APPENDIX 1 – BATH LHC A&E 4HR Recovery Plan
Key actions to sustain performance against the Emergency Care 4 Hour Standard RUH & Bath LHC
LAST UPDATED 12.05.08
Actions and lead
1. Continuation of the
Discharge assessment team
for a further 3 month period.
Principle: rapid & effective
discharge assessment in
A&E.
Lead: Malcolm Newton,
Divisional Lead, Medicine,
Maggie Depledge
2. Maintain medical bed
capacity in MAU, by moving
patients rapidly out of MAU.
Principle: improving patient
flow throughout the hospital
Lead: Malcolm Newton,
Divisional Lead, Medicine.
Input/area of activity
Timetable and risk
status
Evaluation report for DAT 3 Extension to end of
month pilot completed and July 2008.
distributed to PCT leads
end April.
The DAT will help
reduce admissions
and shorten length of
stay and hence reduce
income to the RUH.
Achieva
ble %
improve
ment
0.15%
Comment/Progress
DAT pilot commenced 25th January in limited form moving to
full team (OT and Physio) from Feb’08.
Further data to assess its cost effectiveness and impact will
be collated for next 3 month period including any issues
relating to community services/ capacity that could have
prevented an admission, actual admission avoidance vs LOS
reduction.
MEDIUM RISK



Introduction of non
verbal handovers
from 7th April 08
Use of pre-emptive
transfers
throughout
medicine to
maintain bed
capacity in MAU.
Maintain for a
Completed & ongoing
Risk increasing in July
due to essential
planned maintenance
leading to closure of
MAU.
Plans to re-provide to
be confirmed by end of
Trust Board
16 June 2008
0.65%
Intervention has had a significant impact. Site managers’
report increased engagement from wards staff resulting from
their sense of control over transfer times, plus ownership of
the problem through the principle of shared risk. Time of Day
of Discharge has improved across medicine.
A significant internal action, turning discharge planning into a
‘performance’ process. This is now beginning to work even in
the absence of the matron, demonstrating a sustainable
change in the culture.
APPENDIX 1 – BATH LHC A&E 4HR Recovery Plan
further 3 months
secondment of a
matron to the role
of Patient Flow
facilitator.
3. Review staffing levels to
ensure extended senior
clinician cover within the
MAU and A&E
Principle: improving patient
flow & most appropriate
person makes the right
decision at the earliest point.
Lead: Lead: Malcolm
Newton, Divisional Lead,
Medicine,
4. Reduce DToCs to a 1%
level or less of the occupied
beds.
Principle: rapid & effective
discharge assessment
Leads:
May.
LOW RISK
Proposal for Emergency
ambulatory care to be
expanded and staffed
through additional
Consultant input.
Financial case for
additional staff may
not be demonstrated
Quicker access to
emergency diagnostics
leading to quicker decision
making & speedier
definitive treatment.
MEDIUM RISK
0.65%
Pilot in place for a 3 month period. MAU clinicians’ LOS
projections are more ambitious than those of in-patient
clinicians. More discharges from MAU/MSSU should result,
with a further reduction in LOS.
Delivered in Gastroenterology and Cardiology
Provide 7 day working by
the medical specialties
Scope on back of the is
potential for the provision
of senior support to the
MIU’s within the community
Individual PCT action plans HIGH RISK
0.5%
for BANES & Wiltshire
PCTs attached at Annex 1 Trajectory & timeline to
be shared at next
Local Care
Implementation Group
BANES PCT: Funding increased for block beds to provide
alternatives to acute care to accommodate CHC patients.
Increased presence of discharge liaison nurse on site to
reduce response times. To work with RUH to increase time of
transfer to community beds to earlier in day.
Wiltshire PCT supporting discharge process with in reach
Trust Board
16 June 2008
APPENDIX 1 – BATH LHC A&E 4HR Recovery Plan
BANES PCT : Stella Doble
Assistant Director Adult
Services/ Tracey Cox,
Associate Director
Commissioning
nurse on 3 month basis to look at discharge pathways to
community.
Wiltshire whole systems action plan in place.
Somerset PCT has provided an in reach nurse for three days
a week to reduce DToCs.
Wilts PCT: Dawn Hales, Sally
Sandcraft, Director of
Nursing.
Somerset PCT: Judith
Newman, Director of
Commissioning, Annabelle
Legg
5. Increase the number of
Medical and surgical wards
discharges per day that occur
in the morning
Position monitored via :Weekly DTOC group
RUH Commissioning College
Wiltshire Whole Systems Group
MEDIUM RISK
0.05%
Assessed as already having an effect. Work is ongoing to
ensure this becomes part of routine practice.
0.05%
Clinicians are discharging well at weekends from the shortstay stream is feeding through to prompt discharges on
Monday. Next steps should include discharge planning 7/7 in
the other in-patient areas. Patient transport arrangements to
be reviewed to support change.
Ongoing
Principle: reducing peaks &
troughs in demand
Lead: Jude French, Patient
Flow Facilitator
6. Increase the number of
weekend discharges
Weekend plans completed MEDIUM RISK
by Friday lunchtime with all
potential discharges having
Principle :- 7 day working and both discharge summaries
reducing peaks & troughs in
complete and TTO’s written
demand
and supplied to the ward.
Lead: Dr Hubbard, Chair of
Medical Division and Jude
Trust Board
16 June 2008
APPENDIX 1 – BATH LHC A&E 4HR Recovery Plan
French, Patient Flow
Facilitator
7. To treat and discharge all
minors within 2 hours.
Plan to be developed by
ED department
Principle: rapid & effective
discharge assessment in
A&E.
Lead: Mandy Rumble,
Clinical Services Manager
8. Increase overall capacity
through the reduction of LOS
for all specialties with
particular attention to those
currently above the national
ALOS.
Plan to be agreed by
end of June 08.
0.25%
To assess best practice from elsewhere.
0.15%
Individual PCT service development groups in place.
Joint PCTs and RUH meeting to be arranged for June 08 to
share plans for 2008/09 and assess potential for further joint
working.
0.15%
Joint working group of A& E staff and Trauma team to be
established.
High risk
Key work streams in Falls,
Stroke and COPD linked to
commissioning intentions
for 2008/09.
MEDIUM RISK
Pathway in place by
beginning of June 08Mr S
Hart
MEDIUM RISK
Ongoing
Principle: Treating patients in
a timely manner
Lead: Tracey Cox, associate
Director, Commissioning (as
lead Commissioner) Dr
W.Hubbard, Chair Medical
Division
9.Reduce the incidence of
orthopaedic injury breaches
through the establishment of
an assured trauma pathway.
Trust Board
16 June 2008
APPENDIX 1 – BATH LHC A&E 4HR Recovery Plan
Principle:-Treating patients in
a timely manner
Lead: Steve Hart, Divisional
lead Surgery
10. Reduce Ambulance
Conveyance rates to the
RUH
Principle: peaks and troughs
in demand to be reduced and
most appropriate use of
whole system resources
Lead: Corinne Edwards,
Urgent Care & LTC lead,
BANES PCT , Sally
Sandcraft, Director of
Nursing, Wiltshire PCT
12. Reduce and then
eliminate Ambulance off load
waits, by the use of preemptive transfers from ED to
MAU and MAU to the
general/specialist wards.
RUH has the highest
number of ambulance
conveyed patients
compared to nearby
hospitals.
HIGH RISK
0.25
Implementation of CMS programme to allow ambulance
crews, GPs, community teams and other providers to access
up to date information about all services and capacity
availability.
To reassess potential for clinical desk to provide a hub for
ambulances to seek advice using CMS and access further
clinical advice.
Wiltshire PCT Urgent care GP targeting GWAS calls to
prevent admissions. Service to commence May 08
Individual; PCT trajectories for a reduction in conveyance
rates to be agreed.
New pre-emptive transfer
protocol produced.
MEDIUM RISK
Eradicate . 45 min
breaches by July 31st
2008.
Principle: Reduce peaks and
troughs in demand
Lead: Mandy Rumble ,
Clinical Services Manager
Trust Board
16 June 2008
Ambulance waits reducing. Monitored at weekly taskforce
meeting
APPENDIX 1 – BATH LHC A&E 4HR Recovery Plan
13. Reduce and then
eliminate delays for mental
Health assessment in A&E
and on wards and ensure
timely transfer on
Obtain faster mental health
liaison response for
inpatients.
HIGH RISK
Lead: Diane Fuller, Director
of Patient Care Delivery,
RUH
Tracey Cox, Associate
Director of Commissioning
B&NES PCT
Trust Board
16 June 2008
Mapping of provision and funding of existing adult and older
people’s liaison services underway.
Urgent Care Implementation Group to carry out themed
review at June 08 meeting.