Grampian University Hospitals NHS Trust. Local Report ~ February Older People in Acute Care

Grampian University Hospitals NHS Trust Local Report ~ February 2004 Older People in Acute Care

NHSScotland Board Areas 13 12 15 1 Argyll & Clyde 2 Ayrshire & Arran 3 Borders 9 7 4 Dumfries & Galloway 5 Fife 6 Forth Valley 7 Grampian 1 6 14 5 8 Greater Glasgow 9 Highland 10 Lanarkshire 11 Lothian 8 2 10 11 3 12 Orkney 13 Shetland 14 Tayside 15 Western Isles 4

Our Commitment Our work will be undertaken in line with the following values: patient and public focus ~ promoting a patient-focused NHS that is responsive to the views of the public independence ~ reaching our own conclusions and communicating what we find partnership ~ involving patients, carers and the public in all parts of our work ~ working with and supporting NHS staff in improving quality ~ collaborating with other organisations such as public bodies, voluntary organisations and manufacturers to avoid duplication of effort evidence-based ~ basing conclusions and recommendations on the best evidence available openness and transparency ~ promoting understanding of our work ~ explaining the rationale for our recommendations and conclusions ~ communicating in language and formats that are easily accessible quality assurance ~ aiming to focus our work on areas where significant improvements can be made ~ ensuring that our work is subject to internal and external quality assurance and evaluation professionalism ~ promoting excellence individually and as teams and ensuring value for money in the use of public resources (human and financial) sensitivity ~ recognising the needs, opinions and beliefs of individuals and organisations and respecting and encouraging diversity

This document can be viewed on the NHS Quality Improvement Scotland website. It is also available, on request, from NHS Quality Improvement Scotland in the following formats: Electronic Audio cassette Large print NHS Quality Improvement Scotland Edinburgh Office ~ Elliott House 8-10 Hillside Crescent Edinburgh EH7 5EA Tel 0131 623 4300 Glasgow Office ~ Delta House 50 West Nile Street Glasgow G1 2NP Tel 0141 225 6999 comments@nhshealthquality.org www.nhshealthquality.org This document is produced from elemental chlorine-free material and is sourced from sustainable forests

Local Report ~ February 2004 Older People in Acute Care Older people are the core business of the NHS, and their experience of the health service often covers multiple disciplines and agencies. NHS Quality Improvement Scotland s Older People in Acute Care Project Group identified common patient journeys, including acute admissions, discharge home from hospital, and rehabilitation. By combining these three common journeys of care with the tracer condition of hip fracture, nine standards have been set which apply widely to older people admitted to acute hospital care. This report presents the findings from the peer review of performance against the standards.

NHS Quality Improvement Scotland 2004 ISBN 1-84404-208-1 First published February 2004 NHS Quality Improvement Scotland consents to the photocopying, electronic reproduction by uploading or downloading from the website, retransmission, or other copying of the findings contained in this report, for the purpose of implementation in NHSScotland and educational and not-for-profit purposes. No reproduction by or for commercial organisations is permitted without the express written permission of NHS Quality Improvement Scotland. Copies of this report, the Clinical Standards for Older People in Acute Care, and other documents produced by NHS Quality Improvement Scotland, are available in print format and on the website. www.nhshealthquality.org

Contents Contents 1. Setting the Scene 5 1.1 How the Standards were Developed 6 1.2 How the Review Process Works 6 1.3 Reports 10 2. Summary of Findings 11 2.1 Overview of Local Service Provision 11 2.2 Summary of Findings Against the Standards 11 3. Detailed Findings Against the Standards 15 Appendix 1 Glossary of Abbreviations 57 Appendix 2 Review Team Members 58 Appendix 3 Older People in Acute Care 59 Project Group Members Appendix 4 Timetable of Review Visits 61 Local Report (Grampian University Hospitals NHS Trust) - February 2004 3

1 Setting the Scene 1. Setting the Scene NHS Quality Improvement Scotland was established as a Special Health Board on 1 January 2003, as a result of bringing together the Clinical Resource and Audit Group, Clinical Standards Board for Scotland, Health Technology Board for Scotland, Nursing and Midwifery Practice Development Unit, and the Scottish Health Advisory Service. The purpose of NHS Quality Improvement Scotland is to improve the quality of healthcare in Scotland by setting standards and monitoring performance, and by providing NHSScotland with advice, guidance and support on effective clinical practice and service improvements. About this Report The clinical standards for Older People in Acute Care were published in October 2002. These standards are being used to assess the quality of services provided by NHSScotland in acute care settings nationwide. This report presents the findings from the peer review of Grampian University Hospitals NHS Trust. This review visit took place on 27 and 28 August 2003 and details of the visit, including membership of the review team, can be found in Appendix 2. Local Report (Grampian University Hospitals NHS Trust) - February 2004 5

1. Setting the Scene 1.1 How the Standards were Developed In March 2001, the Older People in Acute Care Project Group was established under the chairmanship of Dr Colin Currie, Consultant Geriatrician. Membership of the Project Group includes both healthcare professionals and members of the public (see Appendix 3). The Project Group oversees the quality assurance process of: developing standards; reviewing performance against the standards throughout Scotland, using self-assessment and external peer review; and reporting the findings from the review. When developing the older people in acute care standards, a Scotlandwide consultation process was undertaken. The views of health service staff, patients, carers and the public were sought, and all the relevant evidence available at the time was taken into account. Draft standards were also piloted at two Trusts, in Dumfries & Galloway Acute & Maternity Hospitals NHS Trust and Lanarkshire Acute Hospitals NHS Trust. 1. References to Trusts refer to the situation at the time of the review visit. Subject to legislation, all Scottish NHS Trusts will be dissolved by April 2004, to be replaced in most cases by operating divisions of the NHS Board. In some areas, the NHS Board will fulfil a dual strategic and operational role and will not therefore have separate operating divisions. The NHS Board will be the single employer for the local system. NHS QIS publications retain the term Trust during the period of Trust dissolution, with the exception of cases where Trusts had already been dissolved by the time of the review visit. 1.2 How the Review Process Works The review process has two key parts: local self-assessment followed by external peer review. First, each Trust 1 assesses its own performance against the standards. An external peer review team then further assesses performance, both by considering the self-assessment data and visiting the Trust to validate this information and discuss related issues. The review process is described in more detail below (see also the flow chart on page 9). Self-Assessment by the Trust On receiving the standards, each Trust assesses its own performance using a framework produced by NHS Quality Improvement Scotland. This framework includes guidance about the type of evidence (eg guidelines, audit reports) required to allow a proper assessment of performance against the standards to be made. 6 Local Report (Grampian University Hospitals NHS Trust) - February 2004

The Trust submits the data it has collected for this self-assessment exercise to NHS Quality Improvement Scotland before the on-site visit, and it is this information that constitutes the main source of written evidence considered by the external peer review team. External Peer Review An external peer review team then visits the Trust and speaks with local stakeholders (eg staff, patients, carers) about the services provided. Review teams are multidisciplinary, and include both healthcare professionals and members of the public. All reviewers are trained. Each review team is led by an experienced reviewer, who is responsible for guiding the team in their work and ensuring that team members are in agreement about the assessment reached. The composition of each team varies, and members have no connection with the Trust they are reviewing. This promotes the sharing of good practice, and ensures that each review team assesses performance against the standards rather than make comparisons between one Trust and another. At the start of the on-site visit, the review team meets key personnel responsible for the service under review. Reviewers then speak with local stakeholders about the services provided. After these meetings, the team assesses performance against the standards, based on the information gathered during both the self-assessment exercise and the on-site visit. The visit concludes with the team providing feedback on its findings to the Trust. This includes specific examples of local initiatives drawn to the attention of the review team (recognising that other such examples may exist), together with an indication of any particular challenges facing the Trust. Local Report (Grampian University Hospitals NHS Trust) - February 2004 7

1. Setting the Scene Assessment Categories Each review team assesses performance using the categories met, not met and not met (insufficient evidence), as detailed below: Met applies where the evidence demonstrates the standard and/or criterion is being attained. Not met applies where the evidence demonstrates the standard and/or criterion is not being attained. Not met (insufficient evidence) applies where no evidence is available for the review team, or where the evidence available is insufficient to allow an assessment to be made. A final category not applicable is used where a standard and/or criterion does not apply to the Trust under review. 8 Local Report (Grampian University Hospitals NHS Trust) - February 2004

The process used for this review: After Visit During Visit Prior to Visit Standards published and issued î Self-assessment framework finalised and issued Trust undertakes self-assessment exercise and submits outcomes to NHS Quality Improvement Scotland ê NHS Quality Improvement Scotland sends information from selfassessment submission to peer review team ê Two-way presentations covering background on NHS Quality Improvement Scotland and local service provision Draft report produced and sent to review team for comment í Review team meets stakeholders to discuss local services Review team assesses performance in relation to the standards Review team feeds back findings to Trust ê ê Draft report sent to Trust to check for factual accuracy ê Project Group considers findings of local reviews and drafts national overview ê NATIONAL OVERVIEW AND LOCAL REPORTS PUBLISHED Local Report (Grampian University Hospitals NHS Trust) - February 2004 9

1. Setting the Scene 1.3 Reports After each review visit, NHS Quality Improvement Scotland staff draft a local report detailing the findings of the review team. This draft report is sent to the review team for comment, and then to the Trust to check for factual accuracy. The local report is published only after all the visits for that topic have been undertaken nationwide. Once a national review cycle is completed, the relevant Project Group reconvenes to examine review findings and make recommendations. The Project Group then oversees the production of a national overview of service provision across Scotland in relation to the standards. This document includes both a summary of the findings (highlighting examples of local initiatives and challenges for the service) and recommendations for improvement. Part of the remit of NHS Quality Improvement Scotland is to report whether the services provided by NHSScotland, both nationally and locally, meet the agreed standards. This does not include reviewing the work of individual healthcare professionals. In achieving this aim, variations in practice (and potentially quality) within a service will be encountered. In such cases, variations are reported. Please note all reports published are available in print format and on the NHS Quality Improvement Scotland website. 10 Local Report (Grampian University Hospitals NHS Trust) - February 2004

2 Summary of Findings 2. Summary of Findings 2.1 Overview of Local Service Provision Grampian is situated in north-east Scotland and has a population of around 523,290. About 40% of the local population live in Aberdeen, which is the largest urban area in the region, although a significant proportion live in rural areas. The proportion of older people in the population is lower than the national average, as are levels of illness and deprivation. Local NHS System and Services NHS Grampian is responsible for improving the health of the local population and for the delivery of the healthcare required. It provides strategic leadership and has overall responsibility for the efficient, effective and accountable performance of the NHS in Grampian. At the time of the review visit, the NHS Board area contained one Acute and one Primary Care Trust (Grampian University Hospitals NHS Trust and Grampian Primary Care NHS Trust), which together provided its clinical services. Both the NHS Board and the Trusts were accountable for the services provided, through the framework of clinical governance. Further information about the local NHS system can be accessed via the website of NHS Grampian: www.show.scot.nhs.uk/ghb 2.2 Summary of Findings Against the Standards A summary of the findings from the review, including examples of local initiatives drawn to the attention of the review team, is presented in this section. A detailed description of performance against the standards/ criteria is included in Section 3. Acute Care The review team commended the responsive services within A&E at both of the acute hospital sites and the acute medical assessment unit at Aberdeen Royal Infirmary. The review team noted the recent development of an integrated patient admission document and encouraged a consistent approach to A&E documentation across the Trust. The review team found a lack of continuity in the approach to cognitive assessment and goal-setting throughout the service. Working towards integrated records to formalise this approach was highlighted as a challenge for the Trust. Local Report (Grampian University Hospitals NHS Trust) - February 2004 11

2. Summary of Findings There are different services working within Grampian to prevent unnecessary admission to hospital. The Trust reported that 23 multidisciplinary health and social care teams are being set up across Aberdeen city. The review team encouraged a Grampian-wide multiagency approach to providing rapid response teams that are able to provide rehabilitation on a 7 days per week basis. Rehabilitation is not routinely monitored, in terms of service impact or patient satisfaction, and this was identified as a challenge for the Trust. Example of a local initiative An admissions telephone line has been set up within the acute medical receiving unit at Aberdeen Royal Infirmary. This admissions line is manned by a senior nurse and provides GPs with a single point of contact for arranging direct admissions. Planning a Safe Discharge Home, Supporting People at Home after their Discharge The review team commended the effective communication and informal networking which underpins the discharge management process within Grampian. The review team praised the pharmacy input to patients care during their hospital stay and on return home. A particular strength is the patient information on discharge medication. The review team suggested that the Trust may find it useful to evaluate its discharge services and undertake patient satisfaction surveys. A challenge remains around the provision of a joint equipment service. Staff do not benefit from the support of a joint, central service to facilitate the timely delivery of essential equipment to older people s homes. The review team noted, however, that this issue is being reviewed within Moray. Example of a local initiative A cross-boundary liaison nurse works at. This is a new role created to assess the patient s journey and to facilitate a co-ordinated approach from the acute setting into the community. 12 Local Report (Grampian University Hospitals NHS Trust) - February 2004

Hip Fracture A Tracer Condition for Older People in Acute Care Both Aberdeen Royal Infirmary and, participate in the Scottish Hip Fracture Audit. The review team commended the inter-departmental working that supports the patient s journey throughout the orthopaedic services. There is effective multidisciplinary communication and consultantsupport to a 7-day service. However, the review team identified providing sufficient geriatrician input to the orthopaedic services in Moray as a challenge for the Trust. Although there is a policy for fast-tracking patients with confirmed or suspected hip fracture from A&E to orthopaedic services at Aberdeen Royal Infirmary, this is not in place at. A major challenge for the Trust is to continue to reduce waits and delays in A&E at both sites. The review team noted that for a large majority of hip fracture patients at, surgery is performed within 24 hours of admission to the orthopaedic unit. The review team commended the 7-day occupational therapy and physiotherapy service for orthopaedic patients at Aberdeen Royal Infirmary. Allied health professionals and the other disciplines throughout the orthopaedic services keep separate records. The review team suggested that Trust staff should continue to review the use and implementation of the orthopaedic integrated care pathway. The review team noted that patients discharge needs are identified from admission. Rehabilitation is provided in the Bruce Howie Unit at Woodend Hospital, Aberdeen; this is a single sex unit for female patients and the review team suggested addressing the inequity of the service for male patients. The provision of early supported discharge is highlighted as a challenge for the Trust. Communication The review team commended the motivation and enthusiasm demonstrated by staff on each site visit. An awareness of the communication support required by older people, in terms of aids and translation services, was found across the service. A particular strength is the language line in use at, which offers a translation service for over 100 languages. Local Report (Grampian University Hospitals NHS Trust) - February 2004 13

The review team found effective inter-agency working and strategy development for the older people services provided within Grampian. An implementation group has been formed to oversee the introduction of the Joint Grampian Older People s Strategy. The review team noted that needs assessment work could assist in identifying priorities for investment and local implementation. The review team found progress in the reduction of delayed discharges; to sustain this reduction will be a continuing challenge for the Trust. Example of a local initiative The review team commended the centralised production of patient information. The Trust is proactive in the involvement of older people in developing and publishing relevant materials in accessible formats. 14 Local Report (Grampian University Hospitals NHS Trust) - February 2004

3. Detailed Findings Against the Standards 3 Detailed Findings Against the Standards Standard 1: The Option to Remain at Home Standard Statement Rather than going into hospital, older people have the option of being treated and cared for at home during illness or following injury, when this is clinically appropriate. Essential Criteria 1.1: Local NHS systems primary care and acute trusts must demonstrate that: Multidisciplinary, multiagency teams are able to respond within 24 hours and provide co-ordinated packages of care and rehabilitation. The rapid response service is a multidisciplinary crisis intervention team funded by NHS Grampian and jointly managed by Grampian Primary Care NHS Trust, Grampian University Hospitals NHS Trust and Aberdeen City Council social work department. The service aims to prevent hospital admission and to facilitate early discharge from hospital for patients living within the city of Aberdeen. The rapid response team can respond within 24 hours during Monday-Friday for rehabilitation services, and 7 days per week for emergency social care. The Frail Elderly Domiciliary Care Team (FEDS) is a multi-skilled community therapy team which supports housebound older people in their own home and works to avoid unnecessary admission to hospital. The Trust reported that 23 multidisciplinary health and social care teams are being set up across Aberdeen city. These integrated care teams will be based in GP practices and will be able to provide early intervention for patients referred by primary care staff. At the time of the visit, however, the care teams did not have a dedicated physiotherapy service. In 2001, an occupational therapy service in A&E was funded from winter pressure funding. This service was supported by the rapid response team and an evaluation showed it to be successful. However, this initiative was not continued. The review team noted that a rapid response service has not been rolled out across Aberdeenshire and that access to rehabilitation services provided by a multidisciplinary team is not available within 24 hours, 7 days per week. Therefore, the review team concluded that the criterion is not met. Local Report (Grampian University Hospitals NHS Trust) - February 2004 15

3. Detailed Findings Against the Standards A rapid response service is provided by different community care teams working within Moray. The Spynie community therapy team aims to prevent unnecessary admission to hospital and to facilitate early discharge from hospital by providing therapy treatment to people over 60 years of age in the Lossiemouth and Elgin areas. There is a community therapy team based at Seafield Hospital, Buckie, providing a similar service to people in Buckie, Keith and Fochabers and a further community care team for people within the Forres area. A hospital social worker based at, co-ordinates the different services and works to facilitate discharge. A single shared assessment is undertaken by the hospital social worker during Monday-Friday, 09:00-17:00, and by the duty social worker outwith these hours. The community therapy teams operate Monday-Friday, 09:00-17:00. Outwith these hours, referrals are made to social services and to the on-call district nurse. Although discussions with staff confirmed that there is a good awareness of the services available within Moray for supporting older people at home, there is no integrated multi-agency care team that can provide co-ordinated packages of care and rehabilitation within 24 hours, 7 days per week. Therefore, the review team concluded that the criterion is not met. 1.2: Local NHS systems primary care and acute trusts must demonstrate that: Multi-agency protocols for the use of these services are in use. A patient information leaflet is available detailing the rapid response service. The rapid response team has defined multi-agency protocols for providing care and rehabilitation to older people. 16 Local Report (Grampian University Hospitals NHS Trust) - February 2004

3. Detailed Findings Against the Standards The different community care teams operating within Moray work closely with community nurses and social work agencies. There is a referral protocol for the local care teams that can provide a rapid response service to older people within their own home. There is not, however, a Moray-wide multiagency team with defined protocols for providing care and rehabilitation to older people. The review team concluded, therefore, that the criterion is not met. 1.3: Local NHS systems primary care and acute trusts must demonstrate that: The effectiveness of these services is monitored, in terms of patient satisfaction as well as service impact. The rapid response team produces an annual report which monitors the effectiveness of this service, including the percentage of annual referrals and the number of unnecessary hospital admissions prevented. The rapid response team has produced patient and carer satisfaction questionnaires. In addition, the rapid response team has undertaken a sample survey of referrers satisfaction with the service. Feedback from the questionnaires has been collated to measure the effectiveness of the service in terms of user satisfaction. The number of people referred to the community care teams was monitored from April-June 2003; from these figures the number of unnecessary hospital admissions avoided and early discharges achieved were estimated. The effectiveness of these services has not been monitored in terms of patient satisfaction and therefore the review team concluded that the criterion is not met. Local Report (Grampian University Hospitals NHS Trust) - February 2004 17

3. Detailed Findings Against the Standards Standard 2(a): Assessment of Older People Being Admitted Briefly Standard Statement Older people being treated in A&E or admitted even briefly for care are assessed for cognitive impairment,functional problems and existing home support. Essential Criteria 2(a)1: A brief screening assessment tool is in use and documents: ability to perform key activities of daily living; cognition; previous support at home; and need for more detailed assessment. A patient admission record has been introduced to some departments within the Trust, including the acute medical assessment unit at Aberdeen Royal Infirmary. The admission document includes screening for activities of daily living; cognition, previous support at home and the need for more detailed assessment. Staff reported on the day that this document has been well received and is a useful tool. The review team noted, however, that this document is not used in A&E. The review team acknowledged that a large percentage of older people being admitted to the hospital go directly to the acute medical admissions unit without first being assessed in A&E. The patients that are assessed in A&E are triaged with the Manchester Triage Scale, which assesses patients by clinical need and is not sensitive to older people. Although staff reported that in practice cognitive screening of older people is carried out, this is not included in the A&E admission documentation. Therefore, the review team concluded that the criterion is not met. The review identified that a challenge for the Trust is to develop a consistent approach to A&E documentation at both Aberdeen Royal Infirmary and., has recently developed an admission tool which screens for the ability to perform activities of daily living, cognition, previous support at home, and the need for more detailed assessment. 18 Local Report (Grampian University Hospitals NHS Trust) - February 2004

Older people are assessed within A&E using the Manchester Triage Scale which assesses patients by clinical need and is not sensitive to older people. The Trust reported, however, that A&E is currently developing admission policies for people over 65 years of age. The review team identified that a challenge for the Trust is to develop a consistent approach to A&E documentation at both Aberdeen Royal Infirmary and. Local Report (Grampian University Hospitals NHS Trust) - February 2004 19

3. Detailed Findings Against the Standards Standard 2(b): Assessment of Older People Being Admitted Briefly Standard Statement If an older person is to be admitted from A&E, admission must occur promptly. Essential Criteria 2(b)1: Patients are transferred from A&E to admission ward bed within 2 hours of triage. The Information & Statistics Division of the Common Services Agency data reflect that the majority of patients are not transferred from A&E to an admission ward bed within 2 hours of triage. The Trust has a standard stating that admission takes place within 4 hours of triage. After 4 hours the patients are transferred to a ward bed and a further more detailed assessment is undertaken, including comfort, pain, pressure area and nutrition. The availability of medical staff to assess patients within A&E and bed availability in the wards are reported contributing factors to delayed transfers. The Information & Statistics Division of the Common Services Agency data reflect that the majority of patients are not transferred from A&E to an admission ward bed within 2 hours of triage. The review team commended the Over 65 Accident and Emergency Audit carried out by the Trust between June and July 2003. The principal reasons given for delays in admission to a ward were the availability of medical staff to assess patients within A&E and bed availability in the wards. The review team noted that patients delayed in A&E are provided with a bed. 20 Local Report (Grampian University Hospitals NHS Trust) - February 2004

Standard 2(c): Assessment of Older People Being Admitted Briefly Standard Statement Where a GP has seen an older person at home and admission to hospital has been agreed with the admitting doctor/bed manager, the older person is admitted directly to the ward, and not delayed or routinely reassessed in the A&E department. Essential Criteria 2(c)1: Trusts must demonstrate that direct admission protocols are in place and are monitored. Older people are not routinely assessed in A&E on admission to Aberdeen Royal Infirmary. An admissions line, operated by a senior nurse, has been set up in the acute medical assessment unit. This provides GPs with a single point of contact for arranging direct admissions into the relevant specialty. Nursing staff work closely with bed managers within the acute medical receiving unit to gather relevant information prior to admission. Although there are no formal direct admission protocols at Woodend Hospital, Aberdeen, the Trust reported that a large majority of older people go directly to a bed within the department of medicine for the elderly. The hospital has a bed management protocol whereby GPs contact the receiving doctor who then liaises with the bed manager. The bed manager contacts A&E to advise of the notified admission. The bed manager works Monday-Friday, 09:00-17:00, and site practitioners oversee the bed management process outwith these hours. The hospital does not operate a direct admissions policy. Older people are assessed in A&E on admission. Therefore, the review team concluded that the criterion is not met. Local Report (Grampian University Hospitals NHS Trust) - February 2004 21

3. Detailed Findings Against the Standards Standard 3(a): Older People Admitted for In-patient Acute Care Standard Statement Older people admitted for in-patient acute care must be screened to ensure that any need for more detailed functional assessment is recognised. Where this need is recognised, assessment by a multidisciplinary team must be carried out. Essential Criteria 3.1: Trusts must demonstrate: How functional screening is performed and by whom. Nursing and medical staff carry out functional screening of older people admitted for in-patient care at Aberdeen Royal Infirmary. This initial assessment identifies the need for more detailed input by the multidisciplinary team. At Woodend Hospital, Aberdeen, functional assessment of older people is carried out by the nursing staff and there is a blanket referral system for physiotherapy and occupational therapy. The hospital reported that functional screening is performed as part of general multidisciplinary team assessment. Nursing staff perform an initial assessment on admission and refer to allied health professionals on a needs basis. 3.2: Trusts must demonstrate: Documentation of results of screening. A patient admission record is used within the medical wards and the orthopaedic ward at Aberdeen Royal Infirmary to document results of screening. This document is not used in the general surgical wards where screening results are recorded within the nursing records. Allied health professionals keep separate records and the orthopaedic integrated care pathway is no longer in use. 22 Local Report (Grampian University Hospitals NHS Trust) - February 2004

At Woodend Hospital, Aberdeen, initial screening is documented within the nursing records. More detailed functional assessment is documented in separate allied health professional records. Staff reported that they would welcome the development of integrated records and the review team identified this as a challenge for the Trust. Nursing staff document results of screening in the Crescendo nursing system and use the emailing system within Crescendo to make referrals to allied health professionals. Discussions with staff indicated an enthusiastic approach to the development of Crescendo to improve communication and the referral process. The review team noted that, although allied health professionals record some information within Crescendo, they also keep separate records. 3.3: Trusts must demonstrate: Where a more detailed functional assessment is needed, how this is performed and by whom. On the general medical wards at Aberdeen Royal Infirmary, patients needing a more detailed assessment are individually referred to allied health professionals. The review team commended the 7 days per week occupational therapy and physiotherapy service for orthopaedic patients. The review team noted that there is no occupational therapy sessional commitment to general surgery. Older people transferred to the general surgical ward due to service pressures receive an occupational therapy service; however, this service is not available to older people under the care of a general surgeon. At Woodend Hospital, Aberdeen, there is a blanket referral system for physiotherapy. Staff reported that there is a blanket referral system for occupational therapy; however, this may be withdrawn due to service pressures. Older people are referred to other allied health professionals on a needs basis. Local Report (Grampian University Hospitals NHS Trust) - February 2004 23

3. Detailed Findings Against the Standards There are weekly multidisciplinary team meetings on the general medical wards (ward 8 and ward 9) and the geriatric ward (ward 7) comprising: nursing staff, medical staff, care of the elderly pharmacist, physiotherapist, dietitian, cross-boundary liaison nurse, community care officer and social services. All meetings are minuted and this document acts as a point of reference for the multidisciplinary team. The Moray adult speech and language therapy team was set up in August 2002 to improve the service provided to patients in acute and community locations. Three members of staff now provide a Monday-Friday service to. Attendance at the department of medicine for the elderly (ward 7) multidisciplinary team meetings is managed as a priority but is not always achievable due to the geographical area covered by a limited staff resource. Similarly, staff reported that there are some delays in speech and language therapy referral; however, acute dysphagia patients are seen within 2 working days. A care of the elderly pharmacist provides a 25 hours per week clinical and ward pharmacy service. Staff reported some delays in pharmacy referral and the review team noted that there is no out-ofhours service. Staff on the general medical wards and general surgical wards reported a delay in occupational therapy referral. The review team noted that there are no multidisciplinary team meetings on the general surgical wards; there is, however, access by referral to a geriatrician within 24 hours. 24 Local Report (Grampian University Hospitals NHS Trust) - February 2004

Standard 4(a): Rehabilitation in Acute Care Wards Standard Statement Older people in acute care who need rehabilitation whether uni or multidisciplinary must have such rehabilitation as soon as their clinical condition permits. Essential Criteria 4(a)1: Trusts must demonstrate: How and when rehabilitation is carried out, and by whom. The hospital reported that there is no specific rehabilitation protocol and that rehabilitation is tailored to meet individual patient s needs. Although patients have access to a multidisciplinary rehabilitation team, the review team noted that this service is not consistent across the acute wards. The review team commended the 7 days per week physiotherapy and occupational therapy provision for orthopaedic patients; however, it was noted patients outwith the medical specialties do not receive the same level of service. The review team noted a lack of occupational therapy input to the general surgical ward. Staff reported that there are issues surrounding access to the physiotherapy gym at Aberdeen Royal Infirmary, which is restricting the level of rehabilitation provided. The review team concluded that not all older people are able to access rehabilitation as soon as their clinical condition permits and therefore the criterion is not met. The review team noted that patients on the acute wards have sufficient access to a multidisciplinary rehabilitation service. Although staff reported some delays in referral to allied health professionals these are not of sufficient lengths to prevent patients accessing rehabilitation as soon as their clinical condition permits. Staff reported that there is a pre-admission service for orthopaedic patients and they would welcome the introduction of this service to the general surgical ward. Local Report (Grampian University Hospitals NHS Trust) - February 2004 25

3. Detailed Findings Against the Standards 4(a)2: Trusts must demonstrate: The arrangements in place for multidisciplinary rehabilitation. The hospital reported that occupational therapists, physiotherapists, dietitians, and speech and language therapists are available to provide multidisciplinary rehabilitation. The review team noted disparity of access to multidisciplinary rehabilitation in the acute wards. There is a 7 days per week physiotherapy and occupational therapy service for orthopaedic patients and an on-call service for emergency respiratory patients. Staff reported that general surgical patients can wait up to 14 days for referral to an occupational therapist due to the lack of sessional commitment on the general surgical ward. Staff reported there can be some delays in speech and language therapy referrals. Dietetic referrals are prioritised on a needs basis and therefore waiting times vary. The patient s date of admission and the date of input from each allied health professional are recorded. The review team noted, however, that the hospital does not monitor and formally report waiting times for patients access to rehabilitation. The hospital reported that patients are referred to physiotherapists, occupational therapists, dietitians and speech and language therapists as appropriate. Allied health professionals are available Monday- Friday, 09:00-17:00, with an on-call emergency weekend service. Although there are some delays in referral to allied health professionals, the review team concluded that arrangements for the timely provision of multidisciplinary rehabilitation are in place. 26 Local Report (Grampian University Hospitals NHS Trust) - February 2004

4(a)3: Trusts must demonstrate: Documentation of rehabilitation goals and progress. Discussions with staff indicated that, in practice, allied health professionals record within their separate documentation patients rehabilitation goals and progress. However, this practice differs throughout the hospital and has not been formalised. Written evidence showed that the documentation does not contain allotted space to facilitate goal-setting. Discussions with staff indicated that occupational therapy documentation is currently under review and will include a formal prompt for recording rehabilitation goals. The hospital reported that where multidisciplinary team meetings take place, patients rehabilitation goals are discussed and progress is recorded within the multidisciplinary team file and in the patients case notes. Discussions with staff indicated some allied health professionals record patients rehabilitation goals and progress within their separate notes and also on Crescendo. However, this practice differs throughout the hospital and has not been formalised. The review team noted that the written evidence does not include a specific section for documenting rehabilitation goals. The hospital does not have a formal approach to documenting patients rehabilitation goals and has not audited the effectiveness of rehabilitation; therefore, the review team concluded that the criterion is not met. Local Report (Grampian University Hospitals NHS Trust) - February 2004 27

3. Detailed Findings Against the Standards Standard 4(b): Rehabilitation in Acute Care Wards Standard Statement Rehabilitation continues throughout the journey of care until agreed goals have been achieved. Essential Criteria 4(b)1: Trusts must demonstrate: Protocols for the referral and transfer of patients to rehabilitation wards. (insufficient evidence) The Bruce Howie Unit at Woodend Hospital, Aberdeen, is a geriatric orthopaedic rehabilitation unit. The unit is for women over the age of 65; male geriatric orthopaedic patients are cared for in the general rehabilitation wards. The review team noted through discussions with staff that there is a clear referral process for orthopaedic patients to the rehabilitation ward at the Bruce Howie Unit. Patients are identified for transfer by twice-daily visits from staff grade medical staff specialising in care of the elderly; however, the lack of consultant geriatrician input was highlighted as a concern. Discussions with staff indicated there are issues concerning the referral process to Maple Ward at Woodend Hospital, Aberdeen. Staff on the general medical wards reported that the referral criteria are difficult to meet. The hospital supplied a protocol for the referral and transfer of patients to the Bruce Howie Unit, Aberdeen, and transfer documentation for the acute medical receiving unit. Although other formal protocols for the referral and transfer of patients to general rehabilitation wards may exist, they were not made available to the review team. There is a protocol for the referral and transfer of patients to rehabilitation beds within the geriatric rehabilitation ward (ward 7). There is a waiting list for ward 7, although there are no systems in place to measure delay in transfer. 28 Local Report (Grampian University Hospitals NHS Trust) - February 2004

The hospital reported that transfer letters and records accompany patients transferred to community hospitals or on discharge home. The review team noted that allied health professionals have strong links with their community counterparts and that there is an effective informal system for transferring patients to community rehabilitation units, ie community hospitals. Staff were enthusiastic about the impact the role of the cross-boundary liaison nurse has on co-ordinating transfers to community hospitals. The review team encouraged the formalisation of the current system for referring patients to community hospitals. 4(b)2: Trusts must demonstrate: The availability, use, and effectiveness of post-acute rehabilitation services: eg stroke rehabilitation units; geriatric orthopaedic rehabilitation units; other rehabilitation services for older people. Post-acute rehabilitation is carried out at Woodend Hospital, Aberdeen, in the stroke rehabilitation centre (ward 12), the Bruce Howie Unit, ward 6 and the Maple Ward. Woodend Hospital, Aberdeen, has a 22-bedded stroke rehabilitation centre (ward 12). The unit is staffed by a multidisciplinary team comprising nursing and medical staff and allied health professionals, including: occupational therapist; physiotherapist; speech and language therapist; dietitian and pharmacist. The stroke unit also has social work, psychology and voluntary organisation input. Close links have been developed with the community rehabilitation teams to facilitate discharge. The Bruce Howie Unit at Woodend Hospital, Aberdeen, is a geriatric orthopaedic rehabilitation unit. The multidisciplinary team comprises nursing and medical staff, allied health professionals, including physiotherapist, occupational therapist and dietitian, as well as social work input. A liaison health visitor co-ordinates hospital and community services. The unit is for women over the age of 65; male geriatric orthopaedic patients are cared for in the general rehabilitation wards at Woodend Hospital, Aberdeen. Ward 6 at Woodend Hospital, Aberdeen, provides specialist rehabilitation for stroke patients. The Maple Ward at Woodend Hospital, Aberdeen, was set up in November 2002 to provide slow stream rehabilitation for older people. A consultant from the department of medicine for the elderly reviews each patient before referral to the ward. There is provision for 12 female patients and two male patients; however, there is the flexibility to manage six male and eight female beds if required. Patients Local Report (Grampian University Hospitals NHS Trust) - February 2004 29

3. Detailed Findings Against the Standards with clear rehabilitation needs are referred to the ward to continue their rehabilitation programme under the care of a multidisciplinary team. Staff reported that the occupational therapy service does not have sufficient holiday or sick leave cover and this can result in delays in referral. The hospital reported that there are some issues concerning the level of speech and language therapy input they are able to provide to patients who have communication difficulties. The hospital does not measure delays in access to allied health professionals in the rehabilitation wards. The Trust provided a Report on the Effectiveness of the Maple Ward (18 July 2003) which evaluated the service and made recommendations for future developments. The Trust was not able to provide similar reports on the other services provided. The review team found that the approach to monitoring the effectiveness of the post-acute rehabilitation services in terms of service impact and patient satisfaction was inconsistent across the service. The hospital reported that post-acute rehabilitation services for older people are carried out by the community rehabilitation teams and within the newly opened day hospital. There is no provision for specialist services such as stroke rehabilitation units or geriatric orthopaedic rehabilitation units for older people within the Elgin area. 30 Local Report (Grampian University Hospitals NHS Trust) - February 2004

Standard 4(c): Rehabilitation in Acute Care Wards Standard Statement Older people are transferred from acute wards only in accordance with their clinical and rehabilitation needs. In the event of the transfer of an older person from an acute ward, their rehabilitation continues until they leave hospital. Essential Criteria 4(c)1: Trusts must demonstrate: Audit of all internal transfers of older people, whether in response to clinical need or service pressures. The department of medicine for the elderly has an internal referral database which tracks all internal transfers but does not record the reason for transferring the patient. A decanting checklist was implemented in 1995 and staff reported that it continues to be an effective and helpful tool. The Trust carried out a decanting audit in 2002 and provided a summary report of the audit in May 2003. Recommendations from the summary report included setting up a working group to update and re-launch the decanting policy and to implement a system to accurately monitor patients in relation to decanting. The review team identified minimising patient transfers and analysing patient flows as a challenge for the Trust. There are daily transfers from acute medicine to the surgical wards due to service pressures. The number of decanted patients is not monitored and the review team noted that some patients are inappropriately selected. Local Report (Grampian University Hospitals NHS Trust) - February 2004 31

3. Detailed Findings Against the Standards Staff reported that the decant checklist on Crescendo is a useful tool. The review team commended a patient information leaflet on decanting produced by the hospital. The leaflet explains what decanting is and how it affects the patient s journey of care, including information on; the medical staff in charge of the patient s care, the treatment received in the new ward, privacy and dignity, and communication with relatives. The review team identified minimising patient transfers and analysing patient flows as a challenge for the Trust. 4(c)2: Trusts must demonstrate: Provision of multidisciplinary rehabilitation for older people still in hospital care. Staff who provide rehabilitation for patients at Aberdeen Royal Infirmary and Woodend Hospital, Aberdeen, indicated that there is good communication between the wards and they were enthusiastic about multidisciplinary working. Staff reported, however, that transfer information is communicated verbally and where formal transfer documentation is in place there is insufficient time to complete it. The review team noted that allied health professional services are often overstretched and staff are therefore unable to follow patients through their journey of care. Staff who provide rehabilitation for patients at, indicated that there is effective provision of multidisciplinary rehabilitation for older people still in hospital care. Every ward is visited daily by an allocated allied health professional from each specialty. There are some delays with speech and language therapy; however, patients who are transferred internally are followed to ensure they receive a consistent level of care. 32 Local Report (Grampian University Hospitals NHS Trust) - February 2004