Length of Stay Dr Derek Thomson GP & Medical Director

To Cover

• What is Northumbria Healthcare FT? • Organisational Integration reducing LOS • Reducing Surgical LOS • What effect are we having ? • What about the future - Northumbria

Specialist Emergency Care Hospital (NSECH)

Northumbria Healthcare Foundation Trust – Integrated Care Provider

• Secondary Care – 9 Hospitals, 3 DGH, 6 Community Hospitals – Soon to be 10 hospitals, then 12 hospitals.

• Community Service – The coming together of; – Nth Tyneside community services, – Northumberland Community services and Northumberland Social care – To create BU (£70million health and £140million social care)

• Social Care - Partnership agreement maintained between the county council and Northumbria

• Population of 500k, spread over c2,500 sq miles and c 9,000 staff

Organisational Structure • Northumbria Formed in 1998, Foundation Trust since

2006 • Many examples of ‘Copy and Paste’

• Leadership and development programs, recruitment process, driven by patient experience and QI

• Built upon strong, accountable Clinical Business Units, – Med and Emergency Care, Emergency and Planned Care,

Paeds, Clinical Support, Community • Paired Clinical and Managerial Leaders • Stable senior management team • Long and strong relationship with Primary Care

Reducing LOS through Integration – What is possible?

• Reducing Hospital Bed usage – Community/Pre-admission, Front of House, Back

of House, Transfer of Care (discharge), Community/re-admission prevention

• Speeding up flow through the Hospital • Reducing Admissions to Nursing and

Residential Care

Community Admission avoidance

Front of House Reducing Length of Hospital stay

Supported Discharge

Community Re-admission avoidance

Ambulatory Care NGH, WGH

Surgical assessment units

Phone Help lines IBD, TIA, Rheum

Admission avoidance program A&E

Facilitated Discharge Team FDT

COPD Program

LTC Management EDD AND Ticket Home

Nurse led early discharge

Discharge Lounge WGH+,NGH

Alcohol Project

Frail Elderly Care Pathway

Hospital Frail Elderly Care

LINS LINS

Short Term Support Team N’land

Specialist FDT in Orthogeriatric,Stroke

Community Hospital Utilisation

Nursing & Care Home Initiatives- matrons

DAART & ENP-NT Pharmacy Incentive

Integrated End of Life incl Community & CS

Consultant Telephone call

Primary Care Incentive Scheme

Matron supporting nursing homes

LTC Annual Rv

OOH D/Nurse

^ Clinic Capacity

Telehealth

JELS

Early Discharge

Pharmacy

(Safeguarding)

(Podiatric waiting list)

(Sexual Health)

Community Investment

Health and social care integration

Pulm Rehab-Nth Tyne

Pulm Rehab N’land

Lung Improvement Program

CGA in hospital, Follow up in Community, 1 wk

Single Point of Access

Hospital to Home Team

Elderly Assessment Unit

Improving Length of Stay

Estimated Discharge

Dates

Nurse led discharge

Complex discharge

Speeding up the pathways

• At Admission - Identification of complex discharge (Mayo risk stratification tool)

• Estimated Day of Discharge and Ticket Home – Visual controls for patient and staff

• Hospital to home team- Community based MDT • Pits stop approach to discharge • Nurse led Discharge • CGA in hospital, seen by D/Nurse within 7 days • Single Point of access to Community Services • Community based Short term Support Service

Complex discharge

• Using the Mayo Tool to identify complex

discharges

• More visual displays for patients

Further improvement cycles

Ticket Home postcard

EDD: Visual display for patients

Ticket Home leaflet

Nurse led discharge Aim to smooth out variation in discharges over 7 days

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NT D/C

Since starting nurse led discharges, we have average of 2 extra discharges per ward at a weekend, that would have stayed in hospital

Hospital 2 Home Team Northumberland

• Northumberland Team Live from November 2013

• Community Matron Team Lead • Social Work, OT, care management, STSS,

mental health specialist. • Work into Front of House – A&E and MAU • Back of House through the MDT’s • Smaller team in North Tyneside

Ambulatory Care and Elderly Assessment Units

• Ambulatory Care – 31,000 cases through ambulatory care in past 12m – Rate now >3,000 per month – 85% medical cases

• Elderly Assessment – Preparation for NSECH – Opening on 3rd site soon – 50% go home, 20% direct to rehab facility and

30% still get admitted

Reducing LOS in Surgery

• Gynae – Laparoscopic Hysterectomy since 2008 now 90% done this way – 70% now as Day cases and 90% <24hr stay – Previously average LOS was 3.5 days – ½ complication rates

• Colo-rectal – Laparoscopic plus enhanced recovery= 1.5 day reduction

• Orthopaedics – Hip and Knee replacement – Fast Track Surgery and enhanced recovery

programs and day zero mobilisation. median LOS = 3.0 days , Mean LOS = 3.8 in 12-13. National LOS was 5.3 days in 11-12.

– Top 5% – All surgeons receive their performance monthly – #NOF

Pre-assessment

• Ensure the pre-assessment screening pathway is a safe and timely assessment

• Optimisation - allow enough time for further investigations or interventions to be put in place prior to surgery

• Identify complex patients early and pre-planned to the H2H team

• Collaborative working between GP’s, Surgeons and Pre-assessment

• Early pre-assessment generates a pool of patients who can fill gaps on operating lists

SO WHAT ?

• Recent CHKS Comparisons • Northumbria average LOS is 3.6 days

compared to National rate of 4.2 days • Mixed across different specialities AND • All targets achieved • Financial Surplus

NORTHUMBRIA HEALTHCARE NHS FOUNDATION TRUSTMidnight bed occupancy 2012/13 and 2013/14NTGH, Wansbeck, Hexham

1800018500190001950020000205002100021500220002250023000Monthly occupied bed days Monthly total OBD OBD reduction trajectory (seasonal)

N.B. Excludes paediatrics beds,well babies, SCBU, obstetrics, critical care,

NORTHUMBRIA HEALTHCARE NHS FOUNDATION TRUSTMean length of spell 2012/13 and 2013/14NTGH, Wansbeck, Hexham

*Mean length of spell (proxy) - occupied bed days in the month divided by total admissions in the month

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Mean length of spell*(days)

mean length of stay 11/12 mean length of stay 12/13 mean length of stay 13/14

N.B. Excludes paediatrics beds,well babies, SCBU, obstetrics, critical care,

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Permanent admissions to care homes, per 100,000 population - 2012/13

Northumbria Specialist Emergency Care Hospital - NSECH

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Specialist Emergency Hospital

Outpatients Diagnostics Day cases Elective Surgery

Sub acute in-patients

A&E Emergency Admissions

Acute in-patients

Minor injuries

Acute in-patients

A&E Emergency admissions

“hot” diagnostics

Outpatients Diagnostics Day cases Elective Surgery

Sub acute in-patients

A&E Emergency Admissions

Acute in-patients

Minor injuries

Focussed around 3 major sites

1 major “emergency site”

Outpatients Diagnostics Day cases Elective Surgery

Sub acute in-patients

A&E Emergency Admissions

Acute in-patients

Minor injuries

Northumbria Specialist Emergency Care Hospital - NSECH

• Services – All ambulance and GP referrals – Major A&E / Specialist ED in the new world, 24/7

emergency Care Consultant delivered service – Acute medicine, GI, Cardio, Resp, Elderly (incl ambl

function), Stroke, Trauma, Maternity, Paeds and Surgery specialist wards with 7 day consultant working

– Critical care – Some high risk elective surgery – Ambulatory care – medically led – Surgical assessment unit

• 24/7 consultant presence – early senior decision making

• Backed up by 8 til late specialist consultants, 7 day working. Quicker specialist decision making,

• Dedicated 7 day Diagnostics • 7 day working for Endoscopy • No longer wait in MAU/ECU – patients will go

directly to speciality ward from A&E

Effect on Length of Stay

• All the business units and specialities working towards reducing LOS

• Working within and across BU and specialities, via integration board

• Working at these for a long time and been able to close wards in the past 3 years

• There is no single silver bullet • Future major reconfiguration to create the next

step-wise change

Summary

Any Questions?