Quality and safety programme: Audit of acute hospitals. Croydon University Hospital Report

Transcription

1 Quality and safety programme: Audit of acute hospitals Croydon University Hospital Report Hospital audit visit date: September 2012

2 Contents 1. Introduction: the need for change in London Background to the audit Summary of findings Overall assessment Results of the patient note audit Compliance with adult emergency services standards: conclusion Hospital self-reported compliance with national standards Appendix 1 - Key information relevant to the hospital audit Appendix 2 - The audit process Appendix 3 Revised acute medicine and emergency general surgery standards

3 1. Introduction: the need for change in London Recommendations from clinical evidence over a number of years have been resoundingly clear: early and consistent input by consultants improves patient outcomes. In 2011 a review of London hospital-based acute medicine and emergency general surgery services found that there was hugely variable and inadequate involvement of consultants in the assessment and subsequent management of acutely ill patients particularly overnight and at the weekend, when average consultant cover was found to be half of what it was during the week 1. This review demonstrated that patients admitted to hospital as an emergency at the weekend in London had a significantly increased risk of dying compared to those admitted on a weekday. Data showed that a minimum of 500 lives in London could be saved every year if the mortality rate for patients admitted at the weekend was the same as for those admitted on a weekday. Reduced service provision, including fewer consultants working at weekends, was associated with this higher mortality rate. London s heart attack centres already operated a consultant-delivered service seven days a week and no observed difference was found in mortality rates for admissions during the week and those at the weekend. This demonstrated that where systems are in place to respond seven days a week, there is a direct effect on mortality rates. Standards for London that will ensure consistent, consultant-delivered services Clinical expert and patient panels developed evidence-based London quality standards for acute medicine and emergency general surgery to address the variations found in service arrangements and patient outcomes. These standards represent the minimum quality of care patients admitted as an emergency should expect to receive in every hospital in London that accepts patients on an emergency basis. Compliance with these standards would ensure that the assessment and subsequent care of patients admitted to these services on an emergency basis would be consultant-delivered, seven days a week and consistent across all providers of these services. London acute hospitals were subsequently commissioned to deliver these standards from April London Health Programmes (2011) Adult emergency services: case for change London Health Programmes (2011) Adult emergency services: commissioning standards 3

4 2. Background to the audit The Quality and Safety Programme The Quality and Safety Programme began in January 2012 and built on the review of emergency general surgery and acute medicine in London. This was a clinically-led programme, supported by over 90 clinicians that formed multi-disciplinary expert panels, and involved patient/ service user and public groups. The programme had two key components: 1) Auditing all acute London hospitals against the agreed and commissioned acute medicine and emergency general surgery standards. 2) Driving the development and commissioning of London quality standards for further areas not covered by the previous review. These were: Critical care; Emergency departments; Fractured neck of femur pathway; Maternity services; and Paediatric emergency services. The audit was developed by clinical expert and patient panels and quality assured by an independent academic review. Following two pilot audits, the full audit was undertaken between May 2012 and January 2013 to ascertain the current status of London hospitals against the achievement of the adult emergency services London quality standards. Details of the key dates for this hospital can be found in Appendix 1. The audit consisted of two main stages: Stage 1 Stage 2 Hospital self-assessment of compliance with supporting evidence. A follow up audit visit. Further details on each stage are included in Appendix 2. The audit was also an opportunity to survey hospitals on their current compliance against national standards in the clinical areas not covered by the 2011 adult emergency services review. This was to understand the current baseline in London hospitals ahead of the development and commissioning of London quality standards for these areas. Assessment of compliance with the acute medicine and emergency general surgery standards was based on findings at the time of the audit visit. Any subsequent action plans and changes made to service delivery have not been included in the assessment and should be the consideration of commissioners. This report details the findings and conclusions from the audit. Please note: during the audit process, some standards were challenged. Due to these challenges, and in light of new publications, some standards were reviewed by the Quality and Safety Clinical and Programme Boards following the audits and revised standards have been agreed. Details of the revised standards can be found in Appendix 3. Audit assessments have not been changed to reflect the revisions to standards. 4

5 3. Summary of findings Table 1 summarises the overall assessment on compliance with each of the twenty-seven acute medicine and emergency general surgery standards that all hospitals in London were commissioned to meet from April Standards were classified as: Red not met; Amber not met but the hospital had a credible plan in place that had Trust board level support, agreed funding and would be delivered in 2012/13 in order to achieve compliance with the standard; or Green met. Table 1: Summary of compliance with the adult emergency standards at Croydon University Hospital Overall assessment Standard No. 1 All emergency admissions to be seen and assessed by a relevant consultant within 12 hours of the decision to admit or within 14 hours of the time of arrival at the hospital. 2* A clear multi-disciplinary assessment to be undertaken within 12 hours and a treatment or management plan to be in place within 24 hours (for complex needs patients see 23 and 24). a) All patients admitted acutely to be continually assessed using a standardised early warning system (EWS). 3* b) Consultant involvement is required for patients who reach trigger criteria. Consultant involvement for patients considered high risk to be within one hour. 4 When on-take, a consultant and their team are to be completely freed from any other clinical duties or elective commitments. 5 In order to meet the demands for consultant delivered care, senior decision making and leadership on the acute medical/ surgical unit to cover extended day working, seven days a week. 6 All patients on acute medical and surgical units to be seen and reviewed by a consultant during twice daily ward rounds, including all acutely ill patients directly transferred, or others who deteriorate. 7 All hospitals admitting medical and surgical emergencies to have access to all key diagnostic services in a timely manner 24 hours a day, seven days a week to support clinical decision making: Critical imaging and reporting within 1 hour; Urgent imaging and reporting within 12 hours; All non-urgent imaging and reporting within 24 hours. Not 5

6 Standard No. 8 All hospitals admitting medical and surgical emergencies to have access to interventional radiology 24 hours a day, seven days a week: Critical patients 1 hour; Non-critical patients 12 hours. 9 Rotas to be constructed to maximise continuity of care for all patients in an acute medical and surgical environment. A single consultant is to retain responsibility for a single patient on the acute medical or surgical unit. Subsequent transfer or discharge must be based on clinical need. 10 A unitary document to be in place, issued at the point of entry, which is used by all healthcare professionals and all specialties throughout the emergency pathway. 11 Patients admitted for unscheduled care to be nursed and managed in an acute medical or surgical unit, or critical care environment. 12 All admitted patients to have discharge planning and an estimated discharge date as part of their management plan as soon as possible and no later than 24 hours post-admission. A policy is to be in place to access social services seven days per week. Patients to be discharged to their named GP. 13 All hospitals admitting emergency general surgery patients to have access to a fully staffed emergency theatre immediately available and a consultant on site within 30 minutes at any time of the day or night. 14 All patients admitted as emergencies are discussed with the responsible consultant if immediate surgery is being considered. For each surgical patient, a consultant takes an active decision in delegating responsibility for an emergency surgical procedure to appropriately trained junior or speciality surgeons. This decision is recorded in the notes and available for audit. 15 All patients considered as high risk to have their operation carried out under the direct supervision of a consultant surgeon and consultant anaesthetist; early referral for anaesthetic assessment is made to optimise peri-operative care. High risk is defined as where the risk of mortality is greater than 10%. 16 All patients undergoing emergency surgery to be discussed with consultant anaesthetist. Where the severity assessment score is ASA3 and above, anaesthesia is to be provided by a consultant anaesthetist. 17 a) The majority of emergency general surgery to be done on planned emergency lists on the day that the surgery was originally planned. The date, time and decision maker should be documented clearly in the patient s notes and any delays to emergency surgery and the reasons why recorded. b) Any operations that are carried out at night are to meet NCEPOD classifications and be under the direct supervision of a consultant surgeon. 18* All referrals to intensive care to be made from a consultant to a consultant. Overall assessment 6

7 Overall assessment Standard No. 19 A structured process to be in place for the medical handover of patients twice a day. These arrangements to also be in place for the handover of patients at each change of responsible consultant/medical team. Changes in treatment plans are to be communicated to nursing and therapy staff as soon as possible if they are not involved in the handover discussions. 20 Consultant-led communication and information to be provided to patients. 21 Patient experience data is captured, recorded and routinely analysed and acted on. Is a permanent item on board agenda and findings are disseminated. 22 All acute medical and surgical units to have provision for ambulatory emergency care. 23* Prompt screening of all complex needs inpatients to take place by a multi-professional team which has access to pharmacy and therapy services, including physiotherapy and occupational therapy, seven days a week with an overnight rota for respiratory physiotherapy. 24* Single call access for mental health referrals to be available 24 hours a day, seven days a week with a maximum response time of 30 minutes. 25 Hospitals admitting emergency patients to have access to comprehensive 24 hour endoscopy services that has a formal consultant rota 24 hours a day, 7 days a week 26 a) All hospitals dealing with complex acute medicine to have onsite access to levels 2 and 3 critical care (i.e. intensive care units with full ventilatory support). b) All acute medical units to have access to a monitored and nursed facility. 27 Training to be delivered in a supportive environment with appropriate, graded consultant supervision * Due to the challenges during the audit process, and in light of new publications, some standards were reviewed by the Quality and Safety Clinical and Programme Boards following the audits (Appendix 3). 7

8 4. Overall assessment Table 2 details the commentary from the audit process as to the reasons why the hospital was concluded to have met, not met, or have a credible plan in place to meet the standard. All of the twenty-seven acute medicine and emergency general surgery standards that all hospitals in London were commissioned to meet from April 2012 are listed. Table 2: Consultant-delivered care: core standards No. Standard Commentary and conclusions 1 All emergency admissions to be seen and assessed by a relevant consultant within 12 hours of the decision to admit or within 14 hours of the time of arrival at the hospital. The acute medical unit operational policy submitted at the self-assessment stage stated consultant physicians were on the medical unit from during weekdays and would review a patient within 14 hours of arrival at the hospital. The consultant conducted a ward round once a day at and a board round at At the weekend, the consultant physician was found to be on-site for eight hours which also did not facilitate this standard being met. A business case submitted as evidence contained the proposal to increase the number of acute medical consultants from four to eight; it was noted that this business case had already been approved by the Trust Executive Management Group. The business case indicated that an increased number of consultants would enable extended cover from seven days a week and facilitate compliance with the standard; however no timeframe for implementation was given. At the audit visit the audit team felt that the acute medicine service were unable to meet this standard with the current rota and number of consultant physicians. A number of patients admitted in the evenings and at weekends would not be seen within the timeframe stated in the standard. Overall assessment The emergency general surgery department did not submit an operational policy as evidence for the self-assessment, neither was a policy presented during the audit visit. The hospital had four full time consultant surgeons on the emergency general surgery rota. At the audit visit the hospital indicated that a business case was completed in August 2012 to recruit two additional general surgeons; however, they intended to recruit a total of four consultant surgeons over time. At the audit visit the audit team found that there was a lack of consultant involvement at the beginning of the patient pathway; patients were initially assessed by a doctor in 8

9 No. Standard Commentary and conclusions training and were then discussed at the board round at 07.30, however, not all patients were seen during the ward round by the consultant and their team. At the audit visit it was also discovered that there was little involvement from the consultant surgeons in the abscess emergency ambulatory pathway. The initial assessment and subsequent procedure was performed by a doctor in training, often without any consultant involvement throughout the pathway. Overall assessment The hospital stated plans to restructure consultant rotas once the additional consultant surgeons were recruited; the consultant job plans would facilitate onsite presence from to enable the department to meet this standard and have a consultant surgeon review all newly admitted patients within 12 hours. The business case did not have board level agreement at the time of the audit visit. The audit team therefore agreed with the hospital s initial assessment that this standard was not met. At the self-assessment stage, the hospital s assessment and the patient notes audit submitted as evidence indicated this standard was not being met for both services. 2 A clear multi-disciplinary assessment to be undertaken within 12 hours and a treatment or management plan to be in place within 24 hours (for complex needs patients see 23 and 24). The acute medical unit operational policy stated that there was a multi-disciplinary review meeting five days a week at 12.30; at the weekend there was no multidisciplinary review for patients. Allied healthcare professionals attended the multidisciplinary meeting and patients that required rehabilitation were assessed within two working days of the initial referral. The multi-disciplinary review meeting attendance included the lead consultant and medical team, the lead matron, as well as representation from radiology, physiotherapy, occupational therapy and a duty social worker. There was a lack of evidence supplied at the self-assessment stage to support that this standard was being met for emergency general surgery. At the audit visit the audit team confirmed that the physiotherapy service was available Monday to Friday for both acute medicine and emergency general 9

10 No. Standard Commentary and conclusions surgery from At the weekend the physiotherapy services had a prearranged caseload of patients, and were therefore unable to review all the acute medicine and emergency general surgery patients on the wards. At the audit visit it was evident that provision was made to see new urgent chest patients, some postsurgical patients and possible discharge patients. Occupational therapy services were available from from Monday to Friday. At the weekend, occupational therapy also operated with a pre-arranged caseload of patients, and were unable to see all patients on the ward; however, they would see possible discharge patients that were not on the pre-arranged list. During discussion with staff throughout the audit visit highlighted that there was no budget to fund a weekend therapy service. Overall assessment The audit team agreed with the hospital s self-assessment that this standard was not met for acute medicine and emergency general surgery. a) All patients admitted acutely to be continually assessed using a standardised early warning system (EWS). At the self-assessment stage the evidence submitted during the self-assessment stage supported compliance with this standard for acute medicine and emergency general surgery. At the audit visit the audit team confirmed that all patients were continually assessed using a VIEWS system and had clear escalation procedures. 3 b) Consultant involvement is required for patients who reach trigger criteria. Consultant involvement for patients considered high risk to be within one hour. At the self-assessment stage the hospital stated that this standard was met for acute medicine and emergency general surgery, however the evidence submitted did not support compliance with this standard. At the audit visit, the audit team confirmed that the VIEWS warning system did not trigger for consultant involvement for high risk patients and the default position was to contact senior trainee doctors. The audit team concluded this standard was not met. 10

11 No. Standard Commentary and conclusions For acute medicine the consultant physician job plan submitted as evidence at the self-assessment stage stated the consultant physician was freed from all other duties whilst on take. At the audit visit the audit team confirmed that the consultant physicians were freed from other duties whilst on take and the hospital was compliant with this standard. Overall assessment 4 When on-take, a consultant and their team are to be completely freed from any other clinical duties or elective commitments. For emergency general surgery, the evidence submitted at the self-assessment stage did not support compliance with this standard. It was unclear from the consultant job plans whether consultant surgeons were freed from other duties whist on take. At the audit visit the audit team discussed the on call arrangements with the hospital and the documentation supporting these arrangements were submitted. The consultant on-call rota was divided into a four-day and a three-day system. One consultant was on-take and on call from Monday to Friday 12.00, with the weekend on-call starting from Friday to Monday The on call arrangement policy for emergency general surgery stated a number of concurrent commitments that consultants were engaged in whilst on take; therefore they were not free from other clinical duties. However, the policy stated that all senior doctors in training were commitment free whilst on call and were expected to carry their bleep at all times. At the audit visit the audit team confirmed that the consultant surgeons were not freed from there duties whilst on-take and were therefore not compliant with this standard. 5 In order to meet the demands for consultant delivered care, senior decision making and leadership on the acute medical/ surgical unit to cover extended day working, seven days a week. At the self-assessment stage the hospital stated that this standard was met for acute medicine. The consultant physician rota submitted as evidence indicated that consultants were on the unit from from Monday to Friday, and present on the unit for eight hours at the weekends. The hospital confirmed that they were unable to provide extended day cover seven days a week with the present consultant numbers. The audit visit confirmed this and therefore concluded that this standard was not met for acute medicine. The proposal to increase the number of consultant physicians from four to eight and extend their working hours from would enable the hospital to meet compliance with this 11

12 No. Standard Commentary and conclusions standard; however timescales for implementation were not confirmed. Overall assessment At the self-assessment stage it was evident that the hospital was unable to provide extended cover to meet this standard with the current number of consultants for emergency general surgery. At the audit visit the audit team found that consultant presence was low during week days and decreased further at weekends. The audit team found there was a lack of visible consultant presence, senior clinical input and decision making particularly at the weekend. The audit team therefore concluded that this standard was not met for emergency general surgery. 6 All patients on acute medical and surgical units to be seen and reviewed by a consultant during twice daily ward rounds, including all acutely ill patients directly transferred, or others who deteriorate. At the self-assessment the hospital stated non-compliance with this standard for acute medicine. The acute medical unit had a once-daily morning ward round and an evening board round. At the audit visit the audit team confirmed there was a ward round once a day in the morning from 08.00, led by the consultant. An afternoon board round was held at for discharge review and particularly sick patients. The audit team agreed with the hospital s self-assessment and concluded that this standard was not met. For emergency general surgery, the hospital stated non-compliance with this standard at the self-assessment stage. At the audit visit the audit team found that a board round was held at for emergency general surgery patients, after which deteriorating patients would be seen by the consultant. The audit team found that it was common practice for surgical doctors in training to lead the daily ward rounds; however, they were unable to see all emergency general surgery patients daily. The hospital highlighted plans to recruit four additional consultant surgeons to enable a consultant-led ward round from The audit team agreed with the hospital s initial assessment that this standard was not met. 7 All hospitals admitting medical and surgical emergencies to have access to all key diagnostic services in a At the self-assessment stage the hospital stated that this standard was not met for both acute medicine and emergency general surgery. The radiology policy submitted as evidence did not include timeframes by which diagnostic tests should be conducted by and subsequently reported. The computed tomography (CT) outof hours service from was outsourced. The hospital submitted an 12

13 No. Standard Commentary and conclusions timely manner 24 hours a day, seven days a week to support clinical decision making: audit which demonstrated that all CT s requested were reported within 18 hours. The diagnostic imaging department reported plans to assess the resources required to meet this standard and subsequently present a business case to the hospital board. Overall assessment Critical imaging and reporting within 1 hour Urgent imaging and reporting within 12 hours All non-urgent imaging and reporting within 24 hours At the audit visit the audit team found that the radiology staffing levels contributed to the difficulty in accessing key diagnostics in a timely way. Form Monday to Friday a consultant radiologist was on site from At the weekend a consultant radiologist was on site from and and on call from From discussion at the audit visit the audit team found the CT service was relatively efficient; however CT waiting times could be longer at weekends. At the audit visit it was evident that there was an issue surrounding access ultrasound (US) scans due to high demand, inadequate capacity and staffing levels. The audit team found the average wait for an US could be up to two days on Monday to Friday and even longer at the weekend. There was no differentiation between critical and non-critical patients in relation to reporting times for an US. The audit team found that Magnetic resonance imaging (MRI) was available at weekends and was reported by the consultant radiologist on site. Patients that presented to the department in the evening requiring an urgent MRI were referred to St Georges Hospital. At the audit visit the audit team found that patients that required an endoscopic retrograde cholangiopancreatography (ERCP) would need to have a magnetic resonance cholangiopancreatography (MRCP) before the radiology department would allow the patient to have an ERCP; this could lead to an overall longer patient stay for this group of patients. From discussion with staff the audit team found that the reduced number of porters in the hospital had an impact on the delay to patients having their diagnostic tests being done. 13

14 No. Standard Commentary and conclusions 8 All hospitals admitting medical and surgical emergencies to have access to interventional radiology 24 hours a day, seven days a week: Critical patients 1 hour Non-critical patients 12 hours At the self-assessment stage the hospital stated that this standard was not met for both acute medicine and emergency general surgery. The interventional radiology service was provided to the hospital via an informal network arrangement. At the audit visit the audit team found that the hospital had an agreement with St Georges Hospital for the provision of interventional radiology services out of hours. The audit team were concerned about capacity issues that could arise if a high number of critical patients needed to be transferred to St Georges Hospital. The audit team also found that the waiting times for non-urgent patients were variable, particularly at the weekend. The hospital was unsure about the clinical leadership for the current interventional radiology network service and had no written policy documenting the network agreements for the provision of interventional radiology to the hospital. The hospital highlighted the future arrangements that would be put in place to improve the interventional radiology service as part of the South West London interventional radiology project which would include a formalised interventional radiology network and rota. The audit team concluded that the hospital did not have access to interventional radiology 24 hours a day, seven days a week and suggested network agreements and a policy should be formalised and documented. Overall assessment 14

15 Consultant-delivered care: admissions ward rounds and theatre No. Standard Commentary and conclusions 9 Rotas to be constructed to maximise continuity of care for all patients in an acute medical and surgical environment. A single consultant is to retain responsibility for a single patient on the acute medical/ surgical unit. Subsequent transfer or discharge must be based on clinical need. The evidence submitted at the self-assessment stage did not support compliance with this standard for acute medicine. The consultant physician rota indicated the consultant of the day model was in place during the week and on-call general medicine consultant cover at the weekend. The audit team confirmed this model was being used at the audit visit. The audit team did not feel that this model was sufficient to maximise continuity of care in acute medicine and concluded that this standard was not met. At the self-assessment stage it was unclear from the evidence submitted whether continuity of care was maximised in emergency general surgery; however, the hospital stated that patients remained under the admitting consultant surgeon for the duration of their hospital stay. At the audit visit, the audit team were not assured that a single consultant surgeon retained responsibility of patients throughout their stay and therefore concluded that this standard was not met. Overall assessment 10 A unitary document to be in place, issued at the point of entry, which is used by all healthcare professionals and all specialties throughout the emergency pathway. At the self-assessment stage the hospital stated that this standard was not met for acute medicine or emergency general surgery. At the audit visit the audit team confirmed that both acute medicine and emergency general surgery did not have a unitary document in place to use throughout the emergency pathway. The hospital stated plans to implement the Cerner Millennium Electronic Patient Record system in May 2013 with the aim that the system would be able to capture all patient data in one place. 11 Patients admitted for unscheduled care to be nursed and managed in an acute medical/ surgical unit, or critical care environment. At the self-assessment stage the evidence submitted for the hospital supported compliance with this standard for acute medicine. At the audit visit the audit team found that the hospital had an acute medical unit with 39 beds. The audit team noted that the unit would benefit from additional acute physician consultants and nurses. The team also noted that patient transfers occurred late at night and there were significant discharge delays due to the lack of senior clinical presence, incomplete discharge paperwork, and the preparation of take home prescriptions. 15

16 No. Standard Commentary and conclusions The lack of an acute surgical admissions ward at this hospital supported the selfassessment that emergency general surgery was not compliant with this standard. Surgical patients were admitted across several wards. In the place of a permanent acute surgical unit, the hospital had three temporary surgical assessment wards. The audit team concluded that this standard was not met. Overall assessment 12 All admitted patients to have discharge planning and an estimated discharge date as part of their management plan as soon as possible and no later than 24 hours postadmission. A policy is to be in place to access social services seven days per week. Patients to be discharged to their named GP. The acute medicine unit operational policy indicated that patients would have a medical management plan and estimated discharge date written on the 'productive board' on admission. The evidence submitted mentioned access to social services seven days a week, with community liaison to support patient discharge. The patient notes audit indicated that this standard was not always being met for acute medicine. At the audit visit the audit team found that not all patients had the estimated date of discharge on the productive board. The audit team also found that there were no multi- disciplinary review meetings at the weekend. The evidence submitted at the self-assessment stage did not support compliance with this standard for emergency general surgery. At the audit visit the audit team found the surgical ward recorded the estimated date of discharge on the white board next to all the patients. However, the audit team were not assured that all patients were having effective discharge planning within 24 hours post admission due to the low level of consultant presence during weekdays and the weekend. At the audit visit the audit team found that social services were available seven days a week. The staff that had facility to refer patients to the Accident & Emergency liaison service and the acute medical unit. Their duties included the identification of potential patients that could be discharged at weekend accompanied by an assessment of their social needs. 16

17 No. Standard Commentary and conclusions 13 All hospitals admitting emergency general surgery patients to have access to a fully staffed emergency theatre immediately available and a consultant on site within 30 minutes at any time of the day or night. At the self-assessment stage the hospital stated compliance with this standard for emergency general surgery. The evidence submitted indicated the hospital had adequate emergency theatre services and consultants would be on site if needed within 30 minutes. At the audit visit, the audit team found that the hospital had an organised NCEPOD theatre list adequately staffed and consultants were able to be on site within 30 minutes. The audit team agreed with the hospital that this standard was met. Overall assessment 14 All patients admitted as emergencies are discussed with the responsible consultant if immediate surgery is being considered. For each surgical patient, a consultant takes an active decision in delegating responsibility for an emergency surgical procedure to appropriately trained junior or speciality surgeons. This decision is recorded in the notes and available for audit. The evidence submitted at the self-assessment stage did not support compliance with this standard. At the audit visit, the audit team were assured that all patients needing immediate surgery were discussed with a consultant surgeon; however, the discussion outcomes were not effectively recorded. Not 15 All patients considered as high risk to have their operation carried out under the direct supervision of a At the self-assessment stage the hospital stated compliance with this standard; however the patients notes audit indicated that the hospital was not fully compliant. At the audit visit the audit team were assured that all high-risk operations were carried out under the direct supervision of a consultant surgeon and anaesthetist and agreed that the standard was met. 17

18 No. Standard Commentary and conclusions consultant surgeon and consultant anaesthetist; early referral for anaesthetic assessment is made to optimise perioperative care. High risk is defined as where the risk of mortality is greater than 10%. Overall assessment 16 All patients undergoing emergency surgery to be discussed with consultant anaesthetist. Where the severity assessment score is ASA3 and above, anaesthesia is to be provided by a consultant anaesthetist. At the self-assessment stage the hospital stated compliance with this standard; however, it was unclear from the evidence submitted. The patient notes audit indicated that this standard was rarely met. At the audit visit the audit team found that the consultant surgeon and consultant anaesthetist discussed all patients that underwent surgery every morning and operated on all high-risk patients before The audit team therefore agreed with the hospital assessment that this standard was met. 17 a) The majority of emergency general surgery to be done on planned emergency lists on the day that the surgery was originally planned. The date, time and decision maker should be documented clearly in the patient s notes and any delays to emergency surgery and the reasons why At the self-assessment stage the evidence submitted did not fully support compliance with this standard. The hospital indicated that patient information was documented in theatre notes and not patient notes. At the audit visit the audit team were assured that this standard was being met and the majority of emergency general surgery was carried out on the day it was planned. 18

19 No. Standard Commentary and conclusions recorded. Overall assessment b) Any operations that are carried out at night are to meet NCEPOD classifications and be under the direct supervision of a consultant surgeon. The evidence submitted during the self-assessment stage indicated that all operations should meet NCEPOD guidelines with a consultant surgeon and anaesthetist present for all surgery at night. However, at the audit visit the audit team found that not all operations carried out at night were under the direct supervision of a consultant surgeon; however, the consultant anaesthetist was present for a majority of cases at night. The audit team concluded that this standard was not met. 18 All referrals to intensive care to be made from a consultant to a consultant. At the self-assessment stage the hospital stated that this standard was not being met as it was not mandatory for referrals to intensive care to be made from consultant to consultant; the critical care outreach team were also able to refer patients to intensive care. At the audit visit the audit team confirmed that a majority of referrals were not made from consultant to consultant and agreed with the hospital that they were not compliant with this standard. 19 A structured process to be in place for the medical handover of patients twice a day. These arrangements to also be in place for the handover of patients at each change of responsible consultant/medical team. Changes in treatment plans are to be communicated to nursing and therapy staff as soon as possible if they are not involved in the handover At the self-assessment stage, acute medicine stated compliance with this standard and referenced the handover policy for acute medicine which documented a number of handover meetings at various times. At the audit visit the audit team found that the handover occurred at the beginning and the end of the consultant shift in the acute medical unit. Nursing and therapy staff were not usually present at the handover meetings and changes in patient treatment were not rapidly communicated to them. On Friday afternoons acute medicine had an enlarged acute medical handover for the weekend consultant physician and their team; the junior medical team handed over specific duties to each other to carry out over the weekend. The audit team concluded that this standard was not met for acute medicine. Emergency general surgery did not submit a handover policy at the selfassessment stage. At the audit visit the audit team found that the surgical handovers were usually registrar-led twice a day and did not usually involve 19

20 No. Standard Commentary and conclusions discussions. nursing or therapy staff. The handover to the entire weekend team was conducted every Friday at The audit team concluded that this standard was not met for emergency general surgery. Overall assessment Patient experience No. Standard Commentary and conclusions 20 Consultant-led communication and Information to be provided to patients and to include the provision of patient information leaflets. The evidence submitted at the self-assessment stage included information regarding a pilot undertaken by acute medicine on communication during ward rounds. No patient information leaflets were submitted as evidence, but reference was made to patient leaflets available on the intranet. At the audit visit the audit team found that the majority of patient communication on the acute medicine ward was not consultant-led. From discussion with staff the audit team found that nurses spent a lot of time giving patient information verbally as there were no conditionspecific leaflets on the unit. At the self-assessment stage the hospital stated compliance with this standard for emergency general surgery. At the audit visit, the audit team found that patient communication on the surgical ward was led by the doctors in training. The hospital did not have any condition specific leaflets for emergency general surgery. The audit team found that patients that could have been discharged earlier would decide to stay in the hospital in order to talk to a senior clinician before being discharged. Overall assessment 21 Patient experience data to be captured recorded and routinely analysed and acted on. Review of data is a permanent item on board agenda and At the self-assessment stage the evidence submitted by the hospital did not fully support the standard being met. Patient experience was an item on the hospital Board agenda bi-monthly and the hospital Board report covered in-patient surveys, complaints, Patient Advice and Liaison service (PALS), as well as using Just a Minute (JAM) cards. The hospital acknowledged low results on the National Patient Experience Survey. 20

21 findings are disseminated. At the audit visit the audit team found that patient experience data was captured, recorded and presented to the board. However, the hospital had no clear approach to communicate the findings to staff, neither was the analysis of these findings adequately displayed for the patients to see. On the acute medical unit the notice board was displayed with real time feedback cards filled out by patients and their families. At the audit visit, there was no evidence of patient experience data displayed on any of the wards that contained emergency general surgery patients. Just a Minute (JAM) cards were given to patients when they came to collect their prescriptions, which excluded most in-patients who were heavy users of the pharmacy service. The Pharmacy service has weekly meetings to review all the results from he JAM cards and would highlight good and bad practice. The audit team noted this as good practice in pharmacy and suggested this method could be implemented for acute medicine and emergency general surgery. Key services No. Standard Commentary and conclusions 22 All acute medical and surgical units to have provision for ambulatory emergency care. The evidence submitted at the self-assessment stage for acute medicine supported compliance with this standard. The hospital stated plans for the new ambulatory facilities to open in October The hospital had previously piloted delivering ambulatory care at an interim facility in the old cardiac day care unit. At the audit visit the audit team confirmed that the acute medical unit had provision for ambulatory emergency care for pathways including deep vein thrombosis (DVT), transient ischemic attack (TIA) and chronic obstructive pulmonary disease (COPD). The DVT service was 7 days a week; however there was no access to a doppler ultrasound service at weekends. The hospital action plan for the development of the current acute medical ambulatory services included opening an Emergency Ambulatory Assessment Clinic in November 2012 as well as agreeing additional ambulatory pathways. At the self-assessment stage the evidence submitted did not support compliance with this standard for emergency general surgery. At the audit visit Overall assessment 21

22 the audit team found that the surgical ambulatory service was led by senior trainee doctors and not supervised by a consultant. The audit team noted the surgical team operated a potentially a good and efficient abscess pathway, but required consultant input. The patients on the abscess pathway were seen and assessed by a doctor in training and brought back for their procedure the following morning. The patients were operated on and discharged without seeing a consultant surgeon. The audit team were concerned that the service was completely dependent on doctors in training and this carried patient risk if the service continued without consultant input. 23 Prompt screening of all complex needs inpatients to take place by a multiprofessional team which has access to pharmacy and therapy services, including physiotherapy and occupational therapy, seven days a week with an overnight rota for respiratory physiotherapy. At the self-assessment stage the evidence submitted did not fully support compliance with this standard for acute medicine and emergency general surgery. At the audit visit the audit team found that multidisciplinary screening of all complex needs patients was not happening in a prompt manner. As mentioned in standard two, both services had a multi-disciplinary meeting during the weekdays, but not at the weekend. There was limited availability of therapy services for all complex needs patients at weekend for both acute medicine and emergency general surgery. The audit team confirmed the hospital had an overnight rota for respiratory physiotherapy. Pharmacy was present Monday to Friday from At the weekend, pharmacy services were available from , after which there was an on call service. The audit team found pharmacists were unable to review all patients at weekends, and therefore prioritised discharge patients. 24 Single call access for mental health referrals to be available 24 hours a day, seven days a week with a maximum response time of 30 minutes. At the self-assessment stage the hospital stated non-compliance with this standard for both acute medicine and emergency general surgery. The hospital stated a quarterly audit was conducted for mental health response times but the associated analysis was not submitted as evidence. At the audit visit the audit team found the earliest response time from the mental health team was within four hours, however, patients were usually seen the day after the initial referral. The audit team found that the elderly psychology team visited patients on the acute medical unit. The hospital had a dementia lead and stated plans to implement a developed dementia strategy; however, the hospital was unable to deliver personalised care plan for 22

23 dementia patients at the time of the audit visit. The hospital highlighted the provision of mental health services for acute emergency patients was discussed at the South West London commissioners group, where it was identified that other Trusts in south west London had similar access issues. Considerations were being made towards collaborative working whist looking at the financial implications of delivering this service within the stipulated standard requirements. 25 Hospitals admitting emergency patients to have access to comprehensive 24 hour endoscopy services that has a formal consultant rota 24 hours a day, seven days a week. At the self-assessment the hospital stated non-compliance with this standard for both acute medicine and emergency general surgery. The evidence submitted stated the current provision from the Croydon Healthcare Service (CHS) team during the daytime as part of the network Gastrointestinal (GI) bleed rota. At the audit visit it was highlighted that the hospital was part of a network emergency upper GI bleed service with St George s Hospital and Epsom & St Helier University Hospital Trust. At the audit visit there was no evidence of a written policy with standard timeframes to support the network arrangements. After discussion with staff, the audit team were assured that the hospital had access to a comprehensive endoscopy service with 24/7 formal consultant cover. The audit team noted that the hospital should have a written policy that contained the existing networked endoscopy arrangements. 26 a) All hospitals dealing with complex acute medicine to have onsite access to levels 2 and 3 critical care (i.e. intensive care units with full ventilatory support). Evidence submitted at the self-assessment stage supported compliance with this standard. At the audit visit the audit team confirmed that the hospital had access to level 2 and 3 critical care and were compliant with this standard. b) All acute medical units to have access to a monitored and nursed facility. At the self-assessment stage the hospital stated compliance with this standard. At the audit visit the audit team confirmed the hospital had access to a monitored and nursed facility and agreed that they were compliant with this 23

24 standard. Training No. Standard Commentary and conclusions 27 Training to be delivered in a supportive environment with appropriate, graded consultant supervision. During the self-assessment the hospital stated compliance with this standard for both acute medicine and emergency general surgery. At the audit visit the audit team found that trainees actively chose the hospital for training, and most junior staff felt they were in a supportive environment. Overall assessment 24

25 5. Results of the patient note audit Table 3 contains the results of the patient note audit which the hospital was asked to perform to demonstrate compliance with the standards. The results of this formed part of the overall assessment of the standards. Table 3: Results of the patient note audit for acute medicine and emergency general surgery Standard* No. 1 All emergency admissions to be seen and assessed by a relevant consultant within 12 hours of the decision to admit or within 14 hours of the time of arrival at the hospital. 2 A clear multi-disciplinary assessment to be undertaken within 12 hours and a treatment or management plan to be in place within 24 hours (for complex needs patients see 23 and 24). 6 All patients on acute medical and surgical units to be seen and reviewed by a consultant during twice daily ward rounds, including all acutely ill patients directly transferred, or others who deteriorate. 10 A unitary document to be in place, issued at the point of entry, which is used by all healthcare professionals and all specialties throughout the emergency pathway. 12 All admitted patients to have discharge planning and an estimated discharge date as part of their management plan as soon as possible and no later than 24 hours post-admission. A policy is to be in place to access social services seven days per week. Patients to be discharged to their named GP 14 All patients admitted as emergencies are discussed with the responsible consultant if immediate surgery is being considered. For each surgical patient, a consultant takes an active decision in delegating responsibility for an emergency surgical procedure to appropriately trained junior or speciality surgeons. This decision is recorded in the notes and available for audit. 15 All patients considered as high risk to have their operation carried out under the direct supervision of a consultant surgeon and consultant anaesthetist; early referral for anaesthetic assessment is made to optimise peri-operative care. High risk is defined as where the risk of mortality is greater than 10%. 16 All patients undergoing emergency surgery to be discussed with consultant anaesthetist. Where the severity assessment score is ASA3 and above, anaesthesia is to be provided by a consultant anaesthetist. 17 The majority of emergency general surgery to be done on planned emergency lists on the day that the surgery was originally planned. The date, time and decision maker should be documented clearly in the patient s notes and any delays to emergency surgery and the reasons why recorded. Any operations that are carried out at night are to meet NCEPOD classifications and be under the direct supervision of a consultant surgeon. Patient note audit Medicine Weekday 5/5 met Weekend 10/12 met Weekday2 /5 met Weekend 4/12 met Weekday 1/5 met Weekend 0/12 met Weekday 0/5 met Weekend 0/12 met Weekday 3/5 met Weekend 10/12 met Surgery Weekday 2 /5 met Weekend 0/1 met Weekday 4/5 met Weekend 1/1 met Weekday 2/5 met Weekend 0/1 met Weekday 0/5 met Weekend 0/1 met Weekday 1/5 met Weekend 1/1 met Weekday 1/5 met Weekend 0/1 met Weekday 2/5 met Weekend 0/1 met Weekday 1/5 met Weekend 0/15 met Weekday0 /5 met Weekend 0/15 met 25