GLOUCESTERSHIRE HOSPITALS NHS FOUNDATION TRUST
EMERGENCY PATHWAY IMPROVEMENT PROJECT
MONTHLY PERFORMANCE REPORT: APRIL 2013
1.
Executive Summary
Key messages


Trust-wide 4 hour Emergency Department (ED) performance in March 2013 was
86.8%
General and Acute average length of stay for non elective admissions for March
2013 was 6.26 days which is above 2011/12 level and behind the 2012/13
internal target of 5.5 days.
Key programme risks




2.
gaps in ED doctors’ rotas remain the biggest risk to delivering ED performance
winter pressures have had an impact on bed occupancy. In March 2013, 43.5%
of all breaches of the 4 hour target in ED were due to waiting for beds.
Emergency Department attendances continue to rise and emergency admissions
continue to exceed plan by 5.4%
enhanced performance is dependent on countywide projects to reduce ED
demand and speed up discharge processes that GHFT is not leading
Report Purpose
To report performance on the key performance indicators together with a summary of
progress against winter planning, key risks identified and the latest Emergency Care
Board (ECB) milestone plan. The report reflects data up to 31st March 2013.
The emergency pathway performance management metrics enables the Board to track
where changes are delivering sustainable performance and identify where further
focus and effort is needed.
3.
Emergency pathway metrics
The diagram on next page shows the key processes within the emergency pathway.
Each process step is colour coded according to performance and sustainability,
defined as:



blue
green
amber

red
- process in control, performance sustained > 3 months
- process measure performance on target
- process measure performance moving in right direction but not
achieving target
- process measure performance off target.
Numbers in brackets refer to paragraph numbers that show the relevant process
measure in more detail.
Improve Emergency Pathway – Monthly Report
Council of Governors – May 2013
Page 1 of 17
GLOUCESTERSHIRE HOSPITALS NHS FOUNDATION TRUST
Figure 1 Emergency pathway key process measures:
[3.8] Gen & Acute ALOS
[3.9] Respiratory ALOS
[3.1] ED attendances
Attendances
[3.3] ED
performance
Emergency
Department
[3.4] Emergency
admissions
Admission
rate &
volume
Ambulance
handovers
[3.9] Cardiology ALOS
[3.9] GOAM ALOS
Acute Care
Surgical
Assessment
Units
[3.2] Ambulance
handover delays
[3.7] ESAU
activity
Front door
3.1
[3.5] ADU attends
[3.6] <2 day LOS
Short-stay
Specialty
wards
[3.10] Patients medically
fit for discharge
Discharge
Respiratory
Cardiology
GOAM
Specialist care
Discharge planning
ED attendances
Aim: To ensure ED attendances remain in line with 2012/13 plan of 120,000.
How: Telehealth, Community Discharge Team (CDT), Frail Elderly pathway, Choose
well campaign, Single Point of Clinical Access (all included in NHSG countywide action
plan).
Narrative: ED attendances in March 2013 were similar to the level of attendances in
the previous month. On average 201 patients attended ED in Gloucester per day and
133 patients per day attended Cheltenham ED during March 2013. Performance in
March 2013 is being delivered against 2.1% higher activity than the same period in
2011/12.
A total of 121,238 ED attendances occurred in 2012/13.
3.2
Ambulance handover delays
Aim: Reduce ambulance handover delays to 50% of 2011/12 average .
How: Increase ED resuscitation and majors capacity, doctor and nurse rotas better
aligned to demand, designated ambulance liaison nurses, improved reporting,
developing escalation plans and use of Rapid Assessment and Treatment (RAT)
model.
Narrative: The number of ambulance delays in March 2013 has increased compared
with February 2013, to 500. There has been a slight increase in number of patients
arriving to ED by ambulance in March 2013 compared with the previous month.
Ambulance handover delay chart is displayed on next page.
Improve Emergency Pathway – Monthly Report
Council of Governors – May 2013
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GLOUCESTERSHIRE HOSPITALS NHS FOUNDATION TRUST
Ambulance Handover Delay Chart:
GLOUCESTERSHIRE HOSPITALS NHS FOUNDATION TRUST
Ambulance Delays over 20 minutes 2012/13
(based on GWAS/SWASFT data)
550
500
No. of Ambulances
450
400
350
300
250
200
150
100
50
Apr-12
May-12
Jun-12
Jul-12
Aug-12
Over 20 mins (< = 1hr)
3.3
Sep-12
Over 1 hr (< =2hrs)
Oct-12
Nov-12
Over 2hrs ( <= 3hrs)
Dec-12
Over 3hrs
Jan-13
Feb-13
Mar-13
Trajectory
ED performance
Aim: To consistently deliver the national 4 hour performance standard
How: ED and length of stay initiatives defined in ECB action plan
Narrative: The table and graph below show ED performance against an improvement
trajectory and national standard. A comprehensive weekly ED performance metrics
pack is used to track performance and direct interventions. High hourly attendances,
dependency, acuity of patient and high bed occupancy in hospital contributed to not
achieving the national target.
3.3.1 Four-hour standard
Metric
Jul-12
Aug-12
Sep 12
Oct-12
Nov-12
Dec-12
Jan-13
Feb-13
Mar-13
CGH trajectory
95%
96%
96%
97%
97%
97%
97%
97%
97%
CGH actual
96.8%
98.1%
98.6%
97.3%
96.4%
93.9%
94.1%
92.65%
58.3%
GRH trajectory
GRH actual
97%
95.8%
98%
95.9%
98%
95.9%
97%
94.8%
97%
94.3%
97%
91.6%
97%
94.5%
97%
93.34%
97%
87.7%
Trust trajectory
96%
97%
97%
97%
97%
97%
97%
97%
97%
National std
95%
95%
95%
95%
95%
95%
95%
95%
95%
Trust actual
96.2%
96.9%
97.2%
95.9%
95.2%
92.6%
94.42%
93.08%
86.8%
Four-hour standard graph:
4-hour performance
100%
95%
90%
85%
80%
75%
Apr-12
CGH trajectory
CGH actual
GRH trajectory
Trust trajectory
National std
Trust actual
May-12
Jun-12
Jul-12
Aug-12
Sep-12
Oct-12
Month - year
Nov-12
GRH actual
Dec-12
Jan-13
Feb-13
Mar-13
3.3.2 Breach analysis
Improve Emergency Pathway – Monthly Report
Council of Governors – May 2013
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GLOUCESTERSHIRE HOSPITALS NHS FOUNDATION TRUST
Narrative: A summary of the main contributing factors to ED 4 hour breaches in March
2013 is outlined in the table below:
Total
Breached
CGH
GRH
Total
%
607
763
1370
Breach
due to
Awaiting
Bed
310
287
597
43.5%
Breach due
to Waiting
Assessment
Breach due
to ED
Capacity
128
205
333
24.3%
39
123
162
11.8%
Breach due
to
Undergoing
Treatment
60
66
126
9.1%
Others
70
82
152
11.09%
Breakdown of breaches by type
The methodology used to identify Major and Minor activity is defined as:
Minors: Mode of arrival is not an ambulance and disposal from ED is not admitted or
transferred.
Majors:
 majors Not Admitted: Mode of arrival is an ambulance and disposal from ED is
not admitted or transferred
 medical Admissions: When disposal from ED is admitted or transferred and the
specialty recorded in the first field on Patient First is a medical specialty
 surgical Admissions: As above, but where a surgical specialty has been
recorded.
The graph below is taken from the weekly ED metrics pack and shows the trend in
breach reasons by type for the last 3 months.
The graphs below are taken from the weekly ED metrics pack and show Emergency
Department >4 hour waits split by Major and Minor:
Improve Emergency Pathway – Monthly Report
Council of Governors – May 2013
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GLOUCESTERSHIRE HOSPITALS NHS FOUNDATION TRUST
Major, minor breach split – Trust wide
Major, minor breach split – Gloucester
Major, minor breach split – Cheltenham
3.3.3 National quality indicators
Improve Emergency Pathway – Monthly Report
Council of Governors – May 2013
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GLOUCESTERSHIRE HOSPITALS NHS FOUNDATION TRUST
Aim: To consistently deliver national ED quality standards.
How: ED and length of stay initiatives defined in ECB action plan.
Narrative: In March 2013 quality indicator (QI) number 3, total time in department, and
QI number 5, time to treatment, were not achieved. Waiting for beds is the main
contributor to time spent in ED delays. The ECB is focused on addressing this. All
other QIs were met.
Measure
Target
Jul
12
Aug
12
Sep
12
Oct
12
Nov
12
Dec
12
Jan
13
Feb
13
Mar
13
Unplanned reattendance at
A&E within 7 days
<5%
4.8%
3.7%
2.8%
3%
3.1%
3.9%
2.1%
2.4 %
2%
Total time spent
in A&E
department – 95th
%’ile
95th %’ile
<4hrs
4hr00
m
3h
59m
3h
59m
4h
00m
4h
00m
4h
51m
4h
28m
4h
48m
5h
56 m
%of patients that
leave A&E
without being
seen
<5%
1.9%
1.2%
1.5%
1.3%
1.8%
1.8%
1.8%
1.6%
2.6%
Time to initial
assessment 95th %’ile
95th %’ile
< 15mins
34min
32min
30
min
0 min
0 min
0 min
0 min
0 min
0 min
Time to treatment
Median =
60 mins
53min
43min
54
min
54
min
58
min
57
min
59
min
1h
15 m
1h
1m
3.3.4 Cumulative time spent in the department
Narrative: To better understand the distribution of time spent in the A&E department,
activity has been plotted for admitted and non-admitted patients. This information is
being used to improve awareness and target changes to process.
Total time spent in ED – admitted patients only
GLOUCESTERSHIRE HOSPITALS NHS FOUNDATION TRUST
CGH & GRH ED Total Time in Department - Distribution of Admitted Patients in March
Threshold = 4hrs (95th Percentile)
200
95th Percentile = 07:08
180
No. of Patients
160
140
120
100
80
60
40
20
00:09:00
00:19:00
00:29:00
00:38:00
00:48:00
00:57:00
01:07:00
01:15:00
01:24:00
01:32:00
01:41:00
01:49:00
01:57:00
02:05:00
02:13:00
02:21:00
02:29:00
02:37:00
02:45:00
02:53:00
03:01:00
03:09:00
03:17:00
03:25:00
03:33:00
03:41:00
03:49:00
03:57:00
04:09:00
04:17:00
04:25:00
04:33:00
04:41:00
04:49:00
04:57:00
05:05:00
05:13:00
05:21:00
05:29:00
05:37:00
05:45:00
05:53:00
06:01:00
06:09:00
06:17:00
06:25:00
06:33:00
06:42:00
06:50:00
07:01:00
07:11:00
07:21:00
07:30:00
07:41:00
07:51:00
08:05:00
08:19:00
08:30:00
08:48:00
09:05:00
09:22:00
09:38:00
09:55:00
10:27:00
10:52:00
11:44:00
0
Total Time in Department (hh:mm)
Improve Emergency Pathway – Monthly Report
Council of Governors – May 2013
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GLOUCESTERSHIRE HOSPITALS NHS FOUNDATION TRUST
Total time spent in ED – non admitted patients only
GLOUCESTERSHIRE HOSPITALS NHS FOUNDATION TRUST
CGH & GRH ED Total Time in Department - Distribution of Non-Admitted Patients in March
Threshold = 4hrs (95th Percentile)
90
Median (50th Percentile) = 02:11
80
No. of Patients
70
60
50
40
30
20
10
00:02:00
00:09:00
00:15:00
00:21:00
00:27:00
00:33:00
00:39:00
00:45:00
00:51:00
00:57:00
01:03:00
01:09:00
01:15:00
01:21:00
01:27:00
01:33:00
01:39:00
01:45:00
01:51:00
01:57:00
02:03:00
02:09:00
02:15:00
02:21:00
02:27:00
02:33:00
02:39:00
02:45:00
02:51:00
02:57:00
03:03:00
03:09:00
03:15:00
03:21:00
03:27:00
03:33:00
03:39:00
03:45:00
03:51:00
03:57:00
04:05:00
04:12:00
04:18:00
04:24:00
04:30:00
04:36:00
04:42:00
04:48:00
04:54:00
05:00:00
05:06:00
05:12:00
05:19:00
05:26:00
05:32:00
05:39:00
05:46:00
05:55:00
06:03:00
06:11:00
06:20:00
06:29:00
06:39:00
06:48:00
06:57:00
07:10:00
07:30:00
07:56:00
08:54:00
09:15:00
10:47:00
12:59:00
0
Total Time in Department (hh:mm)
Total time spent in ED – all patients
GLOUCESTERSHIRE HOSPITALS NHS FOUNDATION TRUST
CGH & GRH ED Total Time in Department - Distribution of All Patients in March
Threshold = 4hrs (95th Percentile)
300
No. of Patients
250
200
150
100
50
00:02:00
00:11:00
00:19:00
00:27:00
00:35:00
00:43:00
00:51:00
00:59:00
01:07:00
01:15:00
01:23:00
01:31:00
01:39:00
01:47:00
01:55:00
02:03:00
02:11:00
02:19:00
02:27:00
02:35:00
02:43:00
02:51:00
02:59:00
03:07:00
03:15:00
03:23:00
03:31:00
03:39:00
03:47:00
03:55:00
04:04:00
04:12:00
04:20:00
04:28:00
04:36:00
04:44:00
04:52:00
05:00:00
05:08:00
05:16:00
05:24:00
05:32:00
05:40:00
05:48:00
05:56:00
06:04:00
06:12:00
06:20:00
06:28:00
06:36:00
06:45:00
06:53:00
07:01:00
07:11:00
07:20:00
07:28:00
07:39:00
07:49:00
08:00:00
08:10:00
08:23:00
08:34:00
08:54:00
09:06:00
09:19:00
09:29:00
09:49:00
10:19:00
10:38:00
11:11:00
11:44:00
0
Total Time in Department (hh:mm)
3.4
Emergency admissions
3.4.1 Emergency activity vs. plan
Aim: To ensure emergency activity remains in line with 2012/13 plan.
How: Ambulatory day unit, Rapid Assessment & Treatment (RAT) model, consistent
See & Treat pathway, Community Discharge Team, Internal Professional Standards
between ED and Specialties, senior decision making in ED – support from Acute
Physicians. In addition to the Trust led actions, we are actively engaging with the wider
community to ensure delivery against the countywide action plan.
Narrative: As at end of March 2013, emergency and non-elective activity is 5.2% over
plan.
Improve Emergency Pathway – Monthly Report
Council of Governors – May 2013
Page 7 of 17
GLOUCESTERSHIRE HOSPITALS NHS FOUNDATION TRUST
3.4.2 ED admission rate
Aim: To ensure the admission rate from ED remains in control.
How: Ambulatory day unit, Rapid Assessment & Treatment (RAT) model, consistent
See & Treat pathway, Community Discharge Team, Internal Professional Standards
between ED and Specialties, senior decision making in ED – support from Acute
Physicians.
Narrative: Emergency admission rate in March 2013 was the same as the previous
month at 35%.
Emergency admission and transfer rate:
Gloucestershire Hospitals NHSFT Emergency Department Admissions & Transfers and Admission & Transfer Rate %
(Includes transfers out of county)April 2010-YTD
3.5
Ambulatory day unit attendances
Aim: To increase the number of emergency patients managed on an ambulatory
pathway.
How: Expand pathways and hours of operation of Ambulatory Day Units (ADU).
Narrative: ADU at GRH delivers 8 key pathways. CGH ADU is limited to DVT only.
The Trust has joined Ambulatory Emergency Care (AEC) Delivery Network to increase
the percentage of medical admissions diverted to ADU. The department ran a trial of
running AEC within Emergency Department during March 2013. During this time 54
patients, who would have been admitted if it wasn’t for AEC service in ED, were turned
around in a few hours as a result of the trial. The trial will be repeated from 15 th April
2013 for another month. The ADU ran as usual during the period of trial.
In March 2013, the ADU activity has increased compared with the previous 3 months.
Gloucestershire Hospitals NHS Foundation Trust
Attendances at ADU Clinics Jan 2012-YTD
300
250
200
150
100
50
0
Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12
Attendances
Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13
2012/13 Plan
Improve Emergency Pathway – Monthly Report
Council of Governors – May 2013
AEC Pilot Activity
Page 8 of 17
GLOUCESTERSHIRE HOSPITALS NHS FOUNDATION TRUST
3.6
Medical patients discharged with length of stay of 2 days or less
Aim: To increase the number of short stay discharges.
How: Expand number of acute care beds at GRH to match demand, Acute Physicians
to focus on ACUs, fewer medical outliers.
Narrative: Note the variability of this measure caused by bed pressures in the
hospital. Number of acute care beds at GRH has increased from 25 to 37 in
December 2012 to improve the management of short-stay patients. This enables
Acute Physicians to focus on acute and ambulatory care areas.
Non-elective admissions with LOS<2days:
3.7
Emergency Surgical Assessment Unit (ESAU) admissions
Aim: To increase and sustain the number of patients managed through ESAUs.
How: Establish ESAUs at both sites.
Narrative: ESAU at CGH went live on 21st March 2012,and GRH on 3rd May 2012.
Data showed that the CGH ESAU was not used consistently so it was moved to
Avening Ward at the end of July to make it more accessible and easier to staff. A
formal referral process to ESAU was agreed to ensure rapid patient flow.
CGH
80
Sep12
131
GRH
120
209
181
221
164
175
167
157
Total
200
340
301
339
287
291
271
276
Target
Oct-12
Nov-12
Dec-12
Jan-13
Feb-13
Mar-13
120
118
123
116
104
119
Emergency Surgical Assessment Unit Activity:
Gloucestershire Hospitals NHS Foundation Trust
Emergency Surgical Assessment Unit activity - March 2012 to date
400
350
CGH ESAU
GRH EASU
GHFT Total
GHFT Target
Patients assessed
300
250
200
150
100
50
0
Mar-12
May-12
Jul-12
Sep-12
Nov-12
Jan-13
Mar-13
Month - year
Improve Emergency Pathway – Monthly Report
Council of Governors – May 2013
Page 9 of 17
GLOUCESTERSHIRE HOSPITALS NHS FOUNDATION TRUST
3.8
General & Acute Emergency Admissions ALOS
Aim: To reduce Trust-wide general and acute emergency length of stay to <5.5days.
How: Every patient reviewed every day, EDD, discharges before 11am, ward level
reports, discharge waiting areas, Blaylock tool, ticket home and PAS+.
Narrative: Data shows emergency LOS below 2011/12 level for 9 out of 10 months in
this financial year. In March 2013, the ALOS was 0.76 days above the internal target of
5.5 days.
Trust General and Acute Non-elective ALOS:
ALOS 2012/13
ALOS 2011/12
Target=5.5
3.9
ALOS of targeted specialties
Respiratory, Cardiology and General Old Age Medicine length of stay benchmark 9%
higher than the national average in 2011/12 (using Dr Foster comparator data). The
initiatives defined in the length of stay action plan have therefore focussed on these
specialties first. The reports below show ALOS in these 3 key specialties.
Specialty ward reports are also included to expose variation and to focus on short
interval controls to drive weekly actions. Addressing variation, driving weekly actions
on the length of stay action plan, is the focus of the weekly length of stay project
meeting. Specialty level reports cover the period to end of February 2013.
3.9.1 Respiratory length of stay – specialty
Narrative: Internal target set at 9% below 2011/12 performance, based on national
benchmarking. Respiratory has seen an increase in ALOS in March 2013 compared
with the previous month.
Respiratory ALOS:
ALOS 2012/13
ALOS 2011/12
Target=9.3
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Council of Governors – May 2013
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GLOUCESTERSHIRE HOSPITALS NHS FOUNDATION TRUST
3.9.2 Cardiology length of stay – specialty
Narrative: Internal target set at 10% below 2011/12 performance, based on national
benchmarking. Work to reduce inpatient delay in getting procedures in the cath-lab
(Hartpury Suite) is underway, focussing on improved booking processes and reduced
turnaround times between patients. In March 2013, ALOS for non-elective cardiology
admissions was 7.23 days.
Cardiology ALOS:
ALOS 2012/13
ALOS 2011/12
Target=5.1
3.9.3 General Old Age Medicine (GOAM) average length of stay – specialty
Narrative: Internal target set at 9% below 2011/12 performance, based on national
benchmarking. In March 2013, GOAM saw an increase in ALOS with performance of
12.58 days. Speciality target was achieved for the 12th consecutive month.
Geriatric ALOS:
ALOS 2012/13
ALOS 2011/12
Target=13.9
3.10 Average number of patients medically fit for discharge
Aim: To reduce the number of medically fit patients occupying an acute bed by
speeding up the process of discharging a patient to a community hospital or home with
support.
How: Every patient, every day, Estimated Discharge Dates (EDD), discharges
discharge waiting areas, Blaylock tool, ticket home, Community Discharge Team,
better working with adult social care services
Narrative: The number of people who are medically fit for discharge is managed daily
with our partners. At the end of March 2013 the number was 84.
Improve Emergency Pathway – Monthly Report
Council of Governors – May 2013
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GLOUCESTERSHIRE HOSPITALS NHS FOUNDATION TRUST
3.10.1 Outliers
Aim: To reduce medical outliers to less than 10 across Trust so that patients are cared
for on the right ward.
How: Expanded acute care beds at GRH, Acute Physicians focused on front door,
revised ACU patient categorisation process
Narrative: initiatives as part of the length of stay project such as weekend discharge
team and patient repatriation were focused on to reduce medical outliers. In March
2013, both sites saw an increase in the number of outliers. Bed closures due to
Norovirus outbreaks in CGH were mainly responsible for the increase in number of
outliers in this site.
Outliers at Gloucestershire Hospitals
Gloucestershire Hospitals NHS Foundation Trust
CGH
Outliers at Cheltenham General & Gloucester Royal Hospitals
2012/13
GRH
90
80
70
Number of Outliers
60
50
40
30
20
31/03/2013
24/03/2013
17/03/2013
10/03/2013
03/03/2013
24/02/2013
17/02/2013
10/02/2013
03/02/2013
27/01/2013
20/01/2013
13/01/2013
06/01/2013
30/12/2012
23/12/2012
16/12/2012
09/12/2012
02/12/2012
25/11/2012
18/11/2012
11/11/2012
04/11/2012
28/10/2012
21/10/2012
14/10/2012
07/10/2012
30/09/2012
23/09/2012
16/09/2012
09/09/2012
02/09/2012
26/08/2012
19/08/2012
12/08/2012
05/08/2012
29/07/2012
22/07/2012
15/07/2012
08/07/2012
01/07/2012
24/06/2012
17/06/2012
10/06/2012
03/06/2012
27/05/2012
20/05/2012
13/05/2012
06/05/2012
29/04/2012
22/04/2012
15/04/2012
08/04/2012
0
01/04/2012
10
3.10.2 Readmission rate
Aim: To reduce the number of patients readmitted to the Acute Trust.
How: Review of 70 patients readmitted in March 2012 to identify process and service
changes necessary to prevent those readmissions. A Project was then set-up to
implement the required change.
Narrative: Commissioner and providers met on 30th May and 1st June 2012 to review
case notes of the 70 patients readmitted in March 2012. As a result, two pilot projects
were initiated in November 2012:

follow-up telephone calls to patients discharged from Acute Care

multi-agency review of treatment plans for frequent attendees. This project has
come to end in March 2013 and roles and responsibilities have been identified to
return to ‘business as usual’.
Improve Emergency Pathway – Monthly Report
Council of Governors – May 2013
Page 12 of 17
GLOUCESTERSHIRE HOSPITALS NHS FOUNDATION TRUST
The funding for these projects is from re-ablement money set aside to reduce
readmissions.
Readmission rate has reduced during March 2013 for the second consecutive month.
Emergency activity where patient re-admitted as an emergency within 30 days
Occupied Bed Days
GHNHSFT
Emergency Readmissions following
Emergency Discharge
% Re-Admissions
% Target
Average 2011/12
4,000
3,500
Re-admission rate %
10.00
3,000
8.00
2,500
6.00
2,000
1,500
4.00
1,000
2.00
March
February
January
0
December
November
October
August
July
June
May
April
September
500
0.00
Occupied bed days (re-admissions)
12.00
3.11 Midnight bed occupancy
Aim: To reduce the number of bed occupancies.
How: Every patient, every day, EDD, discharges, discharge waiting areas, Blaylock
tool, ticket home, bed manager walk-downs.
Narrative: Increase in medical outliers and LOS have contributed to higher midnight
bed occupancy (average per day) at both sites.
Bed Occupancy- Cheltenham
Gloucestershire Hospitals NHS Foundation Trust
Cheltenham Midnight Occupancy - Apr 12 to date
14000
Occupied bed days
12000
10000
8000
6000
4000
2000
0
Month
Bed Occupancy- Gloucester
Gloucestershire Hospitals NHS Foundation Trust
Occupied bed days
Gloucestershire Royal Midnight Occupancy - Apr 12 to date
19000
18500
18000
17500
17000
16500
16000
15500
15000
14500
Month
Improve Emergency Pathway – Monthly Report
Council of Governors – May 2013
Page 13 of 17
GLOUCESTERSHIRE HOSPITALS NHS FOUNDATION TRUST
4
Winter Plan Update
4.1
Key Pressures
The key pressures posed by winter include:
 a tendency for a more complex / dependant case mix leading to an increase in
length of stay and a subsequent reduction in capacity
 reductions in timely discharge of patients due to increased demand from the
hospital Trust and primary care for capacity in community / social care
 increased demand for acute services due to higher levels of infection within the
community
 significant peaks of bed closures due to sustained infection (e.g. Norovirus)
outbreaks
 increase in medical outliers due to the above issues
 pressure on adult critical care capacity across the network
 unplanned absence of staff due to seasonal illnesses eg. flu like symptoms and
winter vomiting (Norovirus)
 adverse weather resulting in difficulty in discharging patients and staff getting into
work.
In managing these pressures the overriding objectives are to maintain:
 safe, high quality services for patients including effective management of infection,
ensuring patients are seen in the right place and right time, and maintaining
privacy and dignity
 achievement of key areas of service performance, including Emergency
Department performance for 4 hour waits and clinical quality indicators, ambulance
turnaround times, cancer waiting times and 18 week referral to treatment waiting
times.
4.2
Winter plan additional capacity status
Ref
1
2
3
4
5
6
4.3
Action
Rehab1 Ward, GHT
Kemerton Ward, CGH
Avening Ward (x10
beds)
Additional medical
staffing
Additional paediatric
nurse
Additional therapy
staffing
Plan
1 Nov to 28 Feb 2013
1 Jan to 28 Feb 2013
Further contingency
Status
Opened on 1st November 2012
Opened January 2013
Opened on 1st November 2012
1 Nov to 28 Feb 2013
Appointed
1 Nov to 28 Feb 2013
Appointed
1 Nov to 28 Feb 2013
Appointed
Winter risks
The following risks have been identified:
 increased emergency admissions above plan continue
 insufficient physical capacity to meet the increased levels of emergency
admissions
 insufficient levels of staffing required to care for the increased numbers of patients
 increased numbers of medical patients outlying in surgical wards
 substandard levels of patient care
 failure of key local and national targets
 failure to maintain income levels
 ability to close winter plan additional capacity whilst demand continues to rise

Improve Emergency Pathway – Monthly Report
Council of Governors – May 2013
Page 14 of 17
GLOUCESTERSHIRE HOSPITALS NHS FOUNDATION TRUST
4.4 Winter plan progress
Ref
Milestone
From
Progress Update
1.
General and Old Age Medicine and
Respiratory to increase their bed
complement
by
28
beds
in
Gloucestershire
Royal
Hospital
(GRH)
To open additional short-stay beds at
GRH
To reopen Kemerton Ward on short
term basis as additional winter beds
for General and Old Age Medicine if
required.
Additional locum consultant and
locum junior employed to support
winter pressure capacity
Bed management team to work with
all ward teams to manage patients to
their Estimated Discharge Date
To ensure the additional capacity is
appropriately staffed by people who
are already aware of the Trust
policies and procedures.
Nov 12
Ward 1 opened from
November 2012.
To appoint an additional nurse for
each shift in Paediatric
High
Dependency Unit during the period
November 2012 to March 2013.
Communication plans in place for
Christmas, New Year and school
holidays
Patients discharged from acute care
and respiratory wards to be
telephoned at home to avoid
readmissions
Review of ‘frequent flyers’ to ensure
case management plans are shared
across organisations.
A trial of an extended and expanded
Integrated Discharge Team
To increase the reach of Choose
Well Communications Campaign
Nov 12
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
Oct 12
Jan 13
Nov 12
15.
Improve Emergency Pathway – Monthly Report
Council of Governors – May 2013
Short-stay beds increased to 37
from 12th December 2012
It was required in November
2012 and
being used as
discharge waiting area
G
G
In place from 1st November 2012
G
Nov 12
Nov 12
To be progressed through LOS
Programme Board
Medical
specialties
have
provided GHFT nurses to winter
pressure capacity and backfilled
with bank and agency on their
wards
In place from 1st November 2012
A
G
G
Oct 12
Feb 13
Christmas/New year opening
confirmed and communicated
G
Team in place February 2013
G
Dec 12
Nov 12
Nov 12
Oct 12
Command and control structure in
place to manage infection outbreaks.
Plans in place in case of significant
adverse weather
1st
G
Seasonal Flu Vaccination
14.
Status
Nov 12
Nov 12
High priority patients reviewed
by end December 2012
G
Funding agreed and team being
established
The campaign has launched,
including South West twitter
account which will be available
from w/c 10 Dec 2012
At the end of February 2013,
total of 3,109 were vaccinated
for GHNHSFT.
Tested and applied during
outbreaks in November 2012
Adverse weather policy relaunched November 2012
G
Page 15 of 17
G
G
G
G
GLOUCESTERSHIRE HOSPITALS NHS FOUNDATION TRUST
5
Programme Report
5.1 Programme key milestones 2013/14
Programme objectives for 2013/14 have been renewed and summarised in milestone plan below.
Improve Emergency Pathway – Monthly Report
Council of Governors – May 2013
Page 16 of 17
GLOUCESTERSHIRE HOSPITALS NHS FOUNDATION TRUST
5.2 Programme risks with score >10
NB. Risks are scored in relation to impact on this programme, not the risk to the Trust (Trust risk register scoring).
R
ef
Risk description
Project
impacted
Risk owner
Impact
score
(1-5)
Probability
score
(1-5)
Total
risk
score
Mitigating action
1
Unable to recruit appropriate medical staff to fill
vacancies and rota gaps
ED
Director of
Service
Delivery
4
5
20
 New ED rota tool & process
implemented
 12th ED Consultant advertised.
2
Increase in the number of patients suffering delayed
access to community beds / social care placements
and packages of care increases - then Trust ALOS
is extended, patient flow slows and patients backup in ED
ED
NHSG, GCS,
GCC
5
4
20
 Gloucestershire Strategic Forum
3
If the number of A&E attendances exceeds plan by
1.5% - then performance will be impacted
ED
NHSG
4
4
16
 SPCA
 Choose Well campaign
 Tele-health.
4
If there is a delay in providing alternative services to
an ED attendance or acute admission then there
will be no reduction in readmission rates increasing
costs and limited bed reconfiguration options
Readmiss
ion rates
NHSG, GCS,
GCC
4
3
12
 Integrated care plans for reattenders
5
The Trust targets for LOS are behind the plan. If the
LOS and bed occupancy levels are not reduced,
the winter pressure ward cannot be closed in the
agreed timeframe of end of February 2013
LOS
Director of
Service
Delivery
3
4
12
6
The ED performance has been below the Trust
trajectory and National required standard for the
last 4 months.
ED
Director of
Service
Delivery
5
3
15
 Use Ward Audit Tracker to monitor
performance
 Target areas with lower scores
 Focus on discharges
 Change in the use of Major 2 area
 Trial of bed managers in the ED to
facilitate uninterrupted flow
 Focus on flow in Acute Care units
Report author: Roshan Robati, Programme Manager
Report signed off and presented by: Eric Gatling, Director of Service Delivery
Date: 9 April 2013
Improve Emergency Pathway – Monthly Report
Council of Governors – May 2013
Page 17 of 17