What was the issue you were addressing or working on?
The Western Isles has a changing demographic with a higher population of older people than the Scottish average, this coupled with an ageing workforce and outward migration of young people has brought into focus the need to continue with the modernisation of our acute services and deliver more services closer to communities.
In conducting a review of unscheduled care the National Dashboard summarises NHS Western Isles performance as:
- A&E attendances -7% WI v.+ 1% Scotland
- A&E admissions : -6% WI v. +10% Scotland
- A&E admissions as % of non-routine discharges: 65% WI v. 71% Scotland
- Ave. Stay Emergency stay (WIH ) : 5 days less than Q4 2011
- Acute beds: down 12% WI v. 2% Scotland
- Acute Beds per 1,000 acute discharges: 66 WI v. 44 Scotland
- Acute emergency discharges: -2.5% WI v. +2% Scotland
- Acute non-emergency discharges: -2.5% WI v. +2.6% Scotland
- Beds lost to DDs: 7 WI
In summary for latest period WI has reducing lengths of stay reflecting reduced bed numbers and reduced acute admissions (both emergency and elective) in turn reflecting reduced A&E attendances and onward admissions from A&E. Some of this contrary to Scottish trend (See above list) but remain above average in comparison to Scottish levels for few areas eg. ALoS and Number of beds relative to number of patients.
NHS Western Isles approach is integrating all of our Unscheduled Care activity under a single work stream, taking a whole system approach and working closely with service users, Local Authority partners and Third Sector providers. This work is ongoing.
What you did?
The Change Fund has supported a number of workstreams under this approach including
Community Unscheduled Care Team, OPAT service and General Practitioner Locally Enhanced Service:
Community Unscheduled Care Nursing Service
The CUCN team is made up of six nurses who have undertaken an advanced course in patient examination / diagnosis and treatment. Until last year they worked exclusively on nights and provided first point of contact for all NHS 24 calls.
The service was very fragile and changes made to shift patterns and workload capacity to make more sustainable. Advanced level practitioners trained in advanced clinical assessment, minor injuries and non medical prescribing. There is a GP lead who manages the medical aspects of their training and works closely to arrange time spent with GPs and consolidate their training.
The service works closely with GPs and attending out of hours calls supporting GPS triaged through NHS 24, strict criteria for access to service.
With the education, development and adaptation to workforce delivery patterns is producing a more robust sustainable model.They now work a rotation from nights / days with 3 on days and 3 on nights. This has enabled them to bring their skills to the community nursing teams on days and work with the GP practices throughout Lewis and Harris. In Lewis there are now 6 Community unscheduled care nurses CUCN (Grade 6) at various stages of the training. 3 x WTE and 3x 0.375WTE – staff in the future will rotate on a 24/7 basis which also aids to maximise learning experience and cover. Educated via Community Nurse Unscheduled Care Course University of the Highlands and Islands)
- Advanced Clinical Practice
- Common presentations
- Minor Injuries
- Non-Medical Prescribing
Unscheduled care nursing team now increased and operating a rotation system of day and night shift, responding to NHS 24 calls and supporting patients to remain at home
This team are now a vital component of the unscheduled care service, in the first two months following service redesign the team responded In house visits to 19.9% of NHS 24 calls as opposed to GP’s 6.0%, 45.2% were given appointments and 28.9% given telephone advice.
Referrals to the service are triaged through NHS 24 or present via OOH GP on call, ENP’s or CSN’s . If the case is not appropriate for the CNUSC they refer to the clinician on call or ambulance service. The CUCN are delivering care inputs previously identified within secondary care provision ie IV antibiotics.
Referrals during the day present from Community Nurses and GPs and McMillan for palliative care support.
The Community Unscheduled Care Nurses carry a limited supply of basic, commonly prescribed drugs which can be administered to patients. Unscheduled Care Nurses may also arrange for a hospital admission, if necessary. A significant part of their remit involves Palliative care delivery and they are competent in relation to the appropriate use of controlled drugs, methods of administration, etc. This service has been well received by patients and carers in the community. Staff involved in service delivery feel they are making a valuable contribution to the drive towards shifting the balance of care.
OPAT – Outpatient Intravenous Antibiotic Therapy
Transferring traditional hospital based service to patients own home.
The OPAT service provides intravenous drug therapies to patients at home. It is led by a team of specially trained nurses who work in the community . The service can be offered on a 24/7 basis as all our overnight nurses are qualified. A skilled team now in place to deliver IV therapy to patients in their own home.
- Service based around CUCN service
- Single point of contact
- Staff trained in IV therapy/ cannulation
- Standard documentation: clear instruction/ responsibility
- Liaison with Discharge Planning
- Development of individualised ACPsThere is a GP lead who works closely with pharmacists and medical colleagues in the WIH . The GP lead is supported by a Nurse Practitioner , who chairs the OPAT meetings which are held monthly and is also involved in the running of the service. The clinical protocol for initiating treatment is available on the Intranet and clear guidelines are followed by all practitioners to ensure a safe and effective service is delivered.
Example -Facilitate early discharge from hospital.
- At time of reporting over a two month period patients were supported through the OPAT service resulting in a facilitated early discharge from hospital or a preventable hospital admission.
- The service has demonstrated that it is significantly reducing hospital admissions and enabled individuals to remain in the comfort of their own homes who would previously have required hospitilisation. The team consistently review and audit the service and are confident that there will be an increase in demand and they will be able to expand on the range of illnesses which can be treated at home
- Originally the project was administered IV antibiotics solely for patients with cellulitis. However, in recent months we have found that patients are being prescribed antibiotics post orthopaedic surgery and for a variety of other infections. Therefore the project is currently reviewing protocols to accommodate this and ensure there are clear guidelines for nurses in relation to worsening advice for patients and hospital admissions.
- Patient with cellulites discharged on IV Flucloxacillin.
- Drug administered by CUCN, CN and WIH over 2 days.
- 6 visits approx 45 mins each visit including travel time +1hr SCN time to arrange staffing schedule.
- 10 mile round trip each visit.
The service receives peer support from, OPAT lead NHS Highland and seeks advice on any complex issues which may arise locally.
General Practitioner Locally Enhanced Service
Point of Care Testing
GP practices conducting INR testing.
A test for blood clotting , primarily used for warfarin therapy, remote monitoring by practices that can also be used by Community Nurses giving an immediate result allowing medication to be adjusted at point of care. Application includes Quality Assurance software and training.
This is being measured through reduced lab tests and reduction in out of hours testing
Patient experience will be improved through less invasive procedure , reduced waiting time, less return visits to GP for results
Polypharmacy / medication training
Training for all GP practices re conducting polypharmacy review
Required to assess the efficacy of increasing numbers of drugs prescribed:
To assess the increasing number of drugs prescribed to older people assessed against the benefits likely to accrue and the associated risks
- Drug side effects related to co morbidities
- Review of patients on 10 or more drugs
- Review of whether drugs should be avoided or restarted where there are side effects
- Indication of shortened life expectancy where medication will be unable to produce significant effect.
Measures include establishing a baseline of high risk patients and the no of people who receive a polypharmacy review over a 12 month period, plus reduction in prescribing costs
What were the outcomes - benefits or otherwise?
Modernising Community Nursing
Upon delivery of the Modernising Community Nursing agenda more people will be treated closer to home this service redesign is a complex process which will deliver changes to the use of staff with a reduction in bed days, with more patients treated within the community
Locally Enhanced Service General Practitioners
- Reduced lab time
- Reduction in lab costs out of hours
- Reduced number of return visits for patients
- Free up practice time
- Patient experience improved due to reduced waiting times
- Equitable access across Western Isles
- Reduction in admissions due to drug side effects
- Reduction in overprescribing
Contacts - to find out more
Kathleen McCulloch, firstname.lastname@example.org 01851 763307