Northern Adelaide Local Health Network (NALHN)

Transcription

1 Northern Adelaide Local Health Network (NALHN) Proposed Intra-NALHN Service Plan February 2016

2 Document Control Date: 03/2/2016 Release: Author: NALHN Executive Owner: Document Number: NALHN Executive A Note: This document is only valid on the day it was printed Revision History Revision Date Previous Summary of Changes Revision Date 3/2/16 New draft Changes Marked Approvals This document requires the following approvals. A signed copy should be placed in the project files. Name Signature Title Date of Issue Version Dr Elaine Pretorius Clinical Lead Transforming Health, NALHN Michael Francese Jenny Browne Scott McMullen Jackie Hanson Executive Sponsor, Transforming Health, NALHN Director Finance, NALHN Chief Operating Officer, NALHN Chief Executive Officer, NALHN Distribution This document has been distributed to: Name Title Date of Issue Version Page 2 of 84

3 Disclaimer The content of this plan was developed by relevant stakeholders drawing on specialty knowledge, information and data that was available at the time. Information contained in this plan may require further refinement and / or realignment based on further improvements that may occur between the time the plan was documented and the commissioning of the services or compromises that may need to be made in order to provide a safe service. Assumptions The development of Service Plans for Lyell McEwin Hospital (LMH) and Modbury Hospital (ModH) are based on a number of assumptions: Service Plans o The Service plan is a point in time document and as such is intended to be a living document that will be revisited and updated along the Transforming Health journey. Activity and workforce o Modelling is based on commissioned activity in accordance with the Service Level Agreement (SLA) between Department for Health and Ageing (DHA) and Northern Adelaide Local Health Network (NALHN). o Specific assumptions relating to service delivery are identified in the relevant sections of this plan. Workforce modelling has been based on these assumptions. o The development of the NALHN Service Plans was based on 2014/15 activity actuals for patient profiles and applied 2015/16 commission activity where significant differences between actuals and commissioned emerged. o Agreed consistent approach to modelling and theatre utilisation/ scheduling and is standardised to 4 hour theatre session lists. o Outpatient Activity will be modelled for every service plan. Management of deteriorating patients, patient transfers and clinical documentation o Management of deteriorating patients will be well defined through Medical Emergency Team (MET) and Rapid Response Teams (RRT). o Hospital-at-Night functions and emergency management response team will support clinical practice and processes. o A system will be in place to address patient movement for rapid transfer and ambulance support. Page 3 of 84

4 o NALHN will maintain controls, checks and balances in both electronic and paperbased information management and data governance for patient identification and transfers. Clinical Support Services and Infrastructure o Interdependencies and infrastructure for Clinical Support Services are built in to models of care. Infection Control o The universal principles relating to Infection Control will continue to support clinical practice. Central Flow Unit in patient transfers o The Central Flow Unit will continue to act as NALHN s strategic capacity and patient flow management centre. Training and Accreditation o NALHN will continue to engage with the relevant Colleges and Professional Bodies to ensure training and development requirements are met. Corporate Services o Corporate functions across NALHN will be considered as a whole of system approach. While these assumptions are important to acknowledge, they do not override or compromise the overarching model of care principles - best care first time, every time, ensuring patients are treated closer to home where possible - and commitment to the Transforming Health journey. Page 4 of 84

5 Contents Disclaimer... 3 Assumptions Introduction Purpose NALHN s commitment to improving the patient journey Population of interest Activity and Service Moves Intra NALHN overview of changes CALHN to NALHN Models of Care NALHN Emergency and Critical Care Services Emergency Departments (including EECU/ ED Short Stay) Rapid Response Team NALHN Intensive Care Unit NALHN Hospital at Home NALHN Surgical Services Referral pathways Preadmissions Discharge and follow up Restorative care and rehabilitation Emergency care Clinical deterioration Elective Surgical Waiting lists Theatres Surgical Sub Specialties Orthopaedics Urology ENT Vascular Surgery Page 5 of 84

6 General Surgery Upper GIT surgery Breast Endocrine Plastics and reconstructive surgery Gynaecology NALHN Medical Services Medical Sub Specialties General Medicine (including Short Stay General Medicine Unit) Cardiology Respiratory Medicine Gastroenterology service Diabetes and Endocrinology Neurology and Stroke Services Renal Services Haematology and Medical Oncology Chronic Disease Management Unit Interdependencies- clinical support summary Interdependencies- non clinical support summary Infrastructure - summary Staff education / training required for implementation Workforce FTE summary by service Activity summary by service Division Medical Sub Specialties Overall summary Current state Future state Surgical Activity Overall summary: Current state Page 6 of 84

7 Future state Risk management Page 7 of 84

8 1. Introduction The SA Health Transforming Health agenda outlines the direction for the delivery of health services across South Australia. Transforming Health aims to provide the best care, first time, every time. To achieve this, there also needs to be significant work undertaken in unlocking existing capacity within hospitals by improving the effectiveness and efficiency of care provided. For NALHN, LMH will develop into a major adult tertiary hospital for the north as planned, supported by ModH as a centre for elective surgery, rehabilitation and sub-acute services. LMH will continue to provide paediatric surgery and paediatric medicine as part of a statewide governance service with the Women s and Children s Hospital and Flinders Medical Centre. LMH neonatal services will also be part of a statewide governance service and will continue to provide complex care to acutely ill newborns with the Special Care Nursery increasing in complexity and volume. In addition to the internal NALHN service profile changes, Transforming Health also outlines the movement of services between Local Health Networks (LHNs) to support the principle of care provided as close to home as possible. This will require a significant change in the service profile of both sites, and associated transfer of activity and resources to support this. 2. Purpose The purpose of the NALHN Transforming Health Intra NALHN Consolidated Service Plan is to provide a clear understanding of the type and volume of services, and necessary supporting infrastructure, to be provided across NALHN as part of the intra NALHN service profile changes. It also provides an overview of the transfers associated with the CALHN to NALHN activity transfer process. 3. NALHN s commitment to improving the patient journey Improving the Patient Journey. Everybody Matters encourages all staff to play an active role in improving the patient journey and reminds us of the core values and behaviours we must uphold to ensure the needs of our patients remain at the forefront of our day-to-day work. As an organisation that embraces Improving the Patient Journey. Everybody Matters, we will continue to move from: work being organised through the needs of the business; changes being reactive to patient demands; information being presented only from the staff point of view; Page 8 of 84

9 staff feeling not empowered to initiate change; and being a silo working culture. Through Improving the Patient Journey. Everybody Matters we ensure: we view our organisation through the lens of people who actually use our services; the provision of information is planned and two way; pathways are mapped to illustrate experience and patient experience data is collected and acted upon; service users are part of the decision making process and our organisation can demonstrate that this leads to improvement; work is based around the patient journey, providing more consistent and integrated care; there is a positive learning approach to complaints handling, and complaints and compliments are shared widely; and patients are supported to be partners in their care and share decisions. The five elements that make up and contribute to Improving the Patient Journey. Everybody Matters 1 is patient-focused and supported by a number of values, behaviours and standards. These include: Patient and Family Centred Care Accessible, Integrated and Coordinated Care Working as a Team Acting on Feedback Safe and Reliable Care 1 Link for Improving the Patient Journey 904/Default.aspx, Page 9 of 84

10 4. Population of interest There were 369,484 people living in the NALHN area as at the last (published) census in The primary catchment for NALHN is the northern Adelaide metropolitan region comprising three Local Government Areas (LGA) in their entirety, the City of Playford, the City of Salisbury and the City of Tea Tree Gully, and part of a fourth, the City of Port Adelaide Enfield. In addition a substantial number of people who access services in the NALHN come from outside the geographic boundaries of the LHN, including people from rural, remote, interstate and overseas locations. A significant number of residents from within the NALHN currently access health services in other LHNs within the state. The proportion of patients accessing services in other LHNs is dependent on the specific service required. In some instances this is appropriate as they are highly specialised, state-wide services, however the intention is that for the majority of services, NALHN should be capable of providing in excess of 85% of the care required for the local population. The Northern area of Adelaide is currently the highest population growth area in SA. This will mean that by 2026 it is expected a quarter of the state s total population is expected to live in the northern metropolitan catchment 2. NALHN has a younger age structure to that of South Australia as a whole and although there will be an increase in the percentage of older persons in the NALHN region, the region will maintain its status as the youngest region until Although the total proportion of older people in NALHN is lower that the state average, the growth in this age group in NALHN is greater that the growth rate for the state as a whole. The NALHN is characterised by significant disadvantage with regard to health and wellbeing, as it contains some of the most disadvantaged parts of the state. As a whole, residents of NALHN rate lower on population health measures than residents of other LHNs, and are also more likely to have chronic disease or risk factors for chronic disease. The proportion of Aboriginal or Torres Strait Islander people living in the NALHN in 2011 (1.9% of the NALHN population) is consistent with the state as a whole (1.9%). However, some SLAs in the NALHN had some of the highest metropolitan proportions of Aboriginal and Torres Strait Islander people. Although there is diversity, the NALHN Aboriginal and Torres Strait Islander population, as a group, rate much lower on most measures of population health relative to the whole population. Since 2 Population projections for South Australia. Projection, May 2011, Medium series based on Census Page 10 of 84

11 2005, an estimated 55% of all refugee new migrants in South Australia have settled in the LGA s of Playford, Salisbury, Tea Tree Gully, Gawler, Mallala and part of Port Adelaide Enfield. This percentage equated to a total of 2,905 people in 2006 and increased by 178% to 8,061 people in This settlement trend is expected to continue 3. Demand increases are not only related to population growth. The NALHN is characterised by significant disadvantage with regard to health and wellbeing, as it contains some of the least affluent parts of the state. The social and economic factors influencing the health services within the NALHN include, but are not limited to the following: High level of obesity and co-morbidities per volume of patients High level of limited literacy (year 10 level) Low socio-economic status The area has a greater avoidable causes of death when compared with the rest of South Australia High level of psychosocial distress level associated with the level of disadvantage High prevalence of smoking and physical inactivity High level of single parent families, people receiving unemployment benefits and disability pensioners. There is one General Practitioner per 1,400 or more people and of particular note is the high proportion of the sole GPs. This impacts on the number and availability of after-hours GP services and the number of presentations to the LMH and ModH s Emergency Departments after hours 4. 3 Northern Adelaide Medicare Local (NAML) Australian Bureau of Statistics Census Data August (Accessed on line 31 st July 2012) 4 data/assets/pdf_file/0006/177936/population_change_fact_sheet_2014.pdf Page 11 of 84

12 5. Activity and Service Moves 5.1 Intra NALHN overview of changes Surgical services ModH will become the elective surgery centre for the north and north east, providing 23-hour and day elective procedures. An expanded one stop breast service will give women access to a breast surgeon, radiologist and a breast care nurse in the same location. Emergency, complex and multi-day surgery will be focused to LMH, including a 24/7 orthopaedic trauma surgery service. Emergency services ModH will continue to operate an ED 24 hours a day, 7 days a week, staffed by specialists, and the majority of patients who present will continue to be seen at the hospital. If patients need ongoing, specialist care not available at ModH, they will be stabilised before being transferred to another hospital. A short stay unit will be established to assist management of admissions from ED. Medical services Establishment of an acute medical short stay unit at ModH providing care for up to 48 hours, with patients who have higher acuity needs or require greater than 48 hours inpatient care transferred to LMH. Gastroenterology outpatient service and elective endoscopies will now be provided at ModH. A new cardiac catheter laboratory will be built at LMH. Rehabilitation services ModH will become the major rehabilitation centre for the north and north east, with a new gym, hydrotherapy pool and therapy spaces, increasing inpatient rehab beds to a total of 52. As a result cardiology, some medical and some surgical inpatient beds will move to LMH with Level 3 at ModH redeveloped to accommodate the additional rehabilitation beds. This redevelopment will be undertaken in two phases and will require the decanting of each wing during the redevelopment phase. Each phase will take approximately three to four months to complete. Bays on level 2 will also require decanting to enable any underfloor work to be completed. The decanting also includes activity movement between Modbury and Lyell McEwin Hospitals. Diagrams 1 and 2 below outline the moves between ModH and LMH and the moves within ModH. Activity currently accommodated in 3 East will transfer to LMH Ward 1B. It is anticipated this decanting of 3 East will occur by early March It is anticipated the decanting of 3 West will occur by June Page 12 of 84

13 Diagram 1: Modbury to LMH Activity Movements Diagram 2: Intra-Modbury Activity Movement Page 13 of 84

14 5.2 CALHN to NALHN As part of Transforming Health, detailed planning work is under way to increase the services available across NALHN and enable more residents of the northern and north eastern suburbs to be treated closer to home. This includes new capital investment in both the LMH and ModH and service realignments across a range of services to transfer the activity currently occurring in CALHN that relates to northern residents into NALHN. During the first half of 2016 activity from selected CALHN services will transition to NALHN. Below is a list of in scope services: Orthopaedics Stroke Cardiology Vascular Renal medicine Urology Medical oncology Upper GIT Endocrinology Haematology Breast surgery ENT 6. Models of Care This section outlines the service models for those units and specialties impacted by the site profile changes and activity moves. 6.1 NALHN Emergency and Critical Care Services The NALHN emergency and critical care services will operate as a single service multi site model under the governance of the Critical Care Division. This model is necessary to ensure the services provided are safe and of a high quality, that staff have the opportunity to provide a range of complex and non-complex procedures, and that trainees are offered a breadth of experience. The single service model will also provide greater consistency of care across the two sites by providing common policies, procedures and patient pathways. Page 14 of 84

15 Emergency Departments (including EECU/ ED Short Stay) The NALHN will continue to provide FACEM (Fellow of the Australian College of Emergency Medicine) led EDs at both LMH and ModH, 24 hours, seven days a week. The EDs will receive, triage, stabilise and manage adult and paediatric patients who present with a range of conditions including; medical and surgical emergencies; paediatric and obstetric emergencies; post trauma and acute mental health. Strong links will continue to be maintained with the SA Ambulance Service, MedStar, CALHN, SALHN and WCLHN for the transfer of patients requiring high acuity state-wide services (e.g. burns, spinal injuries, cardiothoracic, complex vascular and neurosurgery and out of hours stroke). Patients requiring inpatient specialist services not available at the ModH site will be transferred to where the service is provided either at LMH or an alternative LHN. LMH ED will have the capability to stabilise major trauma patients who cannot be transported directly to the Major Trauma Services at the RAH (>16years) or WCH (<16years). Strategies which support patient flow through the ED will continue to be implemented to assist in achieving national ED targets. The Extended Emergency Care Unit (EECU) /ED Short Stay Unit (EDSSU) will address the needs of patients who do not require an inpatient admission to hospital but need extended observation and short-term treatment, or who are waiting for test results to confirm that they can be discharged. EDSSU will adhere to specific admission and discharge criteria and policies as per ED led model below. Key Principles for admission to EECU/EDSSU include: Clinically stable AND Anticipated to require a period of observation or treatment less than 24hours, or In some circumstances are pending transfer to another facility. LMH currently has an EECU in place. The EDSSU will be established at ModH co-located with the Short Stay General Medicine Unit (SSGMU). It is proposed that a purpose built 30 bed short stay unit (EDSSU and SSGMU) be constructed adjacent to the ModH ED. Timeframe to be determined. The ED continues to be supported by an allied health team comprising Physiotherapy, Occupational Therapist, Social Work and other specialties as required and together with the ED discharge liaison nurse form the Emergency Medical Assessment Team (EMAT) from Monday to Friday. Page 15 of 84

16 Rapid Response Team In response to the change in profile of ModH, a RRT will be established to manage deteriorating patients on site for stabilisation and / or transfer out. A RRT is a designated group of healthcare clinicians who are available quickly to deliver critical care expertise in response to clinical deterioration (MET/ Code Blue) of a patient located within the hospital (excluding emergency department patients). It is proposed that the Rapid Response Team will commence following the closure of the High Dependence Unit at ModH. There are three key features of the RRT members: They must be available to respond immediately when called, and not be constrained by competing responsibilities. They must be on site and accessible. They must have the critical care skills necessary to assess and respond. The key roles of the RRT are: Assess and stabilise the patient condition. Communicate to the home treating team. Educate and support the direct care staff. Recommend / assist with patient transfer to a higher level of care as required. The RRT will have two registered nurses rostered per shift over 24 hours. This is to ensure back up is available for simultaneous MET calls and if the first RRT nurse is managing a deteriorating patient waiting for up transfer. There will be a designated RRT medical officer 24 hours a day. In addition, it is proposed that the Medical RRT member assumes the position of medical team leader overnight at ModH, supporting junior medical staff and nursing staff as required. Medical oversight of the service will initially reside with NALHN intensive care, with RRT activity being continuously monitored and ongoing governance reassessed within six months from commencement. The initial response to a deteriorating patient is via a MET call / Code Blue as described in the NALHN Rapid Detection and Response Procedure. If the patient is unstable and requires short term critical care support until an up transfer can occur, the patient will be transferred to ED and managed by the RRT medical Team Leader (TL) and RRT nurse. Only patients requiring up transfer (to LMH or other facility) will be managed in the ED until transfer can occur. Transfer to the ED is at the direction of the Page 16 of 84

17 RRT medical TL following discussion with the ICU / MET Consultant and the home team. The Senior ED Consultant must be notified prior to transfer to ED. If the patient does not require up transfer they will remain on the ward where the RRT medical TL will discuss situation with the patient s home team and adjust treatment plan as required. The RRT nurse will assist and support the ward nursing staff with ongoing management. If the patient requires short term monitoring but not an up transfer, the RRT TL will liaise with the home team and the medical registrar for potential to manage in the Short Stay General Medicine Unit. The RRT will be based in the ED (includes MET 1 and MET 2 nurses and ICU Registrar) and will meet at the beginning of each shift with the Medical Registrar (team huddle). The MET Consultant will provide an overview of the service for the day and will: Undertake a daily ward round of Modbury Hospital either in person or via telephone with MET TL (ICU registrar) Be available for telephone consultations Attend the site if required (e.g protracted MET call, airway concerns) Assist in communication with other facilities if LMH unable to provide relevant service and ensure appropriate transfer occurs RRT Team Leader (ICU Registrar) will: Lead the MET huddle o Identify individual roles and responsibilities at MET o Identify and discuss any patients of concern o Discuss capacity within ED and LMH ICU o Identify ward patient cohorts / redevelopment floor plan changes Attend and lead all MET Discuss all MET calls with Home team Consultant and MET consultant Review patients of concern at the request of the MET nurse and liaise with home teams as necessary Contribute to education relevant to role Page 17 of 84

18 RRT 1 Nurse: Primary role will be to attend MET calls. RRT 1 will remain with patient until no longer required. This includes ongoing care of deteriorating patient until transfer complete. MET 1 role will be expanded to include: Equipment checks including 4 MET trolley s spread throughout the Hospital Data collection for monitoring and evaluation i. Patient reviews post MET ii. iii. iv. Patient reviews not MET MET calls Patient transfer to Short Stay General Medicine Unit v. Patient transfer to LMH ICU or other vi. vii. viii. Time frames for Medstar Incident reporting (SLS) Assessing and monitoring of patients of concern. Handover of such patients will be handed over from shift to shift ix. RDR chart auditing RRT 2 Nurse: Will respond to MET calls when the RRT 1 nurse is still on a previous MET call or RRT 1 requires additional assistance due to skills or staff deficits on wards (especially at night and for calls outside the ward areas). RRT 2 nurse will be supernumerary for the first three months to facilitate transition and evaluation but thereafter will be included in the ED nursing staffing numbers. Communication: Communication will be via mobile phones and pagers. The pagers will notify of any Code Blue calls and of other codes happening in the hospital and the phones enable direct communication between team members. Note: the RRT nurses will be required to regularly rotate into LMH ICU to maintain skills and experience. In addition, all RRT/ MET nursing and medical staff require ALS 2 training. Attachment 1 outlines the RRT process. NALHN Intensive Care Unit NALHN intensive care services will be provided from the LMH ICU which underwent an expansion as part of the LMH Stage C redevelopment. The LMH ICU is a separate and self-contained section of the hospital, staffed and equipped for the management of patients with established life-threatening Page 18 of 84

19 reversible or potentially reversible, organ failure or with a high risk of life-threatening organ failure. The ICU provides specialist expertise and facilities for the support of patients and their families, utilising the skills of medical, nursing and other allied health staff qualified and experienced in the management of critically ill patients. The ICU provides a closed model of care with admission into the ICU and care of the patients whilst in the unit under the medical governance of the intensive care consultants. Neonatal and paediatric are excluded from general adult ICUs. Critically ill paediatric patients will be stabilised and assessed for transfer to the Women s and Children s Hospital. There will be an ongoing requirement for LMH ICU to support the ModH in the care of deteriorating patients. For the patient that is rapidly deteriorating the ModH RRT will respond followed by a direct admit to the ICU at the LMH. NALHN Hospital at Home The NALHN Hospital at Home (H@H) service facilitates early discharge from ward areas reducing length of stay, hospital avoidance by accepting patients directly from ED, and complete hospital/ed avoidance by accepting patients from the community if known by an inpatient Consultant. NALHN H@H functions as a virtual ward where inpatients of the LMH or ModH reside outside of the organisation in their home, nursing home, or temporary place of residence. All H@H patients are in an acute phase of illness and require acute nursing intervention and access to a collaboration of services offered within an acute care organisation, whose care needs cannot be met by outside community service. The H@H services at LMH and ModH is an integrated service, with LMH as the main base from where the service is coordinated. ModH will continue to maintain a limited service on-site providing a liaison role to elicit and assess referrals and potentially provide treatment. The LMH site is supported by a medical assessment clinic 3 days per week to facilitate review of medical patients, with medical off site reviews when appropriate. H@H also has access to treatment rooms to assess the deteriorating patient as an alternative to the ED. 6.2 NALHN Surgical Services The NALHN surgical services will operate as a single service multi site model under the governance of the Division of Surgical Specialties and Anaesthetics, and for Gynaecology under the governance of the Women and Children s Division. Under this model there will be greater consistency of care across the two sites by providing common policies, procedures and patient pathways, staff will have the opportunity to provide a range of complex and non- complex procedures, and trainees will be Page 19 of 84

20 offered a breadth of experience. It is expected that staff, both medical and nursing will rotate across sites as clinically required and appropriate. ModH will be the location within NALHN to provide elective same day and 23 hour surgery for routine, non-complex patients and procedures for the following types of surgical services: Non- complex elective same day and 23 hour surgery, specifically including laparoscopic procedures, for non-complex gynaecology patients. Upper limb procedures and simple lower limb orthopaedic procedures (knee arthroscopies, ACL reconstructions etc.), for non-complex patients. Hernia repairs, appendectomies, cholecystectomies, major and minor bladder, breast, transurethral and perianal and pilonidal procedures for non-complex patients. Ear, Nose and Throat (ENT) surgery for adult patients. Emergency management of patients presenting to the Emergency Department, with cases requiring urgent operative management or inpatient management transferred to the LMH. ModH surgical registrar cover will remain unchanged. Inpatient management of non-complex patients requiring non-operative fracture management who are suitable for medical or geriatric management, e.g. osteoporotic crush fractures A One Stop Breast Care Clinic where assessment, radiological intervention and biopsy (if required) can occur at one visit. Outpatient services, including but not limited to orthopaedics (including review of fractures and non-operative fracture management), general surgery, urology, breast endocrine, ENT, general gynaecology and colposcopy. Ward consults for patients admitted under other specialties during office hours. Stomal therapy and the acute pain service provided currently at ModH will operate from LMH due to the changing profile of surgical procedures being undertaken at ModH. Tele support will be available and consult by appointment. The LMH will provide a 24/7 surgical service and gynaecology service inclusive of all of NALHN s multiday elective and emergency surgery, as well as providing emergency and non routine same day and complex and non-routine 23 hour elective surgery. All paediatric activity, obstetric activity and an early pregnancy advisory service will continue to be provided at LMH as per current NALHN model for these services. Page 20 of 84

21 To support the alignment of services between the two sites, and to accommodate the additional multiday activity at LMH; low risk, non-complex same day and 23 hour activity will be flowed from LMH to ModH as appropriate, noting that a small volume of same day and 23 hour activity will remain at LMH to allow for patient complexity. Outpatient clinics will remain at ModH, however whilst the clinics are provided at one site the surgery may need to occur at a different location to the outpatient appointment. This will be the case for multi-day surgery and complex patients requiring 23 hour or day surgery. LMH will continue to provide outpatient services for surgery, as well as emergency management of patients presenting to the Emergency Department. Under the single service multi site model all outpatient referrals will be triaged centrally and allocated an appointment at either LMH or ModH site. Referral pathways Referral pathways into the NALHN surgical services and gynaecology services will remain largely unchanged. External referrers will continue to send referrals to their existing NALHN hospitals. Establishment of a single referral point is the preferred model. The intent is to support patients attending clinics at their nearest hospital, however this single review of referrals would allow for patients requiring sub specialty review to be directed to the appropriate sub specialty clinic which, for low volume sub specialties, may only be delivered from one site. Internal referrals for inpatient admission (primarily from ED) will be directed to the most appropriate site for follow up, for instance, an ED referral requiring surgery will be referred to the appropriate inpatient ward for direct admission or other appropriate clinical speciality that is provided at LMH, otherwise the patient may need referral to another LHN. Preadmissions NALHN will implement a single model of care for preadmission clinics. There are specific procedures that are identified as requiring a face to face assessment (primarily joint replacements), however beyond this a risk stratification approach will be used based on patient or procedure complexity. Whilst ideally patients will attend their preadmission clinic appointment at the site of surgery this is not a requirement and will be influenced by patient preference and physical capacity of the site. Discharge and follow up For elective surgical patients the principles for discharge and follow up will remain unchanged, i.e. post discharge follow up outpatient appointment will be organised or patient advised to have follow up with their GP. For surgical or gynaecology patients discharged from ED there may be referral to a relevant surgical access clinic or standard outpatient clinic or to their GP for follow up. Page 21 of 84

22 Restorative care and rehabilitation Rehabilitation pathways within NALHN will be enhanced by the expanded rehabilitation services to be provided at ModH, including the orthogeriatric patient pathway (statewide model currently under development). ModH will play a pivotal role in providing restorative care and rehabilitation services for surgical patients, both via the Geriatric Evaluation and Management Unit, and via rehabilitation services. Surgical consults for patients within those services at ModH will still occur. Emergency care The emergency pathway for ModH emergency surgical patients (non gynaecology and non orthopaedics) is outlined in Attachment 2. During normal business hours (Monday to Friday, 7:30am to 5:00pm), there will be an onsite on-call surgical registrar available at ModH to respond to emergency consults. Additional support where required will occur via Surgical Consultants onsite either in OPD or theatre. After hours (Monday to Friday, 5.00pm to 10pm and weekends to midday) an on-site, on-call Surgical Registrar will be available to respond to Emergency Department consults where required. After 10pm weekdays and midday weekends a remote on- call registrar will be available along with consultant support if required. As per current arrangements, an on call consultant roster will be in place for ModH. An emergency on call return to theatre team will be established as a trial to support the 23 hour model of surgery at ModH. This will provide additional support to enable attending consultants to return existing elective 23 hour patients to theatre in a timely manner if required. This is to be reviewed 6 months post implementation. To further support emergency care of patients presenting to ModH, the Division of Surgical Specialties and Anaesthetics will restructure the current outpatient sessions to enable quick access following an ED presentation. It is envisaged that 2 emergency appointments will be allocated from the total surgical outpatient clinic footprint at ModH each day For gynaecology related presentations to ModH ED requiring urgent management (e.g. proven ovarian pathology or PID and significant menorrhagia or early pregnancy conditions) will require transfer to LMH with direct admission to the Women s Health Unit after consultation with the on call registrar. The emergency pathway for ModH gynaecological patients is outlined in Attachment 3. For orthopaedic related presentations it is anticipated the LMH will provide a 5 day a week emergency orthopaedic theatre (with possible extension to an additional half day weekend session), Page 22 of 84

23 which would minimise the requirement for after hours theatre to those patients who require urgent operative management (e.g. significant blood loss, neurovascular compromise, compartment syndrome, life or limb threatening sepsis, severe open fractures). For fractures requiring non urgent operative management, the existing model of discharge from ED, quick review in fracture clinic, and orthopaedic mop up lists will continue. The orthopaedic service will have an after hours on call for ModH via phone to the LMH on call. Attachment 4 outlines the orthopaedic pathways for ModH presentations (Level 1 and 2 trauma patients, isolated limb trauma, ambulant injured). It is proposed that this change will take effect from March Clinical deterioration For patients who undergo elective same day or 23 hour surgery at ModH who become unexpectedly unwell post operatively will be managed via the deteriorating patient pathway outlined in Attachment 5. For those patients requiring an unplanned return to operating theatre out of hours this will occur at ModH by recalling theatre team. Elective Surgical Waiting lists NALHN will move from the current two site approach to managing elective waiting lists to a single model. It is proposed that this change will take effect from March Current positions on wait lists will be maintained as far as possible. Theatres Following the intra NALHN service changes the total elective theatre requirements at ModH will be 2.6 theatres per day Monday to Friday. For LMH elective theatre requirements will be 4.5 theatres per day and emergency theatre requirements 1.8 theatres per day. It is proposed that this change will take effect from March Surgical Sub Specialties Orthopaedics A comprehensive orthopaedic surgery service will need specialised Extended/ Advance scope Allied Health positions and specialist nursing roles. Following the service moves, further analysis and consultation will be undertaken on what the Allied Health requirements are, informed by the SA Health Transforming Health Allied Health project currently underway. Allied Health led outpatient clinics will continue to be provided at both sites to match patient flows. Robust referral pathways to Page 23 of 84

24 non operative treatment for those conditions where there is evidence that conservative treatment is as effective as operative management will be explored for elective outpatient clinics. Specialist nursing roles may include Clinical Practice Consultant or Nurse Practitioner to manage, coordinate and facilitate: pre- and post-operative case management of arthroplasty patients (including active list management of patients awaiting arthroplasty); Neck of Femur management including pathway development and case management; and Orthopaedic trauma resource. Pathways The main categories of orthopaedic patients who present to EDs and how they will be managed are as follows: Level 1 and 2 trauma patients (also refer to Attachment 4a for flowchart): o Patients who require obvious input from specialties not available at LMH (either wholly or for emergency purposes) will bypass NALHN and go directly to the RAH. No internal NALHN patient pathways will be needed to manage these patients; o Patients who present to the LMH ED, either via SAAS or private car will be assessed by ED staff and either identified as needing services not available in NALHN and be on transferred as required, or can be managed within the LMH and be admitted to the general sub-speciality bed card with orthopaedic management as required. Patients presenting to ModH will be assessed by ED staff and transferred to the most appropriate hospital. Trauma transfers are always from ED to ED. Isolated limb trauma patients (also refer to Attachment 4b for flowchart): o For patients picked up by SAAS, where there is obvious surgical input required (e.g., fractured neck of femur, open fractures, severely angulated limbs, neurovascular compromise etc.), these patients will be triaged by SAAS and present directly to LMH for ED assessment and admission to the orthopaedic team. A number of patients may also present via private car/ walk in. o Patients who present directly to ModH will be transferred to LMH following ED assessment and management, with the expectation of this being a direct admission to the ward. Ambulant injured patients (also refer to Attachment 4c for flowchart): o Patients requiring non-operative management will be managed within the ED at which they present (LMH or ModH), provided with relevant assistive devices (plaster, slings, braces, crutches etc.) and referred to the on-site orthopaedic fracture clinic for follow Page 24 of 84

25 up within one week. This patient pathway will remain largely unchanged from current practice. There will be a proportion of these patients that will require admission under orthopaedics. o o Patients requiring non-urgent operative management will be stabilised and provided with initial management within the ED at which they present (e.g., plaster, brace, crutches etc.) and referred to the on-site orthopaedic fracture clinic for review and confirmation of operative management requirements including booking to the relevant theatre list if required. ED staff will be responsible for triaging these referrals and ensuring patients have next business day review if they suspect operative management is required. At LMH there are currently Resident Medical Officer (RMO) slots to facilitate this. ModH will proceed to implement review slots within their existing fracture clinics. Patients requiring urgent operative management a small number of walk in patients may require urgent operative management (e.g. for patients who have neurovascular compromise or who have a compartment syndrome). For patients who present to the LMH, they will be managed via the same emergency processes as for the single limb trauma patients. For patients in this category who present to ModH, their initial assessment, management and stabilisation will be provided by the ModH ED. The ED will be responsible for undertaking relevant neurovascular observations and liaising with the NALHN (LMH) orthopaedic on-call staff to discuss patient management and transfer to LMH for operative management. The transfer to LMH will be facilitated by direct admission transfers to minimise any duplication within EDs. Paediatric Fracture Management o Paediatric patients who present to either LMH or ModH EDs with a fracture will be o o assessed and managed by the ED. Patients who do not require operative management or sedation will be managed within the ED at which they present, and referred to the on-site fracture clinic, consistent with current practice. Paediatric patients requiring operative management, who fulfil the following criteria, are suitable for transfer or admission to LMH: Aged 5 or over No HDU/ ICU requirement (based on either comorbidities or extent of injury) No confirmed or suspected spinal injury Page 25 of 84

26 Injury within the capabilities of LMH Orthopaedic Team o Patients not meeting any of the above criteria will be transferred to the Women s and Children s Hospital (WCH) (or RAH in the event of a spinal injury in a patient over 16 years of age). Orthogeriatric care The statewide orthogeriatric (fractured neck of femur) pathway is currently in development and will include an expectation of surgery the day of or the day after presentation to emergency, except in cases where a delay in surgery is clinically indicated. To facilitate this and support the volume of activity to be managed by LMH (inclusive of potential increased road transfers from Country Health South Australia (CHSA)) a dedicated orthopaedic emergency theatre will be established. Initially this theatre is will operate at 50% capacity, and will increase to full capacity as activity from CALHN to NALHN increases. Weekend cases will initially be managed via on-call, however these volumes will be monitored and if required the option of establishing a dedicated weekend list will be explored. Additional emergency theatre will support the existing scheduled elective sessions. The early involvement of a specialist geriatric team, under a shared model of care is also expected to improve the clinical outcomes for this cohort of patients as well as create improvements in length of stay. There are three broad categories of patients which are anticipated: Nursing home patients - these patients are ideally suited to a short post-operative stay and then return to their residential care facility, with geriatric input facilitating this. The overall inpatient management is expected to remain with orthopaedics. Non-complex patients - this cohort is expected to have a short-medium post-operative stay, with referrals to GEM or rehabilitation services for some patients. Geriatric input will assist with early identification of patients requiring sub-acute care, and also facilitate earlier transfer to these services. The acute post-operative management of this cohort is expected to remain with orthopaedics. Those patients requiring sub-acute care will be transferred to the relevant clinical unit. Complex patients with additional co morbidities, including dementia and delirium - these patients represent a complex group with longer length of stay. It is anticipated the initial post-operative management will be within orthopaedics, however these patients will need to transfer to geriatrics (with ongoing orthopaedic input as required) early post-operatively to ensure the most appropriate specialist input into their complex associated medical conditions. Page 26 of 84

27 As part of the statewide model of care in development, the expectation is that discharge planning for patients with a fractured NOF will be completed by day 2 post operatively. Orthopaedic elective surgery The broad principles for the orthopaedic elective patient pathway, including potential for the introduction of Allied Health substitution clinic, is presented in Attachment 6. Elective outpatient clinics need robust referral pathways to non-operative treatment for those conditions where there is evidence that conservative treatment is as effective as operative management. The range of services required includes podiatry, orthotics, physiotherapy and occupational therapy. Urology The majority of 23 hour and same day urology procedures will occur at ModH. This includes but is not limited to non complex major and minor bladder procedures; transurethral and urethral procedures; and cystoscopes. All multi day and emergency will occur at the LMH along with a small volume of same day and 23 hour surgery to allow for patient complexity. Emergency urology activity will be undertaken at LMH. Refer to Attachment 2 for the emergency pathway for surgical patients presenting to ModH. Ongoing discussions are occurring between CALHN and NALHN to support a hub and spoke model. ENT The NALHN ENT service will continue to provide most adult same-day and 23 hour elective surgery at ModH, with all paediatric surgery provided at the LMH. Emergency ENT activity will be undertaken at LMH. Refer to Attachment 2 for the emergency pathway for surgical patients presenting to ModH. Paediatric ENT services will remain at the LMH within a Hub and Spoke model, LMH being a spoke of the Women s and Children s Hospital (W&CH). A central referral point will be established with the W&CH. All paediatric ENT referrals will be triaged by the W&CH and referred to the LMH where appropriate. Vascular Surgery Post CALHN to NALHN activity transfer the NALHN Vascular Services will provide an inpatient consult service and day surgery procedures over a 5 day model, Monday to Friday. A dedicated Vascular Surgeon will be onsite at NALHN hospitals daily. Whilst initially the service will provide same-day procedures only, any patients requiring an overnight stay will be under the medical governance of the Diabetes and Endocrine team, as is the current arrangement. All patients requiring a vascular consult after hours will be directly transferred to the Royal Adelaide Hospital. Page 27 of 84

28 General Surgery All multi-day and complex procedures will remain or occur at LMH due to complexity. All postoperative infections requiring an inpatient stay will flow from ModH to the LMH. Consultation will occur over the next 12 months regarding an integrated surgical service. Upper GIT surgery Complex cholecystectomy some will remain or occur at LMH, however major cholecystectomy and other major non-complex 23 hour elective surgery will continue at ModH. Upper GIT inpatient activity will be transferred as part of the CALHN to NALHN activity transfer. This will enable the development of sub specialist pancreatic and/or liver expertise enhancing the current model of care. Breast Endocrine The majority of all 23 hour and same-day procedures will occur at ModH, including major malignant breast disorders. All multi-day activity will occur at the LMH. A One Stop Breast Care Clinic will be established at ModH once a week for new patients to provide prompt assessment and treatment of patients with a suspected diagnosis of breast cancer. This clinic will provide all the required elements of a triple assessment during a single visit enabling: a basis for definitive diagnosis in the majority of patients reassurance with no need for further attendance in most patients with non-malignant conditions; and information for multidisciplinary meeting (MDM) treatment planning prior to review of those diagnosed to have cancer The proposed pathway for patients attending the One Stop Breast Care Clinic is outlined in Attachment 7. All NALHN Breast Endocrine surgeons will rotate through the clinic. Given that biopsy results will only be available within 24 to 48 hours following a visit to the Clinic patients will be seen in other Breast Endocrine outpatient clinics to ensure timely follow up. A central triage process will be developed with triaging of referrals to occur twice a week. Plastics and reconstructive surgery The small volume of day and 23hr surgery plastics and reconstructive surgery undertaken in NALHN will continue to be provided. More complex surgery will be referred to CALHN as LMH does not provide this. Refer to Attachment 2 for the emergency pathway for surgical patients presenting to ModH. Page 28 of 84

29 Gynaecology As part of the one service multi site model the Women and Children s Division will establish rapid access appointments at ModH to facilitate discharge from ED for non-urgent gynaecological patients and ensure timely review. The Division will also consolidate the existing early pregnancy service at LMH to a dedicated unit, with all threatened miscarriage patients referred to this unit for follow up and continuity of care. 6.3 NALHN Medical Services The NALHN medical services operate under the governance of the Medical Sub Specialties Division. This Division provides inpatient and outpatient services in a number of sub-specialties. All specialties and Obstetric Medicine are multi-site. Nurse-led clinics form an important part of service delivery. The Chronic Disease Management Unit provides management of chronic disease with a focus on hospital avoidance and frequent-utiliser strategies. Medical Sub Specialties General Medicine (including Short Stay General Medicine Unit) General Medicine will move away from the traditional take system under the current 5 medical units at LMH to 3 medical units. The consolidation of services will allow the Division to move toward a 7 day service and reallocate resources, specifically junior medical staff to sub-specialties where junior medical staff has traditionally been scant. This approach will include daily ward morning rounds by consultant and criteria led discharge. This approach will contribute significantly to equitable dispersion of activity, earlier senior decision-making and hospital avoidance. The General Medicine pathway is outlined in Attachment 8. Ward reconfiguration and movements are outlined under Section 5. Allied Health including dietetics, occupational therapy, physiotherapy, speech pathology, social work, and orthotics and podiatry service will be provided to the 3 general medicine units at LMH. Resources will be relocated to the LMH from the ModH to support the intra NALHN moves with staff rotating across sites. Deteriorating patient: It is proposed that pathways for deteriorating patients at ModH will be either to the 4 higher intensity nursing beds, termed Medical Assessment Beds, or transferred to LMH (refer to Attachment 9 for draft flow chart). LMH processes for deteriorating patients will continue. Outpatients: Page 29 of 84

30 General Medicine outpatient clinics will continue to be available at ModH and LMH. To facilitate early morning ward rounds it is proposed that the outpatient clinics at both sites be scheduled for the afternoon. Short Stay General Medicine Unit (SSGMU) at ModH The model for this unit will be consistent with the LMH acute medical unit (AMU) model, providing care for up to 48 hours. Patients who have higher acuity needs or require greater than 48 hours care will be transferred to LMH. Evidence from the LMH AMU model demonstrates more appropriate and timely care, with more rapid assessment, earlier diagnosis and treatment due to early review by senior medical officer (consultant physician and/or senior medial registrar); reduction in unnecessary admission and investigations; and reduced LOS. Allied Health will work across the SSGMU and the EDSSU. The key components of the ModH SSGMU include: Management responsibility lies with Division of Medical Sub Specialities 18 short stay medical beds General medicine patients will be assessed and admitted in the SSGMU After patients are assessed in the SSGMU, their estimated LOS will be determined and those with an estimated LOS <48 hours will remain in the unit. For patients deemed to require >48 hours of inpatient care, will be transferred to LMH general medicine units (24 hours 7 days a week) to the appropriate inpatient ward Seven day, 24 hours service with features at least once daily consultant led ward rounds Multiple decision making points over 24 hour period Focus on multidisciplinary early assessment, proactive planning and intervention Nursing staff rostered as per business rules and allied health team with sufficient numbers of experienced non-rotational staff dedicated to the unit Clerical support for extended hours Patients can remain in the unit for a maximum of 48 hours with the aim to make a decision about discharge or transfer to inpatient medical units at LMH as soon as possible Exclusion Criteria: Where existing patient admission pathways exist they will continue (i.e. chest pain, ICU, stroke, gastroenterology, etc). Acute general medical patients whose clinical condition would be best managed in a General Medicine inpatient bed at LMH or palliative care at ModH. These are patients who have: Page 30 of 84

31 An anticipated LOS>48 hours with a diagnosis and comprehensive treatment plan in place (prolonged admission) Patients requiring palliative care measures in the terminal phase of the illness Psychiatric illness but no psychiatric package in place to facilitate leaving the SSGMU within 48 hours Patients who do not have a disposition destination on discharge Patients requiring non-invasive ventilation or HDU/ICU interventions Patients present with acute surgical or orthopaedic conditions Patients who are best managed under subspecialty units Deteriorating patient: It is proposed that pathways for deteriorating patients will be either to the Medical Assessment Beds at ModH or transferred to LMH. Cardiology Chest pain is a common presentation to LMH and ModH ED s and is a NALHN priority area for productivity improvement to ensure efficiencies and flow through the ED s and improved inpatient length of stay. A NALHN Chest Pain Pathway has been developed (refer to Attachments 10 and 11 for detail). High risk chest pain patients will go to LMH. ModH will continue to provide a 24 hour walk-in service for low risk chest pain with pathway to LMH if assessed as requiring higher care and intervention. Rapid Assessment clinics for early stress tests and review will be established. Ward reconfiguration and movements are outlined under Section 5. To support the chest pain pathway LMH will provide a central Chest Pain Unit (CPU) service. The aim of the CPU is to provide a cost effective efficient service to manage patients presenting with chest pain with the goal to transfer patients out of ED within 120 minutes of presentation and to reduce length of stay by timely diagnostics (eg High Sensitive Troponin) and management intervention. The CPU will be located in the LMH AMU. Initially the CPU will be a stand-alone unit with minimal supports from the AMU nursing staff, however over time this service will become a more integrated service. Clinical and operational governance of the CPU resides with the Division of Medical Sub- Specialties and at an operational level the Medical Head of Unit for Cardiology and the Cardiology Clinical Service Co-ordinator (CSC). Scope of the Chest Pain Unit - in scope: Low risk chest pain - if index pain began >6hrs from triage is now resolved Page 31 of 84

32 Low risk chest pain - if index pain began <6hrs from triage (ALOS 8-12 hrs) Medium risk chest pain - discriminate degree at assessment Out of scope: Chest pain resulting from a diagnosed non-cardiac cause; eg mechanical injury/ pneumonia/ pulmonary embolism Out-of-Hospital Cardiac Arrest (OOHCA) Cardiogenic Shock and haemodynamic instability Acute Pulmonary Oedema (APO) and other forms of decompensated heart failure Anterior ST-Elevation Myocardial Infarction (STEMI) Non-STEMI Unstable Angina Moderate to high risk Acute Coronary Syndrome (ACS) Physically dependent patient Cardiovascular Intervention Suite (CVIS) LMH: To support the transfer of activity from CALHN to NALHN a second CVIS at LMH will be commissioned. The procedures that would be in scope for the second CVIS are still being confirmed, however may include procedures relating to vascular, electrophysiological cardiac services and STEMI to support vascular, stroke and cardiology. Respiratory Medicine Respiratory (in particular COPD) is a NALHN priority area for productivity improvement to ensure efficiencies and flow through the ED s and improved inpatient length of stay. The COPD group are over represented in the patients who frequently utilise ED and medical beds. Pathways for the acute exacerbation of COPD have been developed (refer to draft in Attachment 12). This will contribute to more appropriate admission criteria and hospital avoidance and the Respiratory service s engagement with the Chronic Disease Management Unit (CDMU) and ED. Respiratory patients will be able to access the SSGMU at ModH if their care needs are assessed as meeting the criteria for this unit. It is anticipated that all sub-specialties will rotate to Modbury Hospital with daily Consultant ward rounds 7 days per week. The 24 bed Ward 2D at LMH will be a mixed ward for the sub-specialties of respiratory, gastroenterology, endocrine and renal. Page 32 of 84

33 Respiratory Quick Access Clinics (QACs) are planned, in addition to close engagement with the CDMU. Modbury Hospital requires additional input. The home oxygen service will be transferred to LMH. Pathways to pulmonary rehabilitation are outlined in the acute exacerbation to COPD pathway to ensure optimal access. Non Invasive Ventilation (NIV) is the next evolution of the inpatient service. With the infrastructure and equipment now in place at LMH; the next step is the process of developing an education plan to support nursing and junior medical staff. It is anticipated CN time will be utilised to resource this program for 12 months. Gastroenterology service The service model for the NALHN Gastroenterology service is based on the principle of one NALHN Gastroenterology Service provided across the two sites of LMH and ModH with a wait list at ModH and a wait list at LMH. Gastroenterology outpatient services and elective endoscopies will be provided at ModH. The service will remain at the same location in the Gastroenterology suite at ModH continuing to utilise the gastroenterology theatre and recovery area. Inpatient activity for the SRG Gastroenterology will not be transferred as part of the CALHN to NALHN activity transfer. In 2016 improving administrative processes and utilising consultant FTE adequately will be progressed and consolidated, in particular: Redistribution of nurse sedationist vs High Risk Anaesthetics lists to allow for more High Risk lists to be undertaken Target of 80% list utilisation Active management of Colonoscopy wait list Increased consult lists for referrals Referral pathways and referral criteria to General Practitioners Inpatient and outpatient consultation service at Modbury Hospital Limited nurse sedationist lists at Modbury Hospital NALHN self-sufficiency in the provision of Gastroenterology services Model for scope cleaning - currently reviewing the model, exploring the use of Technicians to provide this function. Diabetes and Endocrinology The service model for the NALHN diabetes services aims to emulate progressive models on the eastern seaboard, with clinics managed by specialist diabetes teams. Multiple clinics occur at the same time including walk-in clinics and rapid access clinics with senior medical input throughout the Page 33 of 84

34 day. This model facilitates reduced waiting times for new patient appointments, improved access for patients who require rapid care for urgent cases and avoidable hospital admissions. Clinics are located at LMH and GP Plus Superclinic Modbury. Further diabetes inpatient activity will be transferred as part of the CALHN to NALHN activity transfer. This activity will be absorbed into Ward 2D at LMH which will be a mixed ward for the subspecialties of respiratory, gastroenterology, endocrine and renal. Neurology and Stroke Services Stroke is a NALHN priority area for productivity improvement to ensure efficiencies and flow through the ED s, improved inpatient length of stay and earlier initiation of rehabilitation whilst awaiting transfer to sub acute rehabilitation. A NALHN Stroke Pathway has been developed (refer to Attachment 13). Stroke inpatient activity will be transferred as part of the CALHN to NALHN activity transfer. This activity will be absorbed into Ward 1E at LMH which will be a mixed ward for the subspecialties of general medicine and neurology. In addition, the hours of stroke thrombolysis will extend from the current , to The following areas and actions have been identified to improve the efficiency of the NALHN Stroke Service: Areas Actions 1. Service approach Principles, vision, goals: Engagement of staff in the development of common vision, goals and principles to guide the service. Service name: Engagement of staff in the development and promotion of a service name. 2. Multidisciplinary review Trial of an additional formal weekly MDT meeting at LMH. Explore appropriate: membership of MDT; meeting time; agenda format; method of recording meeting outcomes. Explore opportunities for video-conferencing between NALHN sites. Continuation of informal daily stroke team brief. 3. Percutaneous endoscopic Development and implementation of enhanced PEG pathways gastrostomy (PEG) pathway including timeframe for PEG. for patients admitted with A PEG pathway (refer to Attachment 14). has been developed for patients admitted with stroke and is outlined on the Page 34 of 84

35 stroke NALHN PPG OWI02147 Percutaneous endoscopic gastrostomy (PEG) pathway for patients admitted with stroke. 4. Referral on admission Inclusion of prompt for referral on admission in Admission Checklist. Promotion of referral on admission (within 24 hours.) 5. Pathway to rehabilitation Exploration of slow and fast stream pathways- Mild-moderate (2-3 days); Severe (7 days) Changes to MDT frequency, format, etc may assist movement through pathway. 6.TIA Minor stroke pathway Clarify opportunities for implementation of proposed pathway. A TIA nurse has been appointed and nurse-led clinics are being established. Renal Services Renal Medicine is a specialty providing management of chronic renal failure and dialysis, as well as inpatient care for acute renal failure, acute glomerular disease and nephrotic syndrome. Renal failure complicates many conditions, especially Diabetes, Vascular Disease and Hypertension. Renal inpatient activity will be transferred as part of the CALHN to NALHN activity transfer. NALHN currently is unable to provide inpatient dialysis. This activity will be absorbed into Ward 2D at LMH which will be a mixed ward for the sub-specialties of Respiratory, Gastroenterology, Endocrine and Renal. This will enable: Existing LMH patients that require expert Renal care, or inpatient dialysis to be managed by the Renal Team, thus improving the quality of care delivered and reducing the associated morbidity and mortality currently identified within the division. The ability to manage the care of patients who are currently managed within CALHN. This includes patients admitted for non-complex renal diagnoses (as the tertiary renal service for CNARTS, RAH will continue to manage complex and unwell renal patients) as well as patients admitted to CALHN for non-renal diagnoses (e.g., respiratory conditions) who require dialysis during their inpatient stay. No direct admission from ED to a Renal bed card will be allowed. The service to also support patients with renal conditions who require surgery to have their procedures performed at LMH rather than RAH. Page 35 of 84

36 Haematology and Medical Oncology The transfer of haematology and medical oncology inpatient activity as part of the CALHN to NALHN activity transfer will enable NALHN patients to be managed within the network, however is not enough to maintain a stand-alone Haematology bed card. This activity will be absorbed into Ward 1D at LMH which will be a mixed ward with General Medicine and Oncology disciplines, and will enable: an increase in current cancer treatments being undertaken inpatient chemo to be undertaken 4 additional oncology chairs will be introduced to support this the following activity to move back to NALHN: o RBC disorders as described in DRG transfers o Increase in activity currently done in NALHN o Low grade lymphomas and myelomas. Chronic Disease Management Unit The priorities within this unit are hospital avoidance, case identification, case management and coordinated care of all chronic disease programs (refer to Attachment 15 for an overview of the unit). By the end of the 2015/2016 financial year, it is planned that this unit will be fully established and have a profile within the organisation with chronic disease being managed in a structured manner. The clinical leads in Allied Health, Nursing and Medicine are facilitating: Entry and exit criteria for the chronic disease programs Creating single referral point for all chronic disease management Developing screening tools for high risk individuals Meeting with General Practitioners and start developing Shared Care Models Strengthening Hospital Avoidance strategies Incorporating End of Life Project Page 36 of 84

37 7. Interdependencies- clinical support summary NALHN Service Associated with intra NALHN Level of required clinical capability Source - SA Health Clinical Capability Services Framework (2015) Critical Care Services Interdependency LMH ED (based on Level 5) ModH ED (based on Level 3-4) Anaesthetic on site Level 5 on site Level 3-4 Children s anaesthetic on site Level 4 on site Level 4 Cardiac care unit on site Level 5 accessible Level 4 Cardiac diagnostic & interventional on site Level 5 accessible Level 4 Cardiac medicine on site Level 5 Intensive care on site level 5 accessible Level 4 Children s intensive care accessible Level 4 Medical on site Level 5 accessible Level 3; on site Level 4 Children s medical accessible Level 4 accessible Level 4 Medical imaging on site Level 5 on site Level 1-4 Mental Health on site Level 5 accessible Level 4 Mental Health (child & youth) accessible Level 4 accessible Level 4 Nuclear medicine on site Level 4 Children s nuclear medicine accessible Level 4 Pathology on site Level 4 accessible 3-4 Perioperative on site Level 5 accessible Level 3; on site Level 4 Pharmacy on site Level 5 on site Level 3-4 Surgical on site Level 5 accessible Level 3; on site Level 4 Children s surgical accessible Level 4 accessible Level 4 Interdependency LMH ICU Anaesthetic on site Level 5 Cardiac medicine accessible Level 5 Medical on site Level 5 Medical imaging on site Level 4 Mental health accessible Level 5 Pathology accessible Level 4 Page 37 of 84

38 NALHN Service Associated with intra NALHN Level of required clinical capability Source - SA Health Clinical Capability Services Framework (2015) Perioperative on site Level 5 Pharmacy on site Level 5 Renal accessible Level 5 Surgical on site Level 5 NALHN Service Associated with intra NALHN Interdependency LMH impact ModH impact Surgical Services Anaesthetic Emergency; multi day; preadmission Same day; 23 hour; preadmission Theatres Sterilising Unit Post Anaesthetic Recovery Unit Sterilising Unit Post Anaesthetic Recovery Unit ED Bypass or transfer process Bypass or transfer process Intensive care Increased activity Change of service profile Medical imaging Imaging intensifier increase; Ultrasound increase CT scans increase Greater access to ultrasound, mammograms, CT Interventional radiology for emergency activity Pathology Histology; Phlebotomist Histology access for one stop breast care clinic Perioperative Increased activity Pharmacy Increased activity; Increased volume primarily for high volume, low cost prophylactic antibiotics; Clinical pharmacy requirements to support the additional Clinical pharmacy requirements Page 38 of 84

39 NALHN Service Associated with intra NALHN surgical multi day activity at LMH Allied Health Comprehensive Allied Health services including dietetics, occupational therapy, orthotics, physiotherapy, speech pathology, podiatry and social work to provide ward based services. Outpatient clinics Clinic types Clinic types NALHN Service Medical Services Interdependency ED Intensive care Medical imaging Pathology Pharmacy Allied Health Outpatient clinics Associated with intra NALHN LMH & ModH impact Bypass or transfer process Site profile changes Patient identifier / documentation across sites Phlebotomy rounds to match proposed future ward configuration; Access to High Sensitivity Troponin Clinical pharmacy requirements to support the move from ModH (3East) to LMH (1B). Comprehensive Allied Health services including dietetics, occupational therapy, orthotics, physiotherapy, speech pathology, podiatry and social work to provide ward based services. Clinic types and timing 8. Interdependencies- non clinical support summary Intra NALHN Hotel Services ICT Transfers Cleaning A process has been established with Medical records Imprest ICT to identify ICT requirements and transfers between sites; Linen requirements timing / lead in times. This will be PAS UR numbers Orderly support ongoing to encompass the CALHN SAAS transfers Waste removal NALHN transition. Page 39 of 84

40 9. Infrastructure - summary NALHN Service Critical Care Services (note: equipment to be moved from 1 West as appropriate) Associated with intra NALHN [Space / minor /major works / Equipment] Purpose built short stay unit at ModH proposed end 2016 H@H space at ModH Four fully equipped MET trollies either located centrally at RRT home base or strategically located around the hospital. - One trolley will be suited to responding to external MET calls. This trolley will have a Propaq Defibrillator which is lighter Communication devices (pagers and mobile phones) The following equipment will be available (most likely in ED): Surgical Services Transport ventilator oxylog (2 in hospital) Non-invasive ventilators (2) in hospital) Telemedicine technology functionality would be highly valuable to enable consultations between LMH ICU and ModH. Infrastructure available/required at each site to support changes to service location, roles and model of care. 2nd II available at LMH to support theatres although staffing for second is required. Future service changes will require third II. Breast Endocrine gamma probes and nerve monitor already available. Consider future growth for interventional radiology. Consider outpatient audiology booth requirements for ENT. Equipment broad requirements have been identified. Detailed analysis is currently being undertaken. Patient mobility aids and ADL equipment at both sites. Office space to be confirmed Medical Services Location of stress test at ModH and space for admin officer Minor works associated with establishment of chest pain unit at LMH Minor works required to enable the location of a Stress Test Lab to service the chest pain unit at LMH Page 40 of 84

41 NALHN Service Associated with intra NALHN [Space / minor /major works / Equipment] Equipment for Stress Test at LMH: already purchased. Utilise existing bed side monitors Cardiac AED All other equipment to be utilised from AMU 10. Staff education / training required for implementation The three principles that underpin staff education and training in readiness for implementation include: People work safely in their workplace Patient safety is not compromised The work environment is safe To facilitate this the following will occur: Operational procedures and work instructions will be updated so they are suitable for the new environment All staff to complete their work unit induction and any other specialised training required Communication and providing access to online tools Allocate super user/s who will deliver train the trainer unit orientation across both sites Page 41 of 84

42 11. Workforce FTE summary by service The following only includes FTE associated with this NALHN consolidated service plan. INTRA NALHN TRANSFERS labour budget (in scope cost centres only) Current Staffing - Total Total Future State (Intra NALHN) Northern Adelaide LHN - in scope cost centres 1, , Lyell McEwin Hospital Critical Care - LMH LMH EMERGENCY SERVICE ENDP MD MDP MDP MDX RN RN2A RN2C RN3A RN4A LMH ICU/HDU ASO3 1 1 MD MDP RN RN2A RN2C RN3A LMH HOME HOSPITAL AS ENDP RN2A RN2C RN3A RN4A Medical Administration - LMH Medical Sub-Specialties - LMH LMH CHEST PAIN ASSESSMENT - - ASO2 0 - MDP2 0 - RN3A 0 - LMH CARDIOLOGY Page 42 of 84

43 AHP AHP ASO CAMD 0 - MD MDP MDP Lmh Chest Pain Unit RN4A 0 0 RN3A 0 0 RN ENDP 0 0 MDP2 0 1 LMH GASTROENTEROLOGY ASO ENDP MD MDP RN RN2A RN2C RN3A LMH GENERAL MEDICINE ASO ASO MD MDP MDP MOV LMH Ward - Ward 1B ASO ENDP RN RN2A RN2C RN4A Lmh Infectious Diseases MD MDP LMH NEUROLOGY MD TGO LMH ONCOLOGY ASO Page 43 of 84

44 ASO MD MDP RN RN2A RN2C RN3A LMH THORACIC MEDICINE MD MES MES RN2A MDP2 0 1 Surgical Specialties & Anaesthetics - LMH LMH ANAESTHESIA ASO ENDP MD MDP MDP MDP RN RN2A RN2C RN3A LMH Acute Pain Service RN2C RN3A Lmh Surgical & Acute Admin ASO ASO MD RN2C RN3A RN5A LMH CSSD AS WHA WHA LMH RECOVERY RN RN2A RN2C RN3A Page 44 of 84

45 WHA4 0 0 LMH OPERATING THEATRE ASO ASO EN ENDP RN RN2A RN3A WHA WHA LMH PRE ADMISSION CLINICS RN RN2A RN3A LMH BREAST ENDOCRINE MD MDP MDP MDP RN3A LMH COLORECTAL MD MDP MDP MDP LMH WARD 2F-SAME DAY UNIT ENDP RN RN2A RN2C RN3A LMH WARD 2FX (PERMANENT WARD) ENDP RN RN2A RN3A LMH STOMAL THERAPY RN3A LMH WARD 2B EN ENDP RN RN2A Page 45 of 84

46 RN3A LMH WARD 2E ENDP RN RN2A RN3A LMH ORTHOPAEDIC SURGERY MD MDP MDP MDP MOV LMH UPPER GI MD MDP MDP MOV Modbury Hospital Critical Care - Mod Mod Emergency Department ASO ENDP MD MDP MDP MDP RN RN2A RN2C RN3A RN4A MOD WARD - CRITICAL CARE UNIT ASO ENDP RN RN2A RN2C RN3A MD MDP MOD OUTREACH & H@H RN2A RN2C RN4A Page 46 of 84

47 RAPID RESPONSE TEAM RN RN2C Medical Sub-Specialties - Mod MOD GENERAL MEDICINE - CLIN SERV MD MDP MDP MOV Mod Ward - Medical 3E ASO ENDP RN RN2A RN2C RN4A Mod Ward - Short Stay Unit ASO ENDP RN RN3A RN4A MOD WARD - MEDICAL 3W ASO ENDP RN RN2A RN2C RN3A RN4A Surgical Specialties & Anaesthetics - Mod MOD STOMAL THERAPY RN3A Mod Anaesthetics - Nursing RN RN2A RN2C RN3A MOD ANAESTHESIOLOGY - CLIN SERV MD MDP MOV MOD OPERATING THEATRE ASO Page 47 of 84

48 ENDP RN RN2A RN2C RN3A MOD ACUTE PAIN SERVICE RN3A Mod Pre Admission Clinic - Nursing RN RN2C MOD WARD - DAY PROCEDURE UNIT ENDP RN RN2A RN2C RN3A MOD GENERAL SURGERY - CLIN SERV MDP MDP MDP MDO MOV MOV Mod Recovery - Nursing RN RN2A RN2C RN3A MOD WARD - SURGICAL ASO ENDP RN RN2A RN2C RN3A MOD WARD - 23 HOUR ASO ENDP RN RN2A RN2C MOD ORTHOPAEDIC SURGERY - CLIN SERV MDP MOV Page 48 of 84

49 PALLIATIVE CARE MDP An Expression of Interest process will be finalised for all on-going non-medical staff directly affected by the service change. Any on-going employee who may become unattached will be placed into an on-going position in accordance with the relevant industrial instrument. There will be no surplus on-going employeeat the conclusion of all the intra-nalhn moves. 12. Activity summary by service The following tables outline the current activity and indicative future state based on the medicine and surgical models of care outlined in previous sections. Activity is based on NALHN 2014/15 inpatient data set (ISAAC). Division Medical Sub Specialties Overall summary Table 1: Summary NALHN 2014/15 activity for Division Medical Sub Specialties at LMH and ModH 2014/15 Actuals seps per Total LMH ModH site <48 hours 5,688 2,052 7,740 >48 hours 6,754 2,719 9,473 Grand Total 12,442 4,771 17,213 Table 2: Summary future state NALHN Division Medical Sub Specialties at LMH and ModH Future state seps per site Total LMH ModH based on model of care <48 hours 5,839 4,416 10,255 >48 hours 9, ,471 Grand Total 15,310 4,416 19,726 Page 49 of 84

50 Current state Table 3: Current Activity for the LMH by Division Medical Sub Specialties Page 50 of 84

51 Division of MSS /15 Actual Activity (LMH) <48H >48H Seps Bed Days ALOS Seps Bed Days ALOS 01 - CARDIOLOGY 1,235 1, , INTERVENTIONAL CARDIOLOGY , CARDIOTHORACIC SURGERY RESPIRATORY MEDICINE ,551 8, GASTROENTEROLOGY , GIT ENDOSCOPY , NEUROLOGY , NEUROSURGERY ENDOCRINOLOGY , RENAL FAILURE HAEMATOLOGY ENT OPHTHALMOLOGY MEDICAL ONCOLOGY , RHEUMATOLOGY DERMATOLOGY HEAD & NECK SURGERY DENTISTRY UPPER GIT SURGERY COLORECTAL SURGERY ORTHOPAEDICS , UROLOGY VASCULAR SURGERY GENERAL MEDICINE 1,122 1, ,086 8, GENERAL SURGERY BREAST SURGERY PLASTIC & RECONSTRUCTIVE SURGERY GYNAECOLOGY OBSTETRICS TRACHEOSTOMY DRUG & ALCOHOL BURNS PSYCHIATRY ACUTE REHABILITATION UNGROUPABLE Grand Total 5,688 6, ,754 43, Page 51 of 84

52 Table 4: Current Activity for the ModH by Division Medical Sub Specialties Division of MSS /15 Actual Activity (ModH) <48H >48H Seps Bed Days ALOS Seps Bed Days ALOS 01 - CARDIOLOGY , INTERVENTIONAL CARDIOLOGY 03 - CARDIOTHORACIC SURGERY RESPIRATORY MEDICINE , GASTROENTEROLOGY GIT ENDOSCOPY NEUROLOGY , NEUROSURGERY ENDOCRINOLOGY RENAL FAILURE HAEMATOLOGY ENT OPHTHALMOLOGY MEDICAL ONCOLOGY RHEUMATOLOGY DERMATOLOGY HEAD & NECK SURGERY 20 - DENTISTRY UPPER GIT SURGERY COLORECTAL SURGERY 23 - ORTHOPAEDICS , UROLOGY VASCULAR SURGERY GENERAL MEDICINE , GENERAL SURGERY BREAST SURGERY PLASTIC & RECONSTRUCTIVE SURGERY GYNAECOLOGY 31 - OBSTETRICS TRACHEOSTOMY 35 - DRUG & ALCOHOL BURNS 37 - PSYCHIATRY ACUTE REHABILITATION UNGROUPABLE Grand Total 2,052 2, ,719 18, Page 52 of 84

53 Future state Table 5: Future state for the LMH by Division Medical Sub Specialties Division of MSS - Future State (LMH) <48H >48H Seps Bed Days ALOS Seps Bed Days ALOS 01 - CARDIOLOGY 1,245 1, ,248 6, INTERVENTIONAL CARDIOLOGY , CARDIOTHORACIC SURGERY RESPIRATORY MEDICINE ,269 11, GASTROENTEROLOGY , GIT ENDOSCOPY , NEUROLOGY ,127 8, NEUROSURGERY ENDOCRINOLOGY , RENAL FAILURE HAEMATOLOGY , ENT OPHTHALMOLOGY MEDICAL ONCOLOGY , RHEUMATOLOGY DERMATOLOGY HEAD & NECK SURGERY DENTISTRY UPPER GIT SURGERY COLORECTAL SURGERY ORTHOPAEDICS , UROLOGY VASCULAR SURGERY GENERAL MEDICINE 1,141 1, ,630 12, GENERAL SURGERY , BREAST SURGERY PLASTIC & RECONSTRUCTIVE SURGERY GYNAECOLOGY OBSTETRICS TRACHEOSTOMY DRUG & ALCOHOL BURNS PSYCHIATRY ACUTE REHABILITATION UNGROUPABLE Grand Total 5,839 6, ,471 58, Page 53 of 84

54 Table 6: Future state for the ModH by Division Medical Sub Specialties Division of MSS - Future State (ModH) <48H >48H Seps Bed Days ALOS Seps Bed Days ALOS 01 - CARDIOLOGY 1,078 1, INTERVENTIONAL CARDIOLOGY 03 - CARDIOTHORACIC SURGERY RESPIRATORY MEDICINE 972 1, GASTROENTEROLOGY GIT ENDOSCOPY NEUROLOGY NEUROSURGERY ENDOCRINOLOGY RENAL FAILURE HAEMATOLOGY ENT OPHTHALMOLOGY MEDICAL ONCOLOGY RHEUMATOLOGY DERMATOLOGY HEAD & NECK SURGERY 20 - DENTISTRY UPPER GIT SURGERY 22 - COLORECTAL SURGERY 23 - ORTHOPAEDICS UROLOGY VASCULAR SURGERY GENERAL MEDICINE 749 1, GENERAL SURGERY BREAST SURGERY PLASTIC & RECONSTRUCTIVE SURGERY GYNAECOLOGY 31 - OBSTETRICS TRACHEOSTOMY 35 - DRUG & ALCOHOL BURNS 37 - PSYCHIATRY ACUTE REHABILITATION 39 - UNGROUPABLE Grand Total 4,416 6, Page 54 of 84

55 Table 7: ModH Activity for Division Medical Sub Specialties flowing to LMH Modbury >48HR Activity flowing to LMH >48 Hours Row Labels Seps Bed Days ALOS 01 - CARDIOLOGY 368 1, INTERVENTIONAL CARDIOLOGY 03 - CARDIOTHORACIC SURGERY RESPIRATORY MEDICINE 695 3, GASTROENTEROLOGY GIT ENDOSCOPY NEUROLOGY 297 1, NEUROSURGERY ENDOCRINOLOGY RENAL FAILURE HAEMATOLOGY ENT OPHTHALMOLOGY MEDICAL ONCOLOGY RHEUMATOLOGY DERMATOLOGY HEAD & NECK SURGERY 20 - DENTISTRY UPPER GIT SURGERY 22 - COLORECTAL SURGERY 23 - ORTHOPAEDICS UROLOGY VASCULAR SURGERY GENERAL MEDICINE 420 2, GENERAL SURGERY BREAST SURGERY PLASTIC & RECONSTRUCTIVE SURGERY GYNAECOLOGY 31 - OBSTETRICS 34 - TRACHEOSTOMY 35 - DRUG & ALCOHOL BURNS 37 - PSYCHIATRY ACUTE REHABILITATION 39 - UNGROUPABLE Grand Total 2,515 12, Page 55 of 84

56 Surgical Activity Overall summary: Table 8: Summary NALHN Surgical Activity for 2014/15 at LMH and ModH by care type and length of stay category 14/15 Actuals Seps per site based on care type and LOS category LMH ModH Total Elective Emergency Elective Emergency Multiday sub total 771 2, ,427 5,540 23HR sub total ,596 Same day sub total 2, , ,564 Grand total Table 9: Summary future state NALHN Surgical activity at LMH and ModH, by care type and length of stay category (intra NALHN) Future state Seps per site based on care type and LOS category LMH ModH Total Elective Emergency Elective Emergency Multiday sub total 1,178 3,718 N/A N/A 4,896 23HR sub total 358 1,109 1,043 N/A 2,510 Same day sub total ,961 N/A 3,331 Grand total 2,444 5,289 3,004 N/A 10,737 Note: 2014/15 Gastro and GIT endoscopy total separations for the LMH of 644 multi-day, 233 for same-day and 86 for 23 hour has been removed in future state as this activity is now under the governance of the Division of Medicine. Activity undertaken at ModH for Gastro and GIT Endoscopy is included as this is undertaken by General Surgery. Current state Table 10: Current Multi-day Activity for the LMH by Division of Surgery 2014/15 LMH Multi-day Surgical Activity 2014/15 Elective Emergency SRGs Separations Bed Days ALOS Separations Bed Days ALOS 01 - CARDIOLOGY INTERVENTIONAL CARDIOLOGY CARDIOTHORACIC SURGERY 04 - RESPIRATORY MEDICINE GASTROENTEROLOGY GIT ENDOSCOPY NEUROLOGY NEUROSURGERY ENDOCRINOLOGY RENAL FAILURE HAEMATOLOGY ENT MEDICAL ONCOLOGY RHEUMATOLOGY DERMATOLOGY Page 56 of 84

57 19 - HEAD & NECK SURGERY DENTISTRY 21 - UPPER GIT SURGERY COLORECTAL SURGERY ORTHOPAEDICS UROLOGY VASCULAR SURGERY GENERAL MEDICINE GENERAL SURGERY BREAST SURGERY PLASTIC & RECONSTRUCTIVE SURGERY GYNAECOLOGY OBSTETRICS TRACHEOSTOMY BURNS 39 - UNGROUPABLE Grand Total Table 11: Current Multi-day Activity for ModH by the Division of Surgery 2014/15 Multi-day Surgical Activity 2014/15 ModH Elective Emergency SRG Separations Bed Days ALOS Separations Bed Days ALOS 01 - CARDIOLOGY INTERVENTIONAL CARDIOLOGY 03 - CARDIOTHORACIC SURGERY RESPIRATORY MEDICINE GASTROENTEROLOGY GIT ENDOSCOPY NEUROLOGY NEUROSURGERY ENDOCRINOLOGY RENAL FAILURE HAEMATOLOGY ENT MEDICAL ONCOLOGY RHEUMATOLOGY DERMATOLOGY HEAD & NECK SURGERY DENTISTRY UPPER GIT SURGERY COLORECTAL SURGERY ORTHOPAEDICS UROLOGY VASCULAR SURGERY GENERAL MEDICINE GENERAL SURGERY BREAST SURGERY PLASTIC & RECONSTRUCTIVE SURGERY GYNAECOLOGY OBSTETRICS TRACHEOSTOMY 36 - BURNS UNGROUPABLE Grand Total Page 57 of 84

58 Table 12: Current 23 hour Activity for the LMH for the Division of Surgery 2014/15 LMH 23 hour Emergency and Elective 2014/15 Elective Emergency SRGs Separations Bed Days ALOS Separations Bed Days ALOS 01 - CARDIOLOGY CARDIOTHORACIC SURGERY RESPIRATORY MEDICINE GASTROENTEROLOGY GIT ENDOSCOPY NEUROLOGY NEUROSURGERY ENDOCRINOLOGY RENAL FAILURE HAEMATOLOGY ENT OPHTHALMOLOGY 15 - MEDICAL ONCOLOGY RHEUMATOLOGY DERMATOLOGY HEAD & NECK SURGERY DENTISTRY 21 - UPPER GIT SURGERY COLORECTAL SURGERY ORTHOPAEDICS UROLOGY VASCULAR SURGERY GENERAL MEDICINE GENERAL SURGERY BREAST SURGERY PLASTIC & RECONSTRUCTIVE SURGERY GYNAECOLOGY OBSTETRICS PSYCHIATRY 39 - UNGROUPABLE Grand Total Table 13: Current 23 hour Activity for ModH for the Division of Surgery 2014/15 ModH 23 hour Emergency and Elective 2014/15 Elective Emergency SRGs Separations Bed Days ALOS Separations Bed Days ALOS 01 - CARDIOLOGY CARDIOTHORACIC SURGERY RESPIRATORY MEDICINE GASTROENTEROLOGY GIT ENDOSCOPY NEUROLOGY NEUROSURGERY ENDOCRINOLOGY 10 - RENAL FAILURE 12 - HAEMATOLOGY ENT OPHTHALMOLOGY MEDICAL ONCOLOGY RHEUMATOLOGY DERMATOLOGY HEAD & NECK SURGERY DENTISTRY Page 58 of 84

59 21 - UPPER GIT SURGERY COLORECTAL SURGERY ORTHOPAEDICS UROLOGY VASCULAR SURGERY GENERAL MEDICINE GENERAL SURGERY BREAST SURGERY PLASTIC & RECONSTRUCTIVE SURGERY GYNAECOLOGY OBSTETRICS PSYCHIATRY UNGROUPABLE Grand Total Note: 23 hour defined as those patients whose LOS is 29hours or under and where the admission and discharge date are different. Table 14: Current Same-day Activity at the LMH and ModH by Division of Surgery 2014/15 ModH LMH Same-day Separations by Site 2014/15 Elective Emergency Elective Emergency SRGs Seps ALOS Seps ALOS Seps ALOS Seps ALOS 01 - CARDIOLOGY RESPIRATORY MEDICINE GASTROENTEROLOGY GIT ENDOSCOPY NEUROLOGY NEUROSURGERY ENDOCRINOLOGY RENAL FAILURE HAEMATOLOGY ENT OPHTHALMOLOGY MEDICAL ONCOLOGY DERMATOLOGY HEAD & NECK SURGERY DENTISTRY UPPER GIT SURGERY COLORECTAL SURGERY ORTHOPAEDICS UROLOGY VASCULAR SURGERY GENERAL MEDICINE GENERAL SURGERY BREAST SURGERY PLASTIC & RECONSTRUCTIVE SURGERY GYNAECOLOGY DRUG & ALCOHOL PSYCHIATRY Grand Total Page 59 of 84

60 Future state Table 15: 23 Hour Elective Activity at ModH based on intra NALHN transfers 23 Hr Elective Activity at ModH (intra NALHN transfers) SRGs Seps ALOS Bed Days 13 ENT ORTHOPAEDICS UPPER GIT SURGERY GENERAL SURGERY BREAST SURGERY UROLOGY HEAD & NECK SURGERY COLORECTAL SURGERY PLASTIC & RECONSTRUCTIVE SURGERY GENERAL MEDICINE HAEMATOLOGY CARDIOTHORACIC SURGERY NEUROSURGERY GASTROENTEROLOGY MEDICAL ONCOLOGY GIT ENDOSCOPY DENTISTRY DERMATOLOGY RENAL FAILURE GYNAECOLOGY UNGROUPABLE OPHTHALMOLOGY VASCULAR SURGERY OBSTETRICS PSYCHIATRY Total Table 16: Same day Elective Surgical Separations ModH MPH Same- Day Elective Activity SRG Separations 05 GASTROENTEROLOGY GIT ENDOSCOPY ENT HEAD & NECK SURGERY UPPER GIT SURGERY COLORECTAL SURGERY ORTHOPAEDICS UROLOGY GENERAL SURGERY BREAST SURGERY PLASTIC & RECONSTRUCTIVE SURGERY GENERAL MEDICINE VASCULAR SURGERY 5 Page 60 of 84

61 12 HAEMATOLOGY NEUROSURGERY CARDIOLOGY RESPIRATORY MEDICINE 0 07 NEUROLOGY 3 09 ENDOCRINOLOGY RENAL FAILURE OPHTHALMOLOGY MEDICAL ONCOLOGY DERMATOLOGY DENTISTRY 0 30 GYNAECOLOGY DRUG & ALCOHOL 0 37 PSYCHIATRY 1 Grand Total 2571 Note: includes Women s and Children s Division activity under gynaecology Table 17: ModH Multi-day Elective Activity Flowing to LMH ModH Multi-day Activity to transfer to LMH Elec (intra NALHN transfers) Elective Bed Days Minus ICU SRGs Separations ALOS 03 - CARDIOTHORACIC SURGERY RESPIRATORY MEDICINE GASTROENTEROLOGY GIT ENDOSCOPY NEUROLOGY NEUROSURGERY ENDOCRINOLOGY RENAL FAILURE HAEMATOLOGY ENT RHEUMATOLOGY DERMATOLOGY HEAD & NECK SURGERY UPPER GIT SURGERY COLORECTAL SURGERY ORTHOPAEDICS UROLOGY VASCULAR SURGERY GENERAL MEDICINE GENERAL SURGERY BREAST SURGERY PLASTIC & RECONSTRUCTIVE SURGERY BURNS Grand Total Page 61 of 84

62 Table 18: ModH Multi-day Emergency Activity Flowing to LMH ModH Multi-day Activity to transfer to LMH Emergency SRG Seps ALOS Bed Days Minus ICU 01 - CARDIOLOGY CARDIOTHORACIC SURGERY 04 - RESPIRATORY MEDICINE GASTROENTEROLOGY GIT ENDOSCOPY NEUROLOGY NEUROSURGERY ENDOCRINOLOGY RENAL FAILURE HAEMATOLOGY ENT MEDICAL ONCOLOGY RHEUMATOLOGY DERMATOLOGY HEAD & NECK SURGERY DENTISTRY UPPER GIT SURGERY COLORECTAL SURGERY ORTHOPAEDICS UROLOGY VASCULAR SURGERY GENERAL MEDICINE GENERAL SURGERY BREAST SURGERY PLASTIC & RECONSTRUCTIVE SURGERY GYNAECOLOGY OBSTETRICS BURNS 39 - UNGROUPABLE Grand Total Table 19: Multi-day Emergency Activity at LMH (excluding flows from ModH) LMH Multi-day Activity (not including ModH Flows) Emergency SRG Separations ALOS Bed Days Minus ICU 01 - CARDIOLOGY INTERVENTIONAL CARDIOLOGY RESPIRATORY MEDICINE NEUROLOGY NEUROSURGERY ENDOCRINOLOGY RENAL FAILURE HAEMATOLOGY ENT Page 62 of 84

63 15 - MEDICAL ONCOLOGY RHEUMATOLOGY DERMATOLOGY HEAD & NECK SURGERY 21 - UPPER GIT SURGERY COLORECTAL SURGERY ORTHOPAEDICS UROLOGY VASCULAR SURGERY GENERAL MEDICINE GENERAL SURGERY BREAST SURGERY PLASTIC & RECONSTRUCTIVE SURGERY GYNAECOLOGY OBSTETRICS TRACHEOSTOMY UNGROUPABLE Grand Total Table 20: Multi-day Elective Activity at LMH (excluding flows from ModH) LMH Multi-day Activity (not including ModH Flows) Elective Bed Days Minus ICU SRG Separations ALOS 01 - CARDIOLOGY 02 - INTERVENTIONAL CARDIOLOGY RESPIRATORY MEDICINE 07 - NEUROLOGY 08 - NEUROSURGERY ENDOCRINOLOGY 10 - RENAL FAILURE 12 - HAEMATOLOGY ENT MEDICAL ONCOLOGY RHEUMATOLOGY 18 - DERMATOLOGY 19 - HEAD & NECK SURGERY UPPER GIT SURGERY COLORECTAL SURGERY ORTHOPAEDICS UROLOGY VASCULAR SURGERY 26 - GENERAL MEDICINE GENERAL SURGERY BREAST SURGERY PLASTIC & RECONSTRUCTIVE SURGERY GYNAECOLOGY OBSTETRICS 34 - TRACHEOSTOMY 39 - UNGROUPABLE Grand Total Page 63 of 84

64 Table 21: Total 23 hour elective activity at LMH based on intra NALHN transfers 23 Hr Elective Activity at LMH (intra NALHN transfers) SRGS Seps ALOS Bed Days 03 - CARDIOTHORACIC SURGERY GIT ENDOSCOPY HAEMATOLOGY ENT HEAD & NECK SURGERY DENTISTRY UPPER GIT SURGERY UROLOGY GENERAL MEDICINE GENERAL SURGERY BREAST SURGERY PLASTIC & RECONSTRUCTIVE SURGERY ORTHOPAEDICS Total Table 22: Total 23 hour emergency activity at LMH based on intra NALHN transfers 23 hour Emergency Activity at LMH (intra NALHN transfers) Emergency SRGs Seps ALOS Bed Days minus ICU 01 - CARDIOLOGY CARDIOTHORACIC SURGERY RESPIRATORY MEDICINE GASTROENTEROLOGY GIT ENDOSCOPY NEUROLOGY NEUROSURGERY ENDOCRINOLOGY RENAL FAILURE HAEMATOLOGY ENT MEDICAL ONCOLOGY RHEUMATOLOGY DERMATOLOGY HEAD & NECK SURGERY DENTISTRY UPPER GIT SURGERY COLORECTAL SURGERY ORTHOPAEDICS UROLOGY VASCULAR SURGERY GENERAL MEDICINE GENERAL SURGERY BREAST SURGERY PLASTIC & RECONSTRUCTIVE SURGERY GYNAECOLOGY OBSTETRICS Page 64 of 84

65 Grand Total Table 23: Total Same-day Separations at LMH based on intra NALHN transfers Same-day Elective and Emergency Separations at LMH (intra NALHN transfers) Elective Emergency SRGs Seps Seps 13 - ENT HEAD & NECK SURGERY UPPER GIT SURGERY COLORECTAL SURGERY ORTHOPAEDICS UROLOGY GENERAL SURGERY BREAST SURGERY PLASTIC & RECONSTRUCTIVE SURGERY GENERAL MEDICINE VASCULAR SURGERY HAEMATOLOGY NEUROSURGERY CARDIOLOGY RESPIRATORY MEDICINE NEUROLOGY RENAL FAILURE OPHTHALMOLOGY MEDICAL ONCOLOGY DERMATOLOGY DENTISTRY DRUG & ALCOHOL PSYCHIATRY GYNAECOLOGY OBSTETRICS GASTROENTEROLOGY GIT ENDOSCOPY 8 0 Grand Total Notes: includes Women s and Children s Division activity under gynaecology, including the Family Advisory Clinic. 13. Risk management A full risk register has been established for the NALHN Transforming Health program. The risk register sets out risks under the following broad categories: Workforce Public Perceptions Program Delivery Benefits Realisation Clinical Commissioning Governance and Compliance Page 65 of 84

66 ICT Procurement Assets and Infrastructure The risk register outlines two risks of significant concern to NALHN: the ability to transfer and SA Ambulance Service s capacity due to the numbers of transfers NALHN s ICT capacity. NALHN is currently working with SAAS and SA Health s ICT to assist in mitigating and minimising these risks. Page 66 of 84

67 ATTACHMENT 1 RAPID RESPONSE TEAM End of MET call assessment Does the patient still meet RDR Red or Purple Zone Criteria or have unresolved clinical concern about the patient? MET TL to discuss with duty ICU or MET consultant YES NO MET TL to discuss with Home Team / Covering consultant Does the patient need intervention or are organ supports not available at MH? NO Does the patient need intervention or are organ supports not available at MH? YES YES NO TRANSFER TO MH ED (PENDING TRANSFER TO LMH) MET TL to Stabilise for transfer to LMH Lead clinical management Refer to receiving team at LMH Arrange transfer with MedSTAR or SAAS MET nurses to Assist with stabilisation Assist transfer to ED Support and manage patient in ED (remain with patient) Prepare patient for transfer to LMH TRANSFERRED TO LMH ICU or CCU or other ward (as appropriate) TRANSFER TO MH Short-Stay MT TL to document New treatment plan Frequency of observation Escalation pathway Investigations Review time frame Assess response to treatment and liaise with HT consultant. If deteriorates while in Short Stay, recall MET (and duty MET consultant). MET nurses to Assist with stabilisation. Assist ward staff with ongoing management Handover to short stay ward and review as required STAND DOWN Suitability for escalation Suitability to remain in MH CONSIDERATIONS Comorbidities/7 step pathway Current clinical requirements/potential for further deterioration Page 67 of 84

68 ATTACHMENT 2 Page 68 of 84

69 ATTACHMENT 3 Page 69 of 84

70 ATTACHMENT 4a Page 70 of 84

71 ATTACHMENT 4b Page 71 of 84

72 ATTACHMENT 4c Page 72 of 84

73 ATTACHMENT 5 Page 73 of 84

74 ATTACHMENT 6 Page 74 of 84

75 ATTACHMENT 7 Page 75 of 84

76 ATTACHMENT 8 Page 76 of 84

77 General Medicine ATTACHMENT 9 Page 77 of 84

78 ATTACHMENT 10 Page 78 of 84

79 ATTACHMENT 11 Page 79 of 84

80 ATTACHMENT 12 Page 80 of 84

81 Page 81 of 84

82 ATTACHMENT 13 Potential Stroke Pathway - NALHN Walk-in to ED after 8.00pm Patient presents to ED with stroke symptoms Referral to Allied Health through Oacis on admission AH (SP) swallow screen and assessment Treatment if needed Inpatient/ Interhospital transfer CODE Stroke 8.00am-8.00pm YES NO Minor stroke- TIA YES Rapid transfer to RAH for thrombolysis Patient admitted to AMU. (If no inpatient stroke beds or if telemetry required) Patient Admitted to Stroke Service Assessment and Care AH Assessment Nursing malnutrition screen (MUST) 24hrs SP 24 hours: PH/OT 24 hours; Dietician MUST 2/Enteral Nutrition/poor oral intake ; SW 48 hours as requested Medical Assessment - Identify risk factors for secondary prevention. (investigations -Blood/ telemetry/ MRI/ CT/echo) Monitoring - ongoing improvement deficits Rehabilitation, secondary prevention and palliation Multidisciplinary (MDT) rehabilitation assessment ( twice weekly) Rehabilitation service notified Rehabilitation review Initiate post acute management and discharge planning on presentation Consultation with patient, family and GP Notify Stroke Service Patient Admitted to Ward After hours - Admitted to stroke service If medically stable discharged to home TIA Clinic for follow-up after 24 hours TIA nurse End of life management Patient NET (see PEG pathway) Medically stable Ongoing assessment (including MDT), therapy and care Facilitate discharge planning and follow-up Assessment as required: (ACAT/ Rehabilitation/ TCP Medically un-stable Patient remains in stroke unit as long as required Mild to Moderate stroke severity days Severe stroke - 7 days Suitable for RITH or day rehabilitation Unsuitable for RITH or day rehabilitation Inpatient rehabilitation or TCP Long term palliation - Hospice or community Note: Blue indicates potential pathway categories Page 82 of 84

83 ATTACHMENT 14 Page 83 of 84

84 ATTACHMENT 15 Page 84 of 84