lack of integrated critical care service with a single

Rob Flavell55
Lack of Integrated Critical Care Service with a Single Nursing and Medical Administration
180. As described, the current configuration of Critical Care services within
Raigmore Hospital is as follows:
• 7 (8) bedded ICU, Floor 1 (Surgical Directorate)
• 6 bedded Surgical HDU, Floor 4 (Surgical Directorate)
• 6 bedded CCU, Floor 6 (Medical Directorate) • 4 bedded Medical HDU, Floor 6 (Medical Directorate).
This sequence of developments has been supported by the notion of placing
Critical Care services close to their various specialties. Historically, the development of HDUs has been unplanned and haphazard and largely relied on the interest of local clinicians to drive development (DoH 2000). However, there is now an eminent body of opinion (Audit Commission 1999, DoH 2000, SEHD 2000, SGHD 2008) that supports an alternative approach to Critical Care provision – namely the creation of an integrated, flexible service, with a single nursing administration, that is cost-effective and patient focussed. As such, this approach represents a substantial change in direction.
181. Given that demand for Critical Care beds will continue to grow, providing
more Critical Care beds is unlikely to work on its own (Audit Commission 1999), since experience has shown that additional capacity is soon absorbed within routine provision (DoH 2000). Attention must therefore be given to maximising the efficient and effective use of existing Critical Care beds, necessitating an ability to cope with peaks in demand.
182. All ICUs, no matter how well resourced, will experience difficulty in
accommodating all peaks in demand. Patients do not arrive at regular intervals and stay for equal lengths of time. Therefore, several patients arriving simultaneously or one patient staying weeks or months will have a big impact on what is a relatively small service. Locally, Raigmore Hospital faces additional problems because of its geographical isolation. The ICU is under various pressures to take ‘all comers’ and avoid the long-distance transfer of critically ill patients with all of the attendant clinical and social issues.
183. A major thrust of the 2 Health Department reports on Critical Care (DoH 2000,
SEHD 2000) is the need for flexibility in the provision of service. Hugely significant is that both of these Reports (DoH 2000, SEHD 2000) recommend that, wherever possible, all Critical Care beds should be in adjacent locations: ‘Economies of scale and great benefits of flexibility can be achieved by siting HDUs in or next to ICUs, with use of a common nursing workforce. With such an arrangement, a bed can be an HDU bed in the morning and an ICU bed in the afternoon, or vice versa, depending on need’ (SEHD 2000). ‘Flexibility is the real key to coping with growing pressures, especially peaks in demand’ (SEHD 2000).
184. Yet Raigmore Hospital’s Critical Care service is spread across 3 floors, 4
departments and 2 clinical directorates. And as the Audit Commission (1999) has observed, ‘Given what is known about the history of directorate development and relationships across the hospital, [Health Boards] need to consider how likely it is that this whole network of Critical Care resources is being well used’.
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Case Study 12 During an evening visit to the ICU, the Project Co-ordinator observed that 8
patients were receiving care. The nurse in charge reported that none of these patients could be transferred. Additionally, a new patient was currently undergoing emergency surgery and would require ICU management post– operatively. This would challenge the existing nursing resource. Therefore, this ninth ICU patient was to be managed overnight in Theatre Recovery by a Theatre nurse, supported by an anaesthetist.
But one of the existing complement of ICU patients could have been
transferred to Surgical HDU. This patient was 3 days post elective oesophagectomy. He had initially required mechanical ventilation, had a chest drain in situ, and was receiving an epidural infusion for pain control. At assessment, the patient was breathing spontaneously with 45% oxygen. His oxygen saturation was 98% with a SEWS of zero. As such, this patient required a Level 2 standard of care. But the understanding of ICU staff was that the Surgical HDU was full and that none of those patients could be transferred to ward-level care. In the absence of an HDU bed, the ICU consultant had recorded that the ICU patient was too ‘precarious’ to transfer to a ward.
The Surgical HDU was indeed full. But at assessment, immediately prior to
the ICU visit, the Project Co-ordinator had determined that one of these patients was fit for ward-level care. This patient had been admitted to Surgical HDU from ICU 3 days earlier (the ICU admission resulting from a bile leak following laparoscopic cholecystectomy). He was assessed as needing a Level 1 standard of care since he was requiring 4 hourly observations with a SEWS of 1, had no epidural infusion or invasive monitoring, was requiring 36% oxygen and had commenced fluids and diet. This patient had been medically reviewed this day but the case notes contained no discharge plan, reflecting a lack of contingency planning related to the inappropriate discharge policy that has already been discussed.
The ICU complement of patients had also included a medical patient admitted
4 hours earlier with respiratory failure. She was initially managed with mask CPAP but this was discontinued as her condition improved. At assessment she was breathing spontaneously with 45% oxygen. As such, this patient’s true Level of Care requirement was Level 2. However, given the potential for this patient to deteriorate and require mechanical ventilation, the ICU doctor wished her to stay in ICU. Therefore, she was recorded as requiring a Level 3 standard of care.
185. These 2 cases illustrate how the lack of an integrated Critical Care service
inhibits efficiency, inflates demand for ICU beds and burdens ICU staff. Geographical separateness resulted in both patients receiving ICU care – the surgical case relating to sub-optimal communication between Units; the medical case relating to difficulties of clinical supervision over distance. In consequence, the ICU was about to go to 129% occupancy when the actual occupancy should have been 100%. As such, this was a manufactured ICU bed ‘crisis’, emanating from the current structure of the Critical Care service.
186. But it is not just Level 3 patients that would benefit from a co-located Critical
Care service. Consider the scenario, for example, where 5 medical patients
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require Level 2 care simultaneously. Under the current structure one of these patients will receive ward-based care. This will still be the case if there are vacant beds in the Surgical HDU. In consequence, an expensive resource will be under-utilised and a critically ill patient will be misplaced, increasing the risk of sub-optimal care, whilst burdening ward staff. As such, the current structure of the Critical Care service inhibits cost-effectiveness and patient focussed care.
187. Noteworthy, is that the Better Critical Care (SEHD 2000) report strongly
recommended that HDU beds be integrated into a mixed speciality HDU to allow maximum flexibility of bed use and staff deployment. But the Report (SEHD 2000) recognised potential areas of difficulty, such as inter-speciality rivalry for the use of the beds and problems with lines of demarcation. The solution to such issues lay in clear protocols to determine the use of HDU beds (SEHD 2000).
188. But fundamental to the provision of a flexible, integrated service is the
availability of nurses experienced in Critical Care. Indeed the problems that the NHS encountered in the Winter of 1999-2000 in providing ICU services, largely stemmed not from lack of doctors, equipment or facilities but rather from a lack of nursing staff suitably skilled in the care of critically ill patients (DoH 2000, SEHD 2000). As such, there is a need for an effective strategy to expand the number of nurses who do not routinely work in ICU but who possess ICU skills (SEHD 2000). The Scottish Executive Health Department was unequivocal as to how this should be achieved, ‘It is essential to create a single nursing administration for all Critical Care areas in order to facilitate collaboration and flexibility of use’ (SEHD 2000). An excellent example of this is provided by the Audit Commission (1999) which cites one hospital that has a single nursing administration for ICU, HDU, CCU and the acute assessment/admission unit. The hospital has 14 Critical Care beds (5 ICU, 3 HDU, 6 CCU) which are used interchangeably to match demand. These beds are staffed and run as one. Nurses rotate through the different areas, build up expertise, and are deployed flexibly shift-by-shift to match workload.
189. Raigmore Hospital does not have a single nursing administration for Critical
Care. However a dynamic Critical Care nurse rotation programme was commenced in 1998 between ICU, CCU and Surgical HDU. This programme was introduced in response to difficulties in meeting peak demand in ICU, compounded by geographical remoteness and the lack of a local pool of additional nurses with ICU skills. Also, there was a need to equip nurses in the new HDU with Critical Care skills.
190. This rotation programme produced many benefits for patients, nurses and the
Organisation. The creation of a pool of ICU trained nurses to complement those who normally work in ICU increased the hospital’s ability to ‘flex-up’ during peaks in demand. Additional benefits included more appropriate use of ICU beds, raised standards of Critical Care outwith ICU, earlier discharge of surgical patients from ICU, enhanced interdepartmental relations and minimal usage of agency nurses to support ICU escalation. Indeed, the Raigmore model of Critical Care nurse resource management was highlighted in the Better Critical Care (SEHD 2000) report as an example of best practice.
191. That this rotation programme ceased in 2005 must, therefore, be regarded as
a retrograde step. This is evidenced by the fact that the ICU is now reliant on agency nurses for escalation. This represents poor value for money and potentially poorer quality of care, given that agency nurses are an unknown
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quantity and unfamiliar with local policies and procedures. Additionally, recent contingency planning for ICU expansion in the event of pandemic flu revealed large numbers of nurses with lapsed ICU experience who lacked competency to care for Level 3 patients.
192. Recently, the Critical Care nurse rotation programme was re-introduced
between ICU and Surgical HDU, with one Band 5 staff nurse seconded to and from each Unit for several months. But having regard to the purpose and benefits of the Critical Care nurse rotation programme, this current initiative is nominal. This programme needs to be far more expansive to include all 4 Critical Care Units, greater numbers of nurses and, most importantly, senior nurses to support the expansion of nursing practice in the HDUs.
193. Consider the following example. It will be recalled that the lack of CPAP in
the Surgical HDU increases demand for ICU beds, potentially burdening ICU nurses. However, the need for Surgical HDU to introduce this therapy was identified some time ago. That this did not happen relates to a knowledge/skills deficit amongst the HDU nurses. Yet the ICU, a multiple charge nurse department, is relatively rich in senior nursing staff vis-a-vis the Level 2 care departments. As such, there is a wealth of nursing knowledge and experience contained in the ICU. Therefore, the continuous secondment of an ICU charge nurse to Surgical HDU would ensure the introduction of CPAP into this department, with mutual benefits. As the Comprehensive Critical Care (DoH 2000) report observed, ‘the doors of the intensive care unit need to be unlocked, and partnership between professionals and patients form the basis of the service.’
194. But the introduction of expansive and dynamic Critical Care nurse rotation
programmes must be regarded as a ‘stepping stone’ to the introduction of a single nursing administration for all Critical Care Units. (Having regard to the Audit Commission (1999) observation on the role of directorates, financial concern for individual budgets will currently act as a disincentive to the free movement of Critical Care nurses across departmental boundaries.) And this introduction of a single nursing administration must be regarded as a ‘stepping stone’ to the introduction of a fully integrated, co-located Critical Care service.
195. It must be acknowledged that there is a counter argument, emanating from
within Medicine, to maintain the current Critical Care structure. It is argued that the co-location of CCU, Medical HDU and the AMAU already provides many benefits in terms of flexibility of patient placement and staff deployment. Concern has also been expressed that the relocation of the Medical HDU away from Floor 6 would diminish the training of medical doctors, no longer routinely involved in the care of critically ill Level 2 patients.
196. These arguments are not without merit. The educational needs of the medical
workforce must be addressed within the context of Critical Care. The Better Critical Care (SEHD 2000) report recommended that every member of junior medical staff preparing for hospital practice should have training that enables them to deal with the critically ill patient. Additionally, given the highly specialist nature of CCU and its more tenuous relationship with other Critical Care Units, future provision of CCU may be appropriate alongside the AMAU. (CCU provision lay outside the scope and recommendations of the Better Critical Care (SEHD 2000) report.)
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197. However, the argument to maintain the Medical HDU within the current structure must be measured against the weight of opinion within the London and Edinburgh Health Departments (DoH 2000, SEHD 2000) plus the findings in this report. These support that the most patient focussed, cost-effective and flexible Critical Care service, able to adapt to peaks in demand, with a multi-skilled nursing workforce, will be achieved by the creation of an integrated, co-located, single nursing administration model of care.
198. There is also a telling argument for a fully integrated, co-located Critical Care
service relating to the organisation of the medical workforce. It will be recalled that the ICU, with dedicated consultant cover during normal hours, is the only Critical Care Unit to provide dedicated medical cover (middle grade) 24/7. The Surgical HDU has no dedicated medical cover. Indeed, initial medical cover is currently provided by foundation grade doctors. This is contrary to guidance contained in the SMASAC report on HDU beds which asserted that such doctors, who have not yet gained the necessary competencies in the management of critically ill patients, should not work unsupervised in HDU (SGHD 2008). The Medial HDU has nominal dedicated consultant cover during normal hours plus shared middle grade cover with the CCU. But neither Critical Care Unit has dedicated medical cover out of hours.
199. Currently, dedicated physician cover for the whole hospital overnight consists
of one senior middle grade doctor, plus one foundation grade doctor. This service provision must be viewed in the context of activity within the Medical HDU. It will be recalled that 55% of admissions to this Unit occurred out of hours, reflecting the 24/7 nature of acute medicine (SICSAG 2009). Such figures will prove informative to workforce planners and service managers and reinforce the point that ‘continued high quality, safe service provision will be a challenge if the worst predictions of Modernising Medical Careers (MMC) reductions of trainee medical staff are to become reality’ (SICSAG 2009).
200. Shortly, there will be a further reduction in middle grade medical provision in
Raigmore Hospital unrelated to MMC, but resulting from an inability to recruit to GP trainee posts. This will inevitably lead to a further retraction of service provision. The SMASAC report on HDU beds (SGHD 2008) asserted that all HDUs must ensure adequate medical cover (that is, staff with appropriate competencies) is available 24/7. In larger HDUs with high workloads dedicated medical staff would be needed. The Report further asserted that a Critical Care clinician with appropriate skills should be appointed in overall charge of ICU and HDU to co-ordinate and implement Critical Care services. This individual would normally be the lead for the local CCDG (SGHD 2008).
201. In summary, the Critical Care medical service operating across 4 Critical Care
Units, 3 different floors and 2 directorates, that currently provides no dedicated cover out of hours for the Level 2 units, will face further retraction in service relating to MMC and local factors. Therefore, it makes absolute sense that the hospital should concentrate its sickest patients together enabling optimal medical management by a consolidated medical workforce.
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5.5 Need for Additional HDU Beds in Raigmore Hospital
202. The purpose of this report has been to examine the provision of, and need for
adult HDU beds in NHS Highland, so as to help inform the development of Critical Care strategy within this Health Board. Conclusions have already been reached concerning the 3 RGHs. However, the findings of this report have shown the situation within Raigmore Hospital to be extremely complex with multiple influences on the supply of, and demand for, Critical Care beds. As such, it is difficult to determine the exact number of Critical Care beds that is required.
203. The highly influential Critical to Success (Audit Commission 1999) report
revealed widespread variation in how effectively Critical Care services were being managed. The major thrust of the Report (Audit Commission 1999) was that the supply of, and demand for, Critical Care beds needed to be effectively managed before there was investment in additional Critical Care capacity. That is, the solution to Critical Care bed shortages was not simply a case of further funding. This approach was confirmed in the Comprehensive Critical Care (DoH 2000) and Better Critical Care (SEHD 2000) reports which, whilst supporting additional investment, championed new ways of working so as to place the patient at the heart of the service.
204. Within Raigmore Hospital, there is the need to address the various factors
that inflate demand for Critical Care beds – sub-optimal bed management; sub-optimal care at ward level; inappropriate admission and discharge policies; lack of CCU ‘ownership’ of cardiac triage; lack of isolation facilities in Medical HDU and wards; uneven scheduling of surgical activity; knowledge/skills deficit at Level 2 and lack of a co-located, integrated Critical Care service with a single nursing and medical administration. Therefore, additional investment in Critical Care beds should be sequential to maximising the efficient and effective use of existing Critical Care beds.
205. That said, the findings of this report also support that there is under provision
of HDU beds, especially Medical HDU beds, within Raigmore Hospital. It will be recalled that almost 70% of unmet need for Level 2 care was within Medicine. Also, that data from SICSAG (2009) showed length of stay and night time discharges from the Medical HDU to be at great variance from the majority of Scottish HDUs. Additionally, the operation of the Respiratory Ward as an informal HDU plus inequity of access to Medical HDU for ‘step- down’ ICU patients currently disguise the true need for Medical HDU beds.
206. There was also unmet need for Surgical HDU beds from within general
surgery but also, importantly, from within orthopaedic surgery. And, as discussed, there will have been unmet need for Surgical HDU beds not captured due to the limitations of the study methodology. However, unmet need for Surgical HDU beds must be measured against the finding that 41% of patients occupying Surgical HDU beds were assessed as requiring ward- based care.
207. Although 22% of unmet need for Level 2 medical care was for cardiac
patients, the opinion of senior clinicians within CCU was that the current CCU bed provision was adequate. Indeed, this is further supported by the proposal emanating from CCU to reduce the number of CCU beds by one.
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208. Decision making concerning the requirement for HDU beds in Raigmore
Hospital should be influenced by the Better Critical Care (SEHD 2000) report. This Report endorsed a variety of studies in recommending a ratio of 2 HDU beds to every ICU bed as a reasonable target for Health Boards. But the Report (SEHD 2000) also acknowledged that this starting point would be influenced by local needs assessment. The Report (SEHD 2000) further suggested that this Critical Care bed ratio-for-provision might be influenced by a co-located Critical Care service, ensuring maximum flexibility of Critical Care beds.
209. As discussed, there are 7 funded ICU beds in Raigmore Hospital. Application
of the 2:1 formula would suggest the need for 14 general HDU beds. (It will be recalled that CCU lay outside the scope and recommendations of the Better Critical Care (SEHD 2000) report.) Therefore, the current provision of 10 general HDU beds (6 Surgical; 4 Medical) suggests as under provision of 4 HDU beds. (Given that the ICU patient population is, for reasons already described, almost exclusively a local population, the HDUs in the RGHs should not be included in this calculation.)
210. Therefore, it may be reasonably asserted that there is a shortfall of 4 HDU
beds, especially Medical beds, within Raigmore Hospital. But having regard to the significant cost implications and the discussion that has taken place concerning maximising flexibility and economies of scale, this number could be legitimately reduced by a co-located, fully integrated Critical Care service.
211. Whilst the focus of this report has been HDU bed provision, consideration
must also be given to ICU bed provision. The very high occupancy data for 7 staffed ICU beds (86% during this study; 78% according to SICSAG (2009) data) support that an additional ICU bed should be funded. But as with the earlier discussion, this should be sequential to addressing the factors that inflate demand for ICU beds – lack of HDU beds; inequity of access to Medical HDU beds; lack of CPAP provision in Surgical HDU; and lack of a co- located, integrated Critical Care service with a single nursing and medical administration. If these factors are addressed successfully then the current ICU bed provision is likely to prove adequate.
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6 Recommendations
Short-term 1. The Critical Care Delivery Group to agree guidelines for admission to and
discharge from the Critical Care Units, Raigmore Hospital, based on those published by the Department of Health (1996). These local guidelines to be publicised within the Health Board. Conduct regular audit to ensure that these guidelines are in place, remain current, and are being followed.
2. Improve services for cardiac patients by introducing a system whereby CCU
takes ‘ownership’ of the triage of all patients admitted with chest pain. This should be achieved without a reduction in the current provision of CCU beds.
Medium-term 3. Address the current inequity of occupancy across the Organisation,
redistributing this as able, so that resource matches activity. 4. Conduct workforce planning across the Organisation using recognised tools
plus the results of this study as part of a triangulation process to examine nursing workload, plan the nursing workforce and measure the quality of care.
5. Improve services for patients in wards who are at risk of deteriorating into a
need for Critical Care:
• Target investment in ward nurse staffing levels
• Introduce mandatory annual training for all nurses, junior and middle grade doctors in managing patients at risk
• Develop a Medical Emergency Team at Raigmore Hospital. 6. Invest in measures to lessen the impact of misplaced Level 3 patients in the
RGHs:
• Rotate nursing and medical staff through Raigmore Hospital to retain skills
• Develop an ongoing education programme for HDU nurses directed by clinical educationalists from the ICU
• Introduce a dual rotation system between nurses in medical and surgical wards to produce a multi-skilled workforce, greatly increasing the pool of nurses who could be deployed to the HDU at short notice.
7. Implement the SICSAG national dataset in the HDUs in the 3 RGHs as an
essential part of the Health Board’s clinical governance and risk management programme.
8. Improve services for HDU patients at Caithness General Hospital by investing
in a central monitoring system. 9. Develop a transport team within all 4 hospitals for patient movement. A
senior doctor and nurse within each hospital should be responsible for the development of this team.
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10. Improve services for patients in the Respiratory Ward, Raigmore Hospital:
• Enhance nurse staffing levels to reflect the large level 2 patient population (but the longer term aim should be that such patients are managed during the acute phase of illness in a larger HDU)
• Re-locate the ward within acute medical services to facilitate medical review of patients.
11. Improve access to HDU for orthopaedic patients, Raigmore Hospital:
• Target recruitment of HDU nurses with current orthopaedic nursing skills
• Develop an ongoing education programme for HDU nurses directed by the Clinical Educator, Orthopaedics
• Introduce a dual rotation system between nurses from the Surgical HDU and Trauma Ward.
12. Improve bed management at an Organisational, hospital and departmental
level:
• Create integrated networks of care in Raigmore hospital between Critical Care Units and their recipient wards
• Improve patient flow within hospitals and between hospitals
• Address high levels of delayed discharges
• Conduct regular audit to identify the number of Critical Care Unit beds that are occupied because ward/HDU beds are blocked and unavailable to discharge patients into.
13. Improve isolation facilities within general ward areas to prevent inappropriate
admissions to Critical Care Units for this purpose. 14. Improve the scheduling of Level 2 elective surgical activity, by both day and
week, so that there is more even demand for beds. Conduct regular audit to determine levels of cancelled surgery, or modified surgery with ward-based post-operative care rather than HDU care.
15. Introduce CPAP provision into Surgical HDU, underpinned by staff training
and clinical support from ICU nursing staff. 16. Refurbish the ICU, addressing issues of security and the need for additional
isolation facilities to manage control of infection. 17. Re-introduce a dynamic Critical Care nurse rotation programme between the
4 Units in Raigmore Hospital, led by charge nurse rotation, to produce a multi- skilled workforce able to support the expansion of nursing practice in the HDUs and effectively respond to peaks in demand for Level 3 beds.
18. Ensure that medical cover in all Critical Care Units is provided by doctors who
have gained the necessary competencies in the management of critically ill patients.
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Long-term 19. Improve services for critically ill patients at Caithness General Hospital by
funding the nurse staffing of 2 HDU beds. 20. Consider the establishment of a dedicated Critical Care retrieval team for
NHS Highland to lessen the impact of misplaced Level 3 patients in the RGHs, the subsequent loss of medical cover especially at Caithness General Hospital, and ensuring safe inter-hospital transfer.
21. Improve services to the relatives of critically ill patients in all of the Critical
Care Units. The following facilities should be available adjacent to the Unit as a minimum standard:
• A waiting room
of infection:
• At least 50% of Unit beds should be single rooms. 23. Improve services for critically ill patients by the creation of an integrated,
flexible Critical Care Service at Raigmore Hospital that is cost-effective and patient focussed. To include:
• Co-location of ICU with mixed specialty larger HDU
• Single nursing administration with common nursing workforce
• Single medical administration with dedicated medical cover 24/7 • Single clinical directorate
• A Critical Care clinician with appropriate skills in overall charge of ICU and HDU.
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Shift
Annex A Data Collection Form for Use in Ward Areas
Critical Care Needs Assessment – Liam Gaffney 2009 Adapted from W Norrie 2009
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Annex B Data Collection Form for use in Critical Care Units
LEVEL
COMMENTS
CHI
Post-operative: 4 hourly observations
Single organ support
Pre-operative stabilisation and invasive monitoring
Complex post-operative management, detailed monitoring and care
Withdrawal of treatment in HDU
Advanced respiratory support (including potential for rapid intubation and ventilation)
≥ 2 organs supported
Long standing organ failure and management of one acute organ
Withdrawal of treatment in ICU
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Each Unit represents group of wards/areas visited in one day. Ward/Area Speciality Beds Available Lorn and Islands Unit A 90
A Surgery – General (some day case) 24 (12 at W/E) B/ HDU
Medicine – General High Dependency Care – Mixed
18 6
Belhaven Medicine – Rehabilitation 13 Medical Medicine – General including Cardiac 17 Surgical/ HDU
Surgery – General (some day case) High Dependency Care – Surgical
25 2
Caithness General Unit C 84 Bignold Surgery – General (some day case) 24 Henderson Obstetric – Ante/Post-natal (plus Labour) 9 Queen Elizabeth Medicine – Rehabilitation/Stroke 25 Rosebank/ HDU
Medicine – General High Dependency Care – Mixed
23 3
Medicine – Acute Medical Admissions High Dependency Care – Medical
24 4
8 Surgery – Gynaecology / Medicine – General 23 (17/6) Raigmore Unit E 81
4C Surgery – General 29 9 Obstetric – Ante/Post-natal 16 10 Obstetric – Ante/Post-natal 22
ITU Intensive Care 8 SHDU High Dependency Care – Surgical 6 Raigmore Unit F 100 2C* Medicine – Oncology/Haematology
– Rehabilitation 16 14
4A Surgery – Emergency Admissions 34 6C Medicine – Cardiac/Endocrine/Rheumatology 30 CCU Coronary Care – Medical 6 Raigmore Unit G 112 1A Surgery – General and Ophthalmology 14 (closed at W/E)
2A* Medicine – Stroke – Young Adult Rehabilitation
20 10
– Renal 16 18
Raigmore Unit H 94
3C Orthopaedic Surgery – Elective 30 5C Surgery – General and ENT 34 11 Medicine – Respiratory 30 Total 694
* Managed as separate wards
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Note During the study period the bed complement reduced by 30 beds, resulting from reconfiguration of services and permanent bed closures: Unit A Lorn and Islands Hospital Ward E, 24 beds reduced to 18 beds (before visit 2) Unit B Belford Hospital Surgical Ward/HDU became Combined Admissions Unit, 25 ward beds reduced to 17 beds. Surgical HDU became a mixed speciality unit. Medical Ward became Combined Step-Down Ward, 17 beds reduced to 15 beds (before visit 6) Unit F Raigmore Hospital Ward 2C (Rehabilitative Medicine), permanently closed with loss of 14 beds (before visit 6).
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SHIFT
BEDS E L N E L N E L N E L N E L N E L N E L N
OCCUPIED BEDS
STAFFED BEDS
CLOSED BEDS
REFUSED ADMISSIONS
(NO BED)
ELECTIVE ADMISSIONS
EMERGENCY
DISCHARGES CHI NO. PATIENT NAME/SHIFT
N.B This form was alternatively available in 2 and 3 shift format to accommodate 8 and 12 hour nursing shift patterns in different Units.
Annex D Data Collection Form for Critical Care Unit Activity
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Annex E
Glossary Anaemia A condition in which the oxygen-carrying pigment haemoglobin in the blood is below normal. Anaemia is not a disease but a feature of many disorders. It can occur where there is decreased red blood cell production by the bone marrow or decreased survival of the red cells in the blood.
Angiography An imaging procedure that enables blood vessels to be seen clearly on X-ray film following the injection of a contrast medium. Coronary angiography can identify the sites of narrowing or blockage in coronary artery disease.
Angioplasty A technique for treating a narrowed or blocked section of blood vessel by the temporary insertion of a catheter with a balloon that is inflated to widen the narrowed area. Balloon angioplasty is used to restore blood flow in coronary artery disease.
Arterial Blood Gas Measurement of a blood sample from an artery to determine the acidity of the blood, and how much oxygen and carbon dioxide is in it.
Arterial Line A small flexible tube inserted into an artery that when connected to a monitor enables a continuous reading of blood pressure. Additionally, the catheter affords effective access to blood samples for arterial blood gas analysis.
Atrial Fibrillation Abnormality of the heartbeat which is irregular and rapid.
Central Venous Catheter A narrow flexible tube that Is inserted into a vein, normally in the neck or arm. It is threaded onwards towards the heart where it is used to monitor the heart’s functions. Additionally, the catheter is used for multiple drug infusions and intravenous nutrition.
Cerebrovascular Accident Sudden rupture or blockage of a blood vessel in the brain, causing serious bleeding and/or obstruction to blood circulation and leading to stroke.
Chest Drain A catheter inserted into the chest cavity for the removal of air or fluid.
Cholecystectomy Surgery to remove the gallbladder, usually to deal with gallstones. The procedure may be performed using conventional surgery or, more commonly, by minimally invasive surgery using a laparoscope.
Chronic Obstructive Pulmonary Disease A combination of chronic bronchitis and emphysema in which there is persistent disruption of air flow into or out of the lungs.
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Co-morbidity The state or condition of having more than one disease.
CPAP Continuous positive airway pressure. A breathing support system where the patient breathes in and out from a pressurised gas source. The high pressure helps to distend the lungs and eases breathing.
Dyspnoea Shortness of breath.
Epidural Analgesia A method of pain relief administered via the space surrounding the spinal cord.
Febrile Feverish or related to fever.
Haemoptysis Coughing up blood.
Hyperglycaemia An abnormally high level of glucose in the blood that occurs in people with inadequately controlled diabetes mellitus. Hyperglycaemia may also occur in diabetics as a result of infection or stress.
Hypotension Low blood pressure. Acute hypotension is a feature of shock, and may be caused by serious injury or disease.
Hypovolaemia An abnormally low volume of blood in the circulation, usually due to blood loss resulting from injury, internal bleeding or surgery. Untreated, it can lead to shock.
Inotrope A drug that makes the heart muscle work harder, for example, adrenaline.
Intubation The passing of an endotracheal tube (breathing tube) through the nose or mouth into the trachea (wind-pipe) to deliver oxygen to the lungs.
Left Ventricular Failure Left-sided heart failure, where the heart Is unable to cope with the workload of pumping blood away from the lungs and to the rest of the body.
Metastasis A secondary cancerous tumour that has spread from a primary cancer to another part of the body.
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Myocardial Infarction Sudden death of part of the heart muscle due to a blockage in the blood supply to the heart. The disorder is commonly known as a heart attack.
Non-Invasive Ventilation (NIV) Artificial ventilatory support that is delivered by a tightly fitting face mask. This is distinct from artificial ventilatory support that is delivered invasively via an endotracheal tube or tracheotomy tube (breathing tubes).
Oesophageal Varices Widened veins in the walls of the oesophagus, the muscular tube that carries food to the stomach. Varices are a symptom of chronic liver disease that may be associated with alcoholism.
Oesophagectomy Major surgery involving removal of the oesophagus (the muscular tube that carries food to the stomach) due to cancer.
Oliguria The production of low quantities of urine in proportion to the volume of fluid taken in. The condition may be a sign of kidney failure.
Pain Score A pain assessment tool in which the patient reports their experience of pain on a scale of 0 – 10, with a score of 0 being no pain and a score of 10 being the worst pain ever suffered.
Parenteral Nutrition Artificial means of providing nutrition intravenously.
Pleural Effusion An accumulation of fluid between the 2 layers of membrane (pleura) covering the outside of the lungs, making breathing difficult.
Respiratory Arrest Sudden cessation of breathing. If untreated this leads to cardiac arrest, brain damage, coma and death.
Scottish Early Warning Score (SEWS) A protocol to identify patients at risk of clinical deterioration so as to enlist specialist help quickly.
Scottish Patient Safety Programme A national programme to steadily improve the safety of healthcare. This will be achieved using evidence-based tools and techniques to improve the reliability and safety of everyday healthcare systems and procedures.
Sepsis Infection of a wound or body tissue with bacteria that may lead to the multiplication of the bacteria in the blood.
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Tachycardia A rapid heart rate (>100 beats per minute) that may occur in healthy people during exercise or result from illness or disease.
Tachypnoea An abnormally fast rate of breathing which may be caused by lung or cardiac disorders.
Tracheostomy A surgical opening in the trachea (wind-pipe) and insertion of a tube to maintain an effective airway.
Troponin An enzyme released into the blood from damaged heart muscle. Measurement of this enzyme assists in the diagnosis of myocardial infarction.
74
References 1. Audit Commission (1999) Critical to Success: the place of efficient and effective
critical care services within the acute hospital. 2. British Association of Critical Care Nurses (2009) Standards for Nurse Staffing in
Critical Care. 3. Coggins RP (2000) Delivery of surgical care in a district general hospital without high
dependency unit facilities. Postgraduate Medical Journal 76: 223-6. 4. Colvin J (2003) Critical Care Strategy for Tayside (unpublished). 5. Daly K, Beale R, Chang RE (2001) Reduction in mortality after inappropriate early
discharge from intensive care unit: logistic regression triage model. British Medical Journal 322: 1274-6.
6. Department of Health (2003a) Department of Health and Modernisation Agency. The
National Outreach Report. 7. Department of Health (2003b) Department of Health UK NHS Estates. Health
Building Note (HBN) 57 Facilities for Critical Care. 8. Department of Health (2000) Comprehensive Critical Care: a review of adult critical
care services. 9. Department of Health (1996) Guidelines on admission to and discharge from
Intensive Care and High Dependency Units. 10. Everest E & Munford B (2009) Transport of the critically ill. 4: 31-42. In : OH’s
Intensive Care Manual (6th EDN) Bersten AD & Soni N (Editors) Butterworth Heinemann.
11. Garrard C & Young D (1998) Sub-Optimal Care of Patients Before Admission to
Intensive Care. British Medical Journal; 316: 1841-2. 12. Goldfrad C & Rowan K (2000) Consequences of discharge from intensive care at
night. Lancet; 355: 1138-1142. 13. Goldhill DR & Welch JR (2009) Outreach. 2: 11-16. In: OH’s Intensive Care Manual
(6th EDN) Bersten AD & Soni N (Editors), Butterworth Heinemann. 14. Hawker F (2009) Design and organisation of intensive care units. In: Bersten AD &
Soni N (Estates) Oh’s Intensive Care Manual (6th edn), Butterworth Heinemann 1: 3- 10.
15. Hay D & Oken D (1972) The Psychological Stresses of Intensive Care Unit Nursing.
Psychosomatic Medicine; 34: 109-118. 16. Intensive Care Society (2009) Levels of Critical Care for Adult Patients. Standards
and Guidelines. 17. Intensive Care Society (2002) Guidelines for the transport of the critically ill adult.
Standards and Guidelines.
210
75
18. Intensive Care Society (1998) Guidelines for Bereavement Care in Intensive Care Units.
19. Keilty S & Bolt J (1992) Continuous positive airways pressure. Physiotherapy: 78:90-
92 20. MacKenzie S (2004) Organisation of Critical Care Services. Anaesthesia and
Intensive Care Medicine; 5: 1: 23 – 5. 21. McGloin H, Adam S, Singer M (1997) The Quality of Pre-ICU Care Influences
Outcomes of Patients Admitted from the Ward. Clinical Intensive Care; 8:104. 22. McQuillan P, Pilkington S, Allan A et al (1998) Confidential Inquiry into Quality of
Care Before Admission to Intensive Care. British Medical Journal; 316:1853-8. 23. Scottish Executive Health Department (2004) Nursing and Midwifery Workload and
Workforce Planning Project. 24. Scottish Executive Health Department (2000) Better Critical Care: Report of Short-
Life Working Group on ICU and HDU issues. 25. Scottish Government Health Directorates (2008) High Dependency Unit (HDU) Beds:
A Report by a Working Group of the Scottish Medical and Scientific Advisory Committee.
26. Scottish Intensive Care Society Audit Group (2009) Audit of Critical Care in Scotland
2009 Reporting on 2008. 27. Welch JR & Theaker C (2009) Critical care nursing. 6: 53-60. In: OH’s Intensive
Care Manual (6th edn) Bersten AD & Soni N (Editors), Butterworth Heiemann. 28. Wood J & Smith A (1999) Active Management Should Prevent Cardiopulmonary
Arrest. British Medical Journal; 318: 51-2. 29. Woodrow P (2002) A course in critical care for ward staff. Nursing Times; 98: 40, 32-
3.
76
Acknowledgements The authors would like to thank all of those that have contributed to the production of this report, but especially:
• The countless nurses and doctors who supported the project, and particularly the nurses who gave their precious time to provide accompanied ward rounds, thereby enriching the data that was collected
• Michael Bell, Clinical Effectiveness Facilitator, for his expertise and industry in turning raw data into meaningful information
• Lynn Lawrence, Business Support Manager, for her application in the task of inputting vast quantities of information
• Linda Toland and Claire McCall, Administrative Assistants, for secretarial support
• Wendy Norrie, HDU Needs Assessment Project Co-ordinator, NHS Tayside, for helpful advice and the generous offer of data collection tools. Also, John Colvin, Chair, CCDG, NHS Tayside, for kind permission to adapt NHS Tayside documentation for use in the current study.
Annex G 211
212
Raigmore Hospital Theatres Activity
Demand for Elective Theatres Based on Total Operation Time ( Time into Anaesthetic Room to Time out of Theatre) and Current Practice
Prepared by: C Hunter-Rowe
Service Planning ext. 6767
Location: Raigmore Hospital
Exclusions: TH11 (obstetrics theatre), TH8 (emergency theatre), TH7 (trauma pm only)
Specialty: Specialty is attributed to the first session of the session. If there is a mixed specialty list (very rare) the activity would be attributed to the first specialty in the session.
Total Available Time: Theoretical maximum time available calculated as time per session x number of sessions per day x number of days per week x number of weeks per year
TIA_Total Time: Operation time calculated as Time out of Theatre - Time into Anaesthetic Room
80%ile time per week: 80th percentile value of operation time within each theatre or specialty per week
Time required at 80%ile: Annual theatre time required calculated as 80%ile time per week x number of weeks per year
Theatres required at 80%ile: Number of theatres calculated as Time required at 80%ile / Total Available Time
Caveats:
Cancellations: No adjustment made for cancelled sessions or cancelled cases. It is assumed that these will be incorporated within the time frame for analysis.
TH7 Currently used for elective activity 1 half day session per day. All calculations adjusted for this.
Out of Region activity No adjustment made for activity currently sent away and future plans re repatriation.
Consultant code CPW All activity assigned under General Surgery (SURG:SURG) though was a mixture of breast and general.
Summary:
This workbook provides an overview of actual elective theatre activity for Raigmore Theatres for the Calendar years 2012, 2013 and 2014 (upto 27th July/Week 30). The data reflects current
activity based upon all planned elective procedures and waiting list initiatives undertaken during this time period. The number of theatres required has been estimated by calculating the time
required based upon either (a) 80th percentile theatre use or (b) 80th percentile specialty use. Data for each year has been calculated separately to provide some degree of sensitivity around
annual figures.
The theatre based analysis shows a current requirement ranging between 7.6 and 8.3 elective theatres. The specialty based analysis shows a current requirement ranging between
7.9 and 8.9 elective theatres.
Both scenarios have an additional emergency theatre requirement of 1 x dedicated emergency theatre, 1 x obstetrics theatre, 0.5 x trauma theatre (scheduled to increase in theatre redesign
project due to growth in activity).
A crude estimate of the impact of changes in activity can be made using cell D16. Detailed analysis predicting future demand for elective theatre capacity would require modelling of the following:
1. Long term impact of demographic change using National Records of Scotland (NRS) 2012-based population projections for NHS Highland/Highland Local Authority.
2. Short-medium term Demand-Capacity-Activity-Queue (DCAQ) models for each specialty
3. Planned service improvements e.g. theatre efficiency and utilisation.
4. Impact of Treatment Time Guarantees (TTG)
5. Impact of urgent treatments on elective activity e.g. cancer waiting time standards
213
Elective Theatre Requirements Based on Total Operation Time ( Time into Anaesthetic Room to Time out of Theatre) and Current Practice
2012, 2013, 2014 (to week 30) calender year
Please read notes and definitions on Info page
Assumptions:
Session Times Availability
Start End Lunch Adj Time FULL HALF AM ONLY FULL HALF AM ONLY
FULL 8:45 16:30 0:30 7:15 Sessions per day 1 2 1 1 2 1
AM 8:45 12:30 3:45 Days per week 5 5 5 5 5 5
PM 13:15 16:30 3:15 Weeks per year 52 52 52 30 30 30
hh:mm per year 1885:00 1820:00 975:00 1087:30 1050:00 562:30
Percentage change in activity 0%
Table 1: Total Actual Elective Sessions by Theatre
Theatre Full Half
Total as Half
days Full Half
Total as Half
days Full Half
Total as Half
TH1 89 252 430 122 250 494 75 151 301
TH2 135 157 427 148 132 428 75 89 239
TH3 240 17 497 231 27 489 132 10 274
TH4 229 28 486 218 33 469 136 12 284
TH5 223 58 504 195 61 451 117 36 270
TH6 173 60 406 185 53 423 105 30 240
TH7 247 247 1 234 236 144 144 TH7 ELECTIVE AM ONLY
TH9 263 20 546 253 46 552 128 28 284
TH10 69 291 429 135 170 440 87 75 249
TH TEMP 0 10 26 46 0
Elective Total 1421 1130 3972 1498 1032 4028 855 575 2285
Table 2: Actual Elective Activity and 80%ile times by Theatre
hh:mm hh:mm
Theatre 2012 2013 2014* 2012 2013 2014* 2012 2013 2014*
TH1 1267:58 1377:29 825:28 28:15 29:06 30:52 1469:10 1513:22 926:24
TH2 1450:43 1465:57 811:09 32:28 32:18 32:34 1688:36 1679:56 977:06
TH3 1496:24 1349:44 762:20 31:50 29:07 29:18 1655:51 1514:14 879:24
TH4 1572:35 1509:28 854:49 35:12 33:16 31:25 1830:44 1729:52 942:36
TH5 1782:28 1529:41 912:45 41:01 34:15 34:30 2133:12 1781:00 1035:24
TH6 1486:23 1451:06 854:13 34:43 33:40 35:17 1805:47 1750:40 1058:54
TH7 956:48 898:18 535:37 20:50 20:43 19:59 1083:20 1077:47 599:48
TH9 1864:16 1823:21 941:28 41:40 41:01 35:18 2167:00 2133:33 1059:06
TH10 1148:20 1119:23 633:49 26:42 25:50 25:22 1388:24 1343:20 761:12
TH TEMP 0:00 144:37 0:00 0:00 0:00 0:00 0:00 0:00 0:00
Elective Total 13025:55 12669:04 7131:38 292:44 279:18 274:39 15222:08 14523:46 8239:54
Table 3: Number of Elective Theatres Required modelled as Full day or Half Day Sessions
Theatre 2012 2013 2014* 2012 2013 2014*
TH1 0.8 0.8 0.9 0.8 0.8 0.9
TH2 0.9 0.9 0.9 0.9 0.9 0.9
TH3 0.9 0.8 0.8 0.9 0.8 0.8
TH4 1.0 0.9 0.9 1.0 1.0 0.9
TH5 1.1 0.9 1.0 1.2 1.0 1.0
TH6 1.0 0.9 1.0 1.0 1.0 1.0
TH7 0.6 0.6 0.6 0.6 0.6 0.6
TH9 1.1 1.1 1.0 1.2 1.2 1.0
TH10 0.7 0.7 0.7 0.8 0.7 0.7
TH TEMP 0.0 0.0 0.0 0.0 0.0 0.0
Elective Total 8.1 7.7 7.6 8.4 8.0 7.8
Table 4: Addition of Emergency Theatres
Theatre 2012 2013 2014*
Full day Sessions Half day Sessions
Total Actual OP Time 80%ile time per week Time required at 80%ile
hh:mm
Theatres required at 80%ile Theatres required at 80%ile
214
Elective Theatre Requirements Based on Total Operation Time ( Time into Anaesthetic Room to Time out of Theatre) and Current Practice
2012, 2013, 2014 (to week 30) calender year
Please read notes and definitions on Info page
Assumptions:
Session Times Availability
Start End Lunch Adj Time FULL HALF AM ONLY FULL HALF AM ONLY
FULL 8:45 16:30 0:30 7:15 Sessions per day 1 2 1 1 2 1
AM 8:45 12:30 3:45 Days per week 5 5 5 5 5 5
PM 13:15 16:30 3:15 Weeks per year 52 52 52 30 30 30
hh:mm per year 1885:00 1820:00 975:00 1087:30 1050:00 562:30
Percentage change in activity 0%
Table 1: Total Actual Elective Sessions by Specialty
Theatre Full Half
Total as Half
days Full Half
Total as Half
days Full Half
Total as Half
ANAES 0 1 1 0 2 2 0 0 0
ENT 236 75 234 66 136 27
EYES 86 174 346 122 181 425 75 111 261
GYN 68 157 293 62 168 292 30 106 166
OMFS 53 33 139 70 12 152 26 1 53
ORAL 1 26 28 9 25 43 16 17 49
ORTHO 289 390 968 305 381 991 153 204 510
PAED 0 23 23 0 23 23 14 14
PLAS 13 3 29 12 1 25 8 16
SURG:BR 73 27 173 90 43 223 60 32 152
SURG:COLO 127 30 284 137 30 304 75 12 162
SURG:SURG 19 131 169 29 41 99 22 8 52
SURG:UGI 135 25 295 121 11 253 56 20 132
SURG:VASC 143 13 299 132 24 288 84 14 182
UROL 178 22 378 175 24 374 114 9 237
Elective Total 1421 1130 3425 1498 1032 3494 855 575 1986
Table 2: Actual Elective Activity and 80%ile times by Specialty
hh:mm hh:mm
Theatre 2012 2013 2014* 2012 2013 2014* 2012 2013 2014*
ANAES 0:55 3:54 0:00 0:00 0:00 0:00 0:00 0:00 0:00
ENT 1612:00 1433:21 813:08 35:30 31:15 31:36 1846:10 1625:31 948:06
EYES 1049:02 1224:38 731:25 23:55 26:25 27:58 1244:00 1374:21 839:24
GYN 938:21 943:26 563:32 21:02 20:22 21:21 1093:54 1059:04 640:48
OMFS 497:50 499:48 192:17 13:28 13:41 9:09 700:26 711:52 274:54
ORAL 68:21 111:30 147:17 3:00 3:46 6:23 156:31 196:12 191:36
ORTHO 3335:56 3313:10 1701:05 74:20 73:46 63:09 3866:01 3836:02 1894:42
PAED 62:03 56:45 42:24 2:45 2:38 3:03 143:31 137:16 91:36
PLAS 73:57 66:13 50:27 3:44 2:57 4:57 194:18 153:55 148:54
SURG:BR 563:13 706:19 461:11 14:48 19:56 19:06 769:46 1036:32 573:18
SURG:COLO 1028:08 1019:30 576:52 24:54 23:56 23:51 1294:48 1245:03 715:36
SURG:SURG 448:00 209:30 95:40 11:52 8:19 5:37 617:04 433:09 168:48
SURG:UGI 1014:48 872:20 468:13 28:16 21:21 21:20 1470:23 1110:12 640:18
SURG:VASC 1145:43 1032:17 597:55 25:42 24:03 22:30 1336:24 1251:07 675:18
UROL 1187:38 1176:23 690:12 27:16 25:55 25:51 1418:12 1348:00 775:42
Elective Total 13025:55 12669:04 7131:38 279:53 268:27 259:04 16151:32 15518:21 8579:00
Table 3: Number of Elective Theatres Required modelled as Full day or Half Day Sessions
Theatre 2012 2013 2014* 2012 2013 2014*
ANAES 0.0 0.0 0.0 0.0 0.0 0.0
ENT 1.0 0.9 0.9 1.0 0.9 0.9
EYES 0.7 0.7 0.8 0.7 0.8 0.8
GYN 0.6 0.6 0.6 0.6 0.6 0.6
OMFS 0.4 0.4 0.3 0.4 0.4 0.3
ORAL 0.1 0.1 0.2 0.1 0.1 0.2
ORTHO 2.1 2.0 1.7 2.1 2.1 1.8
PAED 0.1 0.1 0.1 0.1 0.1 0.1
PLAS 0.1 0.1 0.1 0.1 0.1 0.1
SURG:BR 0.4 0.5 0.5 0.4 0.6 0.5
SURG:COLO 0.7 0.7 0.7 0.7 0.7 0.7
SURG:SURG 0.3 0.2 0.2 0.3 0.2 0.2
SURG:UGI 0.8 0.6 0.6 0.8 0.6 0.6
SURG:VASC 0.7 0.7 0.6 0.7 0.7 0.6
UROL 0.8 0.7 0.7 0.8 0.7 0.7
Elective Total 8.6 8.2 7.9 8.9 8.5 8.2
Table 4: Emergency Theatres
Full day Sessions Half day Sessions
Total Actual OP Time 80%ile time per week Time required at 80%ile
hh:mm
Theatres required at 80%ile Theatres required at 80%ile
215
216
Raigmore Hospital Critical Care Services Upgrade Communications Plan, Version 1.1 – 21st Jan 15 This plan sets out the requirements to support corporate communications around the Critical Care Services Upgrade and wider improvement work to the hospital estate. This version of the plan covers the period January 2015 to June 2015. It should be read in conjunction with the other relevant supporting documents available on the NHS Highland Intranet/internet M Thompson, Erin Greig and Doreen Bell 1/19/2015
217
Summary of key messages and milestone: Jan 15 – June 15
Ref Message / Milestone Proposed time frame to communicate
Actual time frame to communicate
Reason for any change
Status/Notes
1 Promote State of the art endoscopy facility general update, 1/3 of way through programme £22.5m invested so far
September 2014 January 2015 Suspension of Endoscopy Services in Skye
2 The date of relocating Ward 11 to 7A/B remains the 31st Jan/1st February 2015
January 2015
3 Vanguard on Site on 2nd of Feb W/b 2nd February TBC 4 Re-location of Ward 11 to 7th Floor and
general update Once move taken place
5 Outline Business Case Approved by SG Jan/Feb 15 6 Promote Design Stage Report Jan/Feb 7 Enabling Work for Children’s Ward February 15 Once Ward 11
empty 8a Submit Full Business Case AMG 16 Mar (24 Mar)
13 Apr (21 Apr)
8b Submit Full Business Case Board 26 Mar (14 Apr) 14 May (2 Jun)
8c Submit Full Business CIG TBC 8d Full Business Case Approval 9 Promotion of Community Benefits April 2015 10 Construction work underway for
ITU/Theatres June 2015
OBC Approval - Still awaited. Submit FBC – this may be delayed FBC Approval – date depends on the submission date Mobilisation – maybe delayed depending on the above Construction period - start may be delayed depending on above May/June 2015 – 2017
218
Ref Who Message How When Purpose Lead Status
1 All Promote State of the art endoscopy facility general update, 1/3 of way through programme £22.5m invested so far
Media Release Twitter Facebook NHSH Website Article in Highlights
w/b 19th Jan Promote progress and significant investment in Hospital upgrade: -Fit for purpose next 20 years -Fire upgrade -Modern -Incident free -No disruption to service
EG Pending
2.1 Ward/Clinical area (7A & 7B, Ward 11)
The date of relocating Ward 11 to 7A/B remains the 31st
Jan/1st February 2015
Update on work and timing of moves
DB 14/01/2015
Monthly Monthly
EG EG
14/01/2015 31/01/2015
2.2 RMH Groups E-mail Project Report Monthly MT 31/01/2015 2.3 RMH Patient
Council Update at Patient
Council Get dates Confirm
3.1 Raigmore Staff
Once confirmed
EG LK LK
3.2 NHS Highland
EG LK
Council Update at meeting TBC
3.5 MSP Email Media Release MT 3.6 Public Media Release EG
219
11 to 7th Floor and general update
Media Release Twitter Facebook NHS Highland website
Mid- Feb To inform staff and public of moves and also benefit of investment (isolation facility)
EG EG EG EG
To inform senior managers & Board
MT EG LK EG
Email Media Release To inform of moves and next steps
MT
TBC
MT
Comms Update Leadership Teams SMT HHSC Board
Jan/Feb Explain what this means and next steps
MT NK EM LK EM
Pending Pending Pending Pending Pending
5.2 Raigmore Staff
E-mail Huddle
EM LK
5.3 RMH Groups E-mail Media Release MT 5.4 Partners E-mail Media Release MT 5.5 MSPs E-mail Media Release MT 5.6 Public Media Release EG 5.7 Social Media EG 5.8 Website EG
220
staff Design Stage Report available
Intranet Other ?
Media Release Twitter Facebook NHS Highland website
February 15 Once Ward 11 empty
7.2 NHS Highland
7.3 Raigmore Staff
meeting
Archie Meeting
8a Asset Management Group
Submit Full Business Case
Paper to AMG 16 Mar (24 Mar) 13 Apr (21 Apr)
To get approval before going to Board
8b NHS Highland
221
All Board decision Media Release Twitter Facebook NHS Highland website
NHS Highland
Raigmore Staff
meeting
Archie Meeting
TBC
April 2015
June 2015
224
Stakeholder Management Plan
7. Stakeholder Analysis 11
8. Stakeholder Engagement 12
9. Stakeholder Reporting 14
10. Escalation Process 15
226
1. Document Control This document has been prepared by the project team and the Head of Public
Relations and Engagement at NHS Highland to set out a strategy and plan for the
management of the multiple stakeholders affected by the Critical Services Upgrade project which is underway at Raigmore Hospital.
The document will evolve alongside the project, and will be regularly updated by
the project team for approval by the Project Board.
Any queries on the content of this document should be referred to the following:
Maimie Thompson Head of Public Relations and
Engagement NHS Highland
Upgrade Raigmore Hospital
227
2. Introduction This document sets out the approach and methodology to manage stakeholders
with an interest in the Critical Services Upgrade project which is underway at
Raigmore Hospital, Inverness.
A stakeholder can be defined as:
“Individuals or groups involved in the project or whose interests may be affected by the project’s execution or outcome”.
This document identifies the engagement required to manage both the Critical
Services Upgrade and any inter-dependencies at operational (Raigmore) or strategic (NHS Highland) level, and among the wider project participants such as
the statutory authorities (Scottish Fire & Rescue Service).
An initial overview of how stakeholders would be managed was initially prepared at the outset of the project in May 2014. As the project progresses into the
development of the Full Business Case alongside detailed design and construction
planning stage, it was recognised that there was a need to prepare more a detailed Stakeholder Management Plan and a separate Communications Plan.
This Stakeholder Management Plan forms one part of the overall Critical Services
Upgrade project management plan and this plan builds on feedback from stakeholders, addresses issues highlighted in the project risk register, feedback
received during the development of the Outline Business Case and from the Gateway Review Report prepared in October 2014.
228
3. Communication Plan This document should be read in conjunction with the Communications Plan which
has been developed separately to define the communication requirements for the
Critical Services Upgrade project, and how information will be distributed. The Communication Plan identifies the project milestones which should be
communicated to a wider audience, allocating a responsible ‘owner’ and a timescale for these communications.
The Communications Plan will be maintained by the Head of PR and Engagement,
and will be tabled at the monthly Project Board Meetings for review and approval, and all outgoing communications approved before release. A summary of the key
components which have been considered in the preparation for the communications plan is included in this section for information.
Approach to Communications and Engagement
It was generally felt that the Project was low-profile outwith Raigmore Hospital,
in part, because it was being well managed and The Fire Precautions Upgrade
project has been well established and wards/departments involved closely communicated with. As the project develops, however, it was identified there was
a need to raise the profile and increase the level of communication.
Due to the planned construction works to the theatre block, the need to optimise all theatre capacity in Highland will require wider engagement and understanding
across the health board. It was therefore agreed that the project would benefit from strengthening the range and frequency of communications and engagement
with the wider health board.
Following a review of these objectives, the following high-level actions were identified:
Channel Review Action
NHS Highland website The project has no presence on the website
Develop a project specific portal
NHS Highland intranet The project has no
presence on the intranet
NHS Highland Twitter account
Implement key updates
Implement key updates
Media releases Occasional Issue key milestone updates to the media
Highlights, monthly newsletter
Occasional Monthly update
Project Meetings Outputs could be more widely communicated
All users (Raigmore); internet and intranet
Standing items in
and to get feed-back
Staff Briefings Underway Continue
Internal Review of Communications and Engagement
As part of developing the Communication Plan, the Head of PR and Engagement,
Clinical Adviser and Director of Operations have reviewed the Critical Services
Upgrade project in terms of the risks, constraints and impact on dependencies and this review is summarised in the table below.
This Internal Review has been used in the preparation of the Communication Plan
and will continue to be reviewed as part of the ongoing review of the Communication Plan at the monthly Project Board Meeting.
Issue Description Mitigation
Changing local strategies (Raigmore) impact on the project
Tight management controls and senior clinical leadership and engagement
Demand for services higher than projected
230
Service Risk Disruption to existing services during development or redevelopment
Business continuity and links with Pan-Highland Surgical Review
Stakeholders - contradictory aspirations
Scope Creeping development Tight management controls and senior clinical leadership and engagement
NHS Highland and Scottish Government Approvals process
Executive leadership and close contact with Board and SG
Constraint Need to fully maintain existing clinical services throughout the project period.
Business continuity and links with Pan-Highland Surgical Review
Dependency Projects
Fire precautions project is underway and is being separately funded
Tight management controls - dependencies understood from Raigmore though to NHS Highland Board
Children’s Ward Out-Patients Department (OPD) development and the relocation of the Children’s Ward In-Patient facility to Ward 11. Funding will mainly be sourced via the Archie Foundation albeit with NHS funding required in respect of backlog compliance issues
As above
Separately funded Endoscopy project to provide a new build Decontamination Unit and to re- locate the existing Endoscopy Unit to Ward 8. This will also require the amalgamation of Ward 8 into Ward 9
Now complete
231
4. Stakeholder Management Objectives The OGC notes that “Lack of effective engagement with Stakeholders” is one of
the most common causes of project failure. To mitigate this project risk, it is vital
that the key objectives of Stakeholder Management processes are agreed at the outset.
The following objectives have been agreed among the project team as being the
main objectives of the Stakeholder Management actions:
The project team should maintain a continual focus on effective risk reduction through maintaining stakeholder relationships.
Value long term relationships which are founded on trust which will benefit
the project through the construction phase to handover and operation.
Remain aware of the changing impacts on different stakeholder groups throughout the project lifecycles, and assess the changing scale of project
risk.
Effective stakeholder management demands imagination and innovative
ways of working – Use small defined group meetings to ensure each group has a voice, and information is cascaded effectively.
Co-ordinate project stakeholder engagement (and communications) with
existing strategic communications and policy – through the involvement of Maimie Thomson (Head of PR and Engagement) at Project Board Meetings.
These objectives have informed the development of this Stakeholder Management
Plan and the decisions taken during the Stakeholder Analysis and mapping stage
which is detailed in further sections in this plan.
Figure 4.1 Stakeholder Perception
Management is to improve the stakeholder perception to meet the
strategic project needs as per Figure 4.1.
232
5. Stakeholder Target Level There is an increasing level of sophistication in approaches towards Stakeholder
Management in current project and programme management. In seeking to avoid
an unproductive level of sophistication on the Critical Services Upgrade project, the project team agreed to identify the correct level of stakeholder engagement.
This approach identifies the purpose of the engagement and the level at which the engagement will take place, which is important in setting the objectives for
the project. The different levels of engagement which could be selected are illustrated in the figure below.
Figure 5.1 Stakeholder Target Levels
The project team have identified that the most suitable level of engagement on
the Critical Services Project is a Planned Targeted engagement Project Deliver approach, which ensures a “Systematic engagement for risk management and
increased understanding of stakeholders’.
The main aim of the stakeholder engagement is to inform the stakeholders of the project delivery plans, and provide an opportunity for regular open
communication. This engagement will essentially take place outside the corporate level strategic communication channels, and will focus on the successful delivery
of the project.
The graphic below illustrates an iterative Stakeholder Management Cycle which has been utilised by the project team in order that a transparent and managed
approach could be implemented for the management of project stakeholders.
Figure 6.1 Stakeholder Management Cycle
Similar to the objectives outlined in Section 4, this management cycle assisted the project team in discussion on how to engage with, and communicate with
the identified stakeholder groups.
deliver project success
maximise reputation
and stakeholder needs
the project goals
Record them in
the Stakeholder database
Feedback observations
7. Stakeholder Analysis
A Stakeholder Analysis Database has been created which forms the key component of the Stakeholder Management Plan. The database can be viewed in
Appendix 1.
This database records the key stakeholders, and provides an analysis of each
stakeholder under a number of headings such as perception of the project, power, level of engagement in the project, and their priority level. This is be
demonstrated by the extract below.
Figure 7.1 Stakeholder analysis Database
The Stakeholder Analysis Database is reviewed and updated as required by the Project Team at fortnightly meetings, and is included in the Project Board Report
on a monthly basis for Project Board review and approval.
The agreed outcomes of the database informs the strategy to manage each
identified stakeholder/stakeholder groups and is used to inform the Communications Plan.
Figure 7.2 Stakeholder Power:Interest Grid
The database implements stakeholder management best practice such as a
‘Power:Interest’ review which is often presented in a grid format to
categorise stakeholders in accordance with their levels of ‘Interest’ and
‘Influence’ in the project. An example of this grid can be seen in Figure 7.2
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8.1 Background
Stakeholder engagement was initiated at the outset of this project when an
Options Appraisal was undertaken with the stakeholder groups to identify the preferred option for the Tower Block Reconfiguration. This Options Appraisal
identified Option 2A as the preferred option, and this is detailed in the Initial Agreement and the Outline Business Case for the project.
Subsequent to the Options Appraisal exercise, the stakeholder engagement has
focussed on an iterative process to develop the preferred layouts for the clinical space which forms the Critical Services Upgrade project.
This stakeholder engagement has been managed by the NHS Highland project
team representatives (Doreen Bell & Colin McEwen).
8.2 Full Business Case
As the project is in Stage 1B progressing towards completion of the Full Business
Case, which involves detailed construction planning, the Stakeholder Engagement process has been formalised and updated in line with the Stakeholder Analysis
Database. The purpose of this is to ensure that all relevant stakeholder groups are fully aware of the project objectives, timescales, constraints and challenges
prior to the completion of the Full Business Case and the commencement of the construction works.
This updated stakeholder engagement process is detailed in the following
sections, however this will not replicate the information which is held in the Stakeholder Analysis Database.
8.3 Internal Stakeholder Groups
It was agreed during the Stakeholder Analysis workshop that it would be
beneficial to split the internal stakeholders into groups which are relevant to
their area of interest. This would enable the project team to communicate with each of the groups on the aspects of the project in which they had an interest,
and therefore reduce unnecessary communications.
This analysis resulted in the following groups being identified:
Non-clinical stakeholders – Domestics, catering, security, estates. Clinical stakeholders – Theatres
Clinical Stakeholders – Critical Care Clinical Stakeholders – AMAU/Cardiology/CCU
Equipment Stakeholders – Medical Physics, Procurement, Decontamination
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Effective stakeholder management requires that the project manager should communicate with each stakeholder in order to determine their preferred
frequency and method of communication and their agreement to the proposed method of engagement.
This process was undertaken with the key clinical stakeholder groups in January
2015 and the agreed dates for stakeholder group meetings are noted on the Stakeholder Groups & Schedule document which is included in Appendix 2.
The initial discussion at this meeting was to review the Stakeholder Groups, and
after some discussion and amendments, the groups were agreed as noted in Appendix 2.
It was also agreed that a series of meetings would take place with the individual
groups, and the likely agenda topics were outlined and agreed.
8.5 Meeting Agenda
A number of subject areas have been identified as worthy of discussion with the
Stakeholder Groups. These include the following:
Review of the project Risk Register HAISCRIBE reviews
AEDET reviews Review any changes to project planning and phasing
This list is clearly not exhaustive, and the meetings with stakeholders are
intended to provide an opportunity for the parties to provide feedback on the project, ask questions, and represent the interests of their colleagues.
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9. Stakeholder Reporting Stakeholder reporting will generally form part of the monthly Project Board
Report, and be an agenda point for discussion at the Project Board Meeting.
The purpose of this reporting will be to confirm that the Stakeholder Engagement
is progressing as intended, and to highlight any exceptional issues which arise through this engagement and which may need Project Board intervention.
The Stakeholder Database includes the functionality to generate reports on each
of the listed stakeholders, in a standard pro-forma template. These reports can be generated on request and an example of the report is included below for
information.
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10 Escalation Process
Project Stakeholders may have many different conflicting interests in the project. As issues or complications arise with stakeholders, it may become necessary to
escalate any issue which cannot be resolved within the project team.
The established escalation process for the Critical Services Upgrade project is as
follows:
Figure 10.1 Escalation Process Chart
It is imperative that any disputes, conflicts or discrepancies are resolved in a way
that is conducive to maintaining the project quality, programme and budget and preventing ongoing difficulties.
Project
Stakeholders
(Resolve)
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11. Conclusion This report sets out the Stakeholder Management Plan which has been developed
and implemented for the Critical Services Upgrade project at Raigmore Hospital
The plan provides a background to the development of the Stakeholder
Engagement proposals and the outcome of the Stakeholder Engagements on the project.
This plan will continue to be reviewed and amended as the project progresses
through to the construction phase and beyond to the handover and operation of the new facilities.
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0-03 Node Room 9.1 Staff Area 2018-OBE_(0-)_TH_XX_101
0-04 Office Secretaryx4 20.0 20.9 Staff Area HBN 00-03 - Admin 2018-OBE_(0-)_TH_XX_101 M0252-02
0-06 Office Consultantx2 12.0 12.3 Staff Area HBN 00-03 - Admin 2018-OBE_(0-)_TH_XX_101 M0202
0-09 Office Antenatalx4 24.0 19.9 Staff Area HBN 00-03 - Admin 2018-OBE_(0-)_TH_XX_101 M0252-02
0-10 Office Geneticsx5 30.0 24.4 Staff Area HBN 00-03 - Admin 2018-OBE_(0-)_TH_XX_101 M0252-02
0-08 Office Consultantx3 18.0 17.3 Staff Area HBN 00-03 - Admin 2018-OBE_(0-)_TH_XX_101 M0252-02
0-14 Pantry 20.0 12.3 Staff Area HBN 00-03 2018-OBE_(0-)_TH_XX_101 D0510
0-15 WC 5.0 5.1 Staff Area HBN 00-02 2018-OBE_(0-)_TH_XX_101 V1005
0-16 WC 5.0 5.1 Staff Area HBN 00-02 2018-OBE_(0-)_TH_XX_101 V1005
First Floor Guidance Document Reference
1-02H Equipment Bay 5.0 4.0 Clinical Support HBN 26 - Imaging Equipment Bay 2018-OBE_(0-)_TH_XX_102 G0149 Other options available
1-03 T10 Scrub 11.0 7.2 Theatre HBN 26 - Scrub-up/gowning room (3no. Places) 2018-OBE_(0-)_TH_XX_102 N0217 Change from N0216 due to bay and not room
1-04 T10 Dirty Utility 12.0 14.3 Theatre HBN 26 - Dirty Utility (serves 1no. theatre) 2018-OBE_(0-)_TH_XX_102 Y0402
1-05 T10 Theatre 55.0 54.6 Theatre HBN 26 - Ultra-clean Operating Theatre 2018-OBE_(0-)_TH_XX_102 N0108 Consider N0111 UCV Theatre
1-06 T10 Prep 12.0 14.6 Theatre HBN 26 - Preparation Room 2018-OBE_(0-)_TH_XX_102 T0526
1-07 T10 Exit Bay 12.0 14.4 Theatre HBN 26 - Patient Bed/Trolley Theatre Exit Bay 2018-OBE_(0-)_TH_XX_102 G0405
1-08 T10 Anaesthetic 19.0 18.8 Theatre HBN 26 - Anaesthetic Room 2018-OBE_(0-)_TH_XX_102 N0316
1-09 Prosthetics Store N/A 4.2 Theatre HBN 26 - Clinical Equipment Store 2018-OBE_(0-)_TH_XX_102 W1584-03 Store: bulk supplies, medical and surgical
1-10 Prosthetics Store N/A 7.7 Theatre HBN 26 - Clinical Equipment Store 2018-OBE_(0-)_TH_XX_102 W1584-03 Store: bulk supplies, medical and surgical
1-11 T1 - Scrub 11.0 7.1 Theatre HBN 26 - Scrub-up/gowning room (3no. Places) 2018-OBE_(0-)_TH_XX_102 N0217 Change from N0216 due to bay and not room
1-13 T1 Disposal 12.0 7.0 Theatre HBN 26 - Dirty Utility (serves 1no. theatre) 2018-OBE_(0-)_TH_XX_102 Y0402
1-14 T1 Theatre 55.0 40.0 Theatre HBN 26 - Ultra-clean Operating Theatre 2018-OBE_(0-)_TH_XX_102 N0108 Consider N0106 if laminar flow is not required
Room Number(s)
Theatres: Raigmore CSU Theatres: Raigmore CSU Theatres: Raigmore CSU Theatres: Raigmore CSU
NHS HighlandNHS HighlandNHS HighlandNHS Highland
Raigmore Hospital, InvernessRaigmore Hospital, InvernessRaigmore Hospital, InvernessRaigmore Hospital, Inverness
Comments Actual Area
(m2) DepartmentActivity Space
Area (m2)
Theatres: Raigmore CSU Theatres: Raigmore CSU Theatres: Raigmore CSU Theatres: Raigmore CSU
NHS HighlandNHS HighlandNHS HighlandNHS Highland
Raigmore Hospital, InvernessRaigmore Hospital, InvernessRaigmore Hospital, InvernessRaigmore Hospital, Inverness
Comments Actual Area
(m2) DepartmentActivity Space
1-58A T7 Exit Bay 12.0 11.3 Theatre HBN 26 - Patient Bed/Trolley Theatre Exit Bay 2018-OBE_(0-)_TH_XX_102 G0405
1-65A T9 Disposal 12.0 7.2 Theatre HBN 26 - Dirty Utility (serves 1no. theatre) 2018-OBE_(0-)_TH_XX_102 Y0402
1-68 Multi Person Office 24.0 18.2 Staff Area HBN 26 - Office Accommodation (Multi Person Office) 2018-OBE_(0-)_TH_XX_102 M0221 Open plan office - 6sqm/person plus circulation. Can reduce to 5.5sqm by using
M0222
M0222
M0222
1-71 Female Changing 45.0 42.1 Staff Area HBN 26 - Male Changing Facilities (40no.) 2018-OBE_(0-)_TH_XX_102 V0218
1-71a Scrubs & Boots 2.0 6.6 Staff Area HBN 26 2018-OBE_(0-)_TH_XX_102
1-71b Acc WC Female 4.5 5.4 Staff Area HBN 26 / HBN 00-02 - Staff WC 2018-OBE_(0-)_TH_XX_102 V0904
1-71c Footwear Wash 4.0 7.3 Staff Area HBN 26 - Footwear Washing machine area 2018-OBE_(0-)_TH_XX_102 Y0511
1-71d Acc Shower 2.5 3.9 Staff Area HBN 26 / HBN 00-02 - Staff Shower 2018-OBE_(0-)_TH_XX_102 V0801
1-71e Shower 2.5 2.9 Staff Area HBN 26 / HBN 00-02 - Staff Shower 2018-OBE_(0-)_TH_XX_102 V0801
1-71f Shower 2.5 2.9 Staff Area HBN 26 / HBN 00-02 - Staff Shower 2018-OBE_(0-)_TH_XX_102 V0801
1-71g WC Female 2.0 3.2 Staff Area HBN 26 / HBN 00-02 - Staff WC 2018-OBE_(0-)_TH_XX_102 V1005
1-71h WC Female 2.0 3.2 Staff Area HBN 26 / HBN 00-02 - Staff WC 2018-OBE_(0-)_TH_XX_102 V1005
1-72 Male Changing 45.0 41.1 Staff Area HBN 26 - Male Changing Facilities (40no.) 2018-OBE_(0-)_TH_XX_102 V0218
1-72a Scrubs & Boots 2.0 6.8 Staff Area HBN 26 2018-OBE_(0-)_TH_XX_102
1-72b Acc WC Male 4.5 5.2 Staff Area HBN 26 / HBN 00-02 - Staff WC 2018-OBE_(0-)_TH_XX_102 V0904
1-72c Footwear Wash 4.0 7.2 Staff Area HBN 26 - Footwear Washing machine area 2018-OBE_(0-)_TH_XX_102 Y0511
1-72d Acc Shower 2.5 3.8 Staff Area HBN 26 / HBN 00-02 - Staff Shower 2018-OBE_(0-)_TH_XX_102 V0801
1-72e Shower 2.5 2.8 Staff Area HBN 26 / HBN 00-02 - Staff Shower 2018-OBE_(0-)_TH_XX_102 V0801
1-72f Shower 2.5 2.8 Staff Area HBN 26 / HBN 00-02 - Staff Shower 2018-OBE_(0-)_TH_XX_102 V0801
1-72g WC Male 2.0 3.2 Staff Area HBN 26 / HBN 00-02 - Staff WC 2018-OBE_(0-)_TH_XX_102 V1005
1-72h WC Male 2.0 3.2 Staff Area HBN 26 / HBN 00-02 - Staff WC 2018-OBE_(0-)_TH_XX_102 V1005
1-73 Staff Rest 35 (43) 50.6 Staff Area HBN 26 - Staff Rest Room, Dining Area with Beverage Facilities 2018-OBE_(0-)_TH_XX_102 D0455 Changed from D0453 due to actual staff numbers
1-73A Computer Area N/A 7.5 Staff Area HBN 26 2018-OBE_(0-)_TH_XX_102
1-74 DSR 7.0 10.0 Clinical Support HBN 26 - Housekeeping Room (Cleaner) 2018-OBE_(0-)_TH_XX_102 Y1501 Cleaners room
1-75 Servery 7.6 Staff Area 201

lack of integrated critical care service with a single

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