Urgent and Emergency Care Service Specifications

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1 Urgent and Emergency Care Service Specifications May 2015

2 Urgent, Emergency, and Specialist care centres Service Specifications v1 12/05/2015 Urgent and Emergency Care Service Specifications Introduction These outline specifications describe the characteristics of providing urgent and emergency care services in London. They stem from the Keogh review Phase 1 report which called for clarity and transparency about what services different offer and put forward Urgent Care Centres (UCC), Emergency Centres (EC) and Specialist Emergency Centres (SEC) as terminology to articulate such services. High level overviews of these are outlined in the table below. In London, stakeholders have proposed that the London quality standards for urgent and acute emergency services should be integral to the service specification criteria, in addition to a number of national and London specialty provision. Overview of the Urgent Care Centres Emergency Centres Specialist (Major) Emergency Centres Community-based primary care providing urgent care for a local population. Encompass Walk-in Centres, Minor Injuries Units, GP-led Health Centres and all other similar but now referred to as Urgent Care Centres Consistent in their service provision and available 24 hours, 7 days per week. Where appropriate, colocated with emergency centres on hospital sites Hospital based able to receive a full range of emergency patients, of all ages Provide for the reception, resuscitation, diagnosis, treatment and onward referral. The initial receiving destination for almost all emergency and ambulance patients Entire facility is designated as an Emergency Centre, including the Emergency Department that is located within it. Hospital based with all the features of an EC, but also specialist that receive patients from ECs, or directly from an ambulance which has bypassed an EC. Larger units, capable of assessing and initiating treatment for all patients and providing a range of specialist services Entire facility is designated as a Specialist Emergency Centre, including the Emergency Department that is located within it. 2

3 Facilities Service Specifications Urgent Care Centres Domain Specification Reference Points for discussion 1. Governance i. Each urgent care centre is to have a formal written policy for providing urgent care. This policy is to adhere to the urgent care clinical quality standards. This policy is to be ratified by the service s provider board and the U&EC Network annually. ii. All urgent care centres are to be within an urgent and emergency care network. iii. Co-located and standalone centres to have integrated clinical governance structures with Emergency centres. iv. All patient safety incidents should be reported to the National Reporting and Learning System and reviewed locally to identify and implement learning. Similarly all National Patient Safety Alerts should be implemented in full and in the spirit they are intended. v. All patients attending urgent care centres are able to access the same integrated clinical pathways as if they had attended an Emergency Centre. 2. Location i. Community-based primary care providing urgent care for a local population. ii. Where possible, co-located with emergency centres on hospital sites. i. Urgent care LQS 1 ii. (Based on) Urgent care LQS 2 iii. (Based on) Urgent care LQS 2 iv. Urgent care National draft standards 18 v. Addition specifications - document i specifications - Should this specification be applied to individual or across a number of across a network or SRG footprint to ensure affordability particularly in relation to: - Opening hours - Medical cover - Diagnostics

4 document 3. Operating hours i. Consistent in their service provision and available 24 hours, 7 days per week. specifications - document Should the specification, particularly 24/7, apply to all urgent care or for a network to ensure coverage of in a defined region? 4. Staffing i. During the hours that they are open all urgent care services to be staffed by multidisciplinary teams, including: at least one registered medical practitioner (either a registered GP or doctor with appropriate competencies for primary and emergency care), and at least one other registered healthcare practitioner. ii. All registered healthcare practitioners working in urgent care services to have a minimum level of competence in caring for adults, and children and young people (where the service accepts children), including: (a) Basic life support; (b) Recognition of serious illness and injury; (c) Pain assessment; (d) Identification of vulnerable patients At anytime the service is open at least one registered healthcare practitioner is to be trained and competent in immediate life support and paediatric immediate life support, where the service accepts children. iii. Urgent care services to have arrangements in place for staff to access support and advice from experienced doctors (ST4 and above or equivalent) in both adult and paediatric emergency medicine and other specialties without necessarily requiring patients to be transferred to an emergency department or other service. i. Urgent care LQS 3 ii. Urgent care LQS 14 iii. Urgent care LQS 16 Does the board support that all require this level of staffing? 2

5 5. Assessment & Treatment i. An escalation protocol is to be in place to ensure that seriously ill/high risk patients presenting to the urgent care service are seen immediately on arrival by a registered healthcare practitioner. ii. All patients are to be seen and receive an initial clinical assessment by a registered healthcare practitioner within 15 minutes of the time of arrival at the urgent care service. iii. Within 90 minutes of the time of arrival at the urgent care service 95 per cent all patients are to have a clinical decision made that they will be treated in the urgent care service and discharged or arrangements made to transfer them to another service. iv. At least 95 per cent of patients who present at an urgent care service to be seen, treated if appropriate and discharged in under 3 hours of the time of arrival at the urgent care service. i. Urgent care LQS 4 ii. Urgent care LQS 5 iii. Urgent care LQS 6 iv. Urgent care LQS 7 6. Diagnostics i. Access to minimum key diagnostics during hours the urgent care service is open, with real time access to images and results: - Plain film x-ray: immediate on-site access with formal report received by the urgent care service within 24 hours of examination - Blood testing: immediate on-site access with formal report received by urgent care service within one hour of the sample being taken Clinical staff to have the competencies to assess the need for, and order, diagnostics and imaging, and interpret the results. [It is suggested that a cost-benefit analysis be undertaken by each service prior to implementation]. i. Urgent care LQS 10 Should this level of access to diagnostics apply to all urgent care or for a network to ensure access across a defined region? 7. Equipment i. Appropriate equipment to be available onsite: - a full resuscitation trolley - an automated external defibrillator i. Urgent care LQS 11 ii. Urgent care LQS 12 3

6 - oxygen - suction and - emergency drugs All urgent care service to be equipped with a range of medications necessary for immediate treatment. ii. LQS 12 - Urgent care services to have appropriate waiting rooms, treatment rooms and equipment according to the workload and patient s needs. 8. Mental Health i. Single call access for mental health referrals to be available during hours the urgent care service is open, with a maximum response time of 30 minutes. ii. Dedicated area for mental health assessments which reflects the needs of people experiencing a mental health crisis. iii. Arrangements in place to ensure Mental Health Act assessments take place promptly and reflect the needs of the individual concerned. iv. Access to all the information required to make decisions regarding crisis management including self-referral. i. Urgent care LQS 17 ii. - vi. London Mental Health Crisis standards and Mental Health Crisis Care Concordat Should this be in place at every UCC or a robust pathway in place to access this? 9. Transfer i. All patients to have an episode of care summary communicated to the patient s GP practice by the next day. For children the episode of care is to be communicated to their health visitor or school nurse, where known and appropriate, no later than the second day. ii. All registered healthcare practitioners working in urgent care services to have direct access to urgent referrals to specialist on-call services when necessary, and the right to refer those patients who they see within their scope of practice. iii. To adhere to the inter hospital transfer standards - Urgent care LQS 13 ii. Urgent care LQS 15 iii. London Inter hospital transfer standards 4

7 10. Patient information 11. Patient experience programme/inter-hospital-transfer-and-acceptance-standards/ i. All Urgent Care Centres should have arrangements in place for staff to access an up-to-date electronic patient care record. ii. During all hours that the urgent care service is open it is to provide and support on how to register with a local GP. i. Patient experience data to be captured, recorded and routinely analysed and acted on. Data is to be regularly reviewed by the board of the urgent care provider and findings are to be disseminated to all staff and patients. ii. All patients to be supported to understand their diagnosis, relevant treatment options, ongoing care and support by an appropriate clinician. iii. Where appropriate, patients to be provided with health and wellbeing advice and sign-posting to local community services where they can self-refer (for example, smoking cessation services and sexual health, alcohol and drug services). i. Urgent care National draft standards 13 ii. Urgent care LQS 8 i. Urgent care LQS 18 ii. Urgent care LQS 19 iii. Urgent care LQS Training i. Urgent care services to provide appropriate supervision for training purposes including both educational supervision and clinical supervision. ii. All healthcare practitioners to receive training in the principles of safeguarding children, vulnerable and older adults and identification and management of child protection issues. All registered medical practitioners working independently to have a minimum of safeguarding training level 3. i. Urgent care LQS 21 ii. Urgent care LQS 22 Should the need for an integrated system in relation to training be specified or should this be part of the network specification? 5

8 Emergency centres Domain Specification Reference Points for discussion 1. Governance 2. Location 3. Operating hours i. All Emergency Centres must be part of an identified U&EC Network, with integrated governance structures. ii. Every Emergency Centre should have a formal written policy for providing emergency care, and clear pathways of care, including acceptance and referral criteria, for all common emergency conditions within the over-arching Strategic Network. This policy includes both physical and mental health, and will be ratified by the service s provider board and the U&EC Network annually. i. Emergency Centres must contain an Emergency Department that operates structurally and functionally within a supporting acute hospital. i. Consistent in their service provision and available 24 hours, 7 days per week. i. Emergency care centre National draft standards 1 ii. Emergency care centre National draft standards 2 specifications - document specifications - document 4. Staffing i. Under the continuous supervision and accountability of one or more consultants in Emergency Medicine. ii. A trained and experienced doctor (ST4 and above or doctor of equivalent competencies) in emergency medicine to be present in the emergency department 24 hours a day, seven days a week. iii. A consultant in emergency medicine to be scheduled to deliver clinical care in the emergency department for a minimum of 16 hours a day (matched to peak activity), seven days a week. specifications ii. Emergency Department LQS 1 iii. Emergency 6

9 5. Assessment/ Treatment 6. Diagnostics Outside of these 16 hours, a consultant will be on-call and available to attend the hospital for the purposes of senior clinical decision making and patient safety within 30 minutes. iv. A designated nursing shift leader (Band 7) to be present in the emergency department 24 hours a day, seven days a week with provision of nursing and clinical support staff in emergency departments to be based on emergency department-specific skill mix tool and mapped to clinical activity. i. 95 per cent of patients will wait less than 4 hours from arrival to admission, discharge or transfer. ii. A clinical decision/ observation area is to be available to the emergency department for patients under the care of the emergency medicine consultant that require observation, active treatment or further investigation to enable a decision on safe discharge or the need for admission under the care of an inpatient team. iii. Triage to be provided by a qualified healthcare professional and registration is not to delay triage. i. 24/7 access to the following minimum key diagnostics: - X-ray: immediate access with formal report received by the ED within 24 hours of examination - CT: immediate access with formal report received by the ED within one hour of examination - Ultrasound: immediate access within agreed indications/ 12 hours with definitive report received by the ED within one hour of examination - Lab sciences: immediate access with formal report received by the ED within one hour of the sample Department LQS 2 iv. Emergency Department LQS 6 i. Department of health ii. Emergency Department LQS 5 iii. Emergency Department LQS 7 i. Emergency Department LQS 3 7

10 7. Equipment 8. Mental Health 9. Transfer being taken - Microscopy: immediate access with formal result received by the ED within one hour of the sample being taken When hot reporting of imaging is not available, all abnormal reports are to be reviewed within 24 hours by an appropriate clinician and acted upon within 48 hours. i. The Emergency Department must include a resuscitation area with appropriate equipment to provide advanced paediatric, adult and trauma life support prior to transfer to definitive care. i. Dedicated area for mental health assessments which reflects the needs of people experiencing a mental health crisis. ii. Have access to on-site liaison psychiatry services 24 hours a day, 7 days a week. iii. Liaison Psychiatry services to see service users within 1 hour of ED referral iv. Arrangements in place to ensure Mental Health Act assessments take place promptly and reflect the needs of the individual concerned. v. Access to all the information required to make decisions regarding crisis management including self-referral. i. Following initial stabilisation some patients who require specialist care will be transferred to another Emergency Centre or a Specialist Emergency Centre; this transfer capability is integral to the functioning of an Emergency Centre and the network in which it operates. ii. Emergency department patients who have undergone an initial i. Emergency care centre National draft standards 3 i. vi. London Mental Health Crisis standards and Mental Health Crisis Care Concordat specifications ii. Emergency Department LQS 4 8

11 assessment and management by a clinician in the emergency department and who are referred to another team, to have a management plan (including the decision to admit or discharge) within one hour from referral to that team. When the decision is taken to admit a patient to a ward/ unit, actual admission to a ward/ unit to take place within one hour of the decision to admit. If admission is to an alternative facility the decision maker is to ensure the transfer takes place within timeframes specified by the London inter-hospital transfer standards (See below link). iii. Timely access, seven days a week to, and support from, onward referral clinics and efficient procedures for discharge from hospital. iv. To adhere to the inter hospital transfer standards - iii. Emergency Department LQS 9 iv. Inter hospital transfer standards 10. Clinical support services i. Emergency departments to have a policy in place to access support services seven days a week including: - Alcohol liaison - Mental health - Older people s care - Safeguarding - Social services. ii. Timely access, seven days a week to, and support from, physiotherapy and occupational therapy teams to support discharge. i. Emergency Department LQS 8 ii. Emergency Department LQS Inpatient/ Elective i. Adhere to the following London Quality Standards - Acute medicine and emergency general surgery - - Critical care - Range of LQSs ii. London clinical dependency framework Does the Board support the inclusion of the London quality standards and interdependency framework as part of this specification? 9

12 12. Patient information 13. Patient experience 14. Training safety-programme/critical-care/ - Fractured neck of femur pathway - - Maternity services - ii. Adhere to the London clinical dependency framework - i. IT system for tracking patients, integrated with order communications. A reception facility with trained administrative capability to accurately record patients into the emergency department to be available 24 hours a day, seven days a week. Attendance, and admission record and discharge summaries to be immediately available in case of re-attendance and monitored for data quality. i. Consultant-led communication and information to be provided to patients and to include the provision of patient information leaflets. ii. Patient experience data to be captured, recorded and routinely analysed and acted on. Review of data is a permanent item on the trust board agenda and findings are disseminated. i. The emergency centre to provide a supportive training environment and all staff to undertake relevant ongoing training. i. (Based on) Emergency Department LQS 11 i. LQS i. LQS 10

13 Additional specifications for Specialist Emergency Centres Specialist Emergency Centres will provide all the features of an EC, but also specialist. These additions are outlined below. Domain Specification Reference 1. Governance i. Take lead responsibility for quality of care and operational performance of service across its network. ii. Protocols across networks should be in place with London Ambulance Service in regards to who should be conveyed to a Specialist Emergency Centre. specifications ii. Addition National states that Specialist Emergency Centres should contain specialist and expertise ; in London it is proposed that Specialist Emergency Centres include HASUs, MTCs, and Heart Attack Centres - does the board support the inclusion of these specialist services in the specification? 2. Staffing i. Provide staffing in line with agreed specialist service specifications. i. hp.nhs.uk/services /major-trauma/ hp.nhs.uk/services /stroke/ d.nhs.uk/wpcontent/uploads/2 013/06/a09-cardi- 11

14 3. Assessment/ Treatment 4. Diagnostics 5. Transfer i. Receive patients identified with specialist needs, either from ambulances that have bypassed an Emergency Centre or patients transferred from Emergency Centre in line with agreed protocols. i. Provide24/ 7 immediate access to enhanced diagnostics such as CT and MRI scanning and interventional radiology, and a wider range of. i. Transfer from a Specialist Emergency Centre will be rare, other than for recovering patients being returned to community based settings of care, closer to patients homes or based on agreed protocols for specialist services. primpercutaneous.pdf rsociety.org.uk/wpcontent/uploads/2 013/06/Service- Specification.pdf specifications specifications specifications 6. Specialist care a. Major Trauma i. Contains one of more specialist and expertise likely to fall within the remit of specialised commissioning(outlined below). specifications i. Adhere to standards for Major Trauma Centres. nhs.uk/services/major -trauma/ b. Hyperi. Adhere to standards for Hyper-Acute Stroke Units. nhs.uk/services/strok Does the board support the inclusion of these specialist services in the specification? 12

15 Acute Stroke Units c. Heart Attack Centres d. Vascular Centres i. Adhere to standards for Heart Attack Centres. hs.uk/wpcontent/uploads/2013 /06/a09-cardi-primpercutaneous.pdf i. Adhere to standards for specialised vascular services. hs.uk/wpcontent/uploads/2013 /06/a04-spec-vascuadult.pdf e/ 13

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