APPENDIX 1 (May/June 2014 acuity data/July 2014 Nurse Sensitive Indicators)
Medicine, Rehabilitation & Cardiac Division
Ward
Professional Judgement considerations
The acuity and dependency
outcomes
OCE
This ward has a 54.6%:45.4% skill mix however there is a blended skill mix with therapists No change required to
because of the nature of the rehabilitation. There is on-going work to develop the roles of establishment
registered nurses and CSWs more definitively against therapy competencies working with
the CSW Academy. There have been a number of low impact falls with no harm, which is
not uncommon for this patient group.
Gerontology
Skill mix 58%:42%, this is appropriate due to the nature of the care requirements for these No change required to
patients, and there is high input provided by therapists. Senior staff, including Practice establishment
Development Nurses are working with the Care Support Worker (CSW) Academy to develop
and sign off therapy competencies for CSW staff to develop their roles.
There are a number of low impact falls in these wards; with some low grade pressure ulcers
This patient group includes the elderly frail with cognitive impairment. The Falls Safe Care
Bundle is being implemented to assess and prevent falls
Stroke ward
The skill mix is 65.7%:34.3%, and is currently under review as well as strengthening the No change required to
senior team. This unit has a high dependency area and requires a high level of expertise in establishment.
relation to the management of the acute phase of patients admitted with strokes. There have
been only two falls without harm.
Level 7 wards, These wards received an investment in registered nurses, extended ward clerk hours, The combined revised
Short Stay and shared sisters assistants and Practice Development Nurses (PDN). The recruitment to these acuity/dependency tool has not
additional posts was almost complete, although the turnover of band 5 staff has meant that proved very accurate in these
5a (AGM)
the recruitment campaign is not complete as yet. The skill mix is 64.9%:35.1%. The wards and the next review will be
structured foundation year programme for new graduates is being piloted in these wards to focused principally on the
support junior staff through their first year and complete a competency framework with PDN dependency of patients.
support.
No current change to the
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These wards have high levels of patients with cognitive impairment and dependency. establishment required
Deputy Night Sisters are being deployed from the investment to provide supervision out of
hours to junior staff, this service will also cover stroke and gerontology wards.
There are a number of falls in these wards due to the nature of the type of patient group of
elderly frail with cognitive impairment, the majority without harm. The Falls Safe Care
Bundle is being implemented to assess and prevent falls. Additionally there are a number of
low grade hospital acquired pressure ulcers, which indicates early assessment and
intervention. An educational programme for falls prevention and tissue viability care is ongoing to support staff. There is a good reporting culture.
The ward sisters are supported by the divisional nurse and matrons, who are highly visible
on a daily basis.
PAU
The skill mix is 61.3%:39.7%. This ward has a high number of patients awaiting discharge, No change required to
and the level of acuity is less, although dependency high. The turnover is slower in terms of establishment
patient activity.
A very experienced sister who is putting in place activities to support longer term patients
many of who have dementia
The quality indicators report a number of low impact falls without harm, and the Falls Safe
Care Bundle is being implemented in this ward. There are some low grade pressure ulcers
and preventative interventions are taking place. The patient group is largely the elderly frail
patients awaiting placements in care homes and have a delayed discharge due to health
economy wide reasons.
Laburnham
The skill mix is 62.8%:37.2%. This ward received investment to improve the Registered No change required to
Nurse (RN): Patient ratio at night which has improved the level and quality of care provided establishment
and reduced the levels of stress to staff. The long term sister has just retired and the new
post holder is in post.
There are a number of low impact falls without harm and low grade pressure ulcers, and the
Fall Safe Care Bundle is being put in place with a view to managing these incidents as well
as an educational programme to support the tissue viability care.
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Juniper
The skill mix is 60.4%:39.6% and this ward received investment principally to improve the No change required to
RN: Patient ratio at night, as per the ward above. There are variations of acuity for this establishment
group of patients, many with liver disease.
All the medical wards work in partnership to support each other’s staffing levels with a
flexible approach dependent upon variations in activity.
There are a number of low impact falls without harm, low grade pressure ulcers, and the Fall
Safe Care Bundle is being put into place with a view to managing these incidents and a
number of strategies being strengthened to improve the preventative interventions, including
intentional rounding.
Oak
(stroke care)
A very experienced ward sister in post with specialist sister support. There is a high level of No change required to
therapies input and the skill mix ratio 68.7%:31.3%. The level of vacancies is in part level is establishment
due to the recent investment in additional posts. Investment earlier in the year has been
directed toward the improvement in the RN: Patient ratio at night. This ward has highly
dependent patients, many with cognitive impairment.
There are a number of low impact falls without harm due to the patient group, no pressure
ulcers and low levels of medication administration errors. A number of strategies are being
strengthened to improve the levels of falls including intentional rounding
Geoffrey Harris
This ward has high acuity due to the respiratory specialism and a dedicated section of high No change required to
dependency care in the ward. The patient acuity and activity includes a lot of variation, establishment
against staff levels and trends are being monitored. The skill mix of 66.7%:33.3%, and there
is a newly appointed sister in post. This ward has a few low impact falls, but the indicators
are generally good and well managed.
John Warin
This ward has a challenging patient group, many of whom are homeless and have social No change required to
support needs.
establishment
The skill mix is 68.9%:31.1% and this ward is managed by a very experienced ward sister.
This ward has a few low impact falls but the indicators are generally good and well
managed.
Cardiology ward This ward is large with 41 beds including a high dependency unit, and rapid assessment No change required to
unit, and as such the skill mix ratio is of 71.8%:28.2% in order to provide the level of
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Registered Nurse care required. There is a very experienced sister in post and the establishment
indicators include low grade pressure ulcers and falls. The reporting culture is good and the
quality indicators well managed.
Cardiothoracic
ward
This ward is made up entirely of single rooms and has a high level of acuity for patients who There is a local review of shift
are received from the Cardio Thoracic Critical Care Unit in the immediate phase of step hours and skill mix is underway
with staff, in order to support and
down. The skill mix is 69.8%:30.2%.
strengthen supervisory roles to
The skill mix was revised approximately 2 years ago, and due to changes in the level of
junior staff, especially in the high
patient acuity, the trends and variations of acuity are being monitored over time with a view
care area and at night.
to strengthening the supervisory roles to support more junior staff.
There are low levels of low grade pressure ulcers and low impact falls without harm.
EAU JR & HH
The skill mixes are 76%:24% at the JR and 74.8%:25.2% HH. Both units have repeated No change required to
their acuity and dependency twice, and used a tool adapted for an emergency assessment establishment.
units. However, this still does not truly reflect the level of turnover of patients and the
workload generated. Benchmarking and alternative tools are being researched.
Additional support is being put into place to support junior nursing staff to improve clinical
education through practice educator posts.
There are low levels of low grade pressure ulcers and falls.
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Surgery & Oncology Division
Ward
Professional Judgement considerations
Variations to the establishment
Sobell House
This is a partially funded by a charity and provides hospice facilities for palliative care. The No further change required to the
skill mix is 59.6%:40.4% and this reflects the patient group who require a level of acute care establishment
related to their symptom control and medication but remain high in their dependency of care.
There has been a recent strengthening of leadership with a highly visible deputy matron,
and the skill mix has been reviewed in recent months, which has improved the
establishment in line alignment with patients’ needs within this specialty.
There are a number of low impact falls without harm and low grade pressure ulcers,
strategies have been put in place for early intervention and education for staff.
Haematology
The specialist nature of this ward requires a high level of registered nurse skill mix related to
cancer care and the administration of chemotherapy as well as the care of other patients
with other haematology conditions. This is 81.7%:18.3%. The level of acuity is high in these
patients especially on deterioration, and in the cases of Neutropenia and the increased
numbers of patients requiring Bone Marrow Transplants.
The acuity tool identifies some
minor adjustments to the
establishment but this is being
monitored over time especially in
relation to out of hours.
The acuity of patients varies and the level of registered nurse cover is being monitored for
trends to ensure adequate support for patients especially out of hours.
The quality indicators however are well managed and there is a very experienced sister in
post who is about to go on maternity leave with a deputy to be in charge in her absence.
Oncology
This ward cares for patients with a range of oncology specialities which vary in their acuity The acuity tool registers a 7.61
but have been consistently increasing over the past two years. The skill mix is 73.9%:26.1%. WTE requirement. However,
through making a Professional
This is in order to provide the specialist level of care (prostate brachytherapy and
Judgement against activity and
chemotherapy), psychological care and communication with families and specifically the
layout of the ward, this could be
administration of medications. Many patients are cared for through to end of life on this
modified to provide more support
ward, and there can be a higher dependency related to palliative care. There are a few low
care releasing clinical staff. This
impact falls without harm and very low levels of low category hospital acquired pressure
would include additional
ulcers on this ward related to the frailty and nature of this patient group.
housekeeper and ward clerk hours
The ward receives direct admissions from the Triage Unit which has consistently expanded = 1.6 WTE, as well as 1.4 WTE of
the service due to its activity over the past 3 years, enabling patients to be assessed and
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treated, many without admission. However the haematology and oncology wards cover this an RN to cover out of hours shifts.
service overnight and at weekends. There is an exceptionally experienced sister in charge in
this ward.
5F
This ward is a gastroenterology ward with complex cases requiring psychological care due The acuity tool registers 3.77 WTE
largely to patients with eating disorders and long term feeding therapy. There are multiple increase to increase the skill mix in
teams of medical staff (11) who attend this ward, and it has a skill mix of 76.5%:23.5%.
accordance with the increased
acuity issues.
Peer review highlighted some quality issues and additional staff were moved to the ward to
support the service improvements, which have been effective.
The leadership is being strengthened through high visibility of the matron to support staff.
The skill mix and levels of staff do require additional support in relation to the establishment
of staff and the increased level of acuity and complex patient activity.
SEU
This unit is very complex and has multiple levels of in-patient facilities, and a triage area for The acuity tool is registering that
combined the SEU requires overall
surgical emergency cases. It includes wards 5 C/D, D, E & F.
9.6 WTE. However with
The skill mix ratios vary on each level from 66.2%:33.8% on 5C/D, to 71.9%:28.1% on
Professional Judgement and
wards E & F to 80%:20% on ward D due to the fact that it has the surgical triage centre for
understanding the complexity of
all GP referrals in Oxfordshire and this affects turn over and the level of acuity of the
the geography of the wards; senior
patients.
nurses recommend that by
The level of acuity varies on each level. There are a number of low impact falls without releasing registered nurse clinical
harm, and some hospital acquired pressure ulcers due to the level of frailty and acuity of the time through introducing a
patient group. Preventative interventions are being put into place to address these issues.
phlebotomy team on site, would
support the team more effectively.
Jane
Ashley/LGI
This ward has a skill mix of 68.3%:31.7% which is appropriate for this clinical area and it has There is no change to this ward
effective experienced ward sister providing leadership. The indicators demonstrate low establishment
levels of incidents and the quality indicators are well managed.
UGI
This ward undertakes highly complex surgery with high acuity levels post operatively, The acuity tool is registering 3.78
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including bariatric patients referred from Reading.
WTE requirement against acuity.
However the variations in acuity
The skill mix is 77%:23% and this relates to the specialist levels of care required by this
are considered by the senior
patient group, many of whom ‘step down’ from the Intensive Therapy Unit.
nursing team to require further
The levels of quality indicators are low except for low impact falls, and there is strong monitoring over time. This will
leadership from a very experienced sister.
identify trends of escalation against
quality indicators.
Urology
The urology ward undertakes major complex surgery including specialist referrals from other The acuity tool is registering 6.46
sections of the region; this includes a significant increase in cystectomies and radical WTE requirement against acuity.
prostatectomies.
The indicators with the
There is a high turnover of patients and consistently high acuity and dependency levels of Professional Judgement of the
care. Two new consultants have commenced in post and the referral rate has increased senior nursing team, recommends
that there is an investment of 3.5
significantly.
WTE RNs, and 2.8WTE Care
There are low impact falls without harm and a low grade pressure ulcer during this time
Support Workers, which would be
period. There is an acting sister in post who provides strong leadership while the substantive
sufficient to support the increased
sister is on maternity leave.
level of acuity.
Renal
The renal ward provides care for a range of conditions, including those requiring dialysis and The acuity tool is registering 2.73
end of life care.
WTE requirement against acuity,
although the senior nursing team
The skill mix is 72%:28% and this reflects the technical nature of the care for this patient
wish to monitor over the next few
group. There are some low grade pressure ulcers and low impact falls without harm.
months the trend of acuity against
staffing when all of the vacancies
have been filled.
Wytham
This is a ward with variable levels of acuity due to the nature of variation in activity related to This ward is reviewing its trained
transplant surgery which cannot be predicted, and therefore a contingency level of staff are staff skill mix, as an internal
rostered.
process.
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The indicators demonstrate some low impact falls without harm.
E Ward
Horton Hospital
This ward is currently providing care for medical patients throughout the year, and received No change required to
some investment last year to improve the night time ratio of RNs to patients.
establishment
It is not an outlier in terms of indicators and there is very strong sister leadership, and the
senior nursing team have adapted well to managing patients admitted through the
emergency care pathway.
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Neurosciences, Orthopaedics, Trauma & Specialist Surgery Division
Ward
Professional Judgement considerations
Variations to the establishment
Neurosciences
This large ward has a skill mix split of 68%:32% and is made up of 5 areas including one for The acuity data suggests an
high care. It has 89 bed spaces, with a current use of 70 in-patient beds and 12 day increase in staffing establishment.
However the Professional
case/theatre same day admissions and 5 beds that open for expansion.
Judgement of the senior nursing
The ward is undergoing some re-organisation and being split by specialty i.e. neurology and
team recommends that the reneurosurgery to facilitate more effective ward management, which will support the
organisation of the ward structure
strengthening of local leadership.
and organisation will improve the
The quality indicators demonstrate a number of low impact falls without harm in a patient direct patient contact and quality of
group where this is not an uncommon symptom, and for which strategies are put in place to care.
reduce the level of harm. There are also a number of low grade pressure ulcers.
Falls Safe Care Bundle, introduced and rolled out between May and July2014, has resulted
in an overall decrease in falls.
SSIP
The skill mix is 67.9%:33.1%. This ward has low levels of low grade pressure and falls, in No necessity to alter the
part due to the implementation of the Falls Safe Care Bundle that is being implemented. establishments from the acuity
There is an experienced ward sister in post.
review.
6A
The ward has patients with vascular conditions and includes a triage area. The staff No necessity to alter the
undertake thrombolysis treatment which requires level 2 (high dependency care) and 1:1 establishments from the acuity
ratio of RN to patients during the treatment and continuity of care.
review.
These are a high risk group of patients for pressure ulcers, however none have been
reported for this time period and there have been few low impact falls with no harm. The
Falls Safe Care Bundle has been introduced into this ward.
Trauma
(2A & 3A)
JR
These wards have a high acuity levels and a skill mix 62.2%:37.8%.
No necessity to alter the
establishments from the acuity
The quality indicators suggest that for this patient group there are a few low grade pressure
review.
ulcers and low impact falls for this time period. There are experienced sisters in post in all
three wards.
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F Ward
Horton Hospital
F ward has 3 unfunded beds opened intermittently throughout the year as escalation
capacity for the Horton site, not specifically for trauma patients, relying on short term
bank/agency staff in order to support this increase in capacity.
F ward was one of the original pilot wards in the trust when the Falls Safe project was rolled
out nationally, auditing the Falls Safe Care Bundle for the past 2 years.
Blenheim
This ward has a skill mix ratio of 72%:28%, with a stable workforce. An experienced nurse No necessity to alter the
specialist is currently acting into the sister’s role while the substantive sister is on maternity establishments from the acuity
leave. The quality indicators do not flag any specific issues, with a low level of low impact review.
falls.
NOC wards
These wards have a skill mix of 66.1%: 33.9%, and have a stable workforce managing No necessity to alter the
establishments from the acuity
largely elective surgery and treatment.
review.
The quality indicators suggest that there are few low grade pressure ulcers with a good
safety culture of reporting, and low impact falls without harm. These wards are managed by
experienced sisters. Ward C has just been opened for additional elective surgery capacity,
and there are no indicators currently for this ward.
Neuro ITU
The care provided at the Neuro Critical Care Unit at the JR is according to the Intensive No necessity to alter the
Care Society guidelines and is determined by the levels of acuity.
establishments from the acuity
review.
The unit is open to thirteen level 3 critical care beds with the capability to staff up to a
maximum of 15 beds.
Level 3 - is a patient who has multiple organ support i.e. renal dialysis, ventilation,
intracranial pressure monitoring, and requires 1:1 care.
Level 2 - is a patient who requires 1:2 care if the patients are adjacent to each other and
require high dependency care
Level 1 – is a patient who requires a level of observation and care but could be transferred
to an in-patient ward area.
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Children’s & Women’s Division
Ward
Professional Judgement considerations
Variations to the establishment
Childrens’
Services
Childrens’ in-patient wards have a national acuity tool in development and OUH are No necessity to alter the
contributing the data collection.
establishments.
The current staffing model reflects the RCN staffing guidance.
Critical care staffing model reflects the Paediatric Intensive Care Standards
The New Born Care Unit is aspiring to meet the British Association of Perinatal Medicine
(BAPM), OUH isn’t an outlier as a benchmark nationally.
Gynaecology JR
This ward has a skill mix of 64.6%:35.4%. This ward is made up of 20 beds with an No necessity to alter the
emergency direct access service for GP referrals, suspected ectopic pregnancies and other establishments from the acuity
ward attenders. Otherwise this group of patients do not tend to have co-morbidities and are review.
well. The quality indicators are very low, with few complaints, none related to nursing. It is s
stable workforce and led by an experienced sister.
There is a ratio at night of 1RN:10, and this is justified through Professional Judgement due
to the wellness of this patient group and that major surgery is undertaken early in the day.
The matron is considering supporting the early part of the night on week days with twilight
CSW. It does not warrant an additional RN at night as the care is judged to be safe.
Maternity
Services
JR and Horton
Hospital
The annual birth rate across the OUHT is 8,400; the number at the JR services is 6,500.
The acuity levels are assessed on
a 4 hourly basis and recorded on
The acuity of women becoming pregnant is increasing particularly in relation to obesity,
the BirthRate Plus tool.
underlying medical conditions and older women.
The Birthrate Plus acuity tool is used in maternity to calculate on a 4 hourly basis the ratio of
mothers to midwives and has been well established nationally.
The budgeted establishment
(following the business case
The tool is designed to categorise women into 5 levels to determine the level of care and
investment in 2013) is currently
support required from midwives. There are categories for antenatal women, those requiring
appropriate for the numbers and
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induction of labour, intrapartum and postnatal care who are being cared for on the delivery acuity of births.
suite.
The actual establishment will be
Maternity services are offered on 5 sites, the JR and the Horton provide Consultant Led appropriate once all vacancies
care, the Spires is an alongside Midwifery Led Unit (MLU) at the JR and standalone MLU’s have been filled in September
Midwifery
Led at Wantage, Wallingford and Chipping Norton.
2014. The national standard is 1:28
Units (MLUs)
and the Trust will attain 1:28-29 by
The stand-alone MLU’s are staffed by community midwives and Maternity Support Workers
The
Cotswold, (MSW); only Wallingford is open 24 hours as the MSW working nights takes the phone calls September.
Wallingford and for the community and arranges for the on call midwives to provide care to women.
The senior midwifery team
Wantage Units.
maintains a waiting list of midwives
At the JR site there is a triage area, Maternity Assessment Unit and Observation Area where
who have been interviewed and
women requiring a high level of care are transferred; either pre or post birth. Both of these
are suitable to work in the Trust.
areas are staffed with 2 midwives and an MSW.
The JR now has a Delivery Suite Manager in post after a period of difficulty in recruiting a
suitable individual.
In the event of a deficit in midwives across the service against increased levels of acuity,
and/or an inability to provide 1:1 care in labour; the bleep holder is responsible for moving
staff to provide appropriate and safe staffing. If necessary the on call midwives and then the
community midwives are asked to work in the hospital. .
Newly qualified midwives from Oxford Brookes University and 3 experienced midwives have
been offered posts and will start work on dates up until the end of September 2014.
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Clinical Support Services
Ward
Professional Judgement considerations
Variations to the establishment
AICU at the JR The care provided on the Adult Critical Care Units at the JR and Churchill sites are The establishments are currently
and Churchill
managed as one unit with cross cover, dependent upon acuity and numbers of patients. The appropriate for the levels of care
care is provided according the Intensive Care Society guidelines and determined by the required and are flexibly managed.
levels of acuity.
The Critical Care Units (CCU) at
Level 3 - is a patient requiring advanced respiratory support alone or support of at least 2 the JR and CH manage patients at
organ systems. This level includes all complex patients requiring support for multi-organ level 3 the vast majority of the time.
failure.
The CCU at the Horton site
Level 2 - is a patient who requires more detailed observation or intervention, including manages level 2 patients for the
support for a single failing organ system and those ‘stepping down’ from higher levels of majority of the time, but has to
have the capacity to manage up to
care. Two level 2 patients could be cared for by one nurse.
two level 3 patients if activity
Level 1 – is a patient who requires a level of observation and care but could be transferred
requires.
to an in-patient ward area.
Critical Care Unit This unit largely cares for patients who require level 2 care although the levels of acuity are
very variable and level 3 care is common.
Horton Hospital
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