welcome all! maz marsham lead nurse bromley cldt, oxleas nhs foundation trust claire o’brien...
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Welcome all!Maz Marsham Lead Nurse Bromley CLDT, Oxleas NHS Foundation Trust
Claire O’BrienAssociate Director of Nursing, South London Healthcare NHS Trust
What we did Oct 2010 - Feb 2010 (‘baseline’)
• Did what we had always done!
• Made a plan…..• ……changed the
plan
What we did• Lucy, David, Keith.• What if a big problem with
discharge planning was that we never knew they were in hospital in the first place?
• What if the most important things we needed to change happened before the person was ready for discharge ?
• What help did people really need, and when? How would it get started?
What we did• Lucy, David and Keith taught us:• Work together even if things have not gone well• Use the medical notes• Tackle internal communication and role issues• Don’t delay in letting us know about admission because you aren’t sure if we
can help or not• Urgent admission is a big health deal : we need to make contact and share
information, flag it with clinical leaders, do proactive liaison work.• Once is not enough! You may be saying it for 10th time, to 10 people who are
hearing it for first time• Start from scratch if you have to - patients get moved between wards, so start up
interventions may be needed even if admission is lengthy• What do we do when we get there? Everyone needs to provide the right
intervention in right way at right time
What we did• Aims:• LD urgent admission has standardised intervention
from CLDN in timely fashion according to a joint working protocol
• Communication pathways between ward and CLDT established within 2 days of admission/alert
• Practice improvements must be sustainable
What we did (March 2011-Oct 2011 - ‘Mid’)
• Case finding• Retrospective and
current data collection• Telling people about the
project, (and getting them to help us!)
• Focus groups held• National Conference• Draft CLDN procedure
with 2 day target
What we did
• SLHT recognised excellent practice by Jean Diamond, who won the Patient Experience SLHT Staff recognition award.
What we did - LD Awareness week June 2011 (mid)
• With permission, opportunistically swept 19 wards, 1 (genuinely) too busy to engage - 3 return visits.
• No patient with LD in PRUH who we didn’t already know about• 4 wards had the poster on display, posters provided to those who didn’t.• 3 had ward pack (update in production, electronic version?)• 3 staff familiar with traffic light form, copies supplied to others• Most staff unaware of CLDT support, but keen to hear about it, team
leaflets supplied.• 7 wards requested follow up visit or more training• Stand in canteen entrance lunchtime: approx 100 people stopped, wide
range of disciplines, patients, public• MCA competition - who is the decision maker ? - 16/48 correct entries
What we did• LD awareness week 2011,
2012• Acute care is not by
appointment - just turning up is good
• Training needs to be on site, quick but effective and flexible.
• Interest is greatest when patient with LD is on ward - timing crucial
• Potential champs out there, but might not be obvious…
What we did
What we did (Nov 2011 - Apr 2012 (‘post’)
• Initiated the CLDN Standard Operating Procedure proper
• Trialed the Proforma tool kit• Drafted joint working
protocol• Analysed focus group
transcripts• Crunched numbers• Maz on secondment
What happened - scene setting• 28 people had 54 urgent admissions• 10 people died in hospital or shortly after discharge• 677 bed days, (£135, 400)• Approx 2 admissions per person • Average length of stay 12.5 days (£2,500)• (national average 5.5 days, £1,100)• LoS range 1-96 days• 32 % of admissions lasted >14 days, accounting for
74% of total bed days.
What happened - scene setting• 60% of admissions failed to reach the <30 day
readmission target (financial penalty)• 32% of cohort experienced readmission, 68% had
single admission.• Readmission days ranged from 1-150 days• N of readmissions per person ranged 1-7• 1 person had admissions in each data collection
period, 4 people had admissions across 2 periods.
What happened - scene setting
• 1 person required IMCA services by virtue of Safeguarding Adult status
• 2 people IMCA information was unavailable
• The majority of people had relatives involved in their care
What happened - trendsnumber of urgent admissions
16
21
17
0
5
10
15
20
25
Baseline Mid Post
Data Collection Period
Nu
mb
er
of
ad
mis
sio
ns
number of admissions
number of admissions and readmissions
10 108
6
11
9
0
5
10
15
20
25
Baseline Mid Post
data collection period
nu
mb
er
of
ad
mis
sio
ns
number of readmissions
number of single/firstadmissions
What happened - trendsLength of stay and Mean Length of stay
262
16
265
13
153
9
0
50
100
150
200
250
300
Bed days mean bed days
Length of stay and Mean per data collection period
bed
days
baselinemid post
What happened - trendsNumber of people having more than 1 admission
4
6
3
0
1
2
3
4
5
6
baseline mid post
data collection period
Nu
mb
er
of
peo
ple
havin
g
read
mis
sio
ns
Number of people havingreadmissions
What happened - trendsMean readmission days
26
47
22
0
5
10
15
20
25
30
35
40
45
50
Baseline Mid post
Data collection period
Days b
etw
een
dis
ch
arg
e a
nd
ad
mis
sio
n f
or
sam
e c
on
dit
ion
mean readmission days
What happened - trends<30 day readmission target
83
55 5060
17
45 5040
0
20
40
60
80
100
120
Baseline Mid Post Overall
data collection period/overall
perc
en
tag
e o
f ad
mis
sio
ns
hit targetfailed target
What happened - trends
Admission to Alert lead time:Baseline
43%
14%
29%
0%
14%
same dayNext day>2 daysafter dischargenever alerted
Admission to alert lead time: Mid
23%
23%40%
14%0%
same dayNext day>2 daysafter dischargenever alerted
Admission to Alert lead time:Post
23%
39%
23%
15%0%
same dayNext day>2 daysafter dischargenever alerted
What happened - trendsCLDT Nurse response rate: Baseline
42%
25%
17%
0%
8%
8%
Same dayNext day<4 days4-7 days>7 daysno face to face contact on ward
CLDT Nurse Response Rate: Mid
67%
13%
0%
13%
7% 0%
Same dayNext day<4 days4-7 days>7 daysno face to face contact on ward
CLDT Nurse response rate: post
45%
31%
8%
8%
0%8%
Same dayNext day<4 days4-7 days>7 daysno face to face contact on ward
What happened - trendsCLDT Nurses reponse same/next day target
0
20
40
60
80
100
120
Baseline Mid post
Data Collection Period
% o
f ad
mis
sio
ns
overallCLDT nursesAST nurses
In summary……….• LoS had got shorter • Fewer people had readmission • Fewer complaints were made• CLDT response times got faster• 2 day response target is possible• ‘Never alerted’ admissions stopped• Direct referrals from wards occurred
• The fewer people who did have readmissions returned more quickly
• The number of referrals taking more than 2 days to reach us increased
What happened - perspectives
• Transition to adult services• Not being listened to• Feeling they could not leave their child
because they would not receive personal care in their absence
What happened - perspectives
• Confusion about their role on ward• Complexities and tension in the working
relationship with ward staff• Conflict of interest between providing support
on the ward and maintaining service at home
What happened - perspectives
• Want to use CLDT for training, knowledge and support and improve communication with them (Not everyone knows they exist!)
• Having support from a ‘familiar face’ on the ward is really valuable
What happened - perspectives
• Need to have clear lines of communication with PRUH to ensure contact is made on admission and involvement is at earliest possible stage
• LD awareness week activities had been useful, increasing contact initiated by wards
What happened - perspectives
• Feeling afraid and anxious but comfort and information not forthcoming, feeling too intimidated to ask for help
• Feeling bored with little meaningful activity• Poor communication skills, not listening to carers who were
trying to help
What happened - tools revised
What next ?– Project and LD Equalities group aims converging– 14 recommendations made (see Exec Summary)– Sustainability/embedding practice, training,
audit/monitoring, working with carers, transition planning, patient with LD feedback mechanisms, prevention of urgent (re)admissions through LTC management and improving discharge planning
– Further project work a possibility– Always open to suggestion!
Early Audit Results
44%
9%9%
6%
6%
6%
3%
3%
3%3%
3%3%
Reason for admissionChest infection total
Seizures not related to infection
Falls
Dehydration/ D & V
Hernia
Gall Stones
GP Referral? Cancer?
Drowsiness? Pituitary dysfunc-tion?
Aortic Stenosis/ Fluid on lungs
Unable to swallow
Infected Diabetic Ulcers
Internal Bleeding
Early Audit Results
20
12
Ambulatory Care Sensitive Conditions
Ambulatory Care Sensi-tive Conditions
Non Ambulatory Care Sensitive Conditions
Total 32
So your next patient has Learning Disability.
What are you going to do ?
Have you admitted an adult with Learning Disability ?
• Are you caring for a patient who has a learning disability* ?
• If so, please let us know, as we may be able to help you to support your
patient during their stay.
• You can call us on• 01689 853388 Mon-Fri 9-5pm,
• Please ask for Mel Blair, Vee Nathan
• Stella Haddow - Mendes, • Tony Hollands or Maz Marsham
• (* you may know this as ‘special needs’ ‘mental handicap’ )
Elderly care characteristics• Diagnosis in context of dementia, acute
confusion, cognitive impairment difficult• Effects of immobility on health• Longer stays assoc with risk of acquired
infections, depression, boredom, loss of social functioning
• Need for health and social care sectors to work together
What matters to patients:• Good information provision• Having confidence in staff• Awareness and understanding of specific
health condition• Right treatment from right staff at right time• Continuity of care• Being treated as a person• Partnership with professionals
What matters to patients• Feeling informed and being given
options• Staff who listen and spend time with the
patient• Being treated as a person not a number• Being involved and able to ask
questions• Value of support services• Efficient processes
SLHT patient experience priorities
• Patients rating of the food• Experience of leaving hospital• Making sure patients understand their
medicines and side effects• Organisation of out patient clinics• Making sure staff support patients with
any worries or fears they may have.