Steven Vaughan, Interim Chief Operating Officer

Transcription

1 ENC No. 21 Meeting Trust Board Date 2 nd June 2016 Title of Paper Lead Director Author PURPOSE OF THE PAPER Surgical Assessment Unit Steven Vaughan, Interim Chief Operating Officer Rachael Benson, Divisional Director Contributors Clinical Director General Surgery Matron General Surgery Consultants General Surgery FY1s General Surgery Senior Sisters Wards 10 and 11 DBA Surgery For decision on the proposal for the permanent establishment of the Surgical Assessment Unit. SUMMARY OF THE KEY POINTS: Following the previous non-recurrent approval the unit has been operating as a pilot since February. The pilot has brought a number of benefits, including: o Positive impact on patient experience by reducing waiting times for patients attending the hospital on the urgent care pathway o Support achievement of CQC A&E 4Hour wait times o Positive impact on staff experience o Improves quality service to emergency surgical patients o Has increased the specialty take over the course of the pilot The recurrent costs have been included within the 2016/17 financial planning assumptions Performance Finance and Investment Committee reviewed the business case for approval at its meeting on 27 th May 2016 and are recommending the case to Board for approval For One and All Page 1 of 14

2 RECOMMENDATIONS: The Board approves the case for permanent establishment of a Surgical Assessment Unit LINKS Strategic Objectives First Class Patient Experience Safe, High Quality Services Good Use of Resources Improve interface between Community and Acute care Annual objectives An effective and fit for purpose organisation Improved clinical services High quality services Monitor / CQC / Regulatory Support achievement of CQC A&E 4Hour wait times. Requirements IMPACT Patient Experience The continuation of the Surgical Assessment Unit and robust pathways will represent continued improvement in patient experience Continued increase in Friends and Family scores around surgical emergency pathways Quality & Safety Direct access to this facility to assess and appropriately treat patients quickly and safely. Financial Reduction in fines Emergency Department fines Aid achievement of CQUIN for reduction in use of antibiotics Ensure that patients are properly recorded on Lorenzo to prevent impact on readmission rates Workforce Requirement to provide staffing from 8.00am-Midnight Equality & Diversity Offer equitable service to every patient attending SAU Estates Relocation of SAU during the ICCU build IM&T Recording patients appropriately in line with pathways Communications/ Engagement Raising the profile of the SAU service with the local GP s and commissioning groups RISKS Clinical risk availability of surgical team to attend ED at time of decision to refer Patient s expectations of admission increases exponentially the longer they remain in ED. No reduction in complaints No reduction in Surgical ED breaches. Readmission rates for Surgical patients remain high Loss of income due to non-achievement of Best Practice Tariff (BPT) For One and All Page 2 of 14

3 Low staff morale Surgery will not be able to achieve the 4hr wait time for admissions from ED The Organisation will remain in CQC Special Measures as we will not be able to meet and deliver on specified requirements within the target timeframe No financial savings as LoS would return to pre SAU pilot. Disengagement of Surgical Colleagues for future projects. PREVIOUS CONSIDERATION Executive Committee Performance Finance and Investment Committee 27/05/16 recommendation to Board of Directors for Approval SECTION EXECUTIVE SUMMARY 1 A Surgical Assessment Unit (SAU) provides a service for rapid assessment & treatment of a variety of surgical conditions. Once the patient is assessed in the SAU they will be admitted as an inpatient to the hospital for treatment, treated on the unit itself or discharged home if appropriate. The purpose of the unit is to assess and treat acute surgical patients who would have previously presented to the Emergency Department including emergency GP Referrals. Patients attend SAU for treatment for some surgical conditions without having to admit the patients to hospital. The substantive opening of SAU will ensure the Trust s facilities are in-line with national trends for the development of emergency surgical pathways. SAU supports timely assessment and treatment of emergency surgical patients and as such assists in the management of patient flow through Emergency Departments. SAU departments also provide an environment for emergency GP referrals to be assessed and treated. Research indicates that an established SAU will divert patients away from A+E and can provide a strategy for streamlining the emergency surgery patient journey by ensuring they receive rapid assessment and management by senior surgical staff this leads to: Reduction in A&E waiting times for surgical patients Improved patient flow and increased utilisation of theatre Reduction in number of cancelled patients due to no surgical beds Appropriate facilities and resources to deliver both the assessment services but also Emergency hot review clinics. Reduction in numbers of patients with an overnight stay Improved patient and staff experience Improved collection of patient tracking data with relation to finance and statistical information Meets best practice standards for the management of surgical emergencies outlined For One and All Page 3 of 14

4 by the Royal College of Surgeons Improved opportunity for management of patient expectations at initial contact that they may not require admitting onto a ward or require an operation and may be discharged on the same day. Prior to the April start date Walsall Healthcare Trust did not have a dedicated SAU; patients remained in the ED until referred to the specialism and were then reviewed by a surgical specialist within the department, being transferred to a ward bed if required when one is available. The GP patients attended the main emergency surgical wards and sat in a waiting area waiting for review. Lessons learnt from the trial period and in consultation with other Trusts, are that a SAU should be a stand-alone unit and away from the emergency ward bed base. This is due to the inability to ring-fence beds during peak pressures. Brief description of the proposed solution To have a permanent dedicated Surgical Assessment Unit on Ward 8 as a stand-alone unit which is an operational facility within the Trust following the initial running period of 12 months. Critical Benefits The main benefits of a permanent SAU for Walsall Healthcare NHS Trust are: To improve the patient experience and reduce waiting times and readmissions by simplifying the patient pathway. Improved patient experience scores/family and friends test. To improve staff results in both the NHS staff satisfaction survey and the local pulse survey by making the surgical wards an improved environment in which to work, reducing sickness and increasing morale. Simplification of the patient pathway with improved experience for GP referred patients Patients treated in line with organisational values of Welcomed, In Safe Hands and Cared For. Support the Emergency Department for the management of surgical patients To improve 4hr performance of emergency surgical and Orthopaedic patients by developing an improved surgical emergency admission pathway Potentially increase income for best practice tariff, higher FCE and reduction in fines Key Financials of Proposed Option Dedicated SAU on Ward 8 Financial Indicator Value Recurrent costs Staff 466,000 Non pay/recharges to other Divisions 60,000 Non-recurrent costs Capital 13,000 Set up 18,000 Potential opportunities to offset New income schemes subject to Commissioner 69,000 agreement Avoided costs for other facilities not being open 56,000 overnight For One and All Page 4 of 14

5 Key risks The key risks associated with a decision to decide to end the pilot and not make a recurrent investment are: Loss of surgical capacity which will adversely affect surgical pathways adding delays to admission and early/direct access to the senior clinician for GP referrals Increase demand on the Emergency Department as Surgical patients will be lodged there pending a surgical base ward bed being available Have a negative impact on patient and staff experience, as well as having a detrimental effect on engagement in respect of future developments Financial risk of fines for Emergency Department performance on a recurrent basis and access to the Service Transformation fund in 2016/17 Timescale / Key milestones Key Milestones Responsibility Timescale Running Pilot for SAU RB / CG Feb 15 April 16 Review of SAU pilot Executive Team October Identify recurrent funding DBA March 2016 SECTION BUSINESS NEED 2 Background The Standards for unscheduled surgical care issued by the Royal College of Surgeons (2011) recommends a separation of emergency and elective surgical care, the Trust has dedicated elective and emergency inpatient wards. The Surgical Assessment Unit needs to be an inherent part of this as case studies/research have shown that a Surgical Assessment Unit can provide a strategy for streamlining the emergency surgery patient journey by ensuring they receive rapid assessment and management by senior surgical staff (Royal College of Surgeons, 2007). Prior to the initial set up period of the SAU GP emergency surgical admissions were managed through wards 10 (female) and 11 (male), which are inpatient surgical emergency wards. Patients were referred to the appropriate ward and are then directed to a GP waiting room, they were assessed by the medical team, and they had to wait for a bed space if subsequent treatment was required either prior to admission or discharge. This led to a poor patient experience, as shown in family and friends scores and comments, largely due to the ward facilities not being fit for purpose and the need to maintain available capacity for inpatient beds it was not possible to create dedicated trolley space for patients to be easily and quickly assessed, this was of particular concern for more acutely unwell GP referred patients. Feedback from this cohort of patients has highlighted long waiting times, poor access to pain relief and poor waiting room facilities, which is suboptimal treatment for any cohort of patients and does not fall in line with the Trust s promises. Findings from pilot For One and All Page 5 of 14

6 The pilot period has demonstrated a number of benefits to patients, which would continue and can be further enhanced by committing to a permanent facility. These would be to: Improve patient experience by providing appropriate facilities for assessment and treatment of emergency surgical admissions Meet current demand for the service Provide easily accessible care and improved access to diagnostics Enhance organisational reputation Reduce the number of inappropriate surgical admissions Reduce the number of outliers on Wards 21 and 23 Reduce the number of readmissions by offering telephone and advice. Maximise use of the emergency theatre (Theatre 2) and Trauma theatre Simplify the patient pathway with the development of a seamless pathway Enable creation of dedicated hot clinic slots available daily and bookable via the system for patients to be able to return for results, checks etc. Proposal Location The pilot has run in Ward 8 and following the 12 months operational experience of the Surgical Assessment Unit it is recommended this location is suitable, though other similar locations could be created. Ward 8 provides a functional assessment and treatment space with the following facilities: Ability to meet best practice standards of co-locating emergency patients making dedicated patient care safer and more efficient whilst providing single sex accommodation using one side of the ward for males and the other for females. Single sex accommodation Waiting area Side room from which to run an emergency clinic Appropriate reception facilities Note: The current plans for development of the new critical care unit mean there is a period of time that Ward 8 would need to be temporarily relocated elsewhere within the Trust s estate. There are a number of options including the use of Ward 12 or Ward 26 (which could accommodate 8 patients within their current capacity). Operational arrangements The unit has operated 8.30am to 9pm, 7 days a week managing emergency referrals from GPs and the Emergency Department mainly for general surgery, urological, orthopaedic and ear nose & throat emergency patients more effectively (with the latter two specialties using the unit after the initial set up period). A number of pathways have been developed throughout the period including: For One and All Page 6 of 14

7 Abscess Head Injury Alcohol pancreatitis Urological emergencies Biliary colic and non-specific abdominal pain Assessment of T&O patients excluding NOF s, Caudal equine and fractured femur s The opening hours cater for peak GP referral times into the hospital for surgical emergencies, a standardised operational process has been established; this is detailed at appendix 1. Staffing requirements for Ward 8 SAU Medical Staffing The unit will be staffed using the hot week model, which General Surgery currently operates and there is no need for additional resource for other specialties the current escalation processes would apply. Additionally, it is proposed that the 2nd on call consultant will undertake an emergency clinic within the facility to enable patients seen by the surgical registrars who require review can be booked into an emergency clinic slot the following day. This will reduce patient waiting times in A+E whilst ensuring patients receive their review in a timely manner; this role is being developed through the General Surgery Annual Plan through job planning review and as well as delivering the emergency clinic the role would contribute to supporting wards which will expedite discharges, deliver teaching ward rounds and complete 6 CITs and ensure VTEs are completed. An and telephone advice service would also be implemented for GPs and information included on patient information leaflets signposting patients to these services to support the Care Groups work on reducing readmissions (this may also provide an additional income stream). Nursing Staff/Admin Staff Senior nursing supervision will be provided by the Matron for SAU, T&O and General Surgery. The SAU operates as a standalone unit from the other surgical wards, therefore would be staffed with 2 Qualified Nurses, 1 Care Support Worker and 1 Ward Clerk. With cover for annual leave, sickness and training this gives the following establishment: WTE Band Band Band Band Band 2 A&C 2.62 For One and All Page 7 of 14

8 Total Quality The unit has supported an improvement in the delivery of high quality care whilst improving patient experience and staff morale. The prevention of an admission to the ward has resulted in the average length of stay reducing and a positive impact on our Family and Friends scores. Reduction in Length of Stay Following the introduction of SAU, the average LOS across all three wards reduced. The average length of stay for surgical emergencies reduced from 2.85 (Oct to March) to 2.69 days (Apr to Sept) Month Average Month Average Oct 3.08 Apr 2.26 Nov 2.83 May 2.66 Dec 3.36 Jun 2.74 Jan 2.51 Jul 2.48 Feb 2.52 Aug 2.51 Mar 2.80 Sep 2.61 Potential demand The table below shows the number of emergency patients who are suitable to use the Surgical Assessment Unit. During 2014/15 there were some 6072 short stay patients accommodated on inpatient wards, a significant proportion of those discharged on the same day would be able to be treated within the unit. Nights Stay Grand Total ENT GENERAL SURGERY GYNAECOLOGY T & O TRAUMA AND ORTHOPAEDICS UROLOGY Grand Total During the first few months of the pilot 56% of patients were discharged on the same day. For One and All Page 8 of 14

9 Contract/Finance Implications Patients who transfer from the emergency department to the SAU will be admitted, the graph below shows the immediate impact from the implementation of the unit; there was a stepped increase in the number of admitted patients; leading to some over-performance of contracts in / (10) Oct Total number of patient discharges 2014 (11) Nov 2014 (12) Dec (01) Jan (02) Feb (03) Mar (04) Apr (05) May (06) Jun Implementation of SAU (07) Jul (08) Aug (09) Sep In addition, it is possible to earn additional income by being able to access best practice tariffs relating to same day emergency care, which was introduced in for same day emergency care was introduced in 2013/14; in Surgery the conditions covered are:- For One and All Page 9 of 14

10 Minor head injury Abdominal pain Anaemia Bladder outflow obstruction Renal/ureteric stones Low risk pubi rami fracture Cellulitis Appendicular fracture not requiring fixation on day of emergency attendance Indicatively, the historic performance shows the opportunity to earn at least c 34,000 per annum through the tariff for patients with these conditions who had a 0 day length of stay. Other potential financial opportunities The introduction of the telephone advice line would provide a new income stream via a local tariff in line with tariff guidance for non-face to face outpatient attendances; assuming 500 patients per annum with at a tariff 50% of a New Outpatient this could earn an additional c 35,000 In additional ward 20c has historically provided the additional capacity when surgical beds are full, comparing 2014/15 to /16 approximately 56,000 has been saved. Benefits and Risks The Table below summarises the risks and benefits associated with converting the pilot Surgical Assessment Unit into a permanent facility. Benefits from maintaining unit To improve the patient experience and reduce waiting times and readmissions by simplifying the patient pathway with improved triage and transfer of patients Improved patient experience scores/family and friends test. To improve staff results in both the NHS staff satisfaction survey and the local pulse survey by making the surgical wards an improved environment in which to work, reducing sickness and increasing morale. Simplification of the patient pathway with improved experience for GP referred patients with a specialist co-located surgical team providing increased access to senior clinicians Patients treated in line with organisational values of Welcomed, In Safe Hands and Cared For. Support the Emergency Department for the management of surgical patients To improve 4hr performance of emergency surgical and Orthopaedic patients by developing an improved surgical emergency admission pathway Potentially increase income for best practice tariff, higher FCE and reduction in fines For One and All Page 10 of 14

11 Provides facility to further develop emergency pathways by creating permanent hot clinics Increases surgical bed capacity in overall terms Reduce the number of readmissions by offering telephone and advice Risks of not maintaining the unit Impact on patient satisfaction and quality of care as there are likely to be delays in patients being admitted from the Emergency Department Poor patient experience reflected in the Friends and family scores GP referrals will all attend the emergency department rather than to a separate unit; increasing demand on the department Adverse impact on clinical engagement in future projects as the clinicians believe the pilot has been successful and can be further developed Non-compliance with CQC requirements Poor performance against CQUIN targets Finance o Increased fines, cancellations and access to the Service Transformation Fund o Negative impact on Best Practice Tariff Capacity pressures, potentially affecting the current ability to ring fence elective beds Increased length of stay Risk to 4 hour A&E Target Inability to implement new ways of delivering high quality care across surgical patients For One and All Page 11 of 14

12 SECTION FINANCIAL SUMMARY 3 The service has be operating as a pilot for in excess of 12 months; this, or a similar facility, is commonplace in most NHS Trusts. The provision to establish the Surgical Assessment Unit was discussed and included within the Annual Plan for 2016/17. Detailed below is a summary schedule of the costs. Expenditure Recurrent Costs per annum Divisional Costs Nursing staff -registered Nursing staff CSW Ward Clerk Non pay Other Division s costs Housekeeping 294,000 97,000 55,000 20,000 52,000 Total Recurrent costs per annum 518,000 Non- Recurrent Set Up costs 18,000 Capital 13,000 Potential to offset expenditure On a recurrent basis there are opportunities, described above, which could offset these costs if Commissioners agree to fund these developments in future years. These are: Best practice tariffs 35,000 New hot clinic service 34,000 Total 69,000 In addition, during the pilot phase costs for opening of ward 20c overnight have been avoided; this equated in c 56,000 in year. For One and All Page 12 of 14

13 Further considerations During 2016/17 the Trust is not exposed to Commissioner fines in relation to urgent care pathways (4 hours); under normal circumstances in overall terms this is in excess of ½m. However during this year, failure to meet the agreed performance trajectory the Service Transformation Fund income will be at risk. The Surgical Assessment Unit is an inherent part for surgical specialty pathways and will avoid breaches of the 4 hour standard. SECTION RECOMMENDATION 4 The Committee is asked to recommend that the Board approves the case for permanent establishment of the unit For One and All Page 13 of 14

14 Operational Process Appendix 1 SAU patient pathways Patient presents to ED and assessed by A&E team. Surgical referral made as required GP refers into Surgical Registrar Bleep and patient details noted SAU monitor ED whiteboard and pull referred patients to unit (except those requiring critical care intervention) Patient presents directly to SAU and made welcome and comfortable by nursing staff Patient clerked by FY1/2 in unit and initial diagnostics are ordered if required (45 mins) Staff Grade or Consultant on Hot Week attends unit to assess patients and agree treatment plan (<2Hrs) Patient discharged no further intervention required. EDS to GP Patient discharged with follow up plan hot clinic, OPD clinic or planned procedure. EDS to GP Patient requires inpatient admission within 4 hours of attendance to unit to Ward 9, 10, 11. For One and All Page 14 of 14