AT A GLANCE
THE CHALLENGE
The Royal Hampshire County Hospital (RHCH), a non-trauma receiving hospital, was facing duplication of front door streaming and triage processes, leading to long waits for initial assessment and low staff morale. A high proportion of frail patients were waiting 90 minutes for initial assessment and many were fit for discharge within 24 hours, but transport difficulties resulted in increased length of stay (LoS). There was no dedicated frailty assessment area or early discharge planning and emergency nurses were only trained to deal with minor injuries not minor illnesses.
WHAT THEY DID
Supported by the national CLEAR team, five clinicians gathered insights from key stakeholders from all professional backgrounds and levels of seniority. More than 40 one-to-one interviews were carried out as well as clinical observations within the department. This qualitative analysis was combined with detailed examination of more than 170,000 clinical records to identify trends and patterns which would help pinpoint the specific challenges facing the department, enabling the team to redesign services and roles as part of innovative and practical solutions.
CLEAR RECOMMENDATIONS
A key recommendation was the creation of a minor illness service within the ED and the upskilling of existing emergency nurse practitioners (ENPs), enabling them to treat patients with minor illnesses as well as those with minor injuries.
The establishment of an Older Persons’ Emergency Department (OPED) was recommended to improve the care of frail patients over the age of 65, including those with dementia, confusion and at high risk of falling. It would run 24/7, staffed by a registered nurse and healthcare assistant, and be designed specifically for frail and confused patients – for example with low trolleys, grab rails and clear pictorial signs. Frailty teams, nursing staff and doctors would work collaboratively to ensure patients receive a comprehensive rapid assessment tailored to their individual needs. There would be a focus on discharge planning on arrival with the aim of reducing admissions and lengths of stay in hospital.
Other recommendations included walk-in patients being assessed by an experienced nurse, eliminating the need for extra triage.
FORECAST IMPACT
The proposals have the potential to prevent up to 6,900 annual admissions of frail, older patients and reduce the length of stay in hospital (in cases where admission is unavoidable) generating more than £3m savings.
The £1.2m cost of the minor illness unit would be offset by giving doctors more than five extra hours per day to treat seriously unwell patients, reducing the overall cost to £200,000. ENPs would have career development opportunities and patient satisfaction would be improved with reduced length of stay in ED.
The South Central Ambulance Service would be able to refer patients directly to both the minor illness service and the OPED, relieving pressure on main ED staff. Ambulance waiting times outside the ED would be reduced, resulting in the faster release of crews.
