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SPRING 2018 SEVEN DAY SERVICES SURVEY: SUPPORTING INFORMATION

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CONTENTS

ABOUT THE SURVEY

USEFUL LINKS

IMPORTANT DATES

A. SURVEY TIMESCALES

B. ‘HOW TO’ SUPPORT WEBINARS

C. HELP AVAILABLE TO COMPLETE THE SURVEY

CHANGES SINCE THE AUTUMN 2017SEVEN DAY SERVICES SURVEY

OPTIMISING SURVEY PROCESSES

PROVISION FOR CONSULTANT REVIEW

CLINICAL STANDARD 5: ACCESS TO CONSULTANT DIRECTED DIAGNOSTICS

CLINICAL STANDARD 6: CONSULTANT DIRECTED INTERVENTIONS

1.

2.

3.

4.

5.

6.

7.

CLINICAL STANDARD 2: FIRST CONSULTANT REVIEW

CLINICAL STANDARD 8: ONGOING REVIEW

FREQUENTLY ASKED QUESTIONS (FAQs)



8.

9.

10.

CLINICAL STANDARD 6: CONSULTANT DIRECTED INTERVENTIONS



GENERAL

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7 Day Services Self Assessment Tool Survey Log- in and Registration

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WR i+ i +il'f-N MiHi:I Don't have ,m account or forgotten your pas!.word? Click the rele vant button above.

Timetable for the Next 7DS Self-Assessment Survey Current bulletin: gl NHS Imp rovemen t Provider bulletin: 2 Augus t 2017 Previous bulletin: l!:l NHS Im rovement Provider bulletin: 28 June 2017

Data collection period 1~at: (one con!.ecuti v e 5even day per i od within thi!io wind o w) co t~~on

Data submission date

Wednesday 11 Apri l - Wednesday 9 May 2018 6 wee ks Wednesday 20th June 2018

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User Guide

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CLINICAL STANDARD 6: CONSULTED DIRECTED INTERVENTIONS


FAQs ABOUT THE SURVEY

INTRODUCTION IMPORTANT DATES CHANGES SINCE THE AUTUMN 2017 SURVEY OPTIMISING SURVEY PROCESSES

INTRODUCTION This supporting information has been developed to provide guidance on the questions in the seven day services survey. Further information and guidance is available throughout the document to enable more detail to be accessed about each question if required.

Useful links These documents, hosted on the 7DSAT supporting information page at www.7daysat.nhs.uk provide further useful information to help you to undertake this survey. They can be accessed by clicking on the ‘Resources and FAQs’ tab at the bottom of the log-in page.

• What can I do in preparation for the Spring 2018 Survey? • 7DSAT user guide: registering and approving • Spring 2018 7-day services survey questions • NHS Data Dictionary.

When new information is added to the resources page, you will be alerted by a pop-up box. When you log in the date each document was updated will also be displayed on the resources screen.

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http://www.7daysat.nhs.uk

https://www.7daysat.nhs.uk/fsresources.aspx

https://www.7daysat.nhs.uk/fsuserguide.aspx

https://www.7daysat.nhs.uk/fsresources.aspx

http://www.datadictionary.nhs.uk/data_dictionary/attributes/a/add/admission_method_de.asp

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IMPORTANT DATES Survey timescales

This survey is intended to provide a snapshot of progress between April 2018 to May 2018, with data submission on 20 June 2018. The 6 week data collection period is as follows:

Data collection period (one Data Data submission consecutive seven day period collation date within this window) time

Wednesday 11 April - Wednesday 6 weeks Wednesday 20 June 9 May 2018 2018

Where to fnd help to complete the survey

There are a number of ways you can get help to understand and complete the survey: • Visit www.7daysat.nhs.uk use the contact link for technical

support • Call the telephone helpline (to be confrmed). This is available

between 9am and 5pm. You can use this number for both technical and clinical/survey questions related queries.

• Go to the resources section of the 7DSAT website where survey user guides, supporting information, the questions for the survey and the clinical standards document are available.

• Contact your regional sustainable improvement teamlead using [email protected] stating which trust you work for and how you need support.

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CHANGES SINCE THE AUTUMN 2017 SEVEN DAY SERVICES SURVEY The key changes to this autumn 2017 survey are:

• This iteration of the survey once again focuses on all four priority clinical standards.

• The defnition of a consultant for clinical standard 2 includes doctors on the General Medical Council Specialist Register who are eligible to become consultants, but not doctors who have yet to complete training.

• Stroke patients admitted on a stroke pathway may be excluded from the need for frst consultant review if specifc criteria are met. This criteria has been expanded to give more detail for those stroke patients who are at low-risk of mortality (<10% in frst 72 hours).

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intheprovisionof 7 dayhosp ita l care auainsttheclinicalstand ar dsfor 7 dayservic es. The70SATwillenableyouto assessyourcurrentle ve lof serviceprovision,r;na tionall yag reeddefinltion sandhelpyoutounders tand )'ourloca l needsandrequirementstodeliver7dayservices.

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7DS Survey: Sample Size Calculator - ~ ReturntoHomeScrnen

Prov,sK>n to, Conwltanl Dffe<:ted Conwhant Oo,ected Pabenl Cons11ltan1Rew1w D,agnoshcs lnterven~ons Data --· Oet,iils of Your Ca se Note Review S,irnp le Size - Trust D,it ,i

For further information on how to calculate your sample size, elide on this link ": How to calculate your samp le size

Effective!><!mpling

This round of thesurveyisforclink a l st a nda rd 2onty. Patients who wou ld be excluded from clinica l standard 2 should be exclud ed from the sampl e completely. PAS data alor,e will not e nable identification a ll of th e case notes th at should be excluded from the survey. To compensate, reques t more case notes than the sample calculator Indicates to allow for exclusions, and unavailable notes

Previousroundsofth e surveyh aveshownthatsuccessinthes a mpling processismorelikelyif:

• Thereisaleadpersonresponsibleforcalculatingthesamplesizeandkeepingtrackofnotesused/notesexcluded,andwhothe noteshavebeengiventoforda taentry . • There is a proces s tocheckthenotes before they are reviewedtohelpkeeptrackofnolesordered and then exclud ed. • If the case note record lsstartedonthe7DSATcentrallyanda separate record ofthetrust'sunlquepatientldentiflerls kepi centrallytohelpkeeptrackofnotesallocatedtocliniciansfordataentry

Check the information on exclusions from the survey to be dear on which note s can be readily excluded by reviewing th e samp le calculationsectionin "'l. 7DayServicesSurveySupporting Information Spring 2017 .

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OPTIMISING SURVEY PROCESSES Calculating your sample size The number of case notes each trust should review is based on trust-specifc weekly emergency admission rates. It has been calculated on the minimum number of case notes a trust needs to review to show whether the standard is being met.

How do we access the calculator to work out our sample size and sampling methodology? The sample size can be calculated using the sample size calculator, in the 7DSAT. To access this calculator:

• Log in to the 7DSAT at www.7daysat.nhs.uk • Click on the ‘Enter Data’ button (top left) • Click on the ‘trust data and sample size calculator’

button (far left).

The sample calculator will default to a minimum sample size of 50 patients for those trusts with few emergency admissions, particularly specialist hospitals. In these situations all of the patients admitted as an emergency during the defned week that meet the inclusion criteria should be included.

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Frequently asked questions Why does every trust undertake a different number of case note reviews? How do we use the calculator to work out our sample size and sampling methodology? What does my sampling size methodology mean? What if the randomisation suggests we survey more patients than are admitted on that day? What if patients need to be excluded once the sample size has been selected? How do we use the tool to calculate the sample size by site? Can you provide an example of a sample size calculation by site?

Effective sampling It is diffcult from the PAS data alone to identify all of the case notes that should be excluded from the survey, so it makes sense to request more case notes to review than the sample calculator indicates to allow for exclusions, and for notes being returned before completed or unavailable.

Having a process in place for a quick check of the notes before they are sent out to clinicians will help with keeping a track of which notes are included in the survey. Check the information on exclusions from the survey to be clear on which notes can be readily excluded.

Keep a separate record of the unique patient identifer your trust uses and which number this patient is assigned on the 7DSAT. Success in this process is more likely if there is a lead person responsible for calculating the sample size and keeping track of notes used/notes excluded, and who the notes have been given to for data entry.

A review of the number of case notes entered about half way through the survey process will help to ensure the sample size is on track to meet the calculated number required.

A more detailed description of sampling methodology including calculating by site and examples can be found here.

Exclusions from this round of the survey The following groups of patients admitted as an emergency are those for whom a review by a consultant within 14 hours of hospital admission is not usually necessary, and should be excluded from the survey:

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Exclusions from this round of the survey (continued) • Patients who are admitted as an emergency but who stay in

hospital for fewer than 14 hours from admission. • Patients admitted to a short stay ambulatory care unit

who typically stay for only a few hours before transfer to community-based care e.g. most patients with DVT. Trusts should follow National Institute of Health and Care Excellence (NICE) recommended pathways for further guidance. If the guidance doesn’t include a consultant review then the 14 hour consultant assessment standard will not apply.

• Patients on an inpatient pathway on which care for the entire patient group is, by design, routinely delivered by non- consultants, such as maternity patients under midwifery led care. Detailed information on the criteria affecting the inclusion of this patient group can be found here

• Neonates unless for medical reasons they have an unplanned admission to a ward or to a special care baby unit and have a length of stay of longer than 14 hours.

• Stroke patients admitted directly onto the stroke pathway because they have a clear stroke diagnosis and will appropriately have their frst clinical review by a stroke specialist doctor, or stroke specialist nurse or advanced practitioner. This is not a blanket exclusion for all patients with stroke. Detailed information on the criteria affecting the inclusion of this patient group can be found here

• Please follow the National Institute of Health and Care Excellence (NICE) recommended pathways, so if the guidance doesn’t include a consultant review then the 14 hour consultant assessment standard does not apply.

• Patients admitted to emergency care settings that do not have consultant leadership such as GP-led inpatient units as their review will be undertaken by the unit’s appropriate senior clinician.

Specifc advice for specialist hospitals In principle all specialist hospitals that take emergency admissions via any route, not just through an emergency department, should participate in the survey. The survey aims to measure provision of consistent, high quality care seven days a week and applies equally to patients admitted to specialist trusts as an emergency. Patients transferred to a specialist hospital at the weekend should not need to wait until Monday to be frst reviewed by the consultant.

The transfer of inpatients from a district general hospital to a specialist hospital may constitute an emergency admission even in the absence of an emergency department. Specialist orthopaedic hospitals may for example take people for emergency treatment such as spinal surgery following trauma or to treat metastatic disease causing cord compression.

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The need for early and subsequent consultant review remains clinically appropriate and the involvement of consultants is arguably even more important in the highly specialised environment, particularly for the recognition, timely management and transfers of patients with conditions such as: vascular complications of orthopaedic surgery, inpatient myocardial infarction, stroke, gastro-intestinal bleed or development of acute abdomen.

Patients should be included in the survey when they are transferred to the specialist trust for a procedure which cannot be provided anywhere else. Their care effectively starts on admission to the specialist trust, or the admission starts a whole new episode of care starting with the initial review by a consultant.

Where a patient is transferred to the specialist trust as a continuation of their pathway of care, have already been seen by the specialist consultant or are already under their care, and are being transferred to a particular specialist hospital for a specifc procedure or management plan, then they may potentially, not be included within the survey. However, a new patient to the hospital should still be seen by a consultant, ideally on the day of arrival or as a priority the next day.

Ensuring the data refects service provision Some key factors related to the process used by the trust to complete the survey can make around a 10% difference in measureable achievement of the clinical standards, particularly those related to the case note reviews. These are:

• Using a robust process for selecting the case notes for the sample, including having a member of the team in a co-ordination role for the sampling process, keeping track of the case notes, keeping a list of the patients’ unique hospital identifers alongside the 7DSAT patient identifcation numbers, and being aware of progress towards meeting the sample size allocation.

• Ensure one member of the team is knowledgeable about the survey, familiar with the detailed supporting information and in how to contact the national and regional seven day services team for advice and support. This person should be the co-ordinator for the survey, and the frst point of contact for questions in the trust. This could be the same person who is responsible for the survey sampling.

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• Senior clinical involvement and support in the survey process. Experience and information from previous surveys shows that having senior clinical involvement in the case note reviews from the outset improves the accuracy of the reviews. This could range from the senior clinician being regularly available or contactable to advise more junior staff, medical students, and clinical auditors, to the clinician being in the same room as the people carrying out the reviews or doing them in person.

• Data validation by a senior clinician for all notes where the standards do not appear to have been met. Setting aside notes for further review that appear to indicate a patient wasn’t reviewed within 14 hours of arrival has several benefts. Trusts that have done this have found improvements in their achievement of the standard as inappropriate case notes, such as those for elective admissions, have been removed and unclear information about the review has been clarifed. Trusts have also found a clinical beneft in the raised awareness in specialties where the consultant has not reviewed patients within 14 hours or who have not carried out subsequent reviews.

• Missing or incorrect data recording in the case notes remains a signifcant reason for low achievement of clinical standards 2 and 8 for some trusts. A continued focus on documentation standards could better refect the trusts position for consultant reviews. This particularly applies to date and time entries and recording of the status and delegation of the doctor who has reviewed the patient. Some trusts have found that named consultant date stamps have improved this particular recording issue.

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ABOUT THE PROVISION FOR CONSULTANT REVIEW

CLINICAL STANDARD 5: CLINICAL STANDARD 6: CLINICAL STANDARD 2: CLINICAL STANDARD 8: FAQs SURVEY ACCESS TO CONSULTANT CONSULTED DIRECTED FIRST CONSULTANT ONGOING REVIEW

DIRECTED DIAGNOSTICS INTERVENTIONS REVIEW

PROVISION FOR CONSULTANT REVIEW This question has been included to determine the provision for consultant review within your trust, particularly for patients in specialties for which your trust makes no acute provision.

It is asked once at trust level and should be completed in conjunction with a trust operational lead or medical director with a good understanding of provision of consultant ward rounds and arrangements for obtaining advice from specialties for which your own trust makes no acute provision.

Frequently Asked Questions

• What is a ‘formal arrangement’? • When is it appropriate to obtain specialist advice via the telephone?

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ABOUT THE PROVISION FOR CLINICAL STANDARD 5: ACCESS TO CONSULTANT DIRECTED DIAGNOSTICS

CLINICAL STANDARD 6: CLINICAL STANDARD 2: CLINICAL STANDARD 8: FAQs SURVEY CONSULTANT REVIEW CONSULTED DIRECTED FIRST CONSULTANT ONGOING REVIEW

INTERVENTIONS REVIEW

CLINICAL STANDARD 5

ACCESS TO CONSULTANT DIRECTED DIAGNOSTICS

ACCESS TO DIAGNOSTICS

STANDARD 5

Hospital inpatients must have scheduled seven-day access to diagnostic services, typically ultrasound, computerised tomography (CT), magnetic resonance imaging (MRI), echocardiography, endoscopy, and microbiology. Consultant-directed diagnostic tests and completed reporting will be available seven days a week:

• Within 1 hour for critical patients • Within 12 hours for urgent patients

Information about clinical standard 5 will be collected using two questions • A self-assessment question on the availability of consultant directed diagnostics either

on-site or via a formal arrangement or protocol. • A self-assessment of the availability of urgent inpatient CT slots on a weekday and a

weekend day.

These questions should be completed by a trust operational lead who is fully aware of the provision and availability of these interventions in the trust.

Acute trusts should use their clinical governance processes and discussions with their commissioners to judge which diagnostic tests their patients require access to seven days a week, and whether these are delivered on site or via a formal networked arrangement.

A ‘Yes’ response should only be given to the availability of tests question if there is confdence that patients who are likely to need the test would be very likely to get the test and it will be reported in time if they arrived at the trust during the period in question.

Frequently Asked Questions • What is critical clinical need? • What is urgent clinical need? • For which patients might these diagnostic tests be indicated? • What is a formal network arrangement? • What are informal or ad-hoc arrangements?

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ABOUT THE PROVISION FOR CLINICAL STANDARD 5: CLINICAL STANDARD 6: CONSULTED DIRECTED INTERVENTIONS

CLINICAL STANDARD 2: CLINICAL STANDARD 8: FAQs SURVEY CONSULTANT REVIEW ACCESS TO CONSULTANT FIRST CONSULTANT ONGOING REVIEW

DIRECTED DIAGNOSTICS REVIEW

CLINICAL STANDARD 6

CONSULTANT DIRECTED INTERVENTIONS

ACCESS TO KEY SERVICES/INTERVENTIONS

STANDARD 6

Hospital inpatients must have timely 24 hour access, seven days a week, to key consultant-directed interventions that meet the relevant specialty guidelines, either on-site or through formally agreed networked arrangements with clear written protocols. These interventions would typically be:

• Critical care • Interventional radiology • Interventional

endoscopy • Emergency general

surgery • Emergency renal

replacement therapy

• Urgent radiotherapy • Stroke thrombolysis • Percutaneous Coronary

Intervention • Cardiac pacing (either

temporary via internal wire or permanent)

This standard gathers information as below:

Information about clinical standard 6 will be collected as a self-assessment question on the availability of interventions either on-site or via a formal arrangement or protocol. This question remains the same as that used in previous surveys for this standard.

This question should be completed by a trust operational lead who is fully aware of the provision and availability of these interventions in the trust. The principle is that patients should receive urgent interventions within a timeframe that does not reduce the quality of their care (safety, experience and effcacy).

Acute trusts should use their clinical governance processes and discussions with their commissioners to judge which of the agreed list of clinical interventions their patients may require access to seven days a week and whether these are delivered on site or via a networked arrangement.

Frequently Asked Questions • What is the defnition of a formal network arrangement? • What is an informal or ad-hoc arrangement?

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ABOUT THE PROVISION FOR CLINICAL STANDARD 5: CLINICAL STANDARD 6: CLINICAL STANDARD 2: FIRST CONSULTANT REVIEW

CLINICAL STANDARD 8: FAQs SURVEY CONSULTANT REVIEW ACCESS TO CONSULTANT CONSULTED DIRECTED ONGOING REVIEW

DIRECTED DIAGNOSTICS INTERVENTIONS

CLINICAL STANDARD 2

FIRST CONSULTANT REVIEW

TIME TO FIRST CONSULTANT REVIEW

STANDARD 2 Data in this section is collected from case notes at a patient level, for a defned sample based on the number of emergency admissions seen by the trust.

Specifc advice for the exclusion of obstetrics patients from the survey Patients on maternity units who wouldn’t for clinical reasons usually require consultant involvement in their care, and are receiving midwife led care only can be

All emergency admissions must be excluded from the survey. This would apply to: seen and have a thorough clinical

• Women who are expected to have routine labours with no complications assessment by a suitable consultant as • Women with a medical condition in whom there has been a prior agreement soon as possible but at the latest within

that midwife led care is clinically appropriate e.g. spontaneous labour at term 14 hours from the time of admission to with a known medical complication but clear plan for labour already made. hospital

Where it is identifed that consultant involvement is needed in the woman’s care1, they should be included in the requirement for frst consultant assessment within 14 hours and for daily consultant review until they are transferred back to midwifery care. In these situations the patient’s admission time would become the point at which the patient moved to consultant led care.

1 Royal College of Obstetricians and Gynaecolegists. Good Practice No.8. March 2009 www.rcog.org.uk/globalassets/documents/guidelines/goodpractice8responsibilityconsultant.pdf

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Consultants would be expected to review the patients with the following conditions within 14 hours of admission: • Eclampsia • Maternal collapse (such as massive abruption, septic shock) • Caesarean section for major placenta praevia • Postpartum haemorrhage of more than 1.5 litres where

the haemorrhage is continuing and a massive obstetric haemorrhage protocol has been instigated

• Return to theatre – laparotomy • When requested.

Procedures where the consultant should attend in person or should be immediately available if the trainee on duty has not been assessed and signed-off as competent for the procedure in question are: • Vaginal breech delivery • Trial of instrumental delivery in theatre • Twin delivery • Caesarean section at full dilatation • Caesarean section in women with body mass index greater

than 40 • Caesarean section for transverse lie • Caesarean section at less than 32 weeks of gestation.

Specifc advice for the exclusion of stroke patients from the survey Stroke patients admitted directly onto the stroke pathway because they have a clear stroke diagnosis and will appropriately have their frst clinical review by a stroke specialist doctor, or stroke specialist nurse or advanced practitioner may be excluded from the survey. This is not a blanket exclusion for all patients with stroke and is dependent on the trust protocol being explicit that:

• The option of a face to face review with the consultant physically present always remains available for patients with complex needs.

• All straightforward, uncomplicated stroke patients are discussed with the consultant by telephone or in a telemedicine consultation. This should apply to all stroke patients and not just those deemed appropriate for thrombolysis or thrombectomy.

• The brain imaging should be reviewed within the hour, remotely if appropriate, by a consultant level radiologist or stroke physician.

• The trust should operate a minimum of seven days a week consultant level ward rounds so all patients should be seen by the consultant within a maximum of 24 hours.

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• NEW: For clinical standard 2, confrmed acute stroke patients Where the information is not available in the case notes or with a low risk of mortality (<10% in the frst 72 hours) can be related documentation, the ‘not documented’ option should be reviewed by a consultant within 14 hours of admission using selected from the response options in the survey. By defnition either tele-medicine (via a video link) or by telephone. This the time of the discussion about the consultant review should be should be followed by a face to face consultant review within after the review has taken place. 24 hours of admission.

• NEW: Each acute trust which admits acute stroke patients Frequently asked questions should confrm that this guidance is in operation through the • What is meant by hospital admission? creation of a local written protocol agreed by the trust Medical • What if the time of the consultant review is before the patient Director. is admitted?

• What is the defnition of the consultant for clinical standard 2? Informing the patient of the review Patients, and where appropriate carers and families, must be made aware of consultant reviews. The patient should be informed of discussions about initial review, which may include the diagnosis, management plan and prognosis. Documentation that discussions about the review have taken place with the patient, carers or family should be clearly recorded in the notes, and where a decision is made that discussion with the patient or family is not appropriate, this should also be recorded.

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ABOUT THE PROVISION FOR CLINICAL STANDARD 5: CLINICAL STANDARD 6: CLINICAL STANDARD 2: CLINICAL STANDARD 8: ONGOING REVIEW

FAQs SURVEY CONSULTANT REVIEW ACCESS TO CONSULTANT CONSULTED DIRECTED FIRST CONSULTANT

DIRECTED DIAGNOSTICS INTERVENTIONS REVIEW

CLINICAL STANDARD 8

ONGOING REVIEW

ONGOING REVIEW

8STANDARD

All patients with high dependency needs should be seen and reviewed by a consultant TWICE DAILY (including all acutely ill patients directly transferred and others who deteriorate). Once a clear pathway of care has been established, patients should be reviewed by a consultant at least ONCE EVERY 24 HOURS, seven days a week, unless it has been determined that this would not affect the patient’s care pathway.

Data in this section is collected from case notes at a patient level, for a defned sample based on the number of emergency admissions seen by the trust.

Frequently Asked Questions • What is the defnition of a consultant for clinical standard 8? • How should the frequency of consultant reviews be determined? • What are the Intensive Care Society defnitions of levels of care? • What are the Paediatric Intensive Care Society standards for the care of critically ill

children? • What is the purpose of consultant reviews? • How long after admission should reviews be recorded for the purposes of the

survey? • When can individual patients be excluded from the requirement for the daily

consultant review? • Which units or wards are excluded from the requirement for daily consultant

reviews? • When can the daily consultant review be delegated? • Which patients should not have the daily consultant reviews delegated? • Informing the patient of the review.

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PROVISION FOR CONSULTANT REVIEW STANDARD 5 STANDARD 6 STANDARD 2 STANDARD 8







GENERAL

FREQUENTLY ASKED QUESTIONS

Provision for Consultant Review

What are formal and informal arrangements for provision of consultant review? A formal arrangement with another trust or organisation to carry out the consultant review using a robust and transparent process for timely clinical assessment and if needed patient transfer between sites.

Informal and ad-hoc arrangements are where patients are reviewed by a consultant by asking a favour of a colleague, through a system of phoning around to seek availability, or another arrangement which is not defned, documented and agreed by all parties.

When is it appropriate to obtain specialist advice via the telephone? Where a specialty has an inpatient service it is expected that a consultant will attend the hospital every day to review the inpatients (with delegation permitted as described above) and see any urgent new referrals. Most sites have all or most of the ten key specialties which include the majority of patients.

Where a specialty has no in-patient service at a hospital there should be an established system for clinicians to obtain urgent specialist advice by telephone every day of the week, for example where an urgent neurology opinion is needed on a medical patient in a district general hospital with no inpatient neurology service.

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GENERAL


Clinical Standard 5: Access to Consultant Directed Diagnostics

What is critical clinical need? Critical patients are considered those for whom the test will alter their management at the time. These are patients whose condition would be life-threatening if they did not have rapid access to diagnostic tests, leading to the implementation of a management plan within a few hours.

What is urgent clinical need? Urgent patients are considered those for whom the test will alter their management but not necessarily that day. These are patients whose condition is not critical, but if care was postponed for more than 12 hours it may impact adversely on their clinical outcomes.

For which patients might these diagnostic tests be indicated? Echocardiograph might be indicated for new presentation with suspected acute heart failure, valvular dysfunction, pericardial effusion Upper GI endoscopy might be indicated for acute upper GI bleeding. MRI might be indicated for patients with suspected acute spinal cord compression and some types of stroke. Ultrasound might be indicated for assessing acute abdominal pain such as when suspect acute cholecystitis, and for urgent need in maternity and early pregnancy.

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GENERAL


What is a formal network arrangement? Formal arrangements with another trust or organisation to carry out the test or the reporting of the test exist when there are established protocols formally agreed between the relevant organisations, including: • A robust and transparent process for timely clinical assessment

and patient transfer between sites • A published rota populated with consultant names and contact

details and, • Documented protocols which are available as part of the

assurance process. • Regular audit of such processes to ensure that transferred

patients receive timely high quality care.

A networked approach may involve patient transfer, image transfer or diagnostician in-reach.

What are informal and ad-hoc arrangements? Arrangements where patients are transferred for the test or reports are requested by asking a favour of a colleague, through a system of phoning around to seek availability or another arrangement which is not defned, documented and agreed by all parties.

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GENERAL


Clinical Standard 6: Consultant Directed Interventions

What is the defnition of a formal network arrangement? What are informal and ad-hoc arrangements? Formal arrangements with another trust or organisation to carry out These are arrangements where patients are transferred for the the intervention exist when there are established protocols formally intervention or reports are requested by asking a favour of a agreed between the relevant organisations including colleague, through a system of phoning around to seek availability • A robust and transparent process for timely clinical assessment or another arrangement which is not defned, documented and

and patient transfer between sites agreed by all parties. • A published rota populated with consultant names and contact

details and, • Documented protocols which are available as part of the

assurance process. • Regular audit of such processes to ensure that transferred

patients receive timely, high quality care.

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GENERAL


Clinical Standard 2: First Consultant Review

What is meant by hospital admission? The point at which a patient starts the hospital provider spell and the frst consultant episode. It is the time which the patient goes into a hospital bed on their frst ward under the responsibility of one or more consultants. The time of admission may be before formal admission procedures have been completed.

What if the time of the consultant review is before the patient is admitted? It may be clinically appropriate for the patient to be reviewed by the specialist consultant once decision to admit has been made, and prior to hospital admission. In these cases the time of this frst consultant review should be recorded even if its prior to the time of admission.

What is the defnition of the consultant for clinical standard 2? The defnition of a consultant for clinical standard 2 includes doctors on the General Medical Council Specialist Register who are eligible to become consultants, but not doctors who have yet

to complete training. This applies even for doctors not yet in a consultant post. This is not a signifcant change from the previous defnition and recognises the completion of training of this specifc group and their appropriateness to carry out the frst consultant review.

A suitable consultant is one who is trained and competent in dealing with emergency and acute presentations in the specialty concerned and is able to initiate a diagnostic and treatment plan.

Consultants need adequate support seven days a week from an appropriate team of healthcare professionals to ensure patients receive good quality care. Junior doctors involved in providing urgent and emergency care should have prompt access to consultant support and advice including a consultant presence on site every day to optimise opportunities for training and clinical supervision.

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Clinical Standard 8: Ongoing Review

What is the defnition of a consultant for clinical standard 8? Consultants in this context are defned as doctors on the Specialist Register, CCT-holders and those recognised as being equivalent in the view of the relevant Royal College. These senior decision-makers have a crucial role, not just in identifying and dealing with clinical issues but also in communication with patients and relatives, in taking active and appropriate decisions about discharge from hospital, and in providing support and supervision and education to junior clinical colleagues.

The term ‘consultant’ is maintained because it is believed that this is a term broadly understood by doctors and the public. This description of the consultant is included in this supporting information, to align the standard with professional opinion, and provide clarity on which senior doctors could provide ongoing review without compromising patient safety.

How should the frequency of consultant reviews be determined? Clinical judgement should be used to determine frequency of consultant review required, but as a guide patients with Intensive Care Society levels of care of 2 (level 3 for Paediatric Intensive Care Society standards) and above may require twice daily review, and patients with care needs of below level 2 (3 for paediatrics) may only require once daily review. These levels of need should be used rather than the patients’ geographical ward location in the hospital.

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What are the Intensive Care Society defnitions of levels of care? These can be accessed by clicking the hyperlink above, an abridged version is given below:

Intensive Care Society Levels of Critical Care for Adult Patients (ICS 2009)

Level 0 Patients whose needs can be met through normal ward care in an acute hospital.

Level 1 Patients at risk of their condition deteriorating, or those recently relocated from higher levels of care, whose needs can be met on an acute ward with additional advice and support from the critical care team.

Level 2 Patients requiring more detailed observation or intervention including support for a single failing organ, post-operative care and those ‘stepping down’ from higher levels of care.

Level 3 Patients requiring advanced respiratory support alone or basic respiratory support together with support for at least two organ systems. This level includes all complex patients requiring support for multi organ failure.

What are the Paediatric Intensive Care Society standards for the care of critically ill children? These can be accessed by clicking the hyperlink above, an abridged version is given below:

Level 1 High Dependency Care requiring nurse to patient Ratio of 0.5:1 (1:1 if in a cubicle). Close monitoring and observation required but not requiring acute mechanical ventilation.

Level 2 Intensive Care requiring a nurse to patient ratio of 1:1. A child requiring continuous nursing supervision who is usually receiving advanced respiratory support, i.e. intubated and ventilated or receiving BiPAP. Also the unstable non-intubated child, for example some cases with acute upper airway obstruction who may be receiving nebulised adrenaline. The dependency of a level 2 patient increases to level 3 if nursed in a cubicle.

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https://www2.rcn.org.uk/__data/assets/pdf_file/0005/435587/ICS_Levels_of_Critical_Care_for_Adult_Patients_2009.pdf

https://www2.rcn.org.uk/__data/assets/pdf_file/0005/435587/ICS_Levels_of_Critical_Care_for_Adult_Patients_2009.pdf

http://picsociety.uk/wp-content/uploads/2015/10/PICS_Standards_Appendix_2010.pdf

http://picsociety.uk/wp-content/uploads/2015/10/PICS_Standards_Appendix_2010.pdf

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Level 3 Intensive Care requiring nurse to patient ratio of 1.5:1. The child requiring intensive supervision at all times who needs additional complex therapeutic procedures and nursing. For example, unstable ventilated children on vasoactive drugs and inotropic support or with multiple organ failure. The dependency of a Level 3 patient increases to Level 4 if nursed in a cubicle.

Level 4 Intensive care requiring a nurse to patient ratio of 2:1 Children requiring the most intensive interventions such as particularly unstable patients, Level 3 patients managed in a cubicle, those on ECMO, and children undergoing renal replacement therapy.

What is the purpose of consultant reviews? The purpose of the consultant review is to see any patient who is not on a pathway, to address patient deterioration, to provide urgent important communication with patients and carers where appropriate, to speed fow and remove blockages in the care pathway.

There should be clear escalation protocols so that if a patient deteriorates in-between daily ward rounds there is appropriate timely clinical escalation (Seeing the sickest quickest).

How long after admission should reviews be recorded for the purposes of the survey? Reviews undertaken for up to fve days following the patient’s admission should be recorded for the survey. This fve day period is solely to ensure data can be collected for this standard within a defned timescale, and should not be taken as guidance for the period twice daily reviews should be carried out in practice. Clinical judgement should be the only deciding factor for the period of time twice daily reviews are required.

The survey will ask you to enter the discharge date for each patient, if this results in a stay of fewer than fve days, then only the relevant number of days of responses will be available for you to complete.

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When can individual patients be excluded from the requirement for the daily consultant review? The decision that the patient does not need a daily consultant review should be clearly documented.

The principles in ‘Seven Day Consultant present Care’ from the Academy of Medical Royal Colleges (AoMRC) will help to determine the types of patients who will not require daily consultant review.

The following are considerations in the paper that may be used to exclude individual patients from the need for a daily consultant review: • The patient’s physiological safety (low early warning score (EWS). • The patient’s level of need for further investigations and revision

of diagnosis • The patient’s level of need for therapeutic intervention • The level of need for communication with patient, carers, clinical

colleagues

• Their likelihood of imminent discharge. For example patients who are medically ft for discharge and awaiting a social care placement (delayed transfers of care) may not need daily consultant review unless there are signs of clinical deterioration. The effective use of the skills and experience of a multidisciplinary team (MDT) should be preserved, and this group will still need daily MDT review with access to same day consultant advice.

Which units or wards are excluded from the requirement for daily consultant reviews? In units which are non-medical consultant led such as GP, midwife or therapist led unit, it is acceptable for the consultant leadership to be provided by the GP, therapist, midwife or senior nurse.

A trust may agree with its commissioners to designate certain wards as non-acute rehab or intermediate care wards that don’t require the level of daily consultant intervention described above. There would still need to be a clear escalation protocol for any patient in a rehab or intermediate care bed who deteriorates unexpectedly.

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http://www.aomrc.org.uk/publications/reports-guidance/seven-day-implementation-considerations-1113/

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When can the daily consultant review be delegated? The principles in the ‘Seven Day Consultant Present Care’ from the AoMRC will determine when individual patient reviews can be delegated to an appropriate other.

Case notes, or other sources of clinical documentation will need to record that the consultant has delegated the daily review for a specifc patient, along with the plan for how the patient will be reviewed each day by the multi-disciplinary team to ensure any signs of clinical deterioration are acted upon.

Consultant-led Board rounds should take place on every acute inpatient ward every day, and every patient should have a highly visible care plan (based on written protocols for individual conditions) that is updated daily at the Board round. At the Board round the consultant decides which, if any of the patients’ reviews that day can be delegated to another competent clinician, such as a specialist nurse or senior medical trainee.

Several examples exist of trusts that have segmented their inpatient population to facilitate the appropriate level of daily review. Typically the groups are described as ‘medically active’, ‘medically optimised’ and ‘medically ft for discharge’.

• The medically active group MUST be seen daily by a consultant and not delegated. This includes all patients causing nursing concern, all patients on end-of-life care pathways, all new admissions to a ward in the previous 24 hours and all patients in whom a potential same day discharge decision is required.

• The medically optimised group need daily consultant input via the Board Round, to ensure there is an MDT discussion around progress on therapy and social assessments, then for some in this group the consultant may choose to delegate that day’s face to face review to another member of the multidisciplinary team.

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http://www.aomrc.org.uk/publications/reports-guidance/seven-day-implementation-considerations-1113

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• The medically ft for discharge group (including people who are Delayed Transfers of Care) may be excluded from daily consultant face to face review, and instead reviewed by a senior nurse or equivalent. There would still need to be a safety netting process in place so that if such a patient experiences unexpected deterioration there is a system that ensures that a consultant assesses them promptly.

Which patients should not have the daily consultant reviews delegated? The group of patients considered to be in the medically active group. These patients MUST be seen daily by a consultant and not delegated. This includes all patients causing nursing concern, all patients on end-of-life care pathways, all new admissions to a ward in the previous 24 hours and all patients in whom a potential same day discharge decision is required.

Patients who are not managed on the ward of the appropriate specialty for their condition, who are typically known as outliers. The default position for outlying patients is that they should be seen face to face by a consultant every day.

Informing the patient of the review Patients, and where appropriate carers and families, must be made aware of consultant reviews. Where a review results in a change to the patient’s management plan, they should be made aware of the outcome and provided with relevant verbal, and where appropriate written, information. Documentation that discussions about the review have taken place with the patient, carers or family should be clearly recorded in the notes, and where a decision is made that discussion with the patient or family is not appropriate, this should also be recorded. Where the information is not available in the case notes or related documentation, the ‘not documented’ option should be selected from the response options in the survey.

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FREQUENTLY ASKED QUESTIONS Calculating your sample size

Why does every trust undertake a different number of case note reviews?

The number of case notes each trust should review is based on each trust’s weekly emergency admission rates. The sample calculator defnes the smallest number of cases which can be surveyed for each trust which will give the most robust data.

How do we access the calculator to work out our sample size and sampling methodology? The sample size can be calculated using the sample size calculator, embedded within the 7DSAT. To access this calculator follow the steps below:

1. Log in to the 7DSAT at www.7daysat.nhs.uk 2. Click on the ‘Enter Data’ button (top left) 3. Click on the ‘sample size calculator’ button (far left).

How do we use the calculator to work out our sample size and sampling methodology? Two felds need to be populated to calculate the sample size and sampling methodology: • Number of emergency admissions to your trust in your selected

consecutive seven day period. • Number of emergency admissions to your trust in your selected

consecutive seven day period to be excluded from survey.

Once these have been entered, the calculator will automatically generate your sample size and the sampling methodology.

Trusts with more than one site accepting emergency admissions can use the calculator to determine how many case notes per site need to be reviewed.

What does my sampling size methodology mean? Once you have entered your data and clicked ‘calculate sample size’, you will receive a message similar to the below: “Based on the admission numbers you have given, the calculations have been made and the case note sample size needed for your trust is 243 (35 per day). This sample should be taken by selecting the frst 1 out of every 3 patients.”

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In this example, the trust sample size is 243 patients, which is 35 patients each day (allowing for rounding). The instruction to take ‘the frst 1 out of every 3 patients’ means that you should list your eligible admissions in chronological order and select the frst patient, then miss 2 patients and select the next one, and so on.

What if the randomisation suggests we survey more patients than are admitted on that day? If the number of patients needed for the sample size that day is more than the number of patients admitted, then make up the shortfall on other days. As long as the total number of case note reviews used for the sample is the calculated trust sample size, it is acceptable if there are a few more patients on some days than others.

What if patients need to be excluded once the sample size has been selected? If the case note review shows the patient should have been excluded from the survey prior to sampling. Discard that set of notes and add in another set of notes from the same day. Aim to do this randomly, perhaps taking the next set of notes on the list of admissions for that day. A more pragmatic approach may be needed in that the next set of easily available notes would be chosen in order to meet survey deadlines.

How do we use the tool to calculate the sample size by site? The same process should be used to calculate the per site sample size; put in all of the emergency admissions, count the exclusions from that list then use the tool to calculate the sample size and randomisation.

The total of the sample size by site is likely to yield a greater number than if the sample as a single trust is calculated.

There are two reasons for the difference in numbers: • There is a minimum sample size threshold, so that the smaller

trusts need to survey 50 patients or all of them whichever is greater. So using the calculator for a small site will mean that it may need to sample a higher number than if those numbers were part of a much larger trust population.

• The randomisation process rounds the numbers, so that you are not asked to select for example 2.5 patients in every 3. The rounding could mean that the sample size looks greater than the calculated total sample size.

Essentially, the trust is required to sample the number of patients as if the trust was on one site. You could use the calculator to give you an idea of how many notes to use per site, and adjust it down to meet the whole trust minimum fgure.

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Can you provide an example of a sample size calculation by site? Example 1 Trust 1 which has 2 sites accepting emergency admissions, and has an average of 350 emergency admissions a week and can exclude 65 patients using the exclusion criteria.

When the sample calculator is used for the trust: The trust sample size total is 157 patients, 23 to review per day, 5 patients out of every 9.

When the sample size calculator is used by site: Site A takes 300 of the trust’s emergency admissions, and excludes 40. The total sample size for the site is calculated at 149, 22 patients per day, 4 patients out of every 7.

Site B takes 50 of the trust’s emergency admissions, and excludes 15. The total sample size for the site is calculated at 45 patients and because this is below 50 patients the trust is requested to review every patient.

The site sample size total is 149 + 45= 184 patients. This is 27 patients more than the trust’s minimum sample required. The sites can still submit data for all 184 patients if they choose to but

can if preferred remove the 27 additional patients from site A by reviewing only 18 or 19 patients per day. Site B should include all of their patients as their emergency admission numbers are 50 or fewer per week.

Example 2 Trust 2 has 3 sites accepting emergency admissions and has an average of 535 emergency admissions a week and can exclude 95 patients using the exclusion criteria.

When the sample calculator is used for the trust: The trust sample size total is 195, 28 patients per day, 4 patients out of every 9.

When the sample size calculator is used by site: Site C takes 300 of the trust’s emergency admissions, and excludes 55 patients. The total sample size for the site is calculated at 144, 21 per day patients per day, 3 out of every 5 patients.

Site D takes 235 of the trust’s emergency admissions, and excludes 40 patients. The total sample size for the site is calculated at 125, 18 patients per day, 2 out of every 3 patients.

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The site sample size total is 144+ 125 =269. This is 74 patients more than the trust’s minimum sample required. The sites can still submit data for all 269 patients if they choose to but can if preferred remove the 74 additional patients from site proportionately. This could mean for example that 45 patients per week (approximately 7 per day) and 30 patients per week (approximately 4 per day) are removed from the samples.

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