In this slideshow, Dr Derek Thompson, GP and Medical Director at Northumbria Healthcare Foundation Trust, on reducing the length of hospital stay and building a caring future. Dr Thompson spoke at the Nuffield Trust ‘Reducing the length of stay’ event in September2014.

1. Length of Stay
Dr Derek Thomson
GP & Medical Director

2. To Cover
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What is Northumbria Healthcare FT?
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Organisational Integration reducing LOS
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Reducing Surgical LOS
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What effect are we having ?
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What about the future - Northumbria Specialist Emergency Care Hospital (NSECH)

3. Northumbria Healthcare Foundation Trust – Integrated Care Provider
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Secondary Care – 9 Hospitals, 3 DGH, 6 Community Hospitals
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Soon to be 10 hospitals, then 12 hospitals.
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Community Service – The coming together of;
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Nth Tyneside community services,
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Northumberland Community services and Northumberland Social care
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To create BU (£70million health and £140million social care)
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Social Care - Partnership agreement maintained between the county council and Northumbria
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Population of 500k, spread over c2,500 sq miles and c 9,000 staff

4. Organisational Structure
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Northumbria Formed in 1998, Foundation Trust since 2006
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Many examples of ‘Copy and Paste’
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Leadership and development programs, recruitment process, driven by patient experience and QI
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Built upon strong, accountable Clinical Business Units,
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Med and Emergency Care, Emergency and Planned Care, Paeds, Clinical Support, Community
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Paired Clinical and Managerial Leaders
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Stable senior management team
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Long and strong relationship with Primary Care

6. Reducing LOS through Integration – What is possible?
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Reducing Hospital Bed usage
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Community/Pre-admission, Front of House, Back of House, Transfer of Care (discharge), Community/re-admission prevention
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Speeding up flow through the Hospital
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Reducing Admissions to Nursing and Residential Care

7. 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

8. Improving Length of Stay
Estimated Discharge Dates
Nurse led discharge
Complex discharge

9. Speeding up the pathways
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At Admission - Identification of complex discharge (Mayo risk stratification tool)
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Estimated Day of Discharge and Ticket Home
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Visual controls for patient and staff
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Hospital to home team- Community based MDT
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Pits stop approach to discharge
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Nurse led Discharge
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CGA in hospital, seen by D/Nurse within 7 days
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Single Point of access to Community Services
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Community based Short term Support Service

10. Complex discharge
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Using the Mayo Tool to identify complex discharges

11. •
More visual displays for patients
Further improvement cycles
Ticket Home postcard

12. EDD: Visual display for patients
Ticket Home leaflet

13. Nurse led discharge
Aim to smooth out variation in discharges over 7 days
0
10
20
30
40
50
60
WG D/C
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

14. Hospital 2 Home Team Northumberland
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Northumberland Team Live from November 2013
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Community Matron Team Lead
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Social Work, OT, care management, STSS, mental health specialist.
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Work into Front of House – A&E and MAU
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Back of House through the MDT’s
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Smaller team in North Tyneside

15. Ambulatory Care and Elderly Assessment Units
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Ambulatory Care
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31,000 cases through ambulatory care in past 12m
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Rate now >3,000 per month
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85% medical cases
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Elderly Assessment
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Preparation for NSECH
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Opening on 3rd site soon
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50% go home, 20% direct to rehab facility and 30% still get admitted

16. Reducing LOS in Surgery
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Gynae – Laparoscopic Hysterectomy since 2008 now 90% done this way
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70% now as Day cases and 90% <24hr stay
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Previously average LOS was 3.5 days
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½ complication rates
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Colo-rectal
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Laparoscopic plus enhanced recovery= 1.5 day reduction
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Orthopaedics
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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.
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Top 5%
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All surgeons receive their performance monthly
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#NOF

18. Pre-assessment
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Ensure the pre-assessment screening pathway is a safe and timely assessment
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Optimisation - allow enough time for further investigations or interventions to be put in place prior to surgery
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Identify complex patients early and pre-planned to the H2H team
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Collaborative working between GP’s, Surgeons and Pre- assessment
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Early pre-assessment generates a pool of patients who can fill gaps on operating lists

19. SO WHAT ?
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Recent CHKS Comparisons
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Northumbria average LOS is 3.6 days compared to National rate of 4.2 days
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Mixed across different specialities
AND
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All targets achieved
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Financial Surplus

20. NORTHUMBRIA HEALTHCARE NHS FOUNDATION TRUSTMidnight bed occupancy 2012/13 and 2013/14NTGH, Wansbeck, Hexham1800018500190001950020000205002100021500220002250023000Monthly occupied bed daysMonthly total OBDOBD 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 month5.05.25.45.65.86.06.26.46.66.87.0AprMayJunJulAugSepOctNovDecJanFebMarMean length of spell* (days) mean length of stay 11/12mean length of stay 12/13mean length of stay 13/14N.B. Excludes paediatrics beds,well babies, SCBU, obstetrics, critical care,

24. 988.6988.4916.2911.1889.1862.6857.8856.8831.4809.7781.8766.7756697.2670.3659.8 010020030040050060070080090010001100 SunderlandDarlingtonRedcar & ClevelandMiddlesbroughGatesheadSouth TynesideHartlepoolStockton- on-TeesNorth EastDurhamNorth WestNewcastleupon TyneNorth TynesideENGLANDCumbriaNorthumberlandAdmission rate Permanent admissions to care homes, per 100,000 population -2012/13

25. Northumbria Specialist Emergency Care Hospital - NSECH

26. This image cannot currently be displayed.
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

27. Northumbria Specialist Emergency Care Hospital - NSECH
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Services
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All ambulance and GP referrals
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Major A&E / Specialist ED in the new world, 24/7 emergency Care Consultant delivered service
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Acute medicine, GI, Cardio, Resp, Elderly (incl ambl function), Stroke, Trauma, Maternity, Paeds and Surgery specialist wards with 7 day consultant working
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Critical care
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Some high risk elective surgery
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Ambulatory care – medically led
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Surgical assessment unit

29. •
24/7 consultant presence – early senior decision making
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Backed up by 8 til late specialist consultants, 7 day working. Quicker specialist decision making,
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Dedicated 7 day Diagnostics
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7 day working for Endoscopy
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No longer wait in MAU/ECU – patients will go directly to speciality ward from A&E
Effect on Length of Stay

30. •
All the business units and specialities working towards reducing LOS
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Working within and across BU and specialities, via integration board
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Working at these for a long time and been able to close wards in the past 3 years
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There is no single silver bullet
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Future major reconfiguration to create the next step-wise change
Summary

31. Any Questions?