A Vision and Strategic
Direction for Newark
Hospital
Sustainable local solutions for a cherished
healthcare facility
0 2013
October
Contents
Foreword …………………………………………………………………………………………………
2
Summary and Recommendations ……………………………………………………………
3
1.
Vision for Newark Hospital ………………………………………………………..
7
2.
A new phase for Newark Hospital ………………………………………………
8
3.
Listening to the general public –
local views determined the scope of our work ……………………………
12
4.
Urgent care ………………………………………………………………………………… 16
5.
Elective care ……………………………………………………………………………….
20
6.
Communications and engagement ……………………………………………..
25
7.
Workforce, training and development ………………………………………..
28
8.
Transport ……………………………………………………………………………………
31
Appendices
Appendix 1 – Trust and CCG presentations at the workshop ……………………
34
Appendix 2 – Workshop outputs – July 2013 ……………………………………………. 48
Appendix 3 – Urgent Care Data ………………………………………………………………… 53
Appendix 4 – Additional analysis to support urgent care
56
recommendations ……………………………………………………………………………………..
Appendix 5 – Newark Hospital Ambulance Protocol – Version 5 ………………. 65
Appendix 6 – Elective Procedures at Newark Hospital ………………………………
66
Appendix 7 – Transport Group data …………………………………………………………. 73
1
Foreword
Newark Hospital remains very much at the heart of the local community. Changes in recent years
have been controversial and people remain uncertain about what the hospital can provide. This
document sets out a vision for the hospital’s next phase, with sustainable new services for local
people.
When the Keogh Review team visited the hospital in June, they said that we needed to:
‘…determine and clearly articulate and communicate [our] strategic direction [for] the use of the
facilities at Newark Hospital. Ensure that the facilities are adequate for the services to be provided at
Newark and keep under constant review to provide on-going assurance. The Newark strategy needs
to determine the future of the hospital working with the wider health community and social care and
the public.’
This document describes a vision and strategic direction for Newark Hospital that will meet local
population health needs. It aims to give certainty about the future of the hospital, as well as giving
clarity about what can safely be provided at the site. Recommendations have been developed by a
series of working groups using evidence from independent experts, clinicians and local people. The
scope of this work responds to key concerns that members of the public have described.
Although the future of the hospital is assured, we know that we need to continue to introduce more
innovative services and to provide cutting edge services. There are already some shining examples of
this, such as the Fernwood Community Unit and day case surgery. We will continue the important
work that is set out in this document to ensure that the vision becomes a reality.
We will also continue to review new information as it becomes available and will take advice from
independent experts where necessary. We anticipate the publication of the independent mortality
review in November. The NHS England report of surgery at Newark Hospital will also be published in
the near future. The review team have shared their recommendations with us, in order to inform
this work. Plans will be refined as more detail comes to light. We anticipate that the working groups
who have developed this vision will continue to shape comprehensive plans by the end of
December.
We commend this report to you and pledge to ensure safe and sustainable services at Newark
Hospital for the future.
Sean Lyons
Paul O’Connor
Chair, Sherwood Forest Hospitals
Chief Executive, Sherwood Forest Hospitals
Mark Jefford
Amanda Sullivan
Chair, Clinical Commissioning Group
Chief Officer, Clinical Commissioning Group
2
Summary
The development of a vision for Newark Hospital brings certainty about the future of the facility. It
will also provide better information about what can be delivered locally.
Newark Hospital will be a centre of excellence for a broad range of diagnostic, rehabilitation and
treatment services – including urgent and planned care. Most local people will be able to see their
consultant locally and will be able to have rapid assessments and diagnosis through the Minor
Injuries Unit or rapid access clinics (the same or next day). Increased numbers of non-complex
surgical operations will be performed at the hospital. Newark Hospital will continue to provide
inpatient beds and facilities.
Newark Hospital will also be an intersection where hospital and community services meet. GPs
will work alongside hospital doctors and nurses in the Minor Injuries Unit during evenings,
holidays and weekends. The community teams (including nurses, GPs, mental health workers,
voluntary sector and social workers) will have a base at Newark Hospital so that new relationships
can flourish in the interests of local people – services will be more flexible and joined up around
the needs to individuals and their carers.
Recommendations
Urgent care
Newark Hospital should continue to provide sub-acute care1, based on the existing
ambulance diversion protocol.
Refine the ambulance protocol to include additional sub-acute presentations that could
safely be treated at Newark Hospital as new information comes to light.
Develop ambulatory care (rapid assessment for patients who are able to walk in)
services at Newark Hospital in line with learning from King’s Mill Hospital developments.
Stroke and heart attack protocols should remain as they currently are. Outcomes will be
monitored to ensure that mortality and morbidity from these conditions continues to
improve.
Sub-acute medical admissions to Newark Hospital will continue until 7pm.
GP out-of-hours services should be integrated with MIU (6-12pm, weekends, bank
holidays). Clear plans should be in place by the end of December.
Potential GP out-of-hours walk-in facilities will be explored at Newark Hospital, in line
with PC24 at King’s Mill Hospital. This should be determined by the end of December.
The Fernwood Evaluation Group should consider the feasibility of extending GP
admissions to cover weekends as well. This will need further consultation with the GP
1
Sub-acute conditions are generally of moderate severity and duration. They generally develop more slowly
than acute illness, often over a few days. They are also different from chronic conditions, which are long -term
diseases that remain stable for periods of time. Sub-acute care may also include recovery following an acute
illness.
3
out of hours provider. If no operational or safety issues emerge then this extended
service should be operational by the beginning of 2014.
Elective care
The Keogh Review team asked NHS England to conduct an external assessment of surgical
care at Newark Hospital. Recommendations have been received, although the full report has
not yet been published.
Sherwood Forest Hospitals and commissioners fully accept the NHS England
recommendations, set out below:
“The review team does not consider that the site in its current format and with its current
staffing structure is suitable for the provision of inpatient surgery.
The review team felt that the current out of hours cover was insufficient to allow the safe
management of a surgical emergency and that the management of a medical
complication was likely to fall below the standard expected from that available in a fully
staffed general hospital.
The review team considered that the current level of surgical support from King’s Mill
Hospital was inadequate and that the current process of transferring sick patients from
Newark to King’s Mill was unsafe.
The surgical review team recommends that abdominal cavity surgery (general surgery
and gynaecology) remains excluded from the range of surgery provided at Newark
hospital. The review team considers that the Trust should urgently consider the issue of
out of hours care for the remaining surgical inpatients and either improve the cover or
relocate major joint surgery to King’s Mill Hospital. In the meantime, all major surgery
should be undertaken on morning lists with onsite afternoon surgical and anaesthetic
cover and daily post-operative ward rounds by a surgical specialist doctor2.”
The local working group also developed a set of recommendations that are in keeping with the NHS
England findings:
Consider extending hours of diagnostic and outpatient facilities (after 5pm and
Saturdays).
Develop Newark Hospital and supporting community facilities into a high-quality local
diagnostic assessment and outpatient unit, allowing the people of Newark & Sherwood
to avoid travelling for these procedures.
Deliver as much non-complex surgery and medical treatment (such as day case surgery)
as possible on site. Procedures of either a certain level of complexity or degree of
specialisation (i.e. very rare) would then be referred to a main centre.
The trust and commissioning boards will consider the recommendations of the working
group at their October meetings and will determine a direction of travel for elective
services. Plans for elective surgery at Newark Hospital will be drawn up by the end of
December, in light of the full NHS England report.
2
This has already been introduced for safety reasons.
4
Communications and engagement
Promote Newark Hospital at local events (e.g. Southwell show) and through local groups
(e.g. patient participation groups, trust members).
The trust and CCG should jointly provide consistent information and messages to the
public using a variety of methods (e.g. websites, facebook and twitter).
Proactively release positive stories to reduce negative speculation.
Use trusted sources to communicate (e.g. hospital staff, mail drops, village magazines,
The Voice).
Ensure staffs are well-informed and can act as ambassadors for the hospital.
Hold regular open days.
Ensure on-going and honest dialogue with local communities through a variety of
methods and groups.
Provide regular information to GPs so that they are aware of the services at Newark
Hospital.
Ensure information about Newark Hospital is available in GP surgeries.
Maintain and publicise directory of services.
Workforce, training and development
Create a sustained publicity campaign to help change the perception of Newark Hospital.
Develop a targeted and specific approach to the recruitment of staff at Newark Hospital.
Improve the working environment at Newark Hospital.
Introduce career pathway and succession planning development.
Improve the accessibility of Trust specialist training courses and launch of Trust wide
initiatives and development opportunities.
Ensure that the current and future workforce is supported in their continuing
professional development requirements.
Transport
Review hours of operation of Newark and Sherwood urgent care ambulance and
consider whether capacity needs to be increased at peak times / overall operating hours
need to change. The review should be completed by the end of December and
commissioned for 2013/14.
Monitor transfer rates out of Newark for acute care. Link with urgent care refinement of
the ambulance diversion protocol.
The pilot of community paramedic additional cover in rural areas should be supported
and the impact of this scheme should be closely monitored.
Review the impact of sobering up schemes elsewhere in the country. This should be
completed by the end of December in order to inform commissioning decision for
2013/14.
Ensure that ambulance response times are reported at CCG level.
5
Encourage good community first responder cover across the community.
Undertake further analysis of voluntary driver schemes and Non-Emergency Patient
Transport. This should be completed by the end of December 2013.
Investigate whether out-of-hours doctor vehicles could support non-emergency
transport in hours. This should be completed by the end of December 2013.
Influence the bus company to extend the 28 bus route to Newark Hospital and King’s
Mill sites or to develop a shuttle service. The viability of such a service would need to be
taken into consideration.
6
1. Vision for Newark Hospital
Newark Hospital will serve increased numbers of local people, building innovative and excellent
services that can be provided safely within the existing infrastructure. Services will be developed
to deal with the main health needs of local people and health outcomes will be improved.
Confidence in the hospital will be restored – people will know what services are provided and
there will be certainty about its future.
Newark Hospital will be a centre of excellence for a broad range of diagnostic, rehabilitation and
treatment services – including urgent and planned care. Most local people will be able to see their
consultant locally and will be able to have rapid assessments and diagnosis through the Minor
Injuries Unit or rapid access clinics (the same or next day). Increased numbers of straightforward
surgical operations will be performed at the hospital. Newark Hospital will continue to provide
inpatient beds and facilities.
Newark Hospital will also be an intersection where hospital and community services meet. GPs will
work alongside hospital doctors and nurses in the Minor Injuries Unit during evenings, holidays and
weekends. The community teams (including nurses, GPs, mental health workers, voluntary sector
and social workers) will have a base at Newark Hospital so that new relationships can flourish in the
interests of local people – services will be more flexible and joined up around the needs to
individuals and their carers.
7
2. A new phase for Newark Hospital
2.1 Hospitals have evolved to meet the perceived needs and expectations of the day
Newark’s first hospital was founded by Bishop Alexander of Lincoln to purge him of the sin of
castle building. It was a religious institution that reflected a particular era. The current site was a
workhouse and infirmary. The old pavilion style male and female wings are still evident today,
although they now serve a very different purpose and are part of a national health service. A
maternity wing was added to the hospital through charitable donations in the 1930s and there
was a birth a day in the early 1970s. However, maternity provision changed over the decades
and numbers declined to less than one a week by 1985. By 1988, when the unit was changed
into an outpatient department, only 30/600 Newark births took place at the hospital per year.
Further changes have been made to the hospital in more recent years, following the Newark
Healthcare Review in 2009. The 2009 review was initiated because it was predicted that
the population would increase by 5,000-8,000 by 2026. It was also predicted that the
number of people over 65 years of age would double in that timeframe. The fact that
people live longer is testament to the successes of the NHS over the years. It also means
that we have to develop better ways of caring for the rising number of people with
diseases that become more common in old age.
The review did not save money, but it did bring local services in line with national
standards. There was a public consultation on the proposed changes from November
2009 – March 2010.
A number of service modifications came out of the review – dementia care services in
the community were increased when Friary Ward closed due to quality concerns. People
with complex behavioural problems are now cared for in a specialist environment.
Community services have been strengthened. Newark and Sherwood CCG residents are
some of the first in the country to benefit from pioneering care at home. Teams of
health workers, social workers and mental health workers have been created to provide
better support for people with long-term conditions, so that they require fewer hospital
visits and stays. The new Fernwood Community Unit at Newark Hospital is also a
pioneering service for rehabilitation and recuperation. Local residents have some of the
best sub-acute services for frail people in the country. That is in line with our higher than
average numbers of elderly people.
8
2.2 The most controversial change from the Newark Review has been the reclassification of the Newark A&E into a Minor Injuries Unit (MIU) and Urgent Care
Centre.
When hospital doctors and GPs started working together to look at services, it became
clear that there was a pressing safety issue within the Newark A&E. Although the
hospital had appeared to provide a full A&E service for decades, the essential
infrastructure to care for medically unstable patients was not in place. This included:
Intensive care beds
24 hour anaesthetic cover (including life support)
Access to emergency surgical facilities
Enough patients for doctors to develop and maintain the right skills
None of these were present at Newark Hospital. Analysis was undertaken to see
whether Newark Hospital would be able to support an A&E service once the population
growth had occurred. The results showed that this would still not be feasible, as the
numbers of people attending with serious conditions would not be sufficient for doctors
to maintain their skills. The change from A&E to MIU in Newark happened in April 2011.
2.3 There is now an even more pressing need to spend every penny on health and
social care as wisely as possible.
The public sector financial climate is extremely challenging. We anticipate that NHS
funding will remain static in real terms, whilst demand for healthcare will continue to
rise significantly. We currently spend around £20-25 million more than we receive for
health and social care across Mid-Nottinghamshire each year (including Newark,
Sherwood, Mansfield and Ashfield). If we carry on providing services as they currently
stand, this gap is estimated to grow to £70 million within 5 years and £140 million within
10 years. The increasing gap is mainly due to the anticipated increase in demand for
services through population growth and longer life expectancy.
The funding available to local authorities for social care has been reduced in real terms.
From 2014/15, around 3% of health and social care funding will be formally pooled in
order to join up NHS and social services more. All health and social care spend will need
to be considered in the round if services are to have maximum impact for local people.
There are currently some unhelpful divides between health and social services and
people tell us that they find it difficult to work out where to go to access certain
services.
9
In view of this, an analysis of health and social care took place across MidNottinghamshire in the early part of 2013. A roadmap for future service quality and
sustainability has been developed. This will form the basis of future public engagement
and planning processes. The roadmap will be developed into detailed implementation
plans over the coming months so that we are able to ensure sustainable, high quality
services for our population. Core proposals provide a strategic framework for
considerations concerning the future of Newark Hospital. The main components of the
roadmap are shown below:
Mid-Nottinghamshire health and social care roadmap for the next 5-20 years
Long-term
3
conditions
Urgent care
–
Elective care
Women and
children
Review each specialty to ensure that safety and viability
standards are met – use existing capacity more
effectively
Provide rapid medical assessments for children and
pregnant women. Ensure that children with complex
needs have joined up packages of care and more support
in community settings
2.4 The hospital trust and commissioners have a shared commitment to sustaining Newark
Hospital as a vibrant and viable healthcare facility.
History tells us that hospitals have to change and adapt if they are to thrive. Changes within
Newark itself are evident and the hospital now serves different population needs. We are now
planning the next phase for the hospital. It will be required to care for a growing population with
a diverse range of health needs. This will include young children and families, middle aged
people and growing numbers of older people.
3
This stands for profiling risk, integrated care, self-management
10
2.5 There are two very significant external influences for Newark Hospital that have to be
taken into account.
The first of these is the development of modern medicine and patient safety standards. There
have been significant medical advances over the last decade. Long-established traditions of very
small hospitals offering care for serious life-threatening conditions are now seen as sub-standard
because these hospitals cannot provide modern-day levels of expertise and infrastructure. It is
imperative that local services can meet national safety and professional standards.
Sherwood Forest Hospitals was one of 14 trusts that were part of the Keogh Review. This was
because the hospital standardised mortality ratio (HSMR) was higher than expected. A number
of recommendations were made in relation to patient safety and have been acted on. Future
services at Newark Hospital must take these recommendations into account. A further NHS
England review of elective surgery at the site is nearing completion. Recommendations have
been received and the full report is due to be published in the near future. This vision will take
the full findings of that review into account, once they have been published. A further
independent review of factors influencing mortality is also due to be published imminently. That
report will also influence future service development in and around Newark.
The second important influence is the geographical location of the hospital and surrounding
transport systems. Over £500,000 (above normal contract levels) is spent on additional
ambulance services across Newark and Sherwood. However, i mprovement is still required to
give people the best possible service in an emergency or urgent situation.
The development of the new vision for the hospital takes both of these factors into account. It
can be a fine balance between ensuring that people get the best care in main hospital centres to
improve their outcomes, versus local concerns about travel times and access. As such, we aim to
provide as many safe services as possible in Newark. We will primarily focus on services that
meet the needs of large numbers of people rather than specialist services that only serve the
few.
11
3. Listening to the general public – local views
determined the scope of our work
3.1 Newark Hospital is much-loved by local people and hospital staff – changes are always
controversial.
The hospital trust and commissioners have engaged extensively with local communities over the last
few years, although necessary changes in the interests of patient safety have not always been
popular. A very active campaign group was established in 2009 and has continued to
campaign on increased emergency treatment in Newark over the last few years. This has
resulted in significant media coverage. It is clear that there are different views about the
changes, although some views are more publically aired than others.
Newark Hospital is a lovely facility for certain types of healthcare and should be promoted
within that context. However, doctors and many members of the public believe that trying
to use the facility for emergency treatment of unstable acutely unwell medical patients is
unsafe and will not best serve local residents in the longer-term. Local people consistently
tell us that heated debates and adverse media coverage concerning emergency care have
resulted in a loss of confidence in the hospital and confusion about what can be provided
there. Despite that, people who have been treated there generally have nothing but praise
for the staff and the services provided.
3.2 The development of a future vision for the hospital aims to give people certainty
about the future of the hospital. It will also provide better information about what
can be delivered locally.
Key concerns that have been expressed in recent years are:
Newark needs more emergency care to prevent transfers out of the area and long
journey times.
Transport links to other areas are poor, particularly between Newark Hospital and
King’s Mill Hospital.
People don’t use the hospital because they don’t know the extent of what it can
provide.
The hospital is being run down and will close.
12
Mortality rates are comparatively high in Newark and have been made worse by the
2009 Newark Review.
Lack of vision and plans for the hospital.
Some steps have been taken to ameliorate these concerns. These include provision of a link
bus between Newark Hospital and King’s Mill, additional ambulance services, hospital
adverts in the Newark Advertiser and open public events, open days and an independent
review of mortality.
Representations were made to the Keogh Review team through listening events and other
means. A commitment was made to define and publish a vision for the hospital that would
form part of the trust’s submission of a plan to Monitor by the end of October 2013.
A workshop was held in July 2013, in order to identify the areas of concern and agree a plan
of work to define the future vision. Current provision at the hospital was described and data
regarding activity levels were presented (Appendix 1). Issues that required resolution were
also highlighted and themed (Appendix 2).
Open drop-in sessions were also held during September, in order to give people additional
opportunities to influence the vision for the hospital. The sessions were advertised locally
and around 25 people attended. A number of themes emerged, which largely reflected
previous feedback:
The overwhelming theme that emerged was the need to ensure that Newark Hospital is
a vibrant healthcare centre and provided high quality care that was close to home.
People talked of their passion to see as many services as possible in their hospital.
People want to see services are provided for people that need to come into the hospital
from their own homes as well as coming back from other hospitals as quickly as possible.
Key services included access to a full range of diagnostics alongside a good range of
surgery. A number of people identified the need to ensure that the hospital was fully
functional 24 hours a day to encourage this and that part of the perception as to why it
is not as vibrant as it could be was a direct relationship to the fact that doctor cover was
not available 24 hours a day in all specialities.
People talk with pride about the excellent, friendly care that they received in a clean
hospital. This was very important to people and they talked about the time staff have to
care for them as a person and not a number. Many said that they didn’t get this in other
NHS hospitals.
People talked about the need for specialist care to be provided for the people of
Newark. This did create a greater divide in opinion. Some people recognised the need to
be treated in specialist centres in places like Nottingham, Mansfield and Lincoln – but
13
wanted to have a quick transfer back to Newark once their acute illness was over. Other
people were passionate around ensuring that Newark Hospital needed a fully
functioning Accident and Emergency Department seeing conditions like stroke and
myocardial infarction (heart attacks).
The need for Newark Hospital to develop an area of speciality and a centre of
excellence that people would travel from beyond the natural catchment area was
viewed as a way of building the attractiveness of the hospital to patients and staff (e.g.
Newark Hospital being a centre for Orthopaedics).
Access to care was identified in a number of ways including the difficult journey and
travel times to get to other hospitals for both patients and visitors. People saw that this
was difficult when combined with an ambulance service that was not delivering the best
service possible for the people of Newark.
Information about what Newark Hospital provides was seen as a reason why people did
not access Newark Hospital effectively. There was a desire to see their family doctor as
well as themselves better informed about the services so they can choose to have their
care at Newark Hospital. There was a sense that the referral process into hospital care
was stacked against Newark Hospital as a first choice.
The need to get staff with the right skills and knowledge was seen as important. There
was a sense of ‘chicken and egg’ in getting staff – people talked about the need to have
the vision of services and deliver a fuller range of services to be able to get great staff
and that was a major reason why people wouldn’t see Newark as a dynamic place to
work. There was also a feeling that some staff didn’t want to work at Newark and the
need to also ensure that the doctors that go to Newark need to be passionate about the
place.
A sense that the plans were not ambitious enough came through and are we thinking
broadly and with enough innovation. One person talked of the need to look at areas
outside of England that have rural challenges and how they deliver healthcare – and
whether we are relying on methods of healthcare delivery that were better designed for
urban areas.
Other specific areas of insight included; Newark citizens would be happy to pay a
separate tax to keep a fully functioning hospital (hypothecated taxation), that the
hospital at King’s Mill was draining resources away from the hospital, the NHS needed to
be more efficient and staff in uniform should not wear it in while shopping in Newark.
The similar themes arising from the July workshop (Appendix 2) were used to develop the
work plan. A working group was established for each theme, namely:
14
Urgent care
Elective care
Transport
Communications and engagement
Training and development
Group membership comprised hospital managerial staff and clinicians, commissioners, GPs,
patient representatives, governors, EMAS and councillors. This diversity of group
membership enabled a wide range of views to be expressed and explored. The outputs from
the groups followed robust debate concerning very sensitive and long-standing issues.
Majority views are shown in the recommendations, although some group members were
not entirely in agreement with the conclusions reached by the groups as a whole.
The working groups met on two occasions, initially to review the workshop outputs and to
commission further analysis where required. The second meetings involved a review of the
data and information that had been obtained, as well as the formulation of
recommendations.
The discussions and recommendations from each of the working groups are presented in
the following sections 4.
4
Data and information available to the working groups are presented in the appendices. Notes and action
points from the working group meetings are available on request.
15
4. Urgent care
This working group reviewed urgent care services that are provi ded at Newark Hospital, including
the Minor Injuries Unity (MIU), GP out-of-hours care and sub-acute medicine.5
The MIU is open 24/7. Sub-acute medical admissions are permitted until 7pm. Most admissions are
via GPs. There has been a 2% increase in Newark residents attending King’s Mill A&E since 2010/11
and this is in line with national increases. Very few people attend Newark MIU between 12pm and
6am. MIU attendances have seen a slight downward trend, although there are seasonal variations.
Approximately 75% of people who attend MIU are treated there and do not require further care.
The issues highlighted from the July workshop included:
Thresholds for urgent / sub-acute care at Newark Hospital
Admission criteria / hours of admission
GP / out of hours (OOH) services and single front door
Fernwood Unit – step up / down facilities
Data regarding these services were reviewed (included as Appendix 3). Following discussion, a
further area for consideration was added:
Time taken for heart attack and stroke patients to reach main centres for life-saving
treatments (Primary Percutaneous Coronary Intervention – PPCI – for heart attacks and
guided thrombolysis for strokes caused by blood clots)
Each area was discussed in detail and further analysis of urgent care acti vity was commissioned. The
additional data are included as Appendix 4. The current ambulance diversion protocol for Newark
Hospital is also included as Appendix 5 for ease of reference.
Key discussion points, rationales and recommendations are shown in the table below:
5
Sub-acute conditions are generally of moderate severity and duration. They generally develop more slowly
than acute illness, often over a few days. They are also different from chronic conditions, which are long -term
diseases that remain stable for periods of time.
16
URGENT CARE
Thresholds for
urgent / subacute care
Discussion points / rationale
Recommendations
New admission thresholds were introduced in April 2011. These are
considered successful in providing safe care at Newark Hospital. There
are now few transfers of unstable patients from the medical wards as
the case mix is more appropriate for the site.
MIU self-presenters still need to be transferred at times.
The protocols in place are considered safe. There is an exclusion
protocol in use that results in patients with an increased risk being
taken by ambulance to a main centre. The shortage of consultants
was discussed, which is not driven by an uncompetitive reward, rather
the national and international shortage of specialists.
The hospital has experienced difficulties in recruiting medical staff –
the site does not have Deanery approval for training. It has not been
possible to fill vacancies at times. Sustainability needs to be
considered as part of any future clinical / staffing models.
An assessment area for undifferentiated (undiagnosed) acutely unwell
patients within the MIU is not in keeping with the ‘right place, first
time’ principle. There would be significant patient safety concerns,
since valuable time would be wasted prior to transfer to main centres.
Presentations that may seem relatively minor may belie serious illness
or injury.
6
Newark Hospital should continue to
provide sub-acute care6, based on
the existing ambulance diversion
protocol.
Refine the ambulance protocol to
include additional sub-acute
presentations that could safely be
treated at Newark Hospital as new
information comes to light.
Develop ambulatory care (rapid
assessment for patients who are
able to walk in) services at Newark
Hospital in line with learning from
King’s Mill Hospital developments.
Sub-acute conditions are generally of moderate severity and duration. They generally develop more slowly than acute illness, often over a few days . They are also
different from chronic conditions, which are long-term diseases that remain stable for periods of time. Sub-acute care may also include recovery following an acute illness.
17
URGENT CARE
Time taken for
heart attack and
stroke patients to
reach main centres
Admission criteria
/ hours of
admission
Discussion points / rationale
Recommendations
Current ambulance data show that the worst postcode average red 1
Stroke and heart attack protocols
call to response time is 13.5 minutes (5.5 minutes longer than the
should remain as they currently are.
target time of 8 minutes).
Outcomes will be monitored to
ensure that mortality and morbidity
The worst postcode call to conveyance destination average time is
from these conditions continues to
around 90 minutes. This leaves 30 minutes for PPCI to be undertaken,
improve.
so is within current NICE guidelines which state that the procedure
should be performed within 2 hours.
Thrombolysis treatment for strokes caused by blood clots should be
undertaken within 4.5 hours of presentation. Call to conveyance times
are well within this margin.
There would not be enough cases per year to sustain a PPCI / stroke
thrombolysis service at Newark Hospital, as sites should serve a
population of 400,000 – 500,000. Current sites are King’s Mill, Lincoln
and Queen’s Medical Centre.
There are low numbers of cases overnight
Sub-acute medical admissions to
Newark Hospital will continue until
There would need to be an additional five doctors recruited to deliver
7pm.
a 24/7 admission service at Newark. Even if these were to be
recruited, they would only serve a low number of cases, calling into
question the quality and safety of the service.
‘Twilight’ times of operation were examined, to determine whether
admission times could be extended until midnight. An audit of cases
that were transferred from Newark to King’s Mill who would be
suitable for a Newark Hospital admission showed that numbers of
additional evening admissions would be very low (2-4 per month). It
would not be feasible to increase staff numbers to the required levels
for this number of admissions.
Doctors cannot cross-cover for medical and surgical emergencies, as
they require different types of specialty training.
18
URGENT CARE
GP / out of hours
(OOH) services and
single front door
Fernwood Unit –
step up / down
facilities
Discussion points / rationale
GPs and MIU staff could work more closely together for the benefit of
local patients – there are transferable skills and care could be
provided in a more timely way if teams worked together.
GPs working in MIU would not cover ward areas, as a different skill
set is required.
There is a monthly Fernwood Evaluation Group already in place. This
group will oversee developments in the step up / down services.
19
Recommendations
GP out-of-hours services should be
integrated with MIU (6-12pm,
weekends, bank holidays). Clear
plans should be in place by the end
of December.
Potential GP out-of-hours walk-in
facilities will be explored at Newark
Hospital, in line with PC24 at King’s
Mill Hospital. This should be
determined by the end of
December.
The Fernwood Evaluation Group
should consider the feasibility of
extending GP admissions to cover
weekends as well. This will need
further consultation with the GP
out of hours provider. If no
operational or safety issues emerge
then this extended service should
be operational by the beginning of
2014.
5. Elective care
This working group reviewed the provision of elective (planned) services. This includes outpatients,
diagnostics and surgical procedures (inpatient and day case).
Following the 2009 Newark Review, outpatient activity has increased. Existing capacity is now fully
utilised. There was a view that GPs and members of the public are not always fully aware of
everything that is on offer at the hospital. A number of new services are planned. There is spare
capacity in the minor operations theatre on a Wednesday. Surgical activity data were reviewed
(Appendix 6).
There are two theatres at Newark Hospital and one minor operations theatre. There is also a surgical
ward with 21 beds. Surgical medical cover is 9am-5pm on weekdays. During evenings and weekends,
the MIU doctor covers the surgical and medical wards. Although the MIU doctor is a senior doctor
with experience of resuscitation, they may not have specific surgi cal training. This is different to
main hospitals, where doctors cover medical and surgical wards separately around the clock and
have specific medical / surgical training.
These arrangements were thought to be adequate when the 2009 Newark Review took place, but
were called into question by the 2013 Keogh Review. Medical technology (and the infrastructure
required to achieve optimum outcomes for patients) is continually evolving. The Keogh Review team
had some concerns about the Newark Hospital arrangements and asked NHS England to conduct an
external assessment. Recommendations have been received, although the full report has not yet
been published.
Sherwood Forest Hospitals and commissioners fully accept the NHS England recommendations, set
out below:
“The review team does not consider that the site in its current format and with its current
staffing structure is suitable for the provision of inpatient surgery.
The review team felt that the current out of hours cover was insufficient to allow the safe
management of a surgical emergency and that the management of a medical complication was
likely to fall below the standard expected from that available in a fully staffed general hospital.
The review team considered that the current level of surgical support from King’s Mill Hospital
was inadequate and that the current process of transferring sick patients from Newark to King’s
Mill was unsafe.
The surgical review team recommends that abdominal cavity surgery ( general surgery and
gynaecology) remains excluded from the range of surgery provided at Newark hospital. The
review team considers that the Trust should urgently consider the issue of out of hours care for
the remaining surgical inpatients and either improve the cover or relocate major joint surgery to
King’s Mill Hospital. In the meantime, all major surgery should be undertaken on morning lists
with onsite afternoon surgical and anaesthetic cover and daily post-operative ward rounds by a
surgical specialist doctor7.”
7
This has already been introduced for safety reasons.
20
The local working group developed a set of options for consideration. They then formulated
recommendations that are in keeping with the NHS England findings. The group developed and
considered three options, as shown below:
Option 1
Develop Newark Hospital and supporting community facilities into a high-quality local diagnostic
assessment and outpatient unit, allowing the people of Newark & Sherwood to avoid travelling for
these procedures. Only then have to travel for operations and other specialist treatment.
Option 2
Develop a mixed model at Newark Hospital and supporting community facilities to provide a broad
range, but not all, of diagnostics, outpatient appointments, inpatients and surgical procedures. This
would enable a high-quality generalist facility to the local population, accepting that some
diagnostics and outpatients will have to be provided for elsewhere.
21
Option 3
Look to develop Newark into a specialist centre for particular specialisms, such as completing all
shoulder operations for SFFT. Expand the activity in these areas over time whilst therefore seeing a
decrease in the other treatments provided. This would ensure that Newark has a strong Consultant
presence as well as giving it specific areas it becomes known for.
22
Each of the options was reviewed before making a recommendation. The rationale is shown in the table below:
ELECTIVE CARE
Discussion points / rationale
Recommendations
Option 1
This would allow high numbers of people to be seen
Consider extending hours of diagnostic and
Diagnostic and outpatient
locally.
outpatient facilities (after 5pm and
services only
Saturdays).
Further outpatient services could be developed (e.g.
chemotherapy).
Equipment could be better utilised.
Option 2
This would enable a high-quality generalist facility,
This is the preferred option8.
Mixed model, including
closely linked to population health needs.
Develop Newark Hospital and supporting
diagnostics, outpatient
Some low-volume diagnostics would need to be
community facilities into a high-quality local
and surgical procedures
provided elsewhere.
diagnostic assessment and outpatient unit,
allowing the people of Newark & Sherwood
Surgical case mix (including day case / inpatient) will
to avoid travelling for these procedures.
need to be reviewed in light of NHS England review of
elective surgery at Newark Hospital.
Deliver as much non-complex surgery and
medical treatment (such as day case surgery)
Full surgical rota cover would be required at Newark
as possible on site. Procedures of either a
Hospital if inpatient surgery was to be retained in the
certain level of complexity or degree of
medium-long term. The low volumes of work would not
specialisation (i.e. very rare) would then be
sustain a full surgical rota.
referred out of area.
Option 3
This option may benefit clinical staff, who could
Specialist centre in some
increase their skill level, but it would not serve a wide
areas
range of local population needs.
A few complex services could be provided, but with less
breadth. Again, this would not maximise use for the
local population across a broad range of clinical
conditions.
8
To be reviewed when the NHS England report is received.
23
Following discussion, the group proposed a preferred model for elective care at Newark Hospital, as
shown below:
This model proposes that Newark Hospital provides a wide range of outpatient services, as well as
high volume diagnostic and surgical procedures. This would minimise the need for local people to
travel for straightforward consultations or procedures.
The trust and commissioning boards will consider the recommendations of the working group at
their October meetings and will determine a direction of travel for elective services. Plans for
elective surgery at Newark Hospital will be drawn up by the end of December, in light of the full NHS
England report.
24
6. Communications and engagement
A working group was established to develop ideas about how we engage and communicate with the
general public in the future. Key aims are to provide clarity about what the hospital can offer, as
well as promoting the reputation of Newark Hospital. A further important aim is to develop better
mechanisms for an on-going and honest dialogue with members of the community, so that people
can increasingly influence changes in how care is provided.
Two facilitated workshops were held. Invitees included members of the public, staff, voluntary
organisations, governors, councillors and other stakeholders. A number of questions were posed:
•
How are you currently made aware of services at Newark Hospital?
•
Where do you find out most information about Newark Hospital?
•
Who do you trust when they tell you information about Newark Hospital?
•
How and when should patients, carers and voluntary groups be involved in service planning
and design?
•
What information does your GP or GP practice give you about the type and range of services
at Newark Hospital?
•
What are the barriers to effectively communicating with you about Newark Hospital?
•
How can we help to reduce those communication barriers?
•
How can patients be better educated about the appropriate use of the Minor Injuries Unit at
Newark Hospital?
•
What do you feel is the best way of communicating with you?
A number of themes emerged and these are shown in the table below:
25
COMMUNICATIONS AND
ENGAGEMENT
How and where do you
find out about services at
Newark?
Who do you trust?
How and when to involve
service users?
Discussion points / rationale
Recommendations
Current awareness mainly from:
Trust communications, such as website, Best magazine,
emails to members
Newark Hospital, such as word of mouth, staff and
visitors/patients
Media
GPs and GP surgeries
CCG communications, including website
Staff meetings and staff members informing family
Most trusted sources:
NHS staff, including hospital, GP and EMAS
Hospital managers, hospital Board members, governors
Trust communications
Media
Least trusted sources:
Everyone
Media
Involvement in service planning and design, should be:
As early as possible
Involved in the whole process, at every stage
Before any changes take place
Involving staff as well as patients and carers
Using variety of methods, including:
Questionnaires, surveys
Meetings, focus groups of service users and stakeholders
26
Promote Newark Hospital at local
events (e.g. Southwell show) and
through local groups (e.g. patient
participation groups, trust members).
The trust and CCG should jointly
provide consistent information and
messages to the public using a variety
of methods (e.g. websites, facebook
and twitter).
Proactively release positive stories to
reduce negative speculation.
Use trusted sources to communicate
(e.g. hospital staff, mail drops, village
magazines, The Voice).
Hold regular open days.
Ensure staffs are well-informed and can
act as ambassadors for the hospital.
Ensure on-going and honest dialogue
with local communities through a
variety of methods and groups.
Ensure information about Newark
Hospital is available in GP surgeries.
COMMUNICATIONS AND
ENGAGEMENT
Information given by GPs
Barriers to effective
communication
Discussion points / rationale
Recommendations
Information from GPs:
Overwhelming response that very little information received
from GPs
Respondents felt GPs need to:
Be better informed about services
Be more pro-active about referring patients to Newark
Hospital
Promote Newark Hospital more
Barriers:
Media coverage lacks balance, focuses on negative rather
than positive
Inadequate communications re appointments, sent out late
Language and jargon used by the NHS
Different interpretations of same information
Too much miscommunication in the past
Lack of communication between different NHS services, e.g.
primary and secondary care
Lack of direct mail, door drops.
27
Provide regular information to GPs so
that they are aware of the services at
Newark Hospital.
Maintain and publicise directory of
services.
7. Workforce, training and development
A work stream was established to consider the workforce, training and development needs of the
staff delivering services in Newark and at Newark Hospital
The issues highlighted from the July workshop included:
Recruitment and retention of staff
Location and access for training
Content of training
The work stream considered the following questions to enable development of
recommendations to address the issues highlighted
How can we recruit new staff to work at Newark Hospital and what are the barriers
to achieving this?
What can we do to retain staff and ‘grow our own’?
How can we improve training opportunities for staff at Newark Hospital to equip
them to deliver high quality patient care?
28
WORKFORCE,
TRAINING &
DEVELOPMENT
Barriers to
recruitment of
new staff
Retention of
staff
Discussion points / rationale
Recommendations
Concerns around public perception about the future of Newark Hospital.
Difficulties in recruiting medical staff.
Difficulties in recruiting nursing and AHP staff.
There is a need for the following;
o To develop simple and clear messages of re-assurance regarding the current and
future position of Newark Hospital to both staff and the local population.
o To celebrate the success stories of Newark Hospital.
o To develop a unique selling point for Newark Hospital that can be used to market
services and support recruitment campaigns.
Development of extended roles.
The need for an improved working environment.
The need for more improved career pathways and talent management.
Development of staff in succession planning:
o To identify ways to sell Newark Hospital as an attractive place to work.
o To explore the development of a recruitment package to attract medical staff to
work at Newark Hospital to include lifestyle change, work life balance and study
leave opportunities.
o To explore the development of creating extended roles between hospitals and
explore the possibility for rotating medical, nursing and AHP staff between
Newark Hospital and Kings Mill Hospital. To train managers effectively in sign
posting staff in their career development in order to support succession planning
and talent management opportunities.
o To ensure that succession planning requirements are captured within the Trust’s
Workforce Plan.
o To develop work shadowing opportunities.
29
Create a sustained
publicity campaign to
help change the
perception of Newark
Hospital.
Develop a targeted and
specific approach to
the recruitment of staff
at Newark Hospital.
Improve the working
environment at Newark
Hospital.
Introduce career
pathway and
succession planning
development.
WORKFORCE,
TRAINING AND
DEVELOPMENT
Improved
training
Discussion points / rationale
Recommendations
Development of specialist training courses, held in the Newark area or delivered through
greater use of technology (e.g. video conferencing).
Greater access to training.
Ensure the launch of new Trust wide clinical initiatives are held at Newark Hospital
o To review the current provision of specialist clinical training courses to ensure
that Newark Hospital can access this training and explore the use of video
conferencing technology where appropriate.
o To ensure that all ward leaders development days are video linked into Newark
Hospital to allow relevant staff to participate in this activity.
o To ensure staffs are released to attend training sessions and explore different
delivery of training provision where appropriate.
o To improve engagement from local universities and to develop a better
understanding of the current and future workforce and education needs of
Newark Hospital.
30
Improve the
accessibility of Trust
specialist training
courses and launch of
Trust wide initiatives
and development
opportunities.
Ensure that the current
and future workforce is
supported in their
continuing professional
development
requirements.
Develop more effective
workforce planning
approaches to reflect
the needs of Newark
Hospital.
8. Transport
This working group was established in light of public concerns. There are clear interdependencies
between transport and health services, since people need to be able to access care and need timely
transfers in an emergency situation. The aim of this working group was to review current NHS
commissioned emergency and non-emergency transport that is linked to Newark Hospital services.
Outputs will form the basis of NHS transport commissioning intentions for the CCG. Further analysis
will be undertaken before commissioning decisions are finalised.
Data regarding current ambulance services was reviewed. This is included as Appendix 7.
Ambulance response and conveyance times were discussed in detail. Newark has additional
ambulance capacity over and above normal EMAS contract levels and this appears to have some
benefit in terms of performance targets. Average responses in Newark and Sherwood are similar to
other Nottinghamshire suburban areas and better than other rural Nottinghamshire areas. However,
ambulance performance still needs to be further improved. Response times have not traditionally
been reported at CCG level, but commissioners are in discussion with EMAS to secure this level of
reporting for the future. An urgent care ambulance has been commissioned for Newark and
Sherwood to help improve response time locally. An emergency care practitioner service is also in
place.
Non-emergency patient transport services (NEPTS) is provided by ARRIVA. This service takes patients
for treatments and out-patient appointments. Voluntary car schemes are also in place.
Issues that were raised for the group to discuss were as follows:
Emergency ambulance response times
Non-emergency transport
Public transport
An overview of the discussions and recommendations is shown in the table below:
31
TRANSPORT
Emergency
ambulance
transport
Nonemergency
transport
Public
transport
Discussion points / rationale
Recommendations
Adequate ambulance resources should be
available in Newark to support improved
response times – this may be achieved through
better use of existing resources.
The urgent care ambulance transports patients
between sites (e.g. to help with repatriation).
EMAS is introducing a ring-fenced community
paramedic (CP) model in rural areas. After
attending a call out, the paramedic returns to
their rural base without being called out of the
area. A CP will be based in Retford, Ollerton and
Newark from 23.9.13.
It may be possible to have a local sobering up
scheme for Newark.
The community first responder scheme helps to
support ambulance response times.
Differences in performance between voluntary
driver schemes and NEPTS are unclear. Further
work is required to fully understand how all of
the schemes compare.
It may be possible to better utilise CNCS out-ofhours vehicles. A vehicle could potentially be
based at Newark MIU.
It would be beneficial if the 28 bus route could
be extended to Newark Hospital and King’s Mill
sites.
32
Review hours of operation of Newark and Sherwood urgent
care ambulance and consider whether capacity needs to be
increased at peak times / overall operating hours need to
change. The review should be completed by the end of
December and commissioned for 2013/14.
Monitor transfer rates out of Newark for acute care. Link with
urgent care refinement of the ambulance diversion protocol.
The pilot of community paramedic additional cover in rural
areas should be supported and the impact of this scheme
should be closely monitored.
Review the impact of sobering up schemes elsewhere in the
country. This should be completed by the end of December in
order to inform commissioning decision for 2013/14.
Ensure that ambulance response times are reported at CCG
level.
Encourage good community first responder cover across the
community.
Undertake further analysis of voluntary driver schemes and
Non-Emergency Patient Transport. This should be completed
by the end of December 2013.
Investigate whether out-of-hours doctor vehicles could
support non-emergency transport in hours. This should be
completed by the end of December 2013.
Influence the bus company to extend the 28 bus route to
Newark Hospital and King’s Mill sites or to develop a shuttle
service. The viability of such a service would need to be taken
into consideration.
APPENDICES
Incorporating data and information used to formulate
recommendations for Newark Hospital
33
Appendix 1
Trust and CCG presentations at the workshop
34
35
36
37
38
39
40
41
42
43
44
45
46
47
Appendix 2
Workshop Outputs – July 2013
48
49
50
51
52
Appendix 3
Urgent care data
53
54
55
Appendix 4
Additional analysis to support urgent care recommendations
56
57
58
59
60
61
62
63
64
Appendix 5
Newark Hospital Ambulance Protocol – Version 5
Newark Hospital Admissions Protocol for Ambulance Staff
March 2011
The following patients will not be seen in Newark Minor Injuries Unit and Urgent Care Centre
Where further clarity is required the department should be contacted via the RED phone.
The evidence strongly supports that taking patients to a small unit for stabilisation results in worse
patient outcomes so rapid transfer direct from scene to a major A&E with all the necessary facilities is
the best patient management.
ABC
- Patients with any signs of compromised airway
- History of respiratory arrest or cardiac arrest
- Patients with severe breathing difficulties, Rate <10 or > 25 (known asthmatic with increased
respiratory rate – phone to discuss)
- Oxygen saturation < 92% on air
- Patients who are shocked from any cause, e.g. massive bleed including GI, Systolic BP <100
Capillary Refill time > 2 seconds.
Trauma
- Any patient following major trauma
- Glasgow Coma Score (GCS below 13)
- Abdominal and Thoracic Injury (potentially serious)
- Any patient with long bone fractures (discuss uncomplicated / closed fractures)
- Patients who are non-weight bearing following a fall / with obvious deformity/ hip fracture
- Suspected cervical spine injury
- Serious scalds and burns (>5%, circumferential, burns to genitalia, face, neck, eyes and ears)
Medical and Surgical Patients
- Above ABC
- Impaired level of consciousness patients (GCS below 13)
- Any patient who may require ventilatory support or ICU care
- Patients requiring surgical assessment, including those with acute abdomen
- FAST Positive patients/Suspected Strokes
- Chest Pain
- Heart Attack
- Significant upper GI bleed
Gynaecological and Obstetric Patients
- Any Gynaecological or Obstetric Problem (unless very minor problem suspected – ring and discuss)
A B C (adjusted for age)
Paediatrics
- Children who may require admission e.g.
o Breathing difficulties
o Diarrhoea / Vomiting (with dehydration)
o High temperature / Fit
o Rash
o Any concerns – NAI (where practicable, suspicions may be raised but the crew may
not be able to discuss with parents / feel able to explain the need to take to KMH)
o Long Bone fractures / Deformities
o Facial lacerations
N.B. Children with minor injuries will now be seen if arriving by ambulance with;
- Minor bumps and bruises
- Minor Lacerations (not facial)
- Well children with worried parents for reassurance
Please Ring 01636 685703 to clarify any of the ab ove criteria if you are unsure
65
Appendix 6 – Elective procedures at Newark Hospital
July 2012 - June 2013
In Patient Activity By Primary Procedure
Hospital Calculated Treatment Class
Primary Procedure Recorded on PAS
AMPUTATION OF PHALANX OF TOE
ANT.& POST.COLPORRHAPHY NEC(REPAIR OF PROLAPSE OF VAGINA)
ANTERIOR COLPORRHAPHY NEC (REPAIR OF PROLAPSE OF VAGINA)
ANTERIOR COLPORRHAPHY WITH MESH REINFORCEMENT
ASPIRATION OF JOINT
ASPIRATION OF PLEURAL CAVITY
AVULSION OF NAIL
CARPAL TUNNEL RELEASE (PERIPHERAL NERVE AT WRIST)
CIRCUMCISION (OPERATIONS ON PREPUCE)
COMBINED OPERATIONS ON PRIMARY LONG SAPHENOUS VEIN
CONVERS TO TOTAL PROSTHETIC REPLACE/KNEE JOINT USING CEMENT
CUBITAL TUNNEL RELEASE (PERIPHERAL NERVE AT OTHER SITE)
DEBRIDEMENT OF SKIN NEC
DIAG. ENDOSCOPIC EXAM./BLADDER AND BIOPSY/LESION/BLADDER NEC
DIAG/ENDOSCOPIC EXAM/UTERUS & BIOPSY OF LESION OF UTERUS
DIAGNOST.ENDOSCOP.EXAM./LOW ER BOWEL & BIOPSY/LESION/L.BOWEL
DIAGNOST.FIBREOPT.ENDOSCOP.EXAM./COLO N & BIOPSY/LESION/COLON
DRAINAGE OF ASCITES NEC
ENDOSCOPIC BILATERAL CLIPPING OF FALLOPIAN TUBES
ENDOSCOPIC CAUTERISATION OF LESION OF BLADDER
ENDOSCOPIC CHONDROPLASTY NEC
ENDOSCOPIC DESTRUCTION OF LESION OF PERITONEUM
ENDOSCOPIC DIVISION OF ADHESIONS OF PERITONEUM
ENDOSCOPIC EXTIRPATION OF LESION OF OVARY NEC
ENDOSCOPIC LITHOLAPAXY (THERAPEUTIC OPS ON BLADDER)
Inpatient
Monday
Day Of Week Procedure Performed
Tuesday Wednesday Thursday Friday
2
9
11
2
Saturday
Sunday
8
2
1
1
1
1
1
3
2
1
1
1
6
1
1
1
1
2
1
1
1
3
1
1
1
1
1
1
2
2
1
1
66
1
Grand Total
2
9
19
2
2
1
2
2
3
2
1
1
1
6
2
2
4
4
1
4
1
2
2
2
1
ENDOSCOPIC RESECTION OF SEMILUNAR CARTILAGE NEC
EXCISION OF LESION OF OVARY
EXCISION OF POLYP OF ANUS
EXCISION OF SKIN TAG OF ANUS
FIBREOPT.ENDOSCOP.EXAM/UPPER GAS TRACT&LESION/UPPER GAS TRAC
FIBREOPTIC ENDOSCOPIC PERCUTANEOUS INSERTION OF GASTROSTOMY
FIBREOPTIC ENDOSCOPIC SNARE RESECTION OF LESION OF COLON
FUSION OF FIRST METATARSOPHALANGEAL JOINT NEC
FUSION OF INTERPHALANGEAL JOINT OF TOE NEC
HAEMORRHOIDECTOMY
INJECTION OF THERAPEUTIC SUBSTANCE INTO JOINT
INSERTION OF PROSTHETIC REPLACEMENT FOR LENS NEC
INTERNAL URETHROTOMY (OPERATIONS ON URETHRA)
INTRODUCTION OF TENSION-FREE VAGINAL TAPE
INTRODUCTION OF TRANSOBTURATOR TAPE
LARGE LOOP EXCISION OF TRANSFORMATION ZONE
LAYING OPEN OF LOW ANAL FISTULA
LIMITED RELEASE OF CONTRACTURE OF CAPSULE OF JOINT
MANIPULATION OF PROSTHETIC JOINT NEC
MANUAL EVACUATION OF IMPACTED FAECES FROM RECTUM
OPEN MYOMECTOMY
OPTICAL URETHROTOMY (THERAPEUTIC ENDOSCOPIC OPS.ON URETHRA)
OSTEOTOMY OF BONE OF FOOT AND FIXATION HFQ
OSTEOTOMY OF HEAD OF METATARSAL BONE (FOOT)
OTH SPEC THERAPEUTIC ENDOSCOPIC OPS ON SEMILUNAR CARTILAGE
OTHER SPECIFIED ABDOMINAL OPERATIONS FOR PROLAPSE OF RECTUM
OTHER SPECIFIED OPERATIONS ON TENDON
PERCUTAN. TRANSLUMINAL PERIPHERAL INSERTION/CENTRAL CATHETER
PHACOEMULSIFICATION OF LENS
POSTERIOR COLPORRHAPHY NEC (REPAIR OF PROLAPSE OF VAGINA)
POSTERIOR COLPORRHAPHY WITH MESH REINFORCEMENT
PRIM.HYBRID PROSTH.REPLAC. HIP JOINT/CEMENTED FEMORAL COMPO.
5
1
1
2
1
2
1
3
1
1
3
1
1
1
2
1
1
2
1
1
2
1
15
1
9
2
1
2
1
1
1
1
1
2
1
1
1
3
1
1
1
9
1
2
5
67
5
1
1
4
5
1
2
5
2
1
2
26
1
1
2
1
2
1
3
1
1
1
4
1
1
3
1
1
1
11
1
5
PRIM.HYBRID PROSTH.REPLAC.HIP JOINT/CEMENT.ACETAB. COMPONENT
PRIMARY ARTHRODESIS AND INTERNAL FIXATION OF JOINT NEC
PRIMARY EXCIS ARTHROPLASTY FIRST METATARSOPHALANGEAL JOINT
PRIMARY EXCISION ARTHROPLASTY OF JOINT NEC
PRIMARY REPAIR/FEMORAL HERNIA USE INSERT/PROSTHET. MATERIAL
PRIMARY REPAIR/INGUINAL HERNIA USE INSERT/PROSTHETIC MAT.
PRIMARY RESURFACING ARTHROPLASTY OF JOINT
PRIMARY TOTAL PROSTHETIC REPLACE/HIP JOINT NOT USING CEMENT
PRIMARY TOTAL PROSTHETIC REPLACE/HIP JOINT USING CEMENT
PRIMARY TOTAL PROSTHETIC REPLACE/KNEE JOINT USING CEMENT
RADIOFREQUENCY ABLATION OF ENDOMETRIUM
RECONSTRUCTION OF INTRAARTICULAR LIGAMENT NEC
REMOVAL OF INTERNAL FIXATION FROM BONE NEC
REMOVAL OF SUPPORTING PESSARY FROM VAGINA
REPAIR OF CAPSULE AND ANT LABRUM FOR STAB OF GLENHUM JOINT
REPAIR OF ENTEROCELE NEC(REPAIR OF PROLAPSE OF VAGINA)
REPAIR OF VENTRAL HERNIA USING INSERT OF PROSTHETIC MATERIAL
REPAIR RECURRENT VENTRAL HERNIA USING INSERT PROST MATERIAL
REPAIR/UMBILICAL HERNIA USING INSERT OF PROSTHETIC MATERIAL
REVISION OF ARTHRODESIS AND INTERNAL FIXATION NEC
ROTATION DIAPHYSEAL OSTEOTOMY AND INTERNAL FIXATION HFQ
RUBBER BAND LIGATION OF HAEMORRHOID (DESTRUCTION)
SACROSPINOUS FIXATION OF VAGINA
SIMPLE EXCISION OF BUNION NEC
SUBACROMIAL DECOMPRESSION
SUBTOTAL ABDOMINAL HYSTERECTOMY (OF UTERUS)
TOTAL ABDOMINAL HYSTERECTOMY NEC (OF UTERUS)
TOTAL CHOLECYSTECTOMY NEC
TOTAL EXCISION OF BURSA
TOTAL EXCISION OF NAIL
TOTAL SYNOVECTOMY (EXCISION OF SYNOVIAL MEMBRANE OF JOINT)
TRANSECTION OF PERIPHERAL NERVE
1
1
1
1
2
2
3
3
6
25
38
3
3
2
7
17
8
1
11
3
2
1
1
1
1
1
1
1
1
1
2
1
3
1
4
1
1
3
1
1
2
3
3
8
6
2
17
9
2
1
1
1
68
1
1
1
1
1
24
6
8
34
61
2
1
3
1
1
1
1
1
2
1
8
2
3
4
3
3
14
28
2
1
1
1
UNILATERAL OOPHORECTOMY NEC (OF ADNEXA OF UTERUS)
UNILATERAL SALPINGOOPHORECTOMY NEC(OF ADNEXA OF UTERUS)
UNSPEC.DIAGNOST.ENDOSCOP.EXAM/LOWER BOWEL USE FIB.SIG-SCOPE
UNSPECIFIED AMPUTATION OF TOE
UNSPECIFIED BIOPSY OF CERVIX UTERI
UNSPECIFIED DIAGNOSTIC ENDOSCOPIC EXAM/UPPER GASTRO.TRACT
UNSPECIFIED DIAGNOSTIC ENDOSCOPIC EXAMINATION OF BLADDER
UNSPECIFIED DIAGNOSTIC ENDOSCOPIC EXAMINATION OF COLON
UNSPECIFIED PRIMARY REPAIR OF INGUINAL HERNIA
UNSPECIFIED REHABILITATION FOR MUSCULOSKELETAL DISORDERS
UNSPECIFIED TOTAL PROSTHETIC REPLACE/HIP JOINT USING CEMENT
US VAGINAL EXCISION OF UTERUS
Grand Total
1
2
1
1
2
1
1
2
3
2
2
1
1
1
1
1
1
1
105
69
119
95
38
1
59
3
5
1
2
4
1
1
5
5
3
1
1
1
1
424
Procedures Performed at Newark Hospital By Primary Procedure
In Patients (Patients with Length of stay >= 1 day) January - June 2013
Data
Specialty
GENERAL SURGERY
Primary Procedure
H368-OTHER SPECIFIED ABDOMINAL OPERATIONS FOR PROLAPSE OF RECTUM
H482-EXCISION OF SKIN TAG OF ANUS
H511-HAEMORRHOIDECTOMY
H551-LAYING OPEN OF LOW ANAL FISTULA
T202-PRIMARY REPAIR/INGUINAL HERNIA USE INSERT/PROSTHETIC MAT.
T242-REPAIR/UMBILICAL HERNIA USING INSERT OF PROSTHETIC MATERIAL
GENERAL SURGERY Total
GYNAECOLOGY
GYNAECOLOGY Total
OPHTHALMOLOGY
OPHTHALMOLOGY Total
PODIATRIC SURGERY
P231-ANT.& POST.COLPORRHAPHY NEC(REPAIR OF PROLAPSE OF VAGINA)
P232-ANTERIOR COLPORRHAPHY NEC (REPAIR OF PROLAPSE OF VAGINA)
P233-POSTERIOR COLPORRHAPHY NEC (REPAIR OF PROLAPSE OF VAGINA)
P247-SACROSPINOUS FIXATION OF VAGINA
Q074-TOTAL ABDOMINAL HYSTERECTOMY NEC (OF UTERUS)
Q075-SUBTOTAL ABDOMINAL HYSTERECTOMY (OF UTERUS)
Q089-US VAGINAL EXCISION OF UTERUS
Q231-UNILATERAL SALPINGOOPHORECTOMY NEC(OF ADNEXA OF UTERUS)
Q352-ENDOSCOPIC BILATERAL CLIPPING OF FALLOPIAN TUBES
Q491-ENDOSCOPIC EXTIRPATION OF LESION OF OVARY NEC
T422-ENDOSCOPIC DESTRUCTION OF LESION OF PERITONEUM
T423-ENDOSCOPIC DIVISION OF ADHESIONS OF PERITONEUM
C751-INSERTION OF PROSTHETIC REPLACEMENT FOR LENS NEC
T748-OTHER SPECIFIED OPERATIONS ON TENDON
W144-ROTATION DIAPHYSEAL OSTEOTOMY AND INTERNAL FIXATION HFQ
70
Number of
Patients
1
2
1
1
11
10
2
28
3
7
5
1
6
1
1
1
1
2
2
2
32
13
13
1
6
Sum of
Hospital
Length of
Stay
1
3
1
1
15
10
2
33
10
23
11
2
17
3
4
1
1
2
2
3
79
13
13
1
6
Average of
Hospital Length
of Stay
1.00
1.50
1.00
1.00
1.36
1.00
1.00
1.18
3.33
3.29
2.20
2.00
2.83
3.00
4.00
1.00
1.00
1.00
1.00
1.50
2.47
1.00
1.00
1.00
1.00
W157-OSTEOTOMY OF BONE OF FOOT AND FIXATION HFQ
W572-PRIMARY EXCISION ARTHROPLASTY OF JOINT NEC
W593-FUSION OF FIRST METATARSOPHALANGEAL JOINT NEC
W792-SIMPLE EXCISION OF BUNION NEC
X112-AMPUTATION OF PHALANX OF TOE
PODIATRIC SURGERY Total
TRAUMA & ORTHOPAEDIC
TRAUMA & ORTHOPAEDIC
Total
UROLOGY
UROLOGY Total
CARE OF THE ELDERLY
CARE OF THE ELDERLY Total
GASTROENTEROLOGY
A603-TRANSECTION OF PERIPHERAL NERVE
A651-CARPAL TUNNEL RELEASE (PERIPHERAL NERVE AT WRIST)
O291-SUBACROMIAL DECOMPRESSION
T621-TOTAL EXCISION OF BURSA
W371-PRIMARY TOTAL PROSTHETIC REPLACE/HIP JOINT USING CEMENT
W381-PRIMARY TOTAL PROSTHETIC REPLACE/HIP JOINT NOT USING CEMENT
W401-PRIMARY TOTAL PROSTHETIC REPLACE/KNEE JOINT USING CEMENT
W581-PRIMARY RESURFACING ARTHROPLASTY OF JOINT
W595-FUSION OF INTERPHALANGEAL JOINT OF TOE NEC
W742-RECONSTRUCTION OF INTRAARTICULAR LIGAMENT NEC
W822-ENDOSCOPIC RESECTION OF SEMILUNAR CARTILAGE NEC
W903-INJECTION OF THERAPEUTIC SUBSTANCE INTO JOINT
W913-MANIPULATION OF PROSTHETIC JOINT NEC
W931-PRIM.HYBRID PROSTH.REPLAC.HIP JOINT/CEMENT.ACETAB. COMPONENT
G459-UNSPECIFIED DIAGNOSTIC ENDOSCOPIC EXAM/UPPER GASTRO.TRACT
M422-ENDOSCOPIC CAUTERISATION OF LESION OF BLADDER
M451-DIAG. ENDOSCOPIC EXAM./BLADDER AND BIOPSY/LESION/BLADDER NEC
M459-UNSPECIFIED DIAGNOSTIC ENDOSCOPIC EXAMINATION OF BLADDER
M763-OPTICAL URETHROTOMY (THERAPEUTIC ENDOSCOPIC OPS.ON URETHRA)
N303-CIRCUMCISION (OPERATIONS ON PREPUCE)
G445-FIBREOPTIC ENDOSCOPIC PERCUTANEOUS INSERTION OF GASTROSTOMY
H201-FIBREOPTIC ENDOSCOPIC SNARE RESECTION OF LESION OF COLON
H221-DIAGNOST.FIBREOPT.ENDOSCOP.EXAM./COLON & BIOPSY/LESION/COLON
71
4
1
2
1
1
16
1
1
2
1
19
5
24
2
1
1
1
1
1
1
5
2
2
1
1
18
1
1
2
2
99
24
115
8
2
1
1
1
1
4
1.25
2.00
1.00
1.00
1.00
1.13
1.00
1.00
1.00
2.00
5.21
4.80
4.79
4.00
2.00
1.00
1.00
1.00
1.00
4.00
61
1
3
4
1
1
1
11
1
1
2
1
262
1
3
7
1
1
1
14
2
2
2
1
4.30
1.00
1.00
1.75
1.00
1.00
1.00
1.27
2.00
2.00
1.00
1.00
H251-DIAGNOST.ENDOSCOP.EXAM./LOWER BOWEL & BIOPSY/LESION/L.BOWEL
H524-RUBBER BAND LIGATION OF HAEMORRHOID (DESTRUCTION)
GASTROENTEROLOGY Total
Grand Total
72
1
1
5
167
1
2
6
427
1.00
2.00
1.20
2.56
Appendix 7 – Transport group data
73
74
75
Conveyance times and chief complaints are included within the urgent care appendix.
76