Trust Board Committee: Wednesday 12 November 2014
TB2014.120
Title
Winter Preparedness
Status
This is an annual report to the Trust Board.
History
An outline paper was submitted to Trust Management Executive
on 11th September 2014 and this paper was submitted to Trust
Board Seminar on 24th September 2014 and Finance &
Performance Committee in October 2014.
Board Lead(s)
Mr Paul Brennan, Director of Clinical Services
Key purpose
Strategy
TB2014.120 Winter Preparedness
Assurance
Policy
Performance
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Oxford University Hospitals
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Executive Summary
1. The paper sets out the Trust plans for delivering safe care over the coming winter and
the actions to manage the forecast activity profile for the October 2014 to March 2015
period. The paper also outlines the additional elective activity to be undertaken during
late Q2/Q3 to reflect the capacity implications.
2. Details are provided on the specific service developments being implemented during
October and November 2014 and funded as part of the national £400m System
Resilience Allocation announced by NHS England. Information on the recent external
validation review is also included.
3. Recommendation
The Trust Board is asked to note the report.
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Winter Plan
1.
Background
1.1. This paper sets out the key actions being implemented by the Trust in
preparation for winter. In addition, the paper includes the activity assumptions
that underpin the plan and identifies the initiatives the Trust is implementing as
part of the System Resilience Programme funded by the national non-recurrent
resources.
1.2. The Trust is also seeking to treat additional elective patients as part of the
national RTT programme and the key assumptions are set out in this paper
given the implications this additional activity will have on staff and physical
capacity.
2.
Activity Assumptions
2.1. Emergency and elective spells and ED attendances continue to run at levels
above the position in 2013/14 but in line with the Trust’s activity forecast. At
Month 6 actual activity and forecasts are shown in the table below.
Table 1: Activity April to September 2014 and Year End Forecasts
Activity Type
Month 6 Actual
Year End
Forecast at April
2014
Month 6 Based
Forecast
Emergency Spells
44,751
92,376
91,802
Elective Spells
56,848
115,890
113,696
101,599
208,266
205,498
70,304
140,036
141,902
Total Spells
ED Attendances
2.2. As can be seen from Table 1 the forecast based on Month 6 actual activity is
closely aligned to the start year forecast activity and it is anticipated the 1.5%
variance in spells is likely to close as the additional RTT activity is undertaken.
2.3. ED attendances as at Quarter 2 are 70,304 indicating activity for the year will be
approximately 140,600 which is in line with the start year forecast.
2.4. The Trust is undertaking additional elective activity during 2014 initially to
improve performance against the 18 week standards and subsequently as part
of the national initiative to reduce both the size of the waiting list and the
number of patients waiting over 18 weeks. This additional activity is and will
impact on overall capacity in the run up to winter and during the initial winter
period (October and November 2014). The graphs below identify activity and
breach levels for admitted and non-admitted clock stops for the periods April to
September 2013 and 2014.
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Graph 1: Admitted Clock Stops
Graph 2: Non-Admitted Clock Stops
2.5. During the period September to November 2014 inclusive the Trust is expecting
to treat an additional 1,296 patients compared to the same period in 2013.
2.6. Admitted clock stops for the first six months of 2014 were 26,253 compared to
23,435 for the same period in 2013 representing an increase of 12%.
2.7. Non-admitted clock stops for the first six months of 2014 were 58,576 compared
to 51,866 for the same period in 2013 representing an increase of 12.9%.
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3.
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Winter Plan Initiatives
3.1. The Trust is currently implementing a series of initiatives designed to increase
capacity, improve flow and enhance seven day working in preparation for
winter. The main service developments are set out below:
Capacity Increases
1. Capacity
Project
Adams/Bedford (4 beds)
Workforce Profile
4.5wte Nurses
Performance Indicators
Bed occupancy reduced
to 95%
OCE/NOC (10 beds)
10.75wte Nurses
5.38wte Clincal Support Workers
Bed occupancy reduced
to 95%
F Ward HGH (3 beds)
4.5wte Nurses
Bed occupancy reduced
to 95%
City/Comm JR (20 beds)
21wte Nurses
10wte Clinical Support Workers
3wte Admin/Ward Clerk
Bed occupancy reduced
to 95%
Churchill (5 day to 7 day beds 8 beds)
5wte Nurses
Bed occupancy reduced
to 95%
Workforce Profile
8wte Clinical Support Workers
Performance Indicators
4 hour A&E standard to
95%
4 hour A&E standard to
95%
Improve Flow – ED
2. Emergency Department
Project
Additional Healthcare Assistants
Extend ED Consultant Rota to
increase presence during
afternoon/evening shift
Paediatric CDU
4wte Consultants
2wte Consultants
1.5wte Physio and OT
4 hour A&E standard to
95%
GPs in ED
84 hours GP equates to 2.3wte
ED dedicated portering
12wte Porters
4 hour A&E standard to
95%
4 hour A&E standard to
95%
Improve Flow and Seven Day Working
3. Extended Working and Flow
Project
Workforce Profile
Performance Indicators
SSIP GP referral unit
Pharmacy on AGM Wards
7wte Nurses
1wte Consultant
3 wte Clinical Support Workers
2wte Admin Support Staff
4wte Pharmacy Technicians
4 hour A&E standard to
95%
60 discharges per day
Discharge Lounge
Additional Transport
3.6wte Nurses
4wte Clinical Support Workers
1wte Facility Staff
Contract for service
4 hour A&E standard to
95%
60 discharges per day
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3. Extended Working and Flow
Extended Pharmacy
15wte Care Workers
2wte Nurses
0.5wte Consultant
8wte Pharmacists (using long line
agency staff)
60 discharges per day
7 Day Endoscopy
11PAs Consultant
1.5wte Nurses
0.1wte Admin
Note £7,000 non-pay cost
60 discharges per day and
bed occupancy reduced to
95%
Increase in urgent bookable list
Echocardiology
2PAs Consultant
1wte Scrub Nurse
0.5wte ODO
0.5wte Recovery Nurses
1wte Cardiology Technician
60 discharges per day
60 discharges per day
SHDS Expansion
4.
60 discharges per day
External Validation
4.1 The Trust plans and current arrangements for managing front line urgent care
services were subject to external review by the national Emergency Care
Intensive Support Team on 15th September 2014 as part of a system-wide
review which continued on 16th and 17th September 2014. The review team
visited ED, SEU, four medical wards, the Operations Team and the Discharge
Team. The initial feedback was positive though the following observations were
made:
4.1.1 One of the four wards visited did not have estimated date of discharge for
all patients
4.1.2 Weekend discharges were disproportionately low
4.1.3 Expressed reservations as to whether the twice daily medical ward
rounds were regularly occurring.
4.2 Very positive comments were made about our new approach to managing
surgical emergencies and the reverse triage model introduced in ED alongside
positive comments on staff commitment and resolve to improve performance.
The draft report, for comment on factual accuracy, has been received and
following comments by the Trust we are awaiting publication of the final report.
5.
4 Hour Action Plan
5.1 The Trust has developed an internal four hour action plan which is reviewed
monthly by the Trust Urgent Care Programme Group. The plan covers a wide
range of actions as well as incorporating the winter plan initiatives described in
section 3 above. A copy of the plan is attached at Appendix 1.
6.
Recommendations
The Trust Board is asked to receive the report and note the actions that are being put
in place to ensure that the Trust is able to accommodate the increase in activity that
is anticipated over the winter months.
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Paul Brennan, Director of Clinical Services
September 2014
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Oxford University Hospitals
Appendix 1
ED Action Plan 2014/5 Version 6 Updated 27.08.14
Number
Category
Improvement Description
1
Staffing
Revised MDT model in
EAU concentrated on
rapid assessment,
investigation, decisionmaking and flow
2
Staffing
Medical leadership
3
Staffing
Senior physician
support to level 1
4
Report/Workstream
Development and implementation of new MDT assessment
Reports to AMR Directorate Urgent
and treatment model in EAU to facilitate the rapid assessment, Care/Pressures Group.
ordering of diagnostic tests and decision-making for patients
referred directly by GP's to EAU enabling more timely
decisions about discharge, follow-up on an ambulatory basis
and admission.
This model will also support more rapid investigation of
patients referred from ED to EAU.
1. Task and Finish Group chaired by Dr Sudhir Singh, Clinical Lead for AGM meets fortnightly to manage the process of change associated with
development and implementation of this model
2. Project plan covering implementation phase and review in place
3. Action cards describing the roles for medical and nursing staff in rapid assessment are complete
4. Flow charts mapping the pathway are in the process of being completed and will be displayed in the "Goldfish bowl" in EAU
5. Revised arrangements for deployment of medical staff to ensure there is always a doctor available to EAU to receive the 'take' are in place
6. Communications plan describing the new model has been developed and rolled out.
7. An identified constraint to optimal deployment of the rapid nurse assessment model is the current level of nursing vacancies in EAU and retention of
existing staff. One element of this constraint is being managed via the appointment of a PDN. An attempt is also being in the short term to employ
phlebotomists.
Timescale
(1) In place
(2) Complete
(3) Completed
(4) Completed
05.09.14
(5) In place
(6) Completed
(7) On-going with
review 26.09.14
Staffing
Continuation of drive to recruit to middle-grade vacancies by
AMR Directorate Performance Review
Continuation of drive to participation in further Trust-wide led overseas recruitment
fill middle grade medical initiatives
posts and ensure
Re-invigorate the pro-active scrutiny of middle-grade medical
optimal deployment
staff deployment to ensure best value for money and optimise
input to rota gaps
Programme for the appointment, development and rettention of
ANP's underway.
1. Participate in the forthcoming overseas recruitment drive.
2. Revise and document the process for pro-active review of middle-grade deployment.
3. Programme in place with appointment to posts made.
(1) In progress
(2) Complete
(3)In place
James Price / Larry Fitton
supported by Alex Monahan
and Chris Shields
3. Andrea Dale
5
Staffing
EAAs to continue to play a proactive role with referring GPs,
Continue to develop the supporting flow and fully utilising capacity to review referred
role of the Emergency patients on the following day
Assessment Advisers
AMR Directorate Performance Review
1.EAAs to continue to play a proactive role with referring GPs, seeking alternatives to attendance at EAU wherever possible
2. Fully exercise clinical assessment skills in the same way as ED senior nurses making referrals direct to specialties without the requirement to be
first reviewed by a medic
3. Support medical teams to use next day appointments on DDU.
4. DOS completed.
5. Review of EAA Model following the resignation of one of the two postholders. Preferred emerging model looks to further intergrate the role of the
EAAs into the EAU senior nurse establishment supported by a PDN.
(6) Review of
model to be
complete by
30.09.14
(6) Louise Rawlinson/Lily
O'Connor
6
Flow
Plan at 2 hours for all
patients in ED
Flow
Compliance with
internal standards
All patients to be assessed and have a defined clinical
management plan within a maximum of 2 hours.
Urgent Care Programme Group
Internal monitoring of performance with escalation to ‘floor consultant’ when not being met.
Remains under
active review
Louise Rawlinson Larry Fitton
Continue to work on compliance with internal standards for ED Urgent Care Programme Group
'referred to' specialties to ensure timeliness within the 4 hour
window
ED to exercise their admitting/transfer rights to SEU and SSIP as follows
Remains under
1. Following initial clinical assessment in ED, time critical diagnostics will continue to be ordered by ED. For those requiring a surgical opinion where
active review by
investigation is assessed by ED to be less time critical patients will be immediately transferred to SEU and SSIP.
the UCPG
2. Patients should be managed on an ambulatory basis wherever possible
3. There will be onward direct referral of patients triaged by a senior ED nurse without the requirement to be seen by an ED medic, where appropriate.
4. Patients requiring a surgical opinion in ED will be transferred to the ward for assessment if a request for assessment on ED is not responded to
within 30 minutes.
The above actions will be supported by:
1. Diagnostic availability to SEU will be enhanced to that of ED and EAU
2. Patients will transfer with clinical and demographic information collected at the point of assessment together with details of drugs administered e.g.
pain relief and clear instructions in relation to frequency of observations.
Improvements to responsiveness are evident.
Louise Rawlinson Larry Fitton
8
Flow
Expected referrals and
transfers
Expediting the flow of expected patients and transfers from the Urgent Care Programme Group
Horton ED
1. Transfers from the Horton ED for specialty opinion to be direct to the appropriate ward and not held in ED
2. Increased senior and junior medical staff presence on the medical wards to facilitate earlier decision making and discharge where appropriate.
3. Use of additional assessment bed in EAU to assist with privacy and dignity as well as to aid patient flow
4. SHDS participating in daily (7 day) post take ward rounds to assist in identifying support needs at home for patients
5. SHDS providing home discharge support to patients from southern Northamptonshire (in pilot phase)
6. Review of and increase in the number of patients being treated in the Rowan Day Unit – expansion of types of patients that can be cared for on a
day case basis.
7. Development of a cross site medical staffing hub to aid recruitment of staff and management of staffing resources across JR ED + medicine and
Horton ED + Medicine
(1) Completed
(2) Update
30.09.14
(3) Completed
(4) Partially
implemented
(5) Implemented
(6) Implemented
(7) In progress
James Price, Sudhir Singh,
Siobhan Hurley and Caroline
Mills
9
Flow
General Surgical
support
Increasing JR dedicated Consultant Surgeons to four
Urgent Care Programme Group
(1) One to commence in post in June with two further appointments made on 6.6.14. New appointees to commence in October.
Elective component of these posts will cover the urgent bookable lists and a rota will be introduced on a rolling 4 week basis to cover:
• Surgical Emergency Unit
• Urgent Bookable List – note need to move from two to four scheduled lists per week
• Front door
• Cover
(2) Draft plan to move from 5 to 7 day consultant physician cover on the emergency surgery wards.
(1)Partial
completion
(2) In
Development
(1) Paul Brennan
(2) Sudhir Singh
10
Flow
Paediatrics
Improving flow to Paediatrics
Urgent Care Programme Group
1. Paediatric CDU to continue to pro-actively “pull” patients from ED at all times of the day and night.
2. Requests for Paediatric opinions at the Horton will be consistently responded to within 30 minutes by consultants given 24/7 resident presence.
3.The Children’s & Women’s Divisional Nurse and General Manager to be informed of any failure to respond.
4. Winter pressure bid to recruit 1.5 WTE Paediatric ED Consultant
(1), (2), (3)
Completed
(4) VCFs
approved
Paul Brennan
TB2014.120 Winter Preparedness
RAG Rating
(1) Sudhir Singh
(2) Caroline Mills
(3) Sudhir Singh and Louise
Rawlinson
(4) Caroline Mills
(5) Sudhir Singh
(6) Caroline Mills
(7) Louise Rawlinson/Lily
O'Connor
(1) Larry Fitton
(2) James Price
(3) Louise Rawlinson
Senior decision maker on level 1 for 6 hours a day. Monday to Urgent Care Programme Group
Friday 1pm to 7pm, Saturday and Sunday 2pm to 8pm.
1. ED Consultant job descriptions have been drawn up for an additional four posts and are currently with the CEM for approval. This will allow for a third
Consultant to be on duty during the latter half of the day between 1pm to 10pm, mapped to activity pressures and thereby minimising the build up of
queues into the night.
2. Interviews scheduled for mid October
3.Senior Nurse Coordinator to provide more support to ST4/5s overnight to facilitate decision-making.
Responsible Lead
(1) Completed
(2) In progress,
due for completion
21.10.14
(3) Completed and
kept under active
1. Current model of physician deployment will be kept under active review in the context of the changes to managing more patients on an ambulatory
Partially
basis in EAU. This has been supplemented by a level 1 SHO. 75% of Consultant shifts are covered currently, working towards a 95% coverage during completed and will
the winter period.
be monitored
7
ED Additional ED Consultant presence to enhance the capacity for Urgent Care Programme Group
timely management of patients attending ED.
Action being taken
James Price
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(1) (2) Complete
Paul Brennan
11
Flow
Bed management and
escalation triggers
Escalation triggers to continue to be proactively acted on to
influence bed management decisions
Urgent Care Programme Group
1. Internal mechanisms for escalation in place
2. External (system wide) mechanism in use for escalation
12
Flow
Increase discharges
with the support of
SHDS
Role and function of SHDS extended to include therapy and
nursing staff to support a larger number of dependent patients
and promote their rehabilitation at home
Urgent Care Programme Group
1.Nursing staff have been recruited to work alongside care workers with phone based consultant medical advice available to enable broader spectrum (1) Completed
of patients to be managed at home. The expanded service will initially focus on increasing patients discharged following an acute admission.
(2) In progress
2. SHDS currently working in an intergraed way with ORS to promote discharge by pulling patients from the wards.
3. A senior
physiotherapist has been working alongside an SHDS assessor at the front door promoting the use of Ambulatory pathways and expediting discharge.
(1) Liz Hobbs
(2) Liz Hobbs
(3) Liz Hobbs
13
Flow
Portering
Ensuring access to and availability of porters for the transfer
of patients for investigation and to ward areas is not a
constraint.
Urgent Care Programme Group
1. ED Team have reviewed options regarding the portering service with a view to setting up a dedicated portering team for ED and EAU. The preferred (1) Completed
solution is to have a minimum of two porters available to ED/EAU 24/7 without the requirement to use the current telephone booking system.
(2) Underway
2. To be funded from winter pressure funding. Trust to go at risk with regard to recruitment.
Siobhan Hurley / Louise
Rawlinson
14
Use of Transfer Lounge The Transfer Lounge will proactively take patients from all
specialties in the John Radcliffe. Investment in both trained
and untrained staff being made via winter pressure funding.
Urgent Care Programme Group
(1-4) Completed
1. All Matrons in all specialties have a responsibility to actively support the flow of patients by identifying patients to move to the Transfer Lounge
but kept under
before 10.30am.
active review
2. Matrons to support ward staff to obtain early decisions on discharge from all hospital medical teams.
3. Operations Team to support ED and EAU Coordinator by working more closely with the wards to ensure beds are made available much more quickly
than currently. Further support for this ‘hands-on’ role to be provided by the Directorate Operational Service Managers and Matrons with escalation to
the Divisional General Managers and Divisional Nurses when constraints are not being actively and assertively managed.
4. Discharge by time of day to the Transfer Lounge will be reviewed weekly to monitor performance.
5. Breach analysis to be undertaken for any patients discharged direct from the ward (rather than via the discharge lounge).
Lily O'Connor
15
Flow
Patient transport
Ensuring access to PTS does not continue to be a constraint
to both timely discharge and management on an ambulatory
basis
Urgent Care Programme Group
1. Difficulties with booking and accessing PTS are now being reported on Datix
2. Log of transportation issues to be kept in ED/EAU, particularly regarding access to 2 man/stretcher crews
Sara Randall
16
Alternatives to ED
ENT Referral Unit
Expand the hours of operation for the SSIP GP referral Unit.
Urgent Care Programme Group
1. Activity through the designated cubicles on SSIP is currently reported to be low due to limited hours of operation. A bid to extend coverage has been (1) 1.10.14
made as part of winter planning and recruitment is underway.
(2) 31.03.15
2. There is a requirement to formally evaluate the impact of this on the four hour standard performance.
17
Clinical pathway
Dementia
Emergency Department will develop a pathway for Dementia
patients, similar to the already effective Stroke pathway.
Urgent Care Programme Group and
Trust Dementia Strategy Group
1. Initial focus will be on ambulatory management, expediting a return to home as quickly as possible. The In-reach medicine team will be asked to
make early assessment of patients with dementia in ED to enable some patients to be sent home quickly.
2. To be managed within a maximum of 2 hours and where in-patient admission is required patients will be fast-tracked, by rapid assessment, to a
definitive ward (proposed 7C and 7D) with a largely pre-determined set of test results.
3. The pathway will identify those patients that need to be managed in ED but require special input with guidance on how best to accommodate these
patients to reduce any risks to provide staff with more awareness on care of vulnerable patients and / how to communicate with the family
4. The location of the ward (7C and 7D proposed) or other required area will be assessed and agreed with receiving departments within the Division.
Some modifications to the ward environment may also need to be considered as part of this process.
5. Pathway developed with the Trust Dementia lead and the Trust Safeguarding Adults lead, to ensure staff awareness and good practice is included in
any relevant material
6. Staff awareness sessions for the introduction of the pathway.
7. Monitoring of pathway introduction / appropriate use of the pathway
8. Post implementation review of the pathway.
9. Internal ED Training for 12 "Dementia Champions" to cascade learning/support to ED workforce, which includes simulation training, role play, and
environmental factors consideration.
Emergency Psychiatric Service
In addition the Director of Clinical Services is to review Oxford Health EDPS provision as the introduction of the dementia pathway will ensure that
senior nurses flag dementia patients early and that they are seen by the Trust internal Psychiatry Team in ED or on admission. Note this is a gap as
agreed role split between EDPS and internal team excludes internal team from ED but EPDS focus is self-harm.
Progress
Kathleen Simcock
underway and
regular monthly
updates provided
via CQC Action
Plan
18
Physical works
Provision of additional
ambulatory space in
EAU
Works to increase the number of assessment/ambulatory
spaces in EAU by 14. Work to add 5 additional spaces was
completed December 2013 the programme of works for a
further increase of nine will commence in October 2014.
AMR Directorate Urgent Care/Pressures
Group.
Progress reports taken to Trust Urgent
Care Programme Group chaired by Paul
Brennan
Enabling works (internal and external) 26th August – 3rd October
Delivery, fit out & commissioning of Portacabin 7th September – 3rd October
Phase 1 6th October – 5th January
Commissioning of Phase 1 5th January – 9th January
Removal of portacabin & make good 12th January – 30th January
Time scales as
per phasing
Louise Bishop/Louise
Rawlinson/
Siobhan Hurley
19
Physical works
Environmental
improvement actions
identified by the CQC
Privacy and dignity issues
Urgent Care Programme Group
1.All issues identified by the CQC inspection related to privacy and dignity have been completed.
2. Expansion of Resuscitation. There is potential to expand into x-ray and the admissions office. A specification to increase resuscitation bays from 4
to 6/7 spaces has been developed. Discussed with Director of Clinical Services 04/07/2014 - Feasibility study underway.
(1) Completed
(2) Underway
Siobhan Hurley / Louise
Rawlinson
20
Activity Levels
Monitoring attendances at the two EDs
Urgent Care Programme Group
Q1 ED attendances out turned at 35,300 compared to 32,483 for the same period last year, double previous year on year rise. Trajectory of growth
still predicted.
On-going
Paul Brennan
21
Performance
Daily performance review
Urgent Care Programme Group
1. Daily bed state and performance reports circulated in the Trust at regular intervals throughout the day. Actions to be taken agreed at the Safe
Staffing and Capacity meeting.
2. Daily reports showing attendance, admissions and discharges circulated each day.
On-going
Paul Brennan
22
Winter system
resilience bids
Reference has been made throughout the action plan to
elements of capacity which will be funded through winter
pressure funding. In the interests of getting staff into post the
Trust has commenced recruitment to these posts "at risk"
pending confirmation of available funding.
Urgent Care Programme Group and
System Resilience Group
1. Additional beds will be opened on each of the four Trust sites for a limited period to accommodate winter pressures.
2. Investment will be made in additional consultant posts in ED.
3. Staffing in the Transfer Lounge, SHDS, Pharmacy and HCA's in ED will be increased.
4. Investment will also be made in urgent bookable theatre operating capacity, endoscopy and echo cardiography to promote flow on the urgent care
pathway.
5. Short term enhancement to PTS will be made.
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In progress
Neil Cowan
Paul Brennan
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