Issue - items at meetings - A&E Service Improvements- Six Month Update

Report with updates from Brighton and Sussex University Hospitals Trust and from the Clinical Commissioning Group

91.1    Chief Executive BSUH Matthew Kershaw reported significant progress, in addressing problems causing capacity pressure in A&E at Royal Sussex County Hospital since the last updates to Committee in April and June this year. Work was still in progress, as anticipated; some of the challenges included areas of work with commissioning partners.

91.2    There had been no breaches of the 12 hour national standard (waiting time from decision to admit, to admission). The 4-hour standard, maintained in May, June and July was missed during August with a performance level of 93% of patients. However the service ‘feels’ very different compared with February and March. Performance levels reflect the fact that the emergency department (ED) is only one part of the process.

91.3    Redesign and reconfiguring was continuing, with the main focus on how best to manage patients, to bring benefits especially before the arrival of winter; eg remove the use of the corridor, do more near the point of arrival at ED, change where people work and get patients to services more quickly.

New appointments were being made in ED and other senior staff including consultants across emergency care.

91.4    Chief Nurse Sherree Fagge  told Members that operational technical assistants were now employed to help clear spaces, releasing nurses’ time to care, and extra nurses had been brought into ‘resuscitation’ More resources were being put into managing patient data. The ratio of trained nurses and healthcare assistants had been increased; this change would be reviewed shortly by a Royal College of Nurses colleague for reassurance. Following the CQC visit, privacy/dignity was being improved eg the plaster room and corridor were not now being used as waiting areas. There was more focus on safety and quality. For instance ‘comfort rounds’ were in place and there were new processes in place to monitor and reduce the number of falls.

91.5    Mr Kershaw pointed out that attendance and admission levels remain high and ‘spikes’ were challenging. Spikes in both minor and major cases had made early September particularly challenging to manage. A recent flood had also removed the emergency theatre capacity for a whole day which had caused a backup of patients.

Improvements from new rotas being implemented in September/October will start to flow through the hospital shortly, Mr Kershaw said.

91.6    Managing of discharges each day was critical, the aim being to bring forward the time of discharge earlier in the day to benefit not only the patient, but the hospital and partner colleagues. Changes were being introduced in cover between 8pm and midnight to help reduce number of patients waiting for discharge later in the day. Unusually for a UK hospital, the ED does have consultant cover after midnight.

91.7    Dr Christa Beesley, Clinical Accountable Officer, CCG, set out the improvements designed to integrate with these BSUH workstreams. Integrated Primary Care Teams nurses (IPCTs) were being introduced that included using a risk stratification process. This helped identify potential patients/service users who would benefit most from integrated social care and health front-line services. Mental health workers were being recruited to the IPCTs to work with patients eg with dementia, schizophrenia or drug-related issues.

This work would reinforce Primary Care teams and would be shared by up-loading patients’ care plans with ambulance services. A Community Rapid Response service was also being introduced to help support patients and families and a rapid access clinic will enable timely diagnostics eg CT scan for older people and the frail, including the homeless and those in hostels.

91.8    In Brighton & Hove, the number of calls for an ambulance is not increasing but an ambulance is very likely to take a caller to hospital. This means that more people are being taken to hospital by ambulance, even if they could be dealt with elsewhere. The ‘hear/treat’ system for paramedics and ambulance technical crews was working well to help address this issue.

For those who do need admission, treatment and discharge is then important. More patients now go home with rehabilitation in place, so reducing the demand on beds. Dr Beesley affirmed that beds were not being closed; greater use of home care is better for all.

The Urgent Care clinical forum is taking the lead on bolstering services where frontline staff say they are needed.

91.9    A communications campaign is being planned on how to get the best care. This would include how to identify real A&E emergencies such as chest pain, meningitis etc. and promote alternatives for non-A&E services. Everyone wanted to use the right services and all can help by asking – is an urgent need actually an A&E need?

91.10  The speakers answered Members’ questions;

• It is the staff supporting patients in hospital who jointly make a decision on the homecare that a person needs on being discharged. The Board round for every patient is one part of this process. Some patients unfortunately do get readmitted.
• The 111 service that locally was ‘rocky’ initially is now achieving its targets. We need to ensure that all the pathways are appropriate.
• Mental health patients, carers and staff are becoming more aware of dedicated rapid response alternatives to A&E for their urgent care. However it is taking time for increased awareness and changed behaviours.
• Consultants are resident in the ED, though not full-time. At night time 2am or 3am can sometimes be as busy as 3pm. Staffing of ED is a balance between not only providing the right cover for the sickest patients but also not creating an unnecessary dependency in circumstances where treatment is better provided elsewhere. There is more to do to provide a consistent service all through the week. This is not just a case of ‘doing more.’
• More GP hours are needed; however this would have to be on a voluntary basis. GPs do work out of hours and are already at the ‘front end’ of A&E. There are walk-in medical centres; whether one is best sited next to A&E is under discussion.
• Flu vaccinations are being encouraged for hospital staff and made easier to get. There is a plan for staff including night staff and weekend staff, to receive the vaccine as soon as it is available.
• Mr Kershaw receives performance results from A&E at the Royal Alexandra unit. Children were discharged almost entirely within 4 hours and there is generally very positive feedback on children’s A&E, from patients and parents.
• There is no single reason for spikes in arrivals at ED. Spikes can be very significant. Around 90 ambulance arrivals would be expected per day, that can be as many as 149. In summer these are driven by surgical rather than medical emergencies; in winter it is the opposite. Surgical emergencies did not initially seem to be problematic. It is not straightforward; there is no single answer.
• Preparations can be made for large festival events, eg directing people to walk-in centres. It’s important to ask people not to go to A&E if they don’t need to.
• The aim is to discharge patients home in time for lunch. This is good for the patient and good for the future hospital case; arranging transport and prescriptions gets difficult when patients back up towards 8pm. That means staffing levels and processes need very careful management. It was a small factor that some staff were away at times in August and September but the main issues are the fluctuations in demand on the service. The ED is not perfect but it is improving.

91.11  The system had just received an additional £2.3million for health and social care provision this winter. This would enable extra cover including A&E theatre and nursing care.

91.12  HWOSC Members heard that a weekly message from the Chief Executive is published and is available through the following link http://www.bsuh.nhs.uk/about-us/trust-communications/chief-executives-message/

91.13  At the request of the OPC co-optee, HWOSC asked for further information on action on preventing falls on ice following the Winter Service Plan scrutiny review.

91.14  On behalf of HWOSC the Chair Councillor Sven Rufus thanked all the speakers and asked for an update as necessary.