants.These showed• Referrers and ward sisters at the referring centres reported greater transparency of the IHT wait and improved communication between the centres• The information on the WBTS was believed to have contributed to improved bed usage and better team working across hospital boundaries• Referring consultants believed that the benefits of the WBTS outweighed the increased work load.In addition, the live waiting list has alsoenabled all stakeholders to highlightexceptionally long patient waiting times and attimes enabled intervention to limit these.Greater participation of more stakeholders in theIHT process also ensures better sustainability ofthe transfer process within the NCL sector.Contact informationSwetlana WolfEmail:
  24. 24. 24 Making Best Use of Inpatient Beds Heart Failure Early Discharge Central Middlesex Hospital (part of North West London Hospitals NHS Trust) Brent PCT (Wembley Centre for Health and Care and other Community Clinics) North West London Cardiac Network Issues to address • Average length of stay was nine days Patients with heart failure currently tend to stay • Patient’s follow up was conducted at the in hospital longer than necessary because the cardiology or heart failure hospital clinic. clinical staff must ensure that patients are All patients had one or more co-morbidities completely stable before discharge. Because of with hypertension and diabetes being the difficulty with continuity of care by junior most prevalent. doctors, the period between the patient coming off intravenous diuretics and being stabilised on Actions taken oral medication is often prolonged. Also, A project steering group was set up with key patients are kept in hospital longer than members (involving hospital and community necessary because the medical staff realise that staff) to guide and inform the project. A process they may not see them after discharge for some mapping exercise was conducted to review the time because access to clinics is inflexible. existing care pathway and a baseline audit was conducted for the first eight weeks. The This project reviewed the existing pathway of following points outline the areas reviewed and care and assessed length of stay and emergency developed within the project: readmissions, the objective being to re-engineer the pathway of care to reduce length of stay. • Early discharge protocol and proforma Other areas reviewed were the existing developed by the heart failure (hospital and cardiology services relationship with other community) and CCT specialities such as general medicine, care of the • Promoting information for early discharge elderly, respiratory, gastro, endocrine and the throughout the hospital and with other collaborative care team (CCT). specialties • Working closely with CCT to support the heart Fifty data fields were included in the audit and a failure nurse with early discharge. Patients further 30 for use from day one to ten of their were identified within A&E, CCU and wards to care, which includes inpatient and community discuss possible early discharge care episodes. The following points outline the • A questionnaire was sent out to patients who most significant areas: were on the baseline audit asking to comment on their recent admission and the service • Twenty-four patients were identified for entry provided – this information was used to make onto the baseline audit – our original target of changes to the pilot 30 patients couldn’t be reached due to the • The project was piloted for four months patient criteria, which limited the patients that • Following the change in management process, could be included. This was recognised as a a further 24 patients were audited and as with risk to the pilot and it was agreed to the baseline audit, there were similar problems investigate whether it would be possible to with recruitment. Prior to discharge of each extend the project to include Brent patients patient an individual management plan was admitted to Northwick Park Hospital put together to provide appropriate continuing • Sixteen men and eight women who fitted the care and adjustments to medication set criteria (patients treated with IV diuretics (continuing the stabilisation of the patient with LV systolic dysfunction and not admitted which otherwise would have happened in with ACS) were identified to include in the hospital). A combination of CCT, hospital heart baseline. Six were <65 years and 18 were >65 failure nurses and community heart failure years, this age split is typical of heart failure nurses was used depending on the patient’s where the majority of patients tend to be requirements – home visiting or attendances at elderly.
  25. 25. Making Best Use of Inpatient Beds 25• A patient personal notebook (previously developed by North West London Cardiac Network) was offered to patients on the pilot to promote self-management of care• CCT staff attended a heart failure nurses clinic on a rotating basis as part of a training schedule.Key results/outcomesThe length of stay of patients in the secondaudit was eight days. Although the numbers ofpatients in the study was not enough to allowstatistical analysis, the reduction in length of staywas in the area predicted at the start of theproject (10%), and if born out in a larger studywould represent a significant saving.Furthermore, this approach to patient care isapplicable to other specialties. The project didprovide some unexpected findings and morequalitative than quantitative results.The following points provide a brief outline ofthe conclusions:• Heart failure patients are often complex, admitted with co-morbidities and social issues which impact on being able to provide early discharge• Developed better links with other specialties• Developed a training schedule for CCT and HF to educate A&E staff in recognising HF symptoms and discharging patients without admitting to hospital• Patient follow-up was expanded to incorporate different resources according to need• Further work to review emergency readmissions for patients on pilot in next six months to establish continuity of care• Further work to estimate the resource cost of providing the service to put against the reduction in length of stay.Contact informationTemo DonovanEmail:
  26. 26. 26 Making Best Use of Inpatient Beds Reducing Avoidable Hospital Admissions by Providing Community Support for Patients Referred Through the Single Contact Access Nomination (SCAN) Sheffield Primary Care Trust; Sheffield Teaching Hospitals NHS Foundation Trust North Trent Network of Cardiac Care Issues to address • Support and speed of response led by SCAN is a referral system into and out of patient need secondary care, initiated to provide support in • Utilises a mixture of urgent and non urgent the community. response community services • Local intelligence and directory of services With the restructuring of the primary care trust used to signpost appropriately (PCT) back into one PCT and the admission • Guidelines and protocols in place to underpin avoidance work, the heart failure nurse service process and delivery was reviewed and a new model introduced. • Identified gaps in service and skills • Feedback loop in plan Some of the aims were to: • New model enables two specialist nurses to case find in secondary care, assess and refer • Focus activity to reduce admissions and patients to community heart failure team. maintain reduction in admissions • Increase use of single contact access Key results/outcomes nomination (SCAN) by primary and secondary • 300 cumulative heart failure referrals care and develop further to enable into SCAN patients/carers to self refer to SCAN for • Rate of GP referral increasing rapidly – 73 information/visit heart failure referrals in last quarter • Review heart failure pathway in line with the • Evidence of patient satisfaction 18 week wait • Increased capacity through service redesign eg. • Signpost patients to the appropriate service community staff nurses with special interest in • Reduce discharge delays whilst patients wait heart failure take less complex patients with for social services to provide care packages support from the specialist nurses • Reduce variation in discharge information from • Reduced admissions and improved triage heart failure service in secondary care to system primary care. • Dedicated heart failure ward discussions • Heart failure rehabilitation pilot Actions taken • Early discussion in Telly Health • Single point of access (SCAN) for nominations • Investment and support. and management of the system in place from primary, secondary care professionals, care Contact information homes, social care, patients and carers. Colette Longford Signposting by skilled senior nurses Email: • Development of System One as an administrative/management function as a register for Very High Intensity Users’ (VHIUs) • An additional three nurses from community nursing appointed • A change of role for secondary care nurses so all inpatient and secondary care patients are assessed and if appropriate, referred to the community heart failure team. Education provided for staff working on the medical admissions unit. ‘link nurses’ developed and criteria for case finding
  27. 27. Making Best Use of Inpatient Beds 27Integrated Heart Failure Service Across All Organisational BoundariesAshford and St Peters NHS Trust, North West Locality of Surrey PCT(to be extended to South West Locality and Frimley Park)Surrey Heart and Stroke NetworkThe aim of the project was to provide fully Key results/outcomesintegrated heart failure services across all • Establishment of local HF nurse activityorganisational boundaries to improve the clinical database. For Nov 07 – Jan 08management of all heart failure patients. This demonstrates 72 avoided GP contacts,included increasing referrals to the heart failure three avoided hospital admissions andnurses and integrating the service with the GP one avoided A&E admissionswith special interest ‘heart function’ clinics. • Community Heart Failure Consultant review – this was a four month audit ofIssues to address the direct access by HF nurses to• Reduce heart failure admissions consultant opinion. Review indicates a• Reduce length of stay (LoS) potential saving of 24 inpatient days and• There were two heart failure nurses in old 15 outpatient attendances North Surrey locality • Reduction of heart failure admissions from• Successful BHF bid for heart failure nurses. 65 to 21 per month Came into post July/September 06 (didn’t take • Reduction in LOS from average of 8.59 patients on until late 2006) days to 4.5 days• Two to three weeks waits for inpatient echo • A strong heart failure steering group with up to 16 week wait for outpatient echo committed to improving services in secondary care • Improved access to consultant cardiology• Links with palliative care team established but opinion not consolidated • Improved patient management within the• End of life stage – improved access to home and across organisational boundaries palliative care and hospice. • Home ECG audit – expedited referral to secondary care where appropriate forActions taken intervention/treatment. Improved medicines• New consultant cardiologist with special management within the home. Reduced interest in heart failure and imaging appointed unnecessary care/GP appointments. Increased in April 06 reassurance for patients and carers• Data collection to review heart failure • Improved links with palliative care and other admissions for the first quarter in years 2006, community services 2007 and 2008 for comparison • Consistent documentation across localities• Data collection to establish LoS from April to • Through audit and patient and public March 2007/08 involvement, established sound evidence to• Review documentation; new West Surrey wide inform business proposal for continuation of clinical guidelines and patient information heart failure nurse led service• Establishment of a heart failure nurse service • Engagement from network commissioning across the whole of West Surrey to review group for continuation of service and spread protocols to other localities across Surrey• Establish a process for direct access to • New one stop echo/heart failure clinic run by consultant cardiologist for his opinion with consultant cardiologist within secondary care. complex patients for both heart failure and GP with special interests (GPSI) Contact information• Established links with palliative care Alex Bennett• Access to network shared drive in order to Email: access information by all parties involved in project• Purchase of portable ECG machines for all heart failure nurses across West Surrey• Purchase of weighing scales to help inpatient self-management• Audit of patient satisfaction via questionnaire.
  28. 28. 28 Making Best Use of Inpatient Beds Making Best Use of Inpatient Beds Conquest Hospital Sussex Heart Network Issues to address • Both Tai Chi rehabilitation programmes and The Conquest Hospital inpatient heart failure hand-held records were available for heart service offered an excellent package of care for failure patients those patients who were referred to them, but • Teaching/education sessions for practice the service became fragmented for the patients nurses/community nurses/acute nurses took who were admitted to other consultant teams place elsewhere in the hospital. Problems included: • Links with the hospice team and expansion of the palliative and supportive care services were • Delays in getting echos done developed and progressed. • Heart failure team not being informed of the patient admission Key results/outcomes • Undue delays in medical admissions unit Jan 1998 – Dec 2007 (MAU) • 51.04% reduction in average no. of • Patient not on the correct pathway for admissions/quarter with heart failure in optimisation of care primary diagnosis position • Longer length of stay (LoS) • 36.6% reduction in median LOS/quarter • Unnecessary readmissions has decreased from 11 to seven days • Lack of specialist support for patients • 23% reduction of deaths in hospital in following their discharge. non-elective admissions with heart failure. Actions taken Aug 2007 – Mar 2008 • Established a project steering group and • 20% reduction in number of days waiting process mapped acute and community care for echo from date of referral to date heart failure pathways of test. • Baseline information data was obtained and subsequent data was collected and analysed Please note that these results are calculated • Early identification of heart failure admissions on incomplete HRG performance data. through existing and enhanced methods. These included a telephone hotline for heart Contact information failure admissions with an accompanying Toni De Freitas poster initiative, and an ‘alert’ feature on the Email: hospital information system to highlight all known patients and guidance around contacting the heart failure team • MAU consultants and their teams worked to fast track patients to the heart failure acute team, all cardiology inpatient admissions were centralised to dedicated wards and early access to echocardiogram on the ward was facilitated • Management plans were in place for all heart failure patients following an acute heart failure pathway, and optimised discharge and follow up care were established • Cross boundary communications were further enhanced through multi-disciplinary team discharge planning meetings, ward rounds for heart failure acute teams, enhanced community heart failure nurse links to wards and the establishment of ward-link
  29. 29. Making Best Use of Inpatient Beds 29Project Team Membersand Participating Sites
  30. 30. 30 Making Best Use of Inpatient Beds Project Team Members and Participating Sites Thelma Daly Temo Donovan Avon, Gloucestershire, Wiltshire and Somerset North West London Cardiac Network Cardiac and Stroke Network Brent, Central Middlesex Hospital and Brent tPCT Bristol, Southmead Hospital, North Bristol NHS Trust Chrissie Bennett Nicola Hughes Peninsula Cardiac Managed Clinical Network Avon, Gloucestershire, Wiltshire and Somerset Plymouth, Plymouth tPCT and Plymouth Cardiac and Stroke Network Hospitals NHS Trust Bristol, Southmead Hospital, North Bristol NHS Trust Toni De Freitas Candy Jeffries Sussex Heart Network Bedfordshie & Hertfordshie Heart and Stroke Network Hastings, Conquest Hospital and Hastngs Hemel Hempstead Hospital, West Herts NHS Trust and Rother PCT Caroline Hewitt Alex Bennett Greater Manchester and Cheshire Cardiac Network Surrey Heart and Stroke Network Central Manchester, Central Manchester PCT, Central Woking, Surrey PCT and Ashford and Manchester and Manchester Childrens University St Peters NHS Trust Hospitals NHS Trust and PBC Hub Mimi Parker Luke Coleman Surrey Heart and Stroke Network Greater Manchester and Cheshire Cardiac Network Woking, Surrey PCT and Ashford and Central Manchester, Central Manchester PCT, Central St Peters NHS Trust Manchester and Manchester Childrens University Hospitals NHS Trust and PBC Hub National Team Members Jennifer Watts Lancashire and South Cumbria Cardiac Network Sheelagh Machin Blackburn, East Lancashire NHS Trust, Blackburn Director, NHS Improvement Royal Infirmary Carolyn Heyes Rita Briggs National Improvement Lead, NHS Improvement Lancashire and South Cumbria Cardiac Network Richard Longbottom Blackburn, East Lancashire NHS Trust, Blackburn Commissioning Advisor, NHS Improvement Royal Infirmary Ann Baines Jennifer Watts North Trent Network of Cardiac Care - Rotherham Service Improvement Manager, NHS Improvement Rotherham, Rotherham PCT and Rotherham NHS Anne Coleman Foundation Trust Personal Assistant, NHS Improvement Colette Longford Jonathan Shribman North Trent Network of Cardiac Care - Sheffield National Clinical Lead, General Practitioner Sheffield, Sheffield PCT and Sheffield Teaching Hospitals NHS Trust David Walker Swetlana Wolf National Clinical Lead, Consultant Cardiologist North Central London Cardiac Network Steve Livesey Hampstead, Royal Free Hospital NHS Trust and Heart National Clinical Lead, Consultant Hospital Cardiothoracic Surgeon Jason Antrobus North West London Cardiac Network Ealing, Ealing Hospital NHS Trust, St Marys Hospital and Hammersmith
  31. 31. NHS NHS ImprovementCANCERDIAGNOSTICSHEARTSTROKE NHS Improvement NHS Improvement is a newly formed national improvement programme working with clinical networks and NHS organisations to transform, deliver and sustain improvements across the entire pathway of care in cancer, cardiac, diagnostics and stroke services. 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. NHS Improvement 3rd Floor | St John’s House | East Street | Leicester | LE1 6NB Telephone: 0116 222 5101 | Fax: 0116 222 5184 ©NHS Improvement 2008 | All Rights Reserved Publication Ref: IMP/heart0004