welcome all! maz marsham lead nurse bromley cldt, oxleas nhs foundation trust claire o’brien...

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%


Admission to Alert lead time:Post

23%

39%

23%

15%0%


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%


CLDT Nurse response rate: post

45%

31%

8%

8%

0%8%


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


• 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


• 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


• 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


• 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.

welcome all! maz marsham lead nurse bromley cldt, oxleas nhs foundation trust claire o’brien...

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