Service Innovation Bulletin
Acute Trusts
- Pre-Dialysis Patient Education Pathway
- Stretching Back to Health
- Active Management of Critical Care Demand in Major Elective Surgery
- One Stop Transplant/Dermatology Clinic
- Pain Link Nurse Development Programme
- Alcohol Services within the Acute Trust Setting
- Nurse-Led Generic Vascular Risk Management Service
- Post-ITU Rehabilitation Programme
- Nursing/Service Quality Performance Assessment
- Smoking Cessation Service - Acute Trust Intervention
- Physiological Observation Track and Trigger System (POTTS) Chart
Pre-Dialysis Patient Education Pathway
Central Manchester and Manchester Children’s Hospitals NHS Trust
The pre-dialysis patient education pathway is an element of the pre-dialysis service delivered by a dedicated pre-dialysis team. The aims of the service include monitoring, supporting, educating and coordinating care for pre-dialysis patients.
The education pathway, which includes a workshop, facilitates a smooth transition from pre-dialysis to the treatment of choice. Clinic visits are combined with education, ensuring that patients do not have to return to hospital for multiple appointments.
The workshop gives patients an opportunity to ask questions about dialysis before they make a decision regarding treatment. All pre-dialysis patients attend the workshop. The workshop is particularly useful for patients with mental or physical disabilities, as the equipment provides patients and their families with the opportunity to visualise specific dialysis treatments and the equipment involved. The workshop also enables the pre-dialysis nurse to assess a patients capability and advise on a clinically appropriate therapy. The nurse can use her experience to assess a patients mobility, dexterity and overall physical, psychological and social wellbeing to determine their ability to take on a self-care treatment.
The pre-dialysis workshop in clinic aims to:
- Combine clinic visits with education.
- Provide regular educational reinforcement.
- Provide ‘fast-track’ education for late referrals.
- Provide ‘first-hand’ visual demonstrations of dialysis equipment. Provide visual examples of dialysis access.
- Aid in the decision making processes.
All respondents in a recent survey found the pre-dialysis education workshop helpful and the equipment and discussion to be useful.
Stretching Back to Health
Clatterbridge Centre for Oncology NHS Foundation Trust
The build up of scar tissue is an ongoing, life-long chronic problem for post-surgical and/or radiotherapy patients. This service teaches patients and their carer/partner about the anatomy and physiology behind what has happened to their body during/following surgery and/or radiotherapy. They are taught ‘hands on’ how to be aware of tight areas and how to ensure that pain/stiffness and lack of movement are improved or, if possible, prevented before these issues escalate into a potentially debilitating state.
Physiotherapists teach tissue stretching techniques to the patient and their carer/partner, resulting in patients being less dependent on physiotherapy services as they are able to use the technique themselves. Initially patients and their carers are supported by the physiotherapists, but over time this support becomes less as confidence grows.
Referrals are received for patients that have undergone breast surgery and/or radiotherapy, and for patients following head, neck and other surgery. Patients with cording (lymphatic and blood vessel scarring) can also benefit from this technique. Cording is.a common problem for patients who have received chemotherapy. The principles of the service are transferable as all connective tissue responds to this technique in a similar way.
The main benefits of this service include: control of symptoms for patients (both physical and psychological); pain reduction and improvement to function and movement; control and relief of the patient’s symptoms; and a reduced requirement for intervention from NHS services, resulting in cost savings to the NHS.
The basic technique can be taught to nursing staff to ensure that all patients have access to this preventative treatment. This enables early recognition and appropriate referral for patients who have already developed problems.
Active Management of Critical Care Demand in Major Elective Surgery
North Cheshire Hospitals NHS Trust
The single most common reason for cancellation of major elective surgery is due to the lack of availability of High Dependency Unit (HDU) beds following surgery. The beds may have been used for emergency admissions and other planned admissions requiring post operative critical care. This service aims to actively manage the demand for High Dependency beds following major elective surgery.
All patients requiring High Dependency Care following planned surgery are referred to the Critical Care Lead, who coordinates the availability of beds to meet these requests. (Surgeons complete a ‘Planned HDU Admission Registration Form’ to request a bed). The need for a High Dependency bed is reviewed by the Active Management Team. Activity is coordinated to ensure all elective surgery is managed in an efficient and equitable way.
Prior to the introduction of this service in excess of 25% of planned major surgical procedures in this Trust were cancelled due to a lack of HDU beds. A national audit in 2003 found that 17% of major vascular surgery was cancelled for this reason. The introduction of this approach in this Trust has reduced the cancellation rate for major elective surgery to 7.3%. The financial savings due to a reduction in cancelled operating sessions over a 25 month period has been conservatively estimated to be £179,400.
One Stop Transplant/Dermatology Clinic
Central Manchester and Manchester Children’s University Hospitals NHS Trust
The One Stop Transplant/Dermatology clinic is a joint clinic between Transplantation and Dermatology services for the early detection and treatment of skin cancer in organ recipients. It was developed as a result of 2006 NICE guidelines on ‘Improving Outcomes for People with Skin Tumours’, which highlight organ transplant recipients as a group of patients with a high risk of developing skin cancers due to their long term immunosuppressant therapy.
The weekly one-stop clinic supplements the routine post-transplant annual surveillance clinic attended by patients.
It is led by a Transplant Advanced Nurse Practitioner who specialises in the long term health of transplant patients. The clinic serves a population of 700–800 transplant patients and is held in the Dermatology department alongside the Consultant Dermatologist’s new patient clinic. Fifteen patients are seen by the Advanced Nurse Practitioner per session during which skin surveillance is carried out and advice given. Treatment and/or investigations are expedited immediately by the Dermatology staff.
Prior to the establishment of this clinic, skin surveillance existed as part of the annual transplant review for patients but there were delays in the treatment of suspicious lesions. Additional skin problems prevalent in transplant patients were referred back to the GP; these skin conditions are now assessed and treated in this clinic. Audit data from the clinic has demonstrated that at least 10% of transplant patients attending the clinic had a malignancy or pre-malignancy identified and treated in a timely and effective manner.
Pain Link Nurse Development Programme
Salford Royal Hospitals NHS Foundation Trust
A structured Link Nurse Programme to support the work of the Pain Specialist Team. The service aims to improve the quality of care for patients, by ensuring that awareness of pain management issues improves amongst healthcare staff. It provides a recognised development programme, linked to the knowledge and skills framework, and ensures that the expertise of the pain specialist team is utilised in the most appropriate way.
Link Nurses attend bi-monthly meetings for support and to discuss latest developments; they spend two days per year working directly with a member of the Pain Specialist Team and have an identified member of the team as a mentor. In addition, Link Nurses have a role summary and have one-to-one meetings with their mentor to work through the development programme handbook.
The role summary and handbook are available freely to interested NHS Trusts.
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Alcohol Services within the Acute Trust Setting
Wrightington, Wigan and Leigh NHS Trust, Bolton Hospitals NHS Trust and
Salford Royal Hospital NHS Foundation Trust
According to a report published in 2007 by the Association of Public Health Observatories in England, months of life lost and mortality attributable to alcohol are increasing in the North West. Increases in the rates of alcohol-related hospital admission in the North West and North East are the highest in England for both men and women. In the North West, the total contribution that alcohol makes to a reduction in life expectancy is well above the national level (a loss of 12.6 months vs. 9.9 months for men; and a loss of 5.8 months vs. 4.4 months for women).
The region has the second highest proportion of binge drinkers in England; 22% of men and 10% of women. The proportion of the working population claiming incapacity benefit due to alcoholism is three times higher in the North West than in the East of England. Additionally, people living in the North purchase, as a proportion of total expenditure on food, the greatest amount of alcohol per week.
In response to this trend, three North West Acute NHS Trusts have developed and implemented alcohol services to address the needs of patients admitted to the hospital with alcohol-related illness, as a primary or secondary factor. Services have been developed to standardise alcohol assessment and support, as well as the treatment offered within each Trust. The three acute services have been developed independently and operate as stand-alone services. The services were established to prevent inappropriate admissions, reduce length of stay and reduce the financial burden of alcohol-related illness on the Trusts.
The three services include: access to specialist alcohol nurses, Link Nurse development programmes, brief intervention, staff education/information sessions, resource packs, detoxification clinics, Antabuse® clinics, introduction of acamprosate, rapid access alcohol clinics, nurse-led liver clinics supported by gastroenterologists and links with community alcohol teams.
Each of the three Trusts have seen savings of between £140,000–£300,000 over a 3–12 month period, as a result of reduced alcohol-related admissions and reduced length of stay.
Nurse-Led Generic Vascular Risk Management Service
Salford Royal Hospitals NHS Foundation Trust
The service is led by an Advanced Practitioner and is positioned within renal services; many cases are complex with multiple co-morbidities. The objectives of the service are to slow, or halt, disease progression and to ensure the early management of conditions in order to prevent the development of further complications and to reduce the risk of morbidity and mortality.
In addition to referrals from renal physicians, referrals are received from peers across renal services and other specialties (including dialysis, transplantation and chronic kidney disease or diabetes specialists) with ‘difficult to manage patients’. All patients on the active case load receive ongoing intervention; clinical, social and psychological issues are addressed and multi-disciplinary collaboration is promoted. Patients are referred back to the sole care of the renal physician when their condition has improved or stabilised, or when national targets have been met.
The service places great emphasis on generic vascular risk management and risk reduction whilst maintaining and/or promoting a good quality of life for all patients. Needs are met and admission to hospital is prevented whenever possible. Patients have continuity of care as the clinic is managed by one Advanced Practitioner and supported by one Associate Nurse Specialist.
Post-ITU Rehabilitation Programme
Central Manchester and Manchester Children’s Hospitals NHS Trust
A Physiotherapist-led, out-patient post-Intensive Therapy Unit (ITU) rehabilitation programme has been developed,
consisting of physical exercise and education sessions to improve physical and psychological function in intensive care survivors. The programme encompasses existing guidelines for exercise prescription and rehabilitation.
All patients involved in this programme have shown significant improvement in both walking tests and depression and
anxiety scores. The service increases patient’s functional independence, decreasing dependence on relatives/carers and social care. This in turn facilitates a return to work for patients and relatives. Increased fitness may lead to a reduction in mortality rates and readmissions in this patient group, as well as decreasing GP visits and the cost of ongoing care.
Nursing/Service Quality Performance Assessment
Royal Liverpool and Broadgreen University Hospitals NHS Trust
Comprehensive audit tools to monitor the quality of nursing care/the service based on essence of care standards,
standards for better health and other key indicators (e.g. pressure ulcer incidence, ‘Saving Lives’ indicators). These tools provide a robust method for continuous improvement. They have been designed to support nurses in practice/services to understand how they deliver care, identify what works well and where further improvement is needed.
Each ward/clinic area has an annual audit resulting in an overall audit score. An action plan is then developed for each ward/clinic area to address the areas of poor performance following audit. The frequency of re-audits is determined by a traffic light scoring system.
The assessment and action plans are incorporated into clinical governance portfolios and become part of the Trust’s performance review process. Using a database the audit data can be manipulated to combine ward/clinic areas within each directorate in the divisions, for example all the orthopaedic wards. The performance of different divisions and different Trust hospital sites can be compared.The information is available and reported to the Trust board and the clinical governance committee as an up-to-date and accurate assessment of achievement of nursing/service standards across the Trust.
Copies of the Nursing/Service Quality Performance Assessment are available to NHS Trusts on request.
Smoking Cessation Service – Acute Trust Intervention
Bolton NHS Primary Care Trust
This service offers a collaborative and effective approach to smoking cessation. It was established to overcome a lack of standardised procedures in the acute setting (questioning, documenting, patient referrals, etc.) and reduces post-operative complications, the number of cancelled operations and the length of hospital stay.
The service relies on in-patient assessment for smoking cessation by the Acute Trust* and introduces dual intervention – motivational support and pharmacotherapy. The dual therapy is continued after discharge by the PCT.
All NHS Trusts in the UK should be smoke free by December 2006. As part of the Health Care Commission annual health check Trusts will be required to demonstrate that:
- a ‘smoke-free’ policy is in place and the Trust is committed to the policy.
- stop smoking support is widely available and accessible.
- the smoking status of adult in-patients is recorded.
- the Trust can demonstrate that it has an agreed management process in place for the provision of advice and onward referral of adult in-patients who smoke, to NHS Stop Smoking Services.
This smoking cessation service covers these issues.
*Acute Trust staff receive training from the smoking cessation team for Level 1 and Level 2 interventions.
Physiological Observation Track and Trigger System (POTTS) Chart
University Hospitals of Morecambe Bay Hospitals NHS Trust
Development of a radically new patient chart that fully integrates physiological observations with early warning scoring. The chart has eliminated the need for nurses to calculate the physiological score from an instruction table. Instead physiological scores are automatically advised by ghosted values in the chart area. The only calculation needed is to sum the scores to yield the Early Warning Score (EWS). The chart can be used across general medical and surgical wards.
In a pilot trial, the use of the new chart has improved compliance and accuracy of EWS recording to 95% – a two-fold improvement on the two previous years’ audits. The improvement in compliance and accuracy of EWS may result in the earlier detection of patient’s with deteriorating conditions.