HULL AND EAST YORKSHIRE HOSPITALS NHS TRUST

HULL AND EAST YORKSHIRE HOSPITALS NHS TRUST
NURSING RESOURCE REQUIREMENTS
Trust Board date 26th June 2014
Reference
Director
Author
Amanda Pye
2014-6-18.3
Chief Nurse
Reason for
the report
Information
Type of report
Concept paper
(tick)
Performance
1
Business
case
Review
Strategic
options
Information √
RECOMMENDATIONS
The Board agree the staffing uplift as outlined in the paper for nights.
2
3
4
Key purpose (tick)
Decision
Approval
Information
Assurance
√
Discussion
Delegation
STRATEGIC OBJECTIVES (tick as appropriate)
Safe, high quality effective care
Strong, high performing FT
Creating and sustaining purposeful partnerships
Efficient economic use of resources – targeted and prioritised effectively
Delivery against our priorities and objectives
Capable, effective, valued and committed workforce
Strong respected impactful leadership
LINKED TO
CQC Regulation(s)
Assurance Framework
Ref: If yes
Legal advice
Yes/No
Yes/No
5
The purpose of this paper is to identify to the Board the investment required to uplift the
current registered nursing establishment during the night shift to meet current national
guidance. This links to the trust’s strategic aims of:
 Delivering excellent quality outcomes
 Working in partnerships that add value and in ways that use public money effectively
 Provide assurance to our regulators and commissioners that all necessary standards
are being met.
109
Hull and East Yorkshire Hospitals NHS Trust
TRUST BOARD June 2014
Nursing Resource Requirements
1. Purpose The purpose of this paper is to identify to the Board the investment required to uplift the current registered nursing establishment during the night shift to meet current national guidance. This links to the trust’s strategic aims of:  Delivering excellent quality outcomes  Working in partnerships that add value and in ways that use public money effectively  Provide assurance to our regulators and commissioners that all necessary standards are being met. 2. Background Following the publication of the Francis Report on Mid Staffordshire (Francis 2013), the Keogh review in England (Keogh 2013) and the Berwick Report on improving the safety of patients in England (Berwick 2013) and the recent consultation document from NICE `Safe staffing for Adults in patient wards in Acute Hospitals` (NICE 2014). A need has been placed on all Acute Executive Trust Boards to comprehensively review their current nurse staffing levels in accordance with their patient acuity and dependency levels. In acknowledgement of the above, a comprehensive review of all of the nursing establishments has been completed by the Senior Nursing Team, resulting in an initial investment of £0.5m by the Trust Board to support a minimum staffing ratio of 1:7 and the establishment of the supervisory ward sister/charge nurse role predominantly in the Medical Health Group. Following the recent CQC inspection the Trust received a compliance notification to ensure that there are sufficient numbers of suitably qualified and skilled nursing staff particularly on nights and weekends. In response to the above compliance notice a further review of the current nursing establishments has been completed specifically focused towards reviewing the nurse to patient ratios during night shifts. Patient acuity, dependency and bed occupancy data has been collated to support the following recommendations presented within this paper. 3. Current Nursing Establishments for all Adult Wards with HEY Tables 1 to 4 illustrate the current number of registered and non – registered nurses per shift. The staffing numbers shown are those at peak occupancy, and it should be noted that staff are stepped down at weekends and other times of lower occupancy 110
to maintain comparable ratios. The tables focus predominantly on the registered nurse to bed ratio with reference to the bed occupancy at mid – night and mid –day. Table 1 – Surgical Health Group (SHG) Occupancy
Health Group
Ward
Speciality
Beds
Surgery
C9
Ortho
29
89.4%
Surgery
C8
Plas / intermediate activity
26
Surgery
C10
Colorectal
Surgery
C11
Colorectal
Surgery
C11 HOB
Surgery
Mid day Mid night
Current rota ‐ registered
Current Registered ratio
Current rota ‐ non‐registered
Early
Late
Night
Early
Late
Night
Early
Late
Night
84.6%
5.0
4.0
2.0
1:6
1:7
1:15
2.0
2.0
1.0
90.0%
80.5%
4.0
4.0
2.0
1:7
1:7
1:13
2.0
2.0
1.0
21
90.2%
83.1%
3.0
3.0
2.0
1:7
1:7
1:11
2.0
2.0
1.0
14
92.4%
88.2%
3.0
3.0
2.0
1:5
1:5
1:7
1.0
1.0
1.0
Colorectal ‐ L1
8
92.4%
88.2%
2.0
2.0
2.0
1:4
1:4
1:4
1.0
1.0
1.0
C14
UGI / Gynae Onc
27
89.3%
84.7%
5.0
4.0
3.0
1:5
1:7
1:9
3.0
2.0
1.0
Surgery
C15
Urology
26
90.2%
86.0%
5.0
5.0
3.0
1:5
1:5
1:9
3.0
3.0
2.0
Surgery
C27
CTS
18
94.7%
93.8%
4.0
3.0
2.0
1:5
1:6
1:9
2.0
2.0
1.0
Surgery
C27 HOB
CTS ‐ L1
8
94.7%
93.8%
2.0
2.0
2.0
1:4
1:4
1:4
0.0
0.0
0.0
Surgery
H6/H60
Acute Gen and Plas
44
94.9%
87.0%
6.0
6.0
4.0
1:7
1:7
1:11
6.0
6.0
2.0
Surgery
H6/H60 ‐ HOB
Acute Gen ‐ L1
8
94.9%
87.0%
2.0
2.0
2.0
1:4
1:4
1:4
0.0
0.0
0.0
Surgery
H4
Neurosurgery
30
100.0%
100.0%
5.0
5.0
3.0
1:6
1:6
1:10
2.0
2.0
2.0
Surgery
H40
Neurosurgery ‐ L1
9
89.6%
84.9%
3.0
3.0
3.0
1:3
1:3
1:3
1.0
1.0
1.0
Surgery
H9
Trauma
31
95.4%
90.2%
5.0
5.0
3.0
1:6
1:6
1:10
4.0
3.0
2.0
Surgery
H90
Trauma / OMFS
29
97.6%
89.0%
5.0
5.0
3.0
1:6
1:6
1:10
4.0
3.0
2.0
Surgery
H7
Vascular
29
97.7%
94.4%
6.0
5.0
3.0
1:5
1:6
1:10
2.0
2.0
2.0
Surgery
H100
Gastro
23
100.0%
98.1%
5.0
5.0
3.0
1:5
1:5
1:8
3.0
2.0
1.0
Table 2 – Medical Health Group (MHG) Occupancy
Health Group
Ward
Speciality
Beds
Medicine
C19
DME
28
Medicine
C21
DME
30
Medicine
C22
Respiratory
30
Medicine
C26
Cardiology / CTS
18
Medicine
C26 ‐ HOB
Cardiology / CTS ‐ L1
8
Medicine
C28
Cardiology
17
Medicine
CMU
Cardiac Monitoring Unit
10
Medicine
AAU
Acute Assesment Unit
49
Medicine
H1
Gen Med
20
Medicine
H5
Respiratory
18
Medicine
5 HDU
Respiratory HDU
6
Medicine
H50
Renal
19
Medicine
H70
Acute gen med
28
Medicine
H8/80
ESSU
54
Medicine
H10
Acute gen med
27
Medicine
H11
Neurology
28
Medicine
H110
Stroke
20
Medicine
H110 ‐ HASU
Stroke ‐ Hyper Acute Stroke
4
Medicine
ED Majors
Mid day Mid night
Current rota ‐ registered
Current Registered ratio
Current rota ‐ non‐registered
Early
Late
Night
Early
Late
Night
Early
Late
Night
1:6
1:14
3.0
2.0
2.0
95.9%
95.9%
5.0
5.0
2.0
1:6
96.8%
95.9%
5.0
4.0
2.0
1:6
1:8
1:15
4.0
3.0
2.0
96.9%
93.8%
4.0
3.0
2.0
1:8
1:10
1:15
3.0
3.0
2.0
95.9%
94.0%
4.0
4.0
2.0
1:5
1:5
1:9
2.0
2.0
1.0
95.9%
94.0%
2.0
2.0
2.0
1:4
1:4
1:4
0.0
0.0
0.0
95.5%
93.5%
3.0
3.0
2.0
1:6
1:6
1:9
2.0
2.0
2.0
77.4%
71.0%
4.0
4.0
4.0
1:3
1:3
1:3
0.0
0.0
0.0
94.3%
86.2%
10.0
10.0
6.0
1:5
1:5
1:8
6.0
6.0
4.0
92.4%
91.2%
4.0
3.0
2.0
1:5
1:7
1:10
1.0
1.0
2.0
96.7%
95.3%
4.0
3.0
2.0
1:5
1:6
1:9
2.0
2.0
2.0
96.7%
95.3%
3.0
3.0
3.0
1:2
1:2
1:2
0.0
0.0
0.0
100.0%
100.0%
4.0
3.0
2.0
1:5
1:6
1:10
2.0
2.0
1.0
95.3%
94.9%
5.0
5.0
2.0
1:6
1:6
1:14
3.0
2.0
2.0
94.3%
91.3%
9.0
9.0
6.0
1:6
1:6
1:9
6.0
6.0
4.0
96.9%
95.2%
5.0
4.0
2.0
1:5
1:7
1:14
2.0
3.0
2.0
98.4%
97.2%
5.0
5.0
3.0
1:6
1:6
1:9
3.0
2.0
2.0
91.8%
88.0%
4.0
4.0
2.0
1:5
1:5
1:10
1.0
1.0
1.0
82.4%
83.3%
1.0
1.0
1.0
1:4
1:4
1:4
1.0
1.0
1.0
0.0%
0.0%
11.0
11.0
11.0
N/A
N/A
N/A
4.0
4.0
4.0
111
Table 3 – Cancer and Clinical Support Health Group Occupancy
Health Group
Current rota ‐ registered
Mid day Mid night
Current Registered ratio
Current rota ‐ non‐registered
Ward
Speciality
Beds
Early
Late
Night
Early
Late
Night
C&CS
C30/31
Ocology / haematology
49
100.0%
Early
Late
Night
100.0%
7.0
7.0
4.0
1:7
1:7
1:12
4.0
4.0
2.5
C&CS
C32/33
Ocology / haematology/ TYA
50
100.0%
100.0%
10.0
10.0
5.0
1:5
1:5
1:10
4.0
4.0
3.0
C&CS
C20
Infectious diseases
19
74.4%
75.3%
4.0
4.0
3.0
1:5
1:5
1:6
2.0
2.0
1.0
C&CS
C29
Rehab
15
100.0%
100.0%
2.0
2.0
2.0
1:8
1:8
1:8
3.0
3.0
1.0
Table 4 – Family and Women’s Health Group Occupancy
Health Group
Ward
Speciality
Beds
FWH
C16
Breast / ENT
26
FWH
H30
Gynae
9
FWH
H35
Ophthalmology
8
Mid day Mid night
Current rota ‐ registered
Current Registered ratio
Current rota ‐ non‐registered
Early
Late
Night
Early
Late
Night
Early
Late
Night
100.0%
4.0
3.0
2.0
1:7
1:9
1:13
2.0
2.0
1.0
100.0%
74.3%
3.0
3.0
2.0
1:3
1:3
1:5
2.0
1.0
0.0
100.0%
100.0%
2.0
2.0
2.0
1:4
1:4
1:4
1.0
1.0
0.0
100.0%
As illustrated above, following a recent investment of £0.5m into the Medical Health Group all Adult wards have a minimum staffing ratio of 1:7 during day time shifts with only the following exceptions: 

C22 – 1:8 during early shift and 1:10 during late shift – This ward was to be part of the bed base rationalisation plans for the Medicine Health group. C29 – 1:8 across all shifts – This rehabilitation ward is supported by other professionals forming part of the MDT (e.g. Physiotherapy) The current nursing establishments demonstrated in Tables 1 – 4 appear better than the recommended 1:7 due to the incorporated role of the nurse in charge of the shift. This role supports the operational function of the ward and allows the ability to provide flexibility in variation of activity, changes in patient acuity and dependency, factors, (a concept which is advocated by NICE 2014). For clarity the role of the nurse in charge of the shift is illustrated in Appendix 1. The current rotas exclude the charge nurse/ward sisters who are supervisory, for clarity the attributes of the supervisory role and expected outcomes are outlined in Appendix 2. The nurse to patient ratio falls significantly short of the desired 1:8 as recommended within NICE Consultation Document (2014) in a number of ward areas across the night shifts. As such, a comprehensive review of each of the ward rotas has been completed by the Nurse Directors, supported by the Health Group Accountants to understand the level of investment required to ensure optimum nurse to patient ratios across all shifts. 4. Methodology used to develop nursing rotas The methodology used to determine the most appropriate safe staffing levels for each of the clinical areas, which relate specifically to registered nurses is based upon Guidance on safe nurse staffing levels in the UK (RCN 2012) and the `Safe staffing for nursing in adult inpatient wards in acute hospitals NICE Safe Staffing Guideline Draft for Consultation` (NICE 2014). 112
The professional judgement of the Senior Nursing Team is also used as this is based on an in depth knowledge of the acuity, dependency and activity requirements of each of the clinical specialities. This concept is advocated by NICE (2014 p.15) when formulating nursing establishments. Appendix 3 demonstrates an overview of each of the clinical specialities and acuity levels. The nursing activities and associated timescales for each level of patient acuity are outlined in Appendix 4. It is acknowledged that there is no single nursing staff to patient ratio that can be applied across a wide range of wards to safely or adequately meet the nursing care needs of patients. NICE therefore recommends the factors that need to be systematically assessed at ward level when determining nursing staff requirements, with the nursing care needs of individual patients being the main drive (NICE 2014 p.7). NICE (2014) further suggest that these factors should then be used in a staged approach to set safe nursing requirements through a 24 hour period. 5. Financial Implications The table below demonstrates the proposed transition of registered nurse to patient ratio across night shifts, and the whole time equivalent and cost implications as a result. 113
Night shift ratio
Health Group
Ward
Speciality
Medicine
C19
DME
Medicine
C21
DME
Medicine
C22
Respiratory
Medicine
C26
Cardiology / CTS
Medicine
C26 ‐ HOB
Cardiology / CTS ‐ L1
Medicine
C28
Cardiology
Medicine
CMU
Cardiac Monitoring Unit
Medicine
AAU
Acute Assesment Unit
Medicine
H1
Gen Med
Medicine
H5
Respiratory
Medicine
5 HDU
Respiratory HDU
Medicine
H50
Renal
Medicine
H70
Acute gen med
Medicine
H8/80
ESSU
Medicine
H10
Acute gen med
Medicine
H11
Neurology
Medicine
H110
Stroke
Medicine H110 ‐ HASU Stroke ‐ Hyper Acute Stroke
Surgery
C9
Ortho
Surgery
C8
Plas / intermediate activity
Surgery
C10
Colorectal
Surgery
C11
Colorectal
Surgery
C11 Hob
Coloectal ‐ L1
Surgery
C14
UGI / Gynae Onc
Surgery
C15
Urology
Surgery
C27
CTS
Surgery
C27 HOB
CTS ‐ L1
Surgery
H6/H60
Acute Gen and Plas
Surgery
H6/H60 HOB
Acute Gen ‐ L1
Surgery
H4
Neurosurgery
Surgery
H40
Neurosurgery ‐ L1
Surgery
H9
Trauma
Surgery
H90
Trauma / OMFS
Surgery
H7
Vascular
Surgery
H100
Gastro
C&CS
20
Infectious desieases
C&CS
29
Rehab
C&CS
30 /31
Ocology / haematology
C&CS
32 /33
Ocology / haematology / TYA
FWH
H30
Gynaecology
FWH
H35
Opthamology
FWH
C16
Breast and ENT
Beds
28
30
30
18
8
17
10
49
20
18
6
19
28
54
27
28
24
4
29
26
21
14
8
27
26
18
8
44
8
30
9
31
29
29
23
19
15
49
50
9
8
26
Current
1:14
1:15
1:15
1:9
1:4
1:9
1:3
1:8
1:10
1:9
1:2
1:10
1:14
1:9
1:14
1:9
1:10
1:4
1:15
1:13
1:11
1:7
1:4
1:9
1:9
1:9
1:4
1:11
1:4
1:10
1:3
1:10
1:10
1:10
1:8
1:6
1:8
1:12
1:10
1:5
1:4
1:13
Proposed
1:8
1:8
1:10
1:9
1:4
1:9
1:3
1:7
1:8
1:9
1:2
1:10
1:8
1:9
1:9
1:9
1:10
1:4
1:8
1:8
1:11
1:7
1:4
1:9
1:9
1:9
1:4
1:9
1:4
1:10
1:3
1:10
1:10
1:10
1:8
1:6
1:8
1:10
1:8
1:5
1:4
1:13
Costing based upon average enhancement of 23% and bottom of band 5 due to new recruits
Staffing uplift ‐ REG 1.73
1.73
2.60
‐
‐
‐
‐
2.60
‐
‐
1.16
‐
2.26
‐
1.95
‐
‐
‐
2.60
1.78
‐
‐
‐
‐
‐
‐
‐
2.60
‐
‐
‐
‐
‐
‐
‐
‐
‐
2.60
2.60
‐
‐
‐
26.21
Cost £'000
54.90
54.90
82.51
‐
‐
‐
‐
82.51
‐
‐
36.81
‐
71.72
‐
61.88
‐
‐
‐
82.51
56.49
‐
‐
‐
‐
‐
‐
‐
82.51
‐
‐
‐
‐
‐
‐
‐
‐
‐
82.51
82.51
‐
‐
‐
831.75
All rotas have been standardized to ensure shift start and finish times allocated annual leave and sickness percentages are consistent across all Health Groups. It should be noted, that no investment is proposed into ward C16 on account of the non‐recurrent nature of its current bed base which is currently uplifted to accommodate medical patients in the short term. Should this bed base remain open in the longer term, then additional staffing will be required (c2.6 WTE, £82.5k) 114
The above establishment can be partially funded through savings achieved through nursing skill mix, particularly with regard to the establishment of Junior Sister roles across wards, and therefore the overall reduction of Band 6 roles across the nursing establishment. This is forecast to realise £137k of savings once pay protection has ended. A total investment of £695k is therefore requested to support the above. Aside from the savings associated with the Junior Sisters, further funding options to support the above investment include: 



The future role of the Matron given the more strategic role of the Charge Nurse Benefits realised from introduction of a Site Management team The above investment would also support the realisation of CRES opportunities with particular regard to length of stay Further, it is also proposed that a detailed review be performed of those wards with a bed base of 10 or less given the inherent efficiencies and high cost per bed that these attract. It is proposed that these options be fully worked up through a detailed workforce and investment plan across the whole nursing establishment. 6. Proposed Quality Benefits of Above Investment There is a growing body of research evidence which demonstrates that nurse staffing levels make a difference to patient outcomes, patient experience, quality of care and the efficiency of care delivery (RCN 2012). Information collated via the Trusts incident reporting system and prevalence reviews suggests that a number of fundamental aspects of nursing care (e.g. administration of controlled drug pain relief, I.V antibiotics, completion of intentional rounding and care bundles) are not always completed in a timely manner during night shifts and therefore have the potential to cause patient harm. NICE (2014) called these omissions in nursing care “Red Flags” (Appendix FIVE). Although there is no substantiated evidence, information collated through informal communication channels with clinical staff suggests that they often feel that they have limited time to deliver all elements of care during a night shift, therefore leading to poor staff morale. It is envisaged that the benefits of the above investment (following active recruitment) will support delivery of the following: 



Improvement in Nursing Indicators Reduction in Nursing Red Flags Continual Improvement of Friends and Family Test Improvement in Staff Survey Results 115
7. Recommendations It is acknowledged that there are 12 clinical areas that require investment and that further work is required to determine further mechanisms of funding, in order to determine a viable investment plan, however, it is the view of the senior nursing team that the Trust Board endorse investment within the Medical Elderly Wards as an immediate priority. 116
APPENDIX ONE Role and Responsibilities of the Nurse in Charge of the Shift ROLE OF NURSE IN CHARGE OF SHIFT 
Allocation of Staff 
Review of Workload 
Complete ward safety brief with full MDT 
Nutrition: Ensure Red Tray patients get assistance 
Prepare for Ward Rounds 
Board Round with Consultant 
Ensure Patient flow: confirm actual & potential discharges 
Constantly reviewing & monitoring acuity of patients ensuring care needs are met (Red Flags) 117
APPENDIX TWO Role and Responsibilities of the Charge Nurse/Ward Sister SUPERVISORY CHARGE NURSE ROLE Francis Recommendation 195: Ward Managers should operate in a supervisory capacity and not be office‐bound or expected to double up, except in emergencies as part of the nursing provision on the ward. They should know about care plan relating to every patient on the ward. They should be visible to patients & staff and be available to discuss concerns with all, including relatives. Critically, they should work alongside staff as a role model and mentor, developing clinical competencies and leadership skills within the team. As a corollary, they will monitor performance and deliver training and/or feedback as appropriate including a robust annual appraisal Incidents & Complaints investigated in a timely manner with feedback and SAFE learning shared with all members of the clinical team. Escalation of deteriorating patients Clinical audits completed/ bench marking performance against peers/other EFFECTIVE hospitals Pioneer Teams Improvements in Patient Flow Improved effective multidisciplinary working within the clinical team PDR completed in timely manner CARING Managing poor performance/ sickness Time to lead & implement change ensuring improvements are sustainable. Minimum of Silver score within Setting the Standard High scores in Friends & Family Leading on quality improvements & developments in practice. RESPONSIVE Dementia Friendly environment Charge Nurse to establish what went wrong and why Charge Nurse available at visiting times to speak to patient & carers. Relatives Clinics WELL‐LED Charge Nurse reviewing patient daily, taking part in ward rounds All mandatory staff training at 95% 118
APPENDIX THREE The nursing activities and associated timescales for each level of patient acuity Types of ongoing nursing activities that change nursing staff requirements ROUTINE NURSING CARE CARE PLANNING COMMUNICATION EATING & DRINKING FLUID MANAGEMENT HYGIENE MANAGEMENT OF EQUIPMENT MEDICATION Simple condition & care plan Providing information and support to patients, including all emotional & spiritual needs. Ensuring food & drink provided and consumed 8 hrly IV Fluids Minimal assistance with washing, dressing, grooming Simple intermittent (e.g. catheters, IV access) Regular oral medication ADDITIONAL NURSING CARE NEEDS SIGNIFICANT NURSING CARE NEEDS (Approx 20 – 30 mins per activity) (More than 30 minutes per activity) Complex condition or care plan (e.g. multiple comorbidities) Complex multiple health needs Attending MDT meetings Assistance with eating & drinking Difficulties with communication including sensory or language issues. Parenteral nutrition IV Fluids more frequently than 8 hrly or blood components Complex fluid management (e.g. hourly or requiring monitoring in ml) Assistance for some hygiene Assistance for all hygiene needs needs requiring one nursing staff or requiring two nursing staff Central lines, drains, stoma Multiple lines, drains IV medication or frequent PRN medication Medication requiring complex preparation / administration or two nursing staff Mobilisation with assistance of two nursing staff Intensive mouth care needed ( e.g. patient receiving chemotherapy) More frequent than 2 hourly More frequently than 2 hourly or requiring two nursing staff MOBILISATION No assistance needed Assistance needed (e.g. post‐op or during out of hours periods) Assistance needed MOUTH CARE No assistance needed OBSRVATIONS PRESSURE AREA CARE TOILETING 4 – 6 hourly Less frequently than 4 hourly 2 – 4 hourly 2 – 4 hourly No assistance needed Assistance needed Frequent assistance or two nursing staff needed This is equivalent to ACUITY LEVEL 0 1a 1b Abbreviations: IV = intravenous, PRN Medicines= medicines administered as needed 119
Types of ONE OFF nursing care activities that change Nursing Staff requirements ROUTINE NURSING CARE NEEDS ADMISSION DISCHARGE PLANNING PATIENT & RELATIVE EDUCATION PATIENT ESCORTS PRODECURES & TREATMENTS Simple follow‐up and transfer home Routine teaching about condition, routine post‐op care Routine escorts or transfers for procedures Simple wound dressings, specimen collections ADDITIONAL NURSING CARE NEEDS SIGNIFICANT NURSING CARE NEEDS (Approx 20 – 30 minutes per activity) (More than 30 minutes per activity) Admission assessment Co‐ordination of different services Organising complex services, support or equipment Teaching about a significant new condition (e.g. diabetes, heart disease, cancer) Teaching about a new complex or self‐managed condition Escorting a patient off ward for 20 – 30 minutes Escorting a patient off a ward for more than 30 minutes Catheterisation, nasogastric tube insertion, multiple wound dressings Complex wound dressings (e.g. vacuum assisted closure) tracheostomy care. 120
Appendix 4 Overview of Surgical Wards and Acuity Levels Speciality Vascular Surgery (Ward 7 HRI) Overview of Activity This is a busy 30 bedded acute vascular ward, taking referrals from both Hull and East Yorkshire Hospitals NHS Trust, and Northern Lincolnshire and Goole NHS Trust. The nursing staff are currently coordinating in excess of 8 admissions per day. The patient group varies from patients undergoing major vascular surgery, often stepping down from critical care. To patients requiring interventional radiology to diagnose or treat a vascular disease process. The patient group is usually highly dependent, their vascular problems affecting their skin integrity and their ability to mobilise. The ward also look after all patients post operatively following amputations and the rehabilitation pathway following these operations commences on ward 7. The nursing staff administer high risk medications, including thrombolysis, which is a clot busting drug used to treat limbs that are at risk of becoming compromised. The clinical team have recently reviewed the pathway for patients undergoing Endovascular aneurysm repair, and this group of patients now go directly back to ward 7 instead of having an overnight stay in intensive care. Acuity The acuity of the speciality is one that reflects acuity and emergency surgery. On average the ward supports 50% of 1b patients and 25% 1a and 0 respectively. The ward has a high occupancy running at 94.1%. 121
Acute Surgery – H6/60 There are 2, 26 bedded wards that form the acute surgical admissions unit for the Hull and East Yorkshire Hospitals NHS Trust. The ward accepts any patient with a presenting acute surgical problem and any patients requiring plastic surgery trauma admissions. The ward can admit in excess of 20 emergency patients per day, who all require a full assessment and potentially emergency surgery. The ward also admits all patients on the HRI site stepping down from critical care post acute surgery. The ward includes two 8 bedded high observation areas, these were established following recommendations relating to the higher risk surgical patient. This ward has a high patient turn‐over. The majority of the patients are level 0, but approximately 15% of patients are 1a and either deteriorating or at risk, a number of these patients go on to require level 2 care. 122
Urology – C15, ambulatory care and Urology day services. The Urology service have done a significant amount of pathway work over the last 2 years, and have reduced the bed base from 34 to 26, this has mainly been achieved by the development of an ambulatory care lounge which is staffed by the experienced Urology Nursing team. Any acute Urology admissions are assessed in the ambulatory care lounge and when possible assessed and treated and referred on appropriately, where that is not possible an in‐patient admission is arranged. The Urology ward is able to focus on the major surgery carried out for urological cancers. The ward nurses look after patients who need continuous irrigation post procedure, patients who have stepped down from intensive care and patients who require continuous epidural analgesia. The team also provide all the support for the Urology Day Services, which is the main outpatient facility for patients with a Urological problem, nurse practitioners undertake Cystoscopies (camera tests of the urethral system), investigations into Haematuria (blood in the urine) and Urodynamic investigations. They also support patients undergoing trial without catheters. The acuity on this ward is predominately Level 0 [65%], there are a number of 1a patient which reflects the acute emergency surgical provision. The ward also supports a small number of 1b patients reflective of major surgical procedures. 123
Colorectal – C10/C11 There are 43 beds across two wards providing care for patients who have had colorectal surgery. The teams have two established high observation areas where patients who have undergone major colorectal surgery very often following a cancer diagnosis are looked after in the immediate post‐operative period. The ward has implemented a full ERAS programme, which is enhanced recovery after surgery, where patients are fully briefed about their expected progress following surgery, and empowered to be fully involved in the decision making. The nursing team are experienced in the physiological and psychological care involved in looking after patients following formation of stomas. They also provide complex wound management clinics and provide management for patients who have high output stomas and the complex fluid management that this entails. The ward nursing staff are experienced in caring for patients who have total intestinal failure, who will need to go home on total parenteral nutrition, this involves complex support and education for the patient and carers. A high proportion of the patients have also recently received a cancer diagnosis and a small team of specialist nurses support the ward nursing team to care for this patients. The acuity for both wards is predominately level 0, a small of Level 1a and approximately 15% 1b reflective of major complex surgery. 124
Cardiothoracic Surgery – C27 The speciality admits all patients who have a primary cardiothoracic problem. They accept tertiary referrals from Northern Lincolnshire and Goole Hospitals and York. The team of nursing staff provide care for patients both pre and post operatively who require major thoracic and cardiac procedures, Including heart valve replacements, and coronary artery bypass graft surgery. Patients who have cancer diagnoses undergoing major lung surgery to remove part or all of a lung and patients coming into hospital for diagnostic procedures to assess heart or lung function. The ward has an 8 bedded high observation area, which provides full cardiac monitoring for patients who have stepped down from intensive care following a period of ventilation post‐surgery. Patients very often are high risk, requiring complex interventions such cardiac pacing or chest drains. The acuity is generally reflective of major surgery with over 50% of patients requiring level 1b support. 125
Gastroenterology Ward 100 HRI 23 beds (often open extra capacity x 4 to meet demand.) The majority of patients admitted to ward 100 present through the Acute Assessment Unit often via ED. Therefore these patients are all acutely ill, and often with a high dependency. The ward has a high use of extra capacity to support demand. The majority of the patients are Level 0, but a significant number require Level 1b support. The liver patients have a complex pathway and their condition can fluctuate considerably, very quickly, therefore need careful monitoring and support with complex medication regimes. These patients can often require end of life care. Patients with alcohol related disease require intensive nursing, as these patients are often confused, disorientated and at high risk of falls as they go through the detox process, therefore this group of patients may need 1:1 care, and if aggressive support from security. Mental health issues are also prevalent in this group of patients. Ward 100 also supports patients with complex nutritional needs, such as anorexia, PEG’s etc.. This group will need high levels of nursing interventions including entral feeding and psychological support. Also ward 100 cares for many patients with learning disabilities who can have complex gastro needs which again can have significant psychological implications to the nursing care required. This speciality manages patient with long term conditions that can have debilitating consequences, where patient will need long term care, and many require multi agency input for complex discharges. 126
Upper GI Ward 14 CHH 27 beds (extra capacity x 3 to support demand if required) The majority of patient that are admitted to ward 14 are elective surgical patients, however there are occasions when are emergencies are admitted from the OPD or transferred from the acute surgical wards at HRI. Wards 14 also accept tertiary referrals for neighbouring trusts that are often acutely ill on arrival. These patients often require extensive investigations including endoscopic procedures. This ward predominately support Level 0 patients, with a small number requiring level 1b support following complex major surgery. The clinical team perform major surgery, for Upper GI cancers, these patients will stay in ICU until clinically stable. On return to the ward they will need significant amount of nursing care, especially around nutritional requirements and parental feeding regimes. In some cases long term palliative and end of life care is required. In addition to this the ward also provides care for some of the fast turnover Upper GI patients, requiring post op care and rapid discharge. Ward 14 also provides the Bariatric service, for patients requiring surgical intervention, these patients require additional support immediately post operatively due to their weight issues and the complications associated with this type of surgery. If these patients experience a significant post op complication then their stay can be considerably extended and the nursing resource required to care for these patients during this period is increased. Ward 14 also provide the Oncology Gynaecology surgical bed base, these patient again can require significant nursing input especially from a psychological perspective. 127
Neurosurgery, Ward 4 and 40: 50% of patient on H4 are Level 1b reflective of dependent 30 Ward Beds and 9 HOB beds Sub regional specialist unit accepting care. H40 supporting at risk acute patients, with occasional emergency admissions 24/7. Highly complex group of patients critical care requirements. undergoing brain and spinal surgery. Many patients are subject to cognitive and functional difficulties post operatively and require a high level of nursing support to achieve their activities of daily living. Many patients present with altered or challenging behaviour as a result of their injury/diagnosis and require constant supervision to maintain their safety and the safety of other staff and patients around them. Patients who suffer spinal injury and/or spinal cord injury require significant resources to move them and are at significant risk of complications due to long periods of enforced bed rest. For cervical level injury – 5 staff are required for the moving and handling of each patient at any time. Ward 4 and 40 also provide an elective service for patients with brain and spinal conditions. This can range from simple spinal surgery to complex surgery for high grade, malignant brain tumours. The staff provide a high level of psychosocial support to this group of patients who are also at risk of cognitive and functional disability post operatively. 128
Trauma Orthopaedics, Ward 9 and 90: 60 Beds in total, 50 Trauma and 10 Max fax. Dedicated trauma unit accepting admissions 24/7, forming part of the major trauma network. A large majority of the patients are frail, elderly patients with hip fractures who require high levels of nursing input as they are restricted to bed and are at high risk of developing complications and are subject to undergoing major surgery to repair the fracture. These patients are often compromised by multiple medical ailments and a significant number have dementia. On admission, some of these patients are already significantly compromised as a result of the mechanism of their injury and the time they may have been left before they have been found. Patients who attend following major trauma present with complex injuries and require significant resource to care for their needs in the initial phase of their injury. Predominately Level 1b reflective of post‐operative elderly or complex patients. Many of these patients require complex planning for their discharge home or to rehabilitation facilities. The vast majority of patients are of Acuity Level 1B as a result of the amount of nursing care they require. Ward 90 also has 10 max fax beds where there is a high number of non ‐ complex patients requiring minor surgery under GA and also a small number of highly complex head and neck cancer patients who undergo radical surgery and require high levels of nursing intervention post operatively, the majority requiring a tracheostomy and enteral feeding plans. These patients require high levels of psychological support 129
Elective Orthopaedics, Ward 9 CHH: Predominately Level 0 elective surgical patients. 29 bedded ward caring for elective patients undergoing planned surgery. Many of those are undergoing hip and knee surgery and require intense nursing initially, but with the Enhanced recovery programme are facilitated to mobilise and be as independent as possible until discharge. There are also patients undoing spinal surgery who require close observation post operatively and assistance to mobilise thereafter. There are frequently around 12‐15 admissions per day and therefore requires a high level of nursing resource to ensure the patients are discharged safely and new patients admitted following surgery. 29 bedded ward with a range of elective services. The bed base Ward 8 CHH: Plastic Surgery and reduces to 11 each weekend, but this is frequently over capacity. There are frequently in excess of 20 admissions per day, Monday to 5 day service, Friday.11 beds are allocated for Plastic Surgery, 15 beds allocated for the 5 day service which consists of Upper GI, Urology and Gynaecology. The remaining beds are utilised for Spinal surgery. The vast majority of patients are less complex in the nature of the surgery they are undergoing, but thisresults in a fast turnover of patients and requires precision management of the bed resource. On the other hand the plastic surgery service has some more dependant patients who undergo lengthy reconstructive plastic surgery who require intense observation post operatively for a significant length of time to ensure no complications occur, as well as support to provide all aspects of nursing care to this dependant group of patients. 130
To demonstrate night time investment we need to look at time requirements on a night time – medication rounds – IV etc. Number of falls/ skin bundle/intentional rounding requirements/ basis care requirements remain the same minus the daily activities of ward rounds admissions – need to look at workload how we can become more efficient prep of patients for next day activities etc. Less relative/MDT commitments during the night – we need to focus on workload as well as harm rates – staff sickness. 131
Appendix 4 Overview of Clinical Support Wards and Acuity Levels Speciality Overview of Activity Acuity Ward 20 Acuity reflective of isolation facilities and acutely ill patients with infectious diseases. Infectious Diseases and C‐ Dif Cohort Ward Is a 19 bedded ward, it cares for patients with Infectious diseases (11 beds) and also incorporates the clostridium difficile cohort inpatient beds for the Trust (8 beds). This area is separated from the main ward and to comply with infection prevention is staffed completely separately. 132
Ward 29 Is a 15 bedded ward, caring for patients with complex rehabilitation needs following brain injury or trauma; often referred from neurosurgery/medicine specialities with long term care needs. Use of over‐capacity noted to support general medical patients, some discrepancy in acuity reporting of Level 1a patients not reflective of patient speciality. Ward 30 Is a 22 bedded ward, it cares for oncology/haematology patients. This includes patients undergoing radiotherapy and High number of patient falls noted, predominantly Level 0 patients, with approximately 10% Level 1b. 133
chemotherapy treatments and those patients with complications of treatment/cancers. Ward 31 Is a 28 bedded ward, it cares for oncology/haematology patients. This ward also incorporates the lead lined inpatient single room specifically for the treatment of thyroid cancers with radio‐iodine and 3 negative pressure rooms Acuity reported average 50% Level 0 and 50% level 1b patients, relatively low occupancy [84.5%] noted. 134
for isolation of appropriate patients. 135
Ward 32 High acuity ward predominantly managing Level 1b patients. 136
Ward 33 Occupancy reported at 84.82%. High levels of 1b and 1a’s reported, reflective of Is a 28 bedded ward, caring for Oncology/haematology patients. This includes 4 speciaility. Teenage and Young Adult (TYA) inpatient beds supported by the Teenage Cancer Trust (TCT). This area cares for 18‐25 year olds with cancer and has its’ own day treatment area for Outpatient/Day patients. Ward 33 also has 5 hepafiltered beds (positive pressure rooms) specifically used for the isolation and care of patients undergoing stem cell transplants in the treatment of their haematological malignancy. Due to the nature of the patients treated in this ward and the main speciality being haematology, the staffing levels are higher to reflect the greater patient dependency and acuity and fulfil the patients specialist needs. Appendix 4 137
Overview of Family & Women’s Ward C16, H30,H35 and Acuity Levels Speciality Overview of Activity Acuity Ward C16 Ward 16 Use of over‐capacity noted to support general medical patients, Is a 26 bedded + 4 Trolley ward, providing care to both breast and ENT patients, reducing to 18 beds at the weekend. Which includes both pre and post‐operative care for patients undergoing both major and minor ENT and breast surgery. The ward has the physical space for 34 beds and often reaches this level and demonstrated by the average midday occupancy of 106% (2013‐14). The above staffing establishment does not take into account the increased capacity up to 34 beds The average occupancy levels of this ward during 2013‐14 106% at Midday and 82% at midnight. The recent acuity report presented to Board identified that this ward requires investment of £110k to increase the night‐time establishment by 1 registered nurse. A further £17k is required to make the ward sister fully supervisory The rational for this investment would be improved safety and quality as measured a reduction in incidents and complaints 138
Ward H 35 Ward H35 is an 8 bedded ward for the speciality of Ophthalmology which generally opens extra capacity of 4 additional inpatient beds to support patients from other specialities. Included in the staffing establishment is capacity to support the Ophthalmology day case area which operates Monday to Friday Low acuity activity, high use of extra capacity. Level 1a patients reflective of Medical patients 139
Ward H30 Is a 9 bedded and 11 day case trolley ward which operates Monday to Friday ( 5 day ward). It cares for patients requiring general gynaecology surgical procedures and conditions in both an inpatient and day case environment. The ward accepts direct emergency admissions requiring the specialist support of gynaecologists. Elective surgical ward with 9 overnight beds, low acuity surgery. 140
Appendix 4 Overview of each of the Medical Wards and Acuity Levels Speciality Ward C26 Overview of Activity Acuity Acuity reflective of speciality, occasional Fast‐Track post Level 2 patient, relatively high The ward is a ‐26 bedded Acute Cardiology /Cardiothoracic Ward, patients are both elective patient turn‐over from elective to post ICU. and acute direct admissions. The dependency is high and the ward takes post‐ operative step down patients from ICU on a daily basis. Six of the beds are higher observation areas to manage the ICU transfers and unstable patients. 141
Ward C28 / is a ‐17 bedded Acute Cardiology Ward and 10 CMU bedded Cardiac monitoring Unit, it cares for patients with‐acute cardiology needs. The CMU is a sub‐regional specialty admission area for acute patients who have suffered heart attacks and are triaged by ambulance staff as direct admissions to receive immediate treatment for this life threatening condition. This is a 24/7, 365 days service. Patients are managed on the CMU after this invasive treatment and as their condition improves they will transfer to the ward for care. Acuity demonstrates a number of beds utilised for Level 2 CMU capacity, high acuity ward dealing with at risk and deteriorating patients along with Level 1b dependent patients. 142
Ward H11 is a ‐28 bedded Acute Neurology Ward and rehabilitation for stroke patients, it cares for patients with‐acute neurology needs and rehabilitation stroke needs. The ward has many patients that are highly dependent and need assistance with all aspects of daily living due to the disability or symptoms of stroke and neurological disease, this includes feeding, hygiene needs, positional changes, toileting and dressing. Acuity representative of complex neurology and stroke patients. 143
Ward H110 is a ‐20 bedded ward Acute Stroke Ward + 4 Hyper Acute Stroke Unit , it cares for patients with‐acute stroke needs. The ward takes direct admissions of patients that have suffered a stroke and gives thrombolytic treatment to acute patients that meet the criteria. These patients require close monitoring and intervention for 24 – 48 hours depending on their response to treatment. The dependency is high on the ward with many patients requiring help with all aspects of care. Patients and their relatives need much support during this time as the impact of the diagnosis and potential for recovery impacts dramatically on previous life style. Acuity reflective of Hyper Acute Stroke Unit supporting a number of thrombolytic patients. 144
Ward C19 Acuity reflective of 50% dependent elderly patients requiring Level 1b care. 145
Ward C21 Acuity reflective of 40% dependent elderly patients requiring Level 1b care. 146
Ward C22 Ward 22 ‐ Is a 30 bedded ward, it cares for patients Predominantly high Level patients reflective of stable respiratory patients. with Respiratory conditions and forms part the respiratory tertiary centre for the longer stay respiratory patient. Ward 22 is a specialist centre for Cystic Fibrosis and accepts direct admissions from the community. 147
ESSU Is a made up of TWO 28 bedded wards, it cares for Relatively high harm rates noted in these two wards, mixture of low and high acuity elderly patients with short stay medical needs with noted. a length of stay of up to 5 days. The unit delivers a healthcare setting which takes into consideration the wider needs of the patient group. The ward environment is developed to ensure a dementia friendly approach to the care we deliver. The unit also provides an in‐reach service to ensure that patients are cared for in the right place at right time. 148
Ward H70 is a 28 bedded ward, it cares for elderly patients with age related acute illness and frailty, patients have diverse complex health and social care needs which require complex discharge planning to ensure safe effective transfer from hospital into a community setting. High acuity noted for the complex acute medical elderly patients, high number of Level 1a patients. 149
Ward H50 ‐ Is a 19 bedded ward, caring for patients with renal and general medical conditions. As Hull is a tertiary centre for patients undergoing renal therapy, Peritoneal Dialysis, Haemodialysis, and post‐transplant care Ward 50 provides highly skilled specialist care. The extensive catchment area covers Scarborough, Linconshire and Doncaster and Hull with new renal referrals admitted directly from GP’s or community clinics for a variety of renal investigations. Acuity reflective of complex nature of speciality requiring level 1 b support. High use extra capacity noted leading to a 108% occupancy of established beds. 150
H5 / RHDU Ward 5 ‐ Is a 18 bedded ward incorporating 6 RHDU beds, it cares for patients with respiratory conditions. Ward 5 forms part of the Tertiary centre for complex respiratory conditions accepting direct admissions from clinics and the community. RHDU has 6 beds which are required to meet the national requirement for staffing to care for L2 patients as required. Acuity reflective of a small number of critical care patients. Level 3 long‐term ventilated patient managed through the audit with a reduced bed capacity as a result. 151
H10 High acuity noted for the complex acute medical patients, high number of Level 1a patients. Ward supports fast‐track management of DKA patients. 152
Ward H1 Ward acuity reflective of Level 0 short‐stay, patients with a high turn‐over. 153
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APPENDIX FIVE: Nursing Red Flags NURSING RED FLAGS Reporting of nursing red flag events over each 24 hour period and at hand over between each shift where possible. Unplanned omission in providing patient medications or delay of more than 30 minutes in providing planned pain relief Patient vital signs not assessed and recorded as outlines in the care plan Regular checks on patients to ensure that their fundamental care needs are completed as outlined in the care plan. This is often referred to as “intentional rounding” and involves checks on aspects of care such as:  Pain: asking patients to describe their level of pain level using the local pain assessment tool  Personal Needs: scheduling patient visits to the toilet or bathroom to avoid risk of falls  Placement: making sure the items a patient needs are within easy reach.  Positioning: making sure the patient is comfortable and the risk of pressure ulcers is assessed and minimised. Shortfall of more than 8 hours or 25% (whichever is reached first) of registered nursing staff present compared with the actual total nursing requirement for the shift 155
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