SITUATION LLANDUDNO HOSPITAL PROJECT CYCLE TWO REPORT FOR UNSCHEDULED CARE PROJECT TEAM: IDENTIFICATION OF PREFERRED SERVICE SOLUTIONS MAY 2010 The Cycle One SBAR report detailed the solutions which had been developed by the Unscheduled Care Project Team in response to the recommendations of the Llandudno Hospital Review Final Report, (March 2009). The Project Team has agreed that the solutions should be considered under 4 workstreams as follows: Minor Injuries Unit (MIU)/GP Out of Hours Service led by Mrs Pauline Cutting, Emergency Department Consultant Emergency Admissions led by Dr Salah Elghenzai, Interim Clinical Director (West Division) Day Services led by Angela Howarth, Senior Nurse, Llandudno Hospital Community Services led by Dr Dennis Williams, GP & Deputy Chief of Staff During Cycle Two the Project Team have appraised each of the solutions and agreed a preferred solution for each workstream for consideration by the Stakeholder Group and Project Board. BACKGROUND The Unscheduled Care Project Team was established to develop detailed plans in response to the recommendations of the Llandudno Hospital Review Final Report, (March 2009). As detailed in its terms of reference, the team will produce a services plan and consider the resource implications, including estates, for the range of services included in the section dealing with Unscheduled Care. Recommendations within the Final Project Board Report (March 2009) for Unscheduled Care were: 1. The hospital ceases to admit those emergency medical patients whose 14/05/10 CJ/LLGH/USC 1 final (V2) SBAR report Cycle 2
clinical needs are beyond the agreed safety limits for the hospital. As a consequence the Coronary Care Unit could provide a monitored bed facility for the hospital. 2. The hospital ceases to take emergency medical admissions after midnight as soon as practical and those patients sent directly to Ysbyty Gwynedd and Ysbyty Glan Clwyd. 3. Rapid Access Chest Pain Clinics are developed in Llandudno Hospital. 4. Further specialist clinical advice will be sought with regard to the Minor Injuries Unit (MIU) based on the following options: The service over night is nurse led with medical support from GPs working as part of the Out of Hours Service The MIU be developed as an Out of Hours Centre for Conwy County when the contract is re-let in October 2010. 5. The MIU is redeveloped with a new build. The first SBAR report provided detail regarding the current operational difficulties in the provision of Unscheduled Care at Llandudno Hospital. In summary these relate to: Difficulties in the recruitment and retention of junior doctors; The safe staffing of both sites with significant levels of vacancies cannot be maintained and pose significant clinical risk to patients; Despite ongoing efforts to recruit to the staff grade posts, they remain vacant and have resulted in the ad hoc closure of the MIU at night; Outpatient clinics have had to be reduced on a regular basis to Consultant only to allow mid-grade cover for in-patients on the wards. The Project Team concluded that the current service model for unscheduled care in LlGH is not sustainable and the continued ad hoc response to the immediate operational problems must be addressed. This was also generally supported at the first Stakeholder event and as a result the Do Nothing solution has been excluded from the Project. Preferred solutions for the future model of Unscheduled Care in response to these problems and the recommendations of the CLHB Report have been developed by the Project Team for further consideration. 14/05/10 CJ/LLGH/USC 2 final (V2) SBAR report Cycle 2
ASSESSMENT During the second cycle of work further consideration has been given to the solutions presented in response to the Conwy LHB recommendations, the current operational difficulties and the opportunities for service development. As a result the Project Team has developed the following preferred solutions for further development and consideration during the third cycle in order that a site development plan can be presented for consideration. Emergency Medical Admissions From the work undertaken as part of the CLHB Review, clinical governance and safety concerns for patients who were seriously acutely ill were highlighted by clinicians at LlGH. As a result, changes are required to develop a more robust assessment process which would see an increase in patients being taken to the acute assessment units at both Ysbyty Gwynedd (YG) and Ysbyty Glan Clwyd (YGC) before being transferred back to Llandudno Hospital when deemed clinically safe to do so. The Project Team have further considered the following solutions: Solution 1: No emergency admissions after midnight, but with transfers from YG and Ysbyty Glan Clwyd accepted Solution 2: No emergency admissions after 10pm, but with transfers from YG and YGC accepted Solution 3: No emergency admissions after 6pm, but transfers from YG and YGC, and direct scheduled admissions The Preferred Solution recommended to the Stakeholder Group is: No emergency admissions after 6pm, but transfers from YG and YGC, and direct scheduled admissions This solution would allow emergency admissions from 8am to 6pm, five days a week. In addition transfers of patients from YG and YGC could be accepted outside these hours, once fully assessed and treatment plan agreed, and direct scheduled admissions could be made up until 10pm on agreement between local GPs and senior medical staff at the hospital. At weekends, all emergency medical admissions would go to YG or YGC. Once patients are assessed and stabilised by a consultant, they may be transferred to LlGH. 14/05/10 CJ/LLGH/USC 3 final (V2) SBAR report Cycle 2
The Project Team support this solution, as: It is in line with the recommendations of the CLHB Report which identified clinical governance issues with patients being admitted directly to LlGH who had a medical condition whose care could not be met on site. The report recommended that, The hospital ceases to admit those emergency medical patients whose clinical needs are beyond the agreed safety limits for the hospital. As a consequence the Coronary Care Unit could provide a monitored bed facility for the hospital The medical staffing issues could be resolved at both LlGH and YG, with the need for locums reduced and improved management of rotas; Clinical safety would be improved; The staffing establishments would be more stable; It would allow staff to finish their shift at midnight, caring for scheduled patients admitted up until 10pm with a recognised hand-over period for the next shift; Local GPs would be able to discuss known patients, with chronic disease, with the relevant consultant to agree admissions between 6pm and 10pm during week days. It is also proposed that the Coronary Care Unit (CCU) be redesigned to provide a monitored unit which would reduce the number of patients who require transfer due to deterioration in condition, as their condition may be stabilised with early intervention and acceleration of care. This facility would also allow more sub acute patients to be admitted to LlGH following assessment at YG or YGC. Change of the present CCU to a monitored unit would retain a highly skilled level of nursing staff which would allow access to increased level of nursing care for patients who show signs of acute deterioration, thereby ensuring assessment prior to possible transfer of patient to a higher level of care facility at YG or YGC. Nursing staff from a monitored unit could also provide support throughout the hospital with for example; Advanced Life Support, care of patients who become acutely ill in a ward area, assessment of self presenting chest pains to MIU. These experienced cardiac trained nursing staff could also support the continuation of the cardiac rehabilitation service and the development of a Rapid Access Chest Pain Clinic. A facility such as this would allow stabilised acute patients to be treated at Llandudno Hospital, whilst ensuring the availability of increased assessment and observation/ intervention if their condition deteriorated, prior to transfer to a more critical care facility at another hospital. It would also allow a number of cardiac patients to be transferred back to Llandudno following acute assessment and treatment, therefore reducing some of the potential pressures at other hospital sites. The monitored unit would also ensure that patients with long term chronic conditions who can not be managed at home may be admitted directly to LlGH 14/05/10 CJ/LLGH/USC 4 final (V2) SBAR report Cycle 2
and treated safely within their local area. The benefits of this solution are: clinical safety of patients whose medical condition requires higher dependency care or investigations that are not available or inappropriate for LlGH; reduced bed stay as patients will have all investigations and management plan completed in Medical Assessment Unit prior to transfer to LlGH and prevent inappropriate transfers; compliance with NSF for CHD if patients with chest pain are admitted directly to a DGH with cardiology consultant cover; appropriate, sustainable medical cover which is compliant with European Working Time Directive; the development of a sustainable solution for emergency admissions to LLGH. Whilst the other two solutions considered would resolve some of the current operational difficulties at LlGH, they do not fully address the problems in ensuring appropriate medical staff provision and there would still be a requirement for additional locum consultants. In addition, for solution 1, there would be no clear hand-over period for the next shift, compromising the quality of care being provided. Minor Injuries Unit The Project Team have considered several audits of activity led by Mrs P Cutting, Emergency Department Consultant, Lynn Roberts, Senior Nurse and Malcolm Anglesea, Charge Nurse, as well as the current operational challenges and the MIU service models across Wales. The Project Team have further considered the following solutions: Solution 1: Operate a nurse-led service overnight with no medical support Solution 2: Operate a nurse-led unit with GP medical support Solution 3: Provide a medically led MIU from 8am 10pm Linked to these solutions the Project Team have also considered the provision of services by GPs out of hours as follows: Solution 1: Co-location of GP services with MIU at weekends, from 9am 2pm Solution 2: Co-location of GP services with MIU at weekends, 9am 2pm, appointments only 14/05/10 CJ/LLGH/USC 5 final (V2) SBAR report Cycle 2
Solution 3: Redirect patients presenting with minor illness to GP Out of Hours services The Preferred Solution recommended to the Stakeholder Group is: Provide a medically led MIU from 8am 10pm, with the co-location of GP services with MIU at weekends, from 9am 2pm. This solution would provide the MIU which would be open from 8am 10pm, with a medically led service available during the busiest times of the day, caring for patients up until midnight, and providing a GP out of hours service at LlGH on a Saturday and Sunday from 9am 2pm. This would be a drop-in and appointment service (in line with Wrexham and Bangor). The Project Team support this solution, as: The medical staffing issues could be resolved at both LlGH and YG, with the need for locums reduced; This would help support pressures at YG and YGC during their busiest periods; Both services would compliment each other and patients could be directed to the most appropriate clinician; This responds to public demand for a more local GP out of hours service; This supports the further integration and collaboration of primary and secondary care services. The benefits of this solution are: Increased staffing levels during peak times during the day; Reduced risks associated with difficulties in ensuring appropriate staffing; Enhanced patient care due to increased nurse availability; Improved access to GP out of hours services, for patients presenting with minor illnesses during peak demand; The provision of a more efficient, safe service, responding to staff concerns and ensuring the delivery of a service which addresses current operational problems, gives clarity to patients and their carers, and provides a sustainable solution. In considering the other solutions developed for the MIU, the Project Team felt that these would not deliver the same level of benefits of patient safety and that the demand levels during the night were not sufficient to justify the provision of a nurse-led service or that a GP should be on site. These conclusions are supported by the nursing staff at the MIU. Development of Specialist Day Services Recommendations following the review of at Llandudno Hospital identified patients with medical conditions such as Acute Coronary Syndrome, Cerebral Vascular 14/05/10 CJ/LLGH/USC 6 final (V2) SBAR report Cycle 2
events, and those whose clinical presentation is critically beyond the facilities, should not be admitted during the acute phase of their illness. The resulting impact of changes to the assessment process would see an increase in patients being taken to the acute assessment units at both Ysbyty Gwynedd and Ysbyty Glan Clwyd before being transferred back to Llandudno Hospital when deemed clinically safe to do so. To offset this increased impact of attendance, services which can reduce acute unplanned admissions require local investment to increase avoidable admissions. The Preferred Solution recommended to the Stakeholder Group is: The development of an Assessment and Therapy Unit which would provide comprehensive, multi-disciplinary assessment, treatment and rehabilitation for people with chronic disease and the frail/elderly population (new build facility); The provision of a dedicated immunotherapy/ day care facility; Nurse-led Programmes of Care For Chronic Disease, in particular Heart Failure, Cardiac and Pulmonary Rehabilitation; Provision of Rapid Access Chest Pain Clinics. The Clinic could be nurse led initially under the supervision of the attending Cardiologist until full competencies achieved in the assessment and diagnosis of patients with CHD; Availability of additional nursing/ medical team members if required in an emergency. The benefits are: The provision of a Rapid Access Chest Pain service, would meet target Key Action 10 within the NSF for CHD in Wales; A reduction in the overall unnecessary admissions and length of stay; by for example, being in the right place for diagnostic testing, specialist opinion and quicker decision making by admitting patients directly to Medical Assessment Unit at a DGH; Improved access to short stay day case area for immunotherapy which would improve planned access for patients and ensure more effective use of inpatient medical beds; The day unit/immunotherapy service can be extended to other users that require ward based area for similar treatment procedures; Improved access to active rehabilitation for appropriate patients; Improved seamless service with redesign of working interface with primary care; Continued development and enhancement of staff skills to meet the needs 14/05/10 CJ/LLGH/USC 7 final (V2) SBAR report Cycle 2
of new service design/specialist areas; Cardiac patient condition programmes in line with NICE guidelines and NSF for Cardiac Disease Wales; Improved quality of life for people with heart failure and other chronic conditions. Community Services It is a priority across North Wales to bring care and services closer to people s homes and communities supported by locality working undertaken by primary, community, social care and voluntary services. These services will work together to deliver integrated out of hospital, community based services organised around the needs of the local population. The general objectives of this approach are that the Conwy population will: Remain independent and in their own homes for longer Receive a high quality health and social care service which is equitable, integrated and local. Retain a steady state of health and well-being for as long as viably possible. Receive proactive and preventative health and social care interventions to prevent the onset of ill health, detect any chronic/health condition early or avoid escalation of a health condition or social situation. The new strategic direction for the NHS in Wales is focussed on Locality working, which are defined by populations of between 30,000 and 50,000 although there could be some variation due to the Rural Health Plan (Welsh Assembly Government, 2009). Therefore for Betsi Cadwaladr University Health Board (BCUHB) management and planning purposes there are two Localities in the Conwy county:- Conwy West incorporating the original Rural North, Rural South and Llandudno including Penrhyn Bay. Conwy East incorporating Colwyn Bay, Old Colwyn, Abergele and Kinmel Bay. Underneath this structure it is proposed that the existing 5 sub localities or clusters aligned with social services as identified in the Conwy Community Services Framework will continue for the foreseeable future being: Abergele Colwyn Bay Llandudno 14/05/10 CJ/LLGH/USC 8 final (V2) SBAR report Cycle 2
Rural North Rural South Both Conwy East and Conwy West localities are being developed under the remit of one overarching Localities Steering Group. There will be a Locality Services Coordinator allocated to work as part of the Locality Steering Group to develop and co-ordinate integrated health, social and voluntary sector services. The aim of the multi-agency Localities Steering Group is joint planning, delivery and monitoring of locality services centred around the needs of the individual and population although it is recognised that the needs for each area will differ as will the system for delivering integrated locality working. In terms of supporting Locality development there are certain key elements which will be put into place as identified below: Locality Clinical Lead--Within each of the two Conwy Localities there is requirement to have a GP Clinical Lead to provide clinical leadership and promote a cultural change in the further development of locality working and community services in order to drive forward the improvement agenda. They will be working with the integrated Locality Team to identify opportunities for service change and improvement within the defined locality. As yet in Conwy there are no GP Clinical Leads in post however this is now being addressed on a North Wales basis and it is envisaged GP Clinical Leads will be within each of the localities in the forthcoming months. The Predictive Risk Stratification Tool (PRISM) is a computer-based information tool which utilises inpatient, out patient and GP data in order to sort GP practice populations according to their risk of having an emergency admission in the next twelve months. The Chronic Condition Demonstrator site In North Wales (Gwynedd) is trialling the tool with some of their GP Practices and this learning will be shared across North Wales. To date therefore PRISM has not yet been introduced within the Conwy GP Practices and the readiness activity for this has yet to be undertaken. In the meantime Primary Care and Community Services are being informed of the PRISM Tool and raising awareness in this area is on going. Community Resource Teams--This is an area that requires further understanding, planning and development across North Wales. However, it is recommended within Setting the Direction (WAG, 2009), that community services should be strengthened in terms of capacity and capability and within this should be the establishment of community resource teams. It is suggested that these resource teams should be multidisciplinary in nature, to 14/05/10 CJ/LLGH/USC 9 final (V2) SBAR report Cycle 2
include GPs with advanced skills in clinical assessment and the management of complex needs together with Advanced Practitioners and community based Consultants. This model will also draw on the competencies and skills already available in the community and will need to explore for example admission avoidance schemes, chronic condition case management (currently available in most localities in Conwy) advanced access to diagnostics and enhanced medicine management. The Conwy West Locality has already made some progress in relation to integrated working examples of which are identified below by locality: There is a Joint Working facility, Canolfan Crwst, which has been developed as part of a joint funding stream and the attached Extra Care Housing Facility (Hafan Gwydir) opened with tenants in situ late last year (2009) and has nearly full tenancy occupancy. It accommodates 40 tenancies to include 2 short term care flats accessible to Intermediate Care and Social Services. There is a User Group in place whom will be working on developing the integrated approach at this site. Therapy services are at this site and Child and Adolescent Mental Health services and Podiatry are based on the first floor. There are plans to develop the top floor which is a large space and there are aspirations of looking at this for Leisure and Exercise on Prescription, with the possibility of developing the Health Precinct model. There is also a building in the process of being developed for the GPs. The multi agency team working at Plas Menai Llanfairfechan, adopts an integrated approach and provides high quality, co-ordinated service that are responsive and tailored to the individual s needs within that community in order to promote independence, health and well-being and equity of service. This approach was undertaken as a pilot initially and has undergone a robust monitoring and evaluation process by Bangor University. The development project for Llandudno General Hospital is an important factor to be taken into consideration in terms of planning out of hospital services in the community, therefore the Hospital Manager will be a member of the Conwy Localities Steering Group. There are plans underway for the redevelopment of the Canolfan Yr Orsedd site next to Llandudno General Hospital into Extra Care Housing Accommodation containing 42 apartments and included within this is a Joint Working facility for Health and Social Care staff. This facility is proposed to be ready by March 2012. The four GP Practices will have close links with the joint working aspect at this site. This development needs to be taken into consideration by the Llandudno Hospital Project Team and it is vital that firm links are in place between the two projects in order to ensure the most effective use of resources available. 14/05/10 CJ/LLGH/USC 10 final (V2) SBAR report Cycle 2
Case managers care for patients with chronic conditions who have complex needs and have a history of being admitted to hospital with worsening of their symptoms. The aim of case management is to provide personalised coordinated care and support so that patients can remain safe and healthy in their local community. Patients who have received this service have found it has improved their quality of life and their understanding of their condition. There are currently 4 case managers in post covering Llandudno, Rural North, Rural South and Abergele part of the Conwy East Locality. The Localities Steering Group intends to build and expand on existing developments in Conwy ensuring a cohesive, coordinated and highly organised approach to integrated locality working, and the strengthening of community based services which will eliminate any service fragmentation, assist Hospital Practitioners to have confidence in the availability of alternatives to hospital and ultimately provide better outcomes for the Conwy population as they are receiving quality care and services closer to home. Over the third cycle the Project Team will work closely with the Localities Steering Group to agree specific key deliverables over the next 12 months and beyond. RECOMMENDATION In considering the report, the stakeholders are asked to: Note the progress made; Seek clarification regarding any aspect of the preferred solutions reported; Agree the preferred solutions identified for further consideration in terms of detailed revenue consequences and estates requirements. In addition, given the continued challenges the staff at LlGH face in delivering safe unscheduled care services, the Project Team also recommend that the operational changes presented for emergency admissions and the MIU are implemented during the Summer months. As part of these changes a pilot of the GP Out of Hours weekend provision would also be undertaken. If agreed by the Stakeholder Group and the Project Board, a detailed action plan will be developed and implemented to ensure such changes are made in a coordinated and safe way, with clear communication to the local population, patients, carers and other key partners such as Ambulance Services and Social Services. 14/05/10 CJ/LLGH/USC 11 final (V2) SBAR report Cycle 2