From testing to spread: Sharing the knowledge and learning from organisations spreading the winning principles - case studies

NHS
CANCER
NHS Improvement

DIAGNOSTICS

HEART

LUNG

STROKE

Transforming Inpatient Care Programme
From testing to spread:
Sharing the knowledge and learning from
organisations spreading the Winning
Principles - case studies

Contents

Introduction 3

Winning Principle 1

Electronic alerts for emergency admissions: How the learning
was spread from Sherwood Forest Hospitals NHS Foundation
Trust and United Lincolnshire Hospitals NHS Trust 4

Emergency admissions, the exception rather than the norm 9

Patient Electronic Alert to Key-worker System (PEAKS) 14

Pan Birmingham Network wide spread of neutropenic
sepsis pathway improvements 16

Commissioning and cost benefits of acute oncology:
Supporting spread across the Anglia Cancer Network 19

Winning Principle 2

Spreading the enhanced recovery principles in patients
undergoing colorectal, liver and upper GI surgery 21

Shifting care and reducing length of stay: Ambulatory
care beds in the haematology inpatient ward 23

Adopting the 23 hour model for mastectomy patients 24

Enhanced Recovery Programme (ERP): Integrated
care pathway for elective colorectal surgery 27

Spreading Enhanced Recovery from one test
project to a network wide programme 29

Delivering care in appropriate settings 34

Enhanced Recovery: Colorectal cancer 36

Breast inpatient care: Valuing patient time 38

Winning Principle 3

Protocol for patients admitted with clinical diagnosis of malignant
bowel obstruction secondary to gynaecological cancer 39

Winning Principle 4

The ‘FAB’ Programme: Fatigue, anxiety breathlessness
programme for patients with lung cancer and their carers 42

Acknowledgements and references 46

From testing to spread: Sharing the knowledge and learning from organisations spreading the Winning Principles | 3

Introduction

There has been good progress in patients with cancer or its symptoms, and to
transforming cancer inpatient care. More be seen by the right person, with appropriate
organisations and clinical teams are adopting expertise. The Winning Principles underpin
the Winning Principles and adapting the new these improvements.
models of care, but there is still more to be
done and the pace of spread needs to be Spread and adoption is not easy and requires
accelerated (Consolidation Report: From Testing using a multi-level of methods, levers and factors
to Spread (2009) - published July 2010). to create, inspire and make the connections with
people and organisations within the current
The new levers supporting spread such as Quality, nature of the changing health landscape. The
Innovation, Productivity and Prevention (QIPP), spread case studies within this publication
GP commissioning and a patient led NHS will illustrate many of these factors and provide an
continue to support the drive for improvement opportunity for sharing ‘working’ knowledge and
and encourage further adoption of good practice. learning experiences with the intention to
The recent revised Operating Framework promote further spread, adoption and action
(2010/11) highlighted the importance to continue of good practice across the country and benefit
to deliver improvements in access and quality for more patients.

The Winning Principles

1. Unscheduled (emergency) patients should be assessed prior to the decision to admit.
Emergency admission should be the exception not the norm.

2. All patients should be on a defined inpatient pathways based on their tumour type
and reasons for admission.

3. Clinical decisions should be made on a daily basis to promote proactive
case management.

4. Patient and carers need to know about their condition and symptoms to encourage
self-management and to know who to contact when needed.

4 | From testing to spread: Sharing the knowledge and learning from organisations spreading the Winning Principles

Winning Principle 1
Unscheduled (emergency) patients should be assessed prior to the decision
to admit. Emergency admission should be the exception not the norm.

Sandwell and West Birmingham Hospitals NHS Trust
Electronic alerts for emergency admissions:
How the learning was spread from Sherwood Forest Hospitals
NHS Foundation Trust and United Lincolnshire Hospitals NHS Trust

Background For the period 2007-2008 the figures the benchmark data. It appeared that
The colorectal team at Sandwell and highlighted that 64% of all bed days patients were not under the care of
West Birmingham Hospitals NHS Trust (3975) followed an emergency colorectal MDT members or
(SWBH) and the Pan Birmingham admittance. A simple trend indicates interacting with the colorectal CNS
Cancer Network (PBCN) have been that by 2010 emergency bed days will following an emergency admission
working to improve patient account for 70% of colorectal and this required further investigation.
experience, outcomes and reduce inpatient spells. At Sandwell General
length of stay (LOS) for emergency Hospital (SGH) and City Hospital (City) The wider MDT is used to identify
admissions of colorectal cancer almost 55% of emergency admissions healthcare professionals who would
patients. ended without a specific surgical be reasonably expected to be involved
intervention (surgery, invasive in patients with colorectal cancer. For
Baseline data collection demonstrated diagnostics, or an invasive procedure). an analysis of Finished Consultant
that SWBH colorectal services mirrored Episodes (FCE) as well as colorectal
the national landscape. The service It was important to place the baseline surgeons clinicians from the
had the largest number of emergency data into an operational context, the specialities of upper GI surgery,
bed days and longest average LOS three years of data was analysed and gastroenterology, medical and clinical
when compared with all other tumour used to identify a cohort of 250 oncology were also included. An FCE
sites at the trust. patients for a review of the healthcare is only recorded when a patient is
records (notes review). The review was passed into the care of a consultant
designed to record patient journey and will not identify any discussion
from arrival at A&E through to between colleagues concerning
discharge noting any interactions or patients but as the HES data has only
diagnostics of significance. patients with colorectal cancer
Interactions include those by Allied recorded in their diagnosis the
Health Professionals (AHP) and expectation is that the majority of
specialist services but exclude ward patients have an FCE with a member
rounds and observations where no of the wider MDT.
further actions or decisions were
made. The review also investigated if At SGH, 224 of 380 patients admitted
admitted patients were brought to the as colorectal emergencies did not
attention of the Clinical Nurse interact with a member of the wider
Specialist (CNS) or multidisciplinary MDT. If patients with a short stay of
team (MDT) during each stay and if up to four days are excluded (84) that
any provisional discharge dates were leaves 160 (70%) patients with a stay
decided as part of the patients of five days and greater who have not
recorded management plan. The seen a member of the wider MDT.
notes review validated the findings of
WINNING PRINCIPLE 1

the Hospital Episodes Statistics (HES) At City, 60 of the182 patients
data review. admitted as colorectal emergencies
did not interact with a member of the
The notes review covered 20% of wider MDT. Excluding short stay
colorectal cancer emergency patients (30) leaves 30 (50%) patients
admissions for a two year period and with a stay of five days and greater
provided context and granularity to who have not seen a member of the

CFrom testing to spread: Sharing the knowledge and learning from organisations spreading the Winning Principles | 5

wider MDT. At City there were 29
stays of 16 days and greater that did Emergency Admissions - Health Record Audit - Health Care Role Interactions
not have any interaction from the 100
wider MDT until at least day six.
90

80
The wider MDT interactions were

Percentage of patients seen
comparable with the interactions 70

abstracted from the notes review 60

were, for instance, documented 50
CNS attendance is 18%. 40

30
The data also demonstrated that just
20
over 50% of patients admitted as an
10
emergency did not have a procedure
or intervention that could be coded 0
CNS Physiotherapist Dietician Social Pain Outreach Palliative Case Discharge US/MRI/
with OPCS4 and that half of patients Services Management Team Care Team Manager Liaison CT/XR

admitted presented with symptoms of Healthcare Role
Patients seen Patients not seen
abdominal pain, nausea and vomiting.

A report was presented to the
colorectal team, cancer services and
cancer operational team, summarising Emergency Admissions - Presenting symptoms
the findings with a data appendix
containing in depth analysis of ICD10 9 10
codes, FCEs, co-morbidity etc as a 8

whole trust and by individual site (City
and SGH). Following discussions with 13
the clinical director, management, the 7
clinical team and the CNS’s it was
agreed that the emergency pathway 6
5 11
would benefit from service 1
12
improvement and that PBCN would 4
provide a service improvement
facilitator (SIF) to support this work. 3
2

Delays to progress
1. Pain and vomiting (50%) 8. Other (15%)
The service improvement work had 2. Acute abdomen obstruction (4%) 9. Temperature >36C (1%)
been authorised but the colorectal 3. Anaemia (4%) 10. Temperature >38C (3%)
4. Bleeding (10%) 11. Pain and vomiting 13%)
service at SWBH were in a transitional 5. Constipation and diestension (1%) 12. Vomiting (10%)
6. Deep vein thrombosis (3%) 13. Pain (27%)
state with a reconfiguration exercise 7. Generally unwell (9%)
to integrate the service on a single
site, adoption of bowel screening and
taking on the care of gynae-oncology
single and dual stoma patients. In
addition, the long standing Clinical were suggested and attempted on The City CNSs had reviewed the
Director was stepping down and it several occasions but it became clear findings and the graphical
was uncertain who would be his that the opening steps of any representations of the patients time
replacement and the SGH site was improvement ideas would have to be spent in hospital. They commented on
developing a fast track elective small and local until some of the the fact that sometimes they were
pathway whilst City were transitional issues had resolved only aware of a patients admittance if
implementing enhanced recovery. themselves. they saw them on the ward or a
Service improvement methodologies relative phoned.


They also recognised that the data
showed that once they were involved Electronic Emergency Alert Model
in a patient’s care that patient
journeys became more ordered and Mail/SMS alert CNS attends Patient Speedy
sent to CNS patient to receives discharge for
the patient was brought to the
when patient resolve timely patient
attention of the wider MDT and arrives in A&E colorectal treatment
received the appropriate clinical care or ward issues
and referrals to allied health
professionals (AHPs).

The CNSs felt that if they were made
aware of a patient being admitted
that they could visit the patient earlier Using data for the period April 2007 - The median and mean LOS for the 19
and bring there skills and expertise to May 2009 and City MDT lists each patients who could reasonably expect
bear in addition to the reassurance month there was circa 650 known to be colorectal emergency the LOS
that having a known face (keyworker) colorectal cancer patients who would are as follows:
visiting the patient would bring. The potentially trigger an alert for A&E
Service Improvement Facilitator (SIF) attendance or and inpatient Mean 3.2 and Median1 with CNS
shared the learning gained from admittance. Additions were also attendance 68%.
Sherwood Forest Hospitals NHS added following each MDT.
Foundation Trust and United (Caveat this is a small data set and for
Lincolnshire Hospitals NHS Trust of The alert system utilised the existing City only patients but the mean is
how successful their emergency Lorenzo IPM interface and the Health suggestive in relation to the increased
communication alert system had been Care Professional flag on the patient CNS attendance).
and the CNSs agreed that if a local PDS screen. Other than internal
solution could be found they were interface team time there were no As well as the overall reduction in
prepared to test it. additional costs associated with the IT median LOS there was also a
interface. significant increase in the percentage
On contacting the SWBH electronic of patients who stayed in hospital for
patient record development team the Impact 0 to 5 days to 79%. The increase in
SIF found that a similar system was The baseline data from April 2007 to CNS attendance may explain this shift
being used by the infection control March 2009 identified 243 emergency as there are examples of potential
team and with a little re-designing for admissions with a median LOS of 13 admissions to the wards being shifted
operational fit e-mails and text days and a mean LOS of 20 days to the Surgical Admission Unit (SAU)
messages could be sent to a for washouts, enemas and outpatient
smartphone when a known colorectal The team were hoping that they could appointments which resulted in the
cancer patient was admitted. reduce median LOS from 13 days to patients leaving hospital in less than
11 and aim for CNS contact with 70% four hours. Attendance of a known
On 14 September 2009, an electronic of patients. patient with a fractured femur
emergency alert test cycle was highlighted two missed follow up CT
commenced at City Hospital to Test cycle preliminary results scans for which outpatient appoints
ascertain if early CNS attendance and The results reflect the patient have been made.
intervention would have an impact on population of City Hospital who are
patient LOS using the model. generally in a fitter state than those of It also appears that early CNS
Sandwell. There has been a response provides the junior doctors
reconfiguration of the colorectal with a colleague who has a clinical
service with the majority of surgery knowledge of the patient and this
moving to Sandwell. may stop diagnostics test and
unnecessary treatment being
Alerts in total 45 undertaken.
Alerts perceived to be colorectal 19
Actual colorectal related alerts 16


As the colorectal team had moved Emergency alerts: Internal What is the impact of the
through their transitional phase these spread at SWBH incremental spread
indicative test cycle results helped Upper GI The emergency alert flags for Upper
with the consolidation of the project In April 2010, when it became clear GI have been populated using the
board and a commitment to test that there were delays in the second MDT outcomes from April 2010 and
electronic emergency alerts colorectal test cycle it opened a even with a small alert population
concurrently on both sites for six window of opportunity to offer during the period the 1 May 2010 to
months with the final three months emergency alerts to the upper GI 10 June 2006 they have received
being used to test the impact of CNS team. The CNS were already seven emergency alerts for patients
facilitated discharge. experiencing difficulty with knowing admitted as an emergency.
when their patients were admitted.
The second stage of the test cycle was The preliminary results meant that the Off those seven alerts, three patients
due to start in March 2010 when it upper GI CNS could test the are still inpatients. However, the
was intended that an additional CNS opportunities this system offered results have been very encouraging
would commence in post. them. The SIF added the flags to the and match those of the trial with City
system from ongoing MDT outcomes colorectal patients and the Upper GI
Unfortunately, the new CNS will not and on the 1 May 2010 a test cycle CNS confirmed the following.
be in post until after June 2010 and began. The upper GI CNS have ready
that has delayed the test cycle start access to emails throughout the day
date. so preferred not to use a smart phone.

Extract of Emergency Alerts - Upper GI


These are early results and the Incremental spread – What has The spread still continues
expected LOS represents best clinical been learned? The chemotherapy unit manager from
experience as baseline data is still It was challenging to engage and City Hospital has enquired how she
being validated and analysed. keep momentum with the colorectal could set up her own alert system to
services but once the service ensure patients on active
As encouraging as the preliminary improvement project was authorised chemotherapy who are admitted as
data is, it is as encouraging that the and a clear need to alert the CNS had elective inpatients for all disease
CNS has found the alerts very useful. been identified the Winning Principles groups don’t have their care
In the past they would have been case studies provided a documented compromised.
unaware of these patient admissions solution that could be shared with the
and they are conscious that many of team and adapt to work locally. Cancer services at SWBH will approve
their patients are on palliative care the roll out of electronic emergency
plans more suited to management at It is useful to have the Colorectal alerts to all tumour groups if the data
their place of choice, mostly their Project Board structure as it has from haematology and oncology,
home. They have used the alerts to delivered the implementation of upper GI and colorectal can
proactively manage the patient electronic emergency alerts and as demonstrate a reduction in LOS,
pathways to ensure that patients word gets around the Trust other readmissions and unnecessary tests
spend the minimum time in an acute teams are willing to accept the and diagnostics.
setting receiving the most appropriate concept knowing that it has been
treatment and medicines using accepted clinically by their peers.
outpatient services for urgent referrals
where required. The teams that you work with need to
be aware of the value of
Haematology and oncology benchmarked data and aim for a local
The haematology and oncology team measurable target that can be
were looking for a solution to the assessed against the benchmarked
challenges of identification of patients data.
who were admitted with potential
neutropenic sepsis and delivery of the It is important to let the various teams
one hour ‘door to needle’ time. find an operational fit for their own
Flagging the patients has been service and needs and if its successful
relatively easy but the alert has had to the message will spread and the roll
be tailored to prevent false positives. out will follow.
For chemotherapy patients the alert is
only sent if it is an A&E or Emergency Ownership is key to spreading the
Admission Unit (EAU) admission. learning. The colorectal CNS are
spreading the message across the
The alert however was only part of network with other cancer nurses
the solution and it requires the through presentations and by word
emergency admissions team to receive of mouth.
refresher training and to adopt the
HEAT campaign. In addition junior
doctors on rotation and induction also
require specific training.

It is expected that in late June 2010,
the Neutropenic Sepsis Alerts will go
live to support the delivery of
antibiotics within one hour of
presenting at the trust.


Winning Principle 1

Cambridge University Hospitals NHS Foundation Trust
Emergency admissions, the exception
rather than the norm

Background • National End of Life Care Strategy – Problems identified
Cambridge University Hospitals NHS Advanced care planning and High frequency of emergency
Foundation Trust (CUHFT) is a large avoidance of inappropriate inpatient admission of cancer patients to
teaching hospital located in South admissions CUHFT and the corresponding impact
Cambridge. The hospital has a • Chemotherapy Services in England: on bed days meant initial
catchment population of 500,000 but Ensuring Quality and Safety (NCAG) investigations and testing was focused
as a specialist tertiary centre serves a – Acute Oncology Service around Winning Principle 1 –
wider patient group. Currently, CUHFT • The Quality and Productivity assessment prior to admission. As
has 1,188 beds accommodating Challenge – which asks: How CUHFT has 69 inpatient beds within
65,000 inpatient admissions each quality of care can be improved its cancer division, it was felt that it
year. Expansion plans for the trust whilst also improving productivity. would be appropriate to look first at
over the next 20 years will see the the emergency pathways (see
capacity for clinical services increase in Local drivers pathway diagram) into this division
size by 50%. The hospital has an • Towards the best, together – East of and see whether any service
average length of stay of 5.4 days and England SHA ten year strategy improvements could be applied here
currently runs at an average capacity • CUHFT Effective Patient Care to make emergency admission the
of 97%, both these figures are higher programme – reducing length of exception for these patients rather
than the recommended national stay than the norm.
averages and the local standards the • CUHFT Trust Values – Kind, Safe and
trust are aiming for of; 3.4 days and Excellent
85% capacity respectively. • CUHFT Releasing Capacity – striving
to reduce emergency department
In the March 2009, the Anglia Cancer and inpatient capacity.
Network (ACN) provided funding for a
Service Improvement Facilitator post CUHFT Cancer Patient Statistics (February 2008 – January 2009)
at CUHFT. The post was established to
support CUHFTs inclusion in the Trust-wide 22,000 patients with a diagnosis of cancer attended CUHFT
Transforming Inpatients programme statistics 6,100 inpatient admissions (38,300 bed days)
being led by NHS Improvement. 3,100 emergency inpatient admissions (28,000 bed days)

Strategic contexts warranting CUHFT Cancer division 14,500 patients attended the cancer division
desire to be involved with the statistics 2,350 inpatient admissions (15,835 bed days)
programme: 1,600 emergency inpatient admissions (12,160 bed days)

National drivers
• Cancer Reform Strategy - 20%
reduction in cancer inpatient bed
days for each SHA
• Our Health, Our Care, Our Say –
Patient choice and care closer to
home


Baseline data Data Analysis (February 2008 – January 2009)
To understand the current assessment
processes for emergency admission Referral source Accounting for % of admissions
patients admitted to the cancer
division, The CUHFT Transforming 1. Self referral / Direct to ward 30%
Inpatient Cancer Care project team 2. Emergency Department 25%
conducted: 3. GP referral 15%
• High level data analysis using
PAS data 4. Outpatient Clinic 10%
• Retrospective clinical notes audit 5. Oncology / Haematology Day Unit 10%
• Patient satisfaction/experience 6. Inter-hospital transfer 10%
questionnaire
• Staff interviews and service
evaluation questionnaire.
Patient satisfaction and experience • Slow response times of Cancer
The outcome of emergency questionnaire specialists to the ED
attendance, i.e. admission or 274 questionnaires were sent out to • Lack of resources to carry out
discharge following assessment, varies patients who experienced an thorough assessments
depending on what route in to the emergency attendance / admission to • Too many emergency routes in to
hospital the patient has taken. Those the cancer division between the hospital for patients admitted to
patients who go directly to the ward November 2008 – February 2009; we the cancer division
or to the Emergency Department (ED) received 103 responses, 31 of these • Professionals making decision to
for an assessment have a 95% chance patients went through the ED and 73 admit tend to be recently qualified
of admission after assessment, via the other emergency routes, and doctors with limited experience of
compared to those who were showed the following: assessment and risk aversive
assessed in either of the day units attitude to avoiding admission
who have a 45% chance of admission • Patients want more information • Admitting patients appears to be
following assessment. Except for a around symptom management at easier than considering alternatives
small number of very poorly patients home, what to expect and who to to admission.
who attended the ED, there was no contact in an emergency
obvious difference in the acuity of the • 70 patients had a specific contact Objectives
patients who came through the number to ring in an emergency; From the information we discovered
different emergency routes. within this, there were 21 different through our comprehensive baseline
people/places analysis, we set the following
Retrospective clinical notes audit • High level of reliance remains with objectives:
A clinical notes audit was undertaken the GP as first point of contact in an • Reduce unnecessary emergency
on 51/147 emergency admissions to emergency admissions
the Cancer division in January 2009, • Patients who attended a specialist • Reduce number of pathways
and showed the following: area for assessment were more currently used by patients admitted
satisfied with their experience than in to the cancer division
• Documentation is poor and difficult those admitted via other routes. • Improve patient experience
to track route from initial referral to • Have a reliable single point of
assessment to admission Staff service evaluation contact to be used for advice by
• 25% of emergency admissions interviews and survey patients and professionals
could have been planned for or Staff interviews were carried out with • Improve recording of information
predicted a wide range of multi-disciplinary • Embed a culture that views
• 33% of the patients could have professionals who may be involved in emergency admission as a last
been cared for elsewhere (i.e. in the the emergency admission pathway for resort.
community, hospice or district patients admitted in to the cancer
general hospital) division. To compliment the
• 30% of patients admitted were in interviews, two short surveys were
their last month of life. sent out to staff working the in the ED
and cancer division, and showed the
following:


Models for testing Cancer Assessment Unit Outcomes from testing
The results from the base lining The CAU was located in a four The CAU had 36 attendances, 28 of
process were presented to a bedded bay and staffed by an these were oncology patients and
multidisciplinary steering group, which Oncology Specialist Registrar, two eight were haematology patients.
included both CUHFT staff and Oncology Clinical Nurse Specialists
external professionals. Internal staff and one Haematology Clinical Nurse This test increased the capacity for
included; consultants, specialist Specialist. The pilot ran for two weeks assessment in a specialist area and
registrars and senior nurses from the and the assessment unit was open maintained the low admission rate
emergency department, oncology Monday to Friday 08:00-17:00. Staff which was identified in the day units
team, haematology team and in the assessment unit also manned in the base lining exercise.
palliative care team and there was the SPC and there was one SPC for
internal administrative representation Oncology and one SPC for Additional benefits
from the associate director and Haematology. • Assessment procedure and
operational manager of the cancer development of treatment plans
division. External staff invited on to All areas within CUHFT which were was rapid
the group included the NHS identified as taking calls from patients • Improvements reported in recording
improvement lead, lead commissioner or professionals seeking specialist of clinical information
from the PCT, a local GP, and cancer advice were given the bleep • Useful having one pathway for
representatives from the cancer numbers for the SPC and were told to emergency admission both for the
network. divert all calls during the two weeks to patient but also for the staff in
the professionals carrying these terms of tracking admissions and
The steering group considered the bleeps. Advice given to patients were decision making processes
various themes identified from the recorded on the electronic telephone • Staff reported that working within
base line work and decided to test record form which was then faxed to the unit was rewarding and
three service improvement initiatives: the patients GP. interesting.
i) Cancer Assessment Unit (CAU)
ii) Single Point of Contact (SPC)
iii) Electronic telephone triage system. Percentage of patients admitted following testing in three clinical areas
during testing period
NB: During the five weeks preparation
before the pilot it was felt that ii) and 100
iii) would be more appropriate if they
Percentage of patients admitted

14
were combined into one work stream. 22
80
By time of launching the pilot the
electronic telephone triage system had 60
not been developed; however a new
electronic method of recording 40
telephone advice was introduced to 36
support those staff managing the 20
single point of contact.
0
ED Ward CAU
Clinical Area


Single Point of Contact SPC
The SPC was contacted 156 times, Patient Experience Results
118 of these contacts were oncology Single point of access: Wait to Current experience compared with
enquiries and 38 were haematology speak to appropriate person previous experience of telephone
enquiries. access

Additional benefits 13% 13% 13%
• Information and advice given over
the phone to patients was much
better recorded 13%
• Time available for follow-up phone
25%
calls allowed for safer practice and 54%
continuity of care
20% 49%
• Only 11 out of the 156 calls were
redirected to the patients consulting
team
• 100% of GPs who received a copy
of the electronic telephone record 0 to 5 mins 6 to 10 mins Much better Better
form said that the seeing the 11 to 15 mins Not recorded Similar Not recorded
emergency advice given to the
patient was useful
• 73% of GPs said that having a
reliable SPC would help them to
manage cancer patients safely from
the practice/community rather than Benefits of these services ‘I was treated very well- as always. But
sending them to the acute trust. The CAU and SPC have wide reaching I had the same nurse look after me
implications in terms of service from coming in from home to being
Financial Implications delivery and quality of care and would admitted on to the ward. Really quick
• 833 emergency inpatient admissions benefit not only the trust and patients and it was nice to have her follow me
August 2008 – July 2009; Monday - but also the commissioners and through.’
Friday 8am to 10pm primary care partners: One pathway
• 202 of these admissions came through a specialist area would reduce Lessons learned
through the day units which provide the rate of unnecessary admissions, • Engagement of all stakeholders
the same level of specialist take pressure off the ED and inpatient from the outset of the project and
assessment as the CAU ward areas and offer patients ensuring that the group plays a key
• The extra 631 patients were continuity of care during anxious role in directing the project.
admitted as inpatients via the ED or times. By offering a specialist Arranging short informal meetings
went directly to the ward. assessment prior to admission in a individually with steering group
specialist environment we have shown members in between formal
Assuming that the extra 631 patients that admission can become the steering group meetings also
had been assessed in the CAU where exception and not the norm. ensures they remain up-to-date with
the 41% admission rate could be developments and their opinions are
applied: Patient’s thoughts on their being constantly reviewed and
• 259 patients admitted experience discussed.
• 372 admissions averted (59%). ‘The pre-admission advice and contact • Clinical champions who bought in
• 2,760 bed days or £1,023,960 prior to my admission via the doctor to the idea and were able to
potentially could be saved. was second to none. I was constantly encourage colleagues to view the
informed of the steps being taken to pilot positively. The most effective
ensure my safety; including knowing a champions were those clinicians
CT scan was being booked for the engaged on the ground floor who
following day, so I felt more informed were already directly involved in
and involved with my own treatment.’ assessments; clinical nurse
specialists and special registrars.


• Patients at the centre of all Challenges became very evident. Also, the
developments and service redesign • The pilot was limited because we environment was not ideal; the four
options engages clinicians and helps also used staff from our existing beds were in close proximity to each
to channel the direction of the human resource. This meant that and separated by curtains which
project. we were unable extend the opening raise questions regarding its
• Alignment with national, local and hours later than 5pm and as such compliance with single sex
organisational priorities is key to get missed out on applying this model accommodation, there was not a
engagement from stakeholders. to patients who attended the specified area for clinical
Reminding people of this alignment hospital for emergency assessment preparation and only a small desk
as often as possible helps to embed in the evening. for the staff to work on.
the necessity of change and • Resources required to successfully • Identifying a single model of
encourage a sense of urgency implement this service were initially emergency assessment which meets
within the project. underestimated. During the pilot, the diverse needs of oncology and
the need for increased access to haematology patients.
both computers and telephones

Emergency admissions pathway – pre testing

Medical secretary Inpatient
ward (95%
admission
On call SpR/SHO Oncology rate)

On call SpR/SHO Haematology Emergency
dep’t (95% Admission
Consultant admission
GP rate)
Discharge
Day units
Day unit
Other hospitals On call (40%
Inpatient ward SpR/SHO admission
Oncology rate)
Patient
Main hospital switchboard
On call
SpR/SHO
GP liaison team Haematology

Clinical nurse specialist

Emergency admissions pathway – post testing

GP

Other hospitals
Cancer Admission
Patient Assessment Unit
(41% admission rate)
Discharge
CUH Emergency
Department

GP liaison


Winning Principle 1

Doncaster and Bassetlaw Hospitals NHS Foundation Trust
Patient Electronic Alert to Key-worker System (PEAKS)

Background
The PEAKS Alert for cancer patients Patient Electronic Alert to Key-worker System (PEAKS) How it works
went live at Doncaster and Bassetlaw Patient attends
Hospitals (DBH) in September 2009, A&E/Emergency
Admission
initially rolled out by the lung multi- IT SYSTEM
disciplinary team (MDT) and Information
trigger PEAKS database
Patient
subsequently across every tumour attendance input
of patients linked
to specialist
into PAS/EMIS
group. The alert is now live across all treatment
Patient live on
four of the hospital sites in nine PEAKS updated
tumour groups and the Specialist Key worker calls
via CNS or MDT

Palliative Care team. ward to check
reason for
Email and SMS
message sent
admission to key worker

The alert meets the requirements of
QIPP, showing: Key worker visits
receiving areas (A&E, MAU,
Patient/carer feel
supported by key
• Quality of care for patients and ward) Staff to inform of
patient treatment plan/
worker awareness
of visit
carers is improved pathway/preferences

• Innovation of ‘pull’ style alert
• Productivity increase of the OUTCOMES
Improved patient experience
reduction in length of stay Reduced length of stay
Reduced inappropriate
• Prevention of inappropriate admissions

admissions and treatments.

The idea of the cancer alert came
from a review of similar alerts
implemented at both Sherwood Forest registered key worker informing them If the patient is admitted, the key-
Hospitals NHS Foundation Trust and of the patient attendance and current worker gets additional alerts as they
United Lincolnshire Hospitals NHS location. are transferred onto a ward, and so
Trust. Both schemes were based on are again able to make contact with
the RAPA (Recurring Admission This then enables the key-worker to the ward staff to ensure that they are
Patient Alert) project work detailed in make contact with the clinical staff fully aware of the patient’s current
Transforming Inpatient Care currently treating the patient initially diagnosis, treatment plan and
Programme for Cancer Patients – The to understand whether the preferred place of care.
Winning Principles. attendance is cancer related and then
to ensure that the team are fully Funding
The alert also met requirements for aware of the patient’s current DBH decided to develop the IT
DBH to meet local End of Life Strategy diagnosis, treatment plan and functionality of the alert system after
(2008) requirements and Cancer preferred place of care. considering the purchase of a bespoke
Reform Strategy (2007) initiatives. If appropriate, the key-worker can visit system from an external supplier, as
the patient and carers to provide this was felt to provide best flexibility
How the PEAKS alert works additional support. In this way some and value for money. Additional costs
When a diagnosed cancer patient emergency admissions have been included one off payments for mobile
attends hospital as an emergency, the avoided, although it is acknowledged phone hardware and clinical audit
registration (on PAS or eMIS) triggers that particularly for patients on End of support and regular costs for mobile
the PEAKS system, which sends an Life pathways attending A&E out of phone messaging and calls and MDT
alert in the form of a simultaneous hours, hospital admission may be administrative support.
SMS text message and email to the appropriate.


Benefits
After the initial implementation, an
evaluation demonstrated:-
• Improved patient and carer
experience (through collection of
‘good news’ stories)
• Reduction in LOS for these patients
(via Information department data)
• Anticipated release of capacity in
other areas as a result of patients
not undergoing unnecessary
diagnostic tests, treatment and
medication.

Additionally, feedback from the
Clinical Nurse Specialists (CNS), who
are the key-workers receiving the alert
at DBH, suggests that while the alert
is an additional activity to manage, it
has brought an increase in job
satisfaction through seeing an
improved delivery of appropriate care
for their patients and an improved
patient experience.

Challenges
The key workers who receive the
alerts work standard hours, so
patients attending out of hours (OOH)
saw a delay in response time.
However, part of the project also
involved the circulation of detailed
OOH guidance for the treatment of
cancer patients attending with various
complaints. Additionally the auditing
of the project is currently aiming to
identify the reasons for OOH
admissions and inform work by other
community teams on improving
services for these patients outside of
normal working hours.
It is an ongoing task to ensure that In conclusion, the overall feedback from
The auditing process itself was an the ‘right’ patients are on PEAKS. the cancer MDTs is that PEAKS is a
additional burden on the key workers Initially, this means deciding how long positive initiative and good news stories
during the initial six months of the ago a patient cancer diagnosis would and initial evaluations support this.
implementation, but brought essential still be relevant in impacting on their
information and evidence to the likelihood of emergency attendance. After excellent initial success, the
evaluation of the project roll out In addition, in order to maintain the Doncaster locality are already looking
regarding number and timing of accuracy of the patients on PEAKS, at the benefits of roll-out of the
alerts, nature of attendance and there is a regular administrative PEAKS alert to bring benefits to the
response times. Subsequently some requirement to update PEAKS with wider health community, for example,
teams have retained the audit newly diagnosed patients for each patients undergoing chemotherapy or
paperwork to use to support their tumour group, which is currently with other long term conditions,
own systems for patient monitoring. being undertaken by MDT staff. known infections or those on an End
of Life Pathway.


Winning Principle 1

Pan Birmingham Cancer Network
Pan Birmingham Network wide spread of
neutropenic sepsis pathway improvements

A review of the neutropenic sepsis • A raised temperature may be the The review found the following:
pathway identified that within hours only sign of infection in a • Lack of awareness of the pathway
the team were able to deliver neutropenic patient. Conversely a and the neutropenic sepsis guideline
antibiotics within one hour. Out of patient may be septic and not have • Difficulty in accessing the electronic
hours (OOH) the pathway was not a raised temperature guideline
able to achieve the recommendation. • Neutropenic sepsis is a medical • Lack of formal condition and central
A 50% improvement and a three-day emergency requiring line management training
reduction in length of stay have been commencement of intravenous • Poor symptom and condition
achieved in the ‘door to needle’ OOH antibiotics. awareness
neutropenic sepsis pathway at • Poor communication between in
Birmingham Heartlands Hospital. The National Chemotherapy Advisory patient ward and acute ward
Learning from PDSA cycles has been Group (NCAG) report, August 2009, • Poor awareness of key resources
shared and spread to other trusts to recommends that the delivery of such as the triage bleep holder and
improve Network wide delivery of the antibiotics ‘door to needle time’ patient alert cards
‘one hour door to needle’ should occur within one hour of • Variation in place of patient
recommendation. presenting with neutropenic sepsis. presentation
• Absence or poor availability of
Network spread In January 2009, the PBCN intravenous antibiotics appropriate
The testing work initially commenced commenced a three month audit to for the treatment of neutropenic
with the OOH pathway at Birmingham capture ‘door to needle’ performance sepsis.
Heartlands Hospital. This work has of trusts. Audit results highlighted
subsequently spread to Good Hope variation in pathways and trusts ability Despite the availability of a pathway
Hospital, and Solihull Hospital, the to deliver antibiotics within one hour. and tools to support delivery, there
three acute sites which make up Heart remained barriers to staff using these
of England NHS Foundation Trusts Birmingham Heartlands Hospital audit tools effectively in order to provide
(HEFT). Improvements achieved at results highlighted that out of hours treatment in a timely manner. A
(HEFT) have been shared and spread patients would present at A&E or the number of improvements were tested
throughout trusts within the Pan Acute Medical Unit (AMU). In addition and measured to determine benefit.
Birmingham Cancer Network (PBCN). the pathway was not delivering timely
treatment. A project team consisting One point of access
Background of senior nurses, haematologists, Previously, patients presented at A&E
The PBCN guidelines for the matrons and a service improvement or AMU. Multiple access points
management of Febrile Neutropenia facilitator (SIF) was convened and they impacted on the length of delay
state that: agreed a period of service review. The experienced by patients. In addition
• Neutropenia a neutrophil count of focus of the review was to gain a patients with neutropenic sepsis may
<1.0 x109/l baseline through audit and an or may not have a temperature and
• Febrile neutropenia is any fever of understanding of the OOH pathway. they can appear well. Without an
38 °C or more maintained for over In reality this meant meeting with understanding of the symptoms these
an hour or > 38.3°C on one urgent care medical and nursing patients are at risk of not being
occasion leads, a group of clinicians who are prioritised as requiring urgent
outside the common groups of intervention.
clinicians that the Network usually
works with.


Clinical service leads agreed and Development of electronic
committed to AMU as the designated patient alerts Benefits of training staff
point of access for patients. A period An electronic flag is now attached to • Improved knowledge and
of training for AMU staff to support the patient electronic record and it skills of nursing
delivery was also instigated. There was highlights the need for urgent • Increased likelihood of staff
also agreement to educate and treatment. The electronic flag was recognising the symptoms
signpost patients to AMU. A by produced through partnership of neutropenic sepsis
product of the project has been working between nursing and IT staff. • Supporting ‘right person,
improved communication between It uses existing capabilities of right time’ thinking
teams and a breakdown of silo electronic patient record system, and • Increasing the liklihood of
working. so did not incur any additional the delivery of timely care
financial outlay. It also includes the • Terms such as ‘neutropenic
Patient alert card redesigned alert card and guideline information. sepsis suspected’ or
The original patient alert card antibiotics given as per
provided patients with a 24 hour Future developments are planned policy’ are documented
telephone contact number to access which will enable the system to be more frequently
the haematology/oncology triage more proactive. It will be able to • Training provides
bleep holder. The role of the triage communicate with a bleep or pager to coordinated way of raising
bleep holder is to provide the patient inform a nominated staff member of condition awareness and
with advice and support. Before the patient’s presentation to hospital. management which is in
testing if urgent treatment was This would enable the individual to line with trust policy.
required, patients were advised to provide timely support or administer
present with their card at the antibiotics. The benefit of utilising an
emergency department. alert system has been shared with
various trusts within the Network. this update is 51% of patients
A survey identified 71% (28/44) of receiving antibiotics with an hour and
acute staff had not seen a Delivery of competency a 72% within 1½ hours.
neutropenic sepsis alert card, based training
potentially due to patients not The staff survey identified 68% Improving condition awareness
showing the card to staff. Additionally (30/44) of staff surveyed had not read and management based on trust
the card did not promote urgent the guideline. In addition, 75% policy and guidance
medical treatment. (33/44) of staff had not had any A survey of acute staff identified that
formal training in the management of 32% (14/44), do not know where to
The alert card was redesigned and is neutropenia. find the guideline and more
now visually alerting as it is red as significantly 45% (20/44) did not
opposed to the original white. It The Haematology CNS now provides know there was a guideline.
highlights the life threatening nature competency based training to acute
of the condition and provides patients staff which is aligned with policy. She Before testing electronic access to the
and staff with a checklist of also provides nursing staff with guideline was not intuitive, it took ten
symptoms. Staff members have readily practical skills to identify the steps and several minutes to access it,
available guidance on how to treat condition, manage central lines and as it was not located in the trust
the patient and also directions on how facilitate the delivery of timely care. intranet policy section. Improvements
to access the electronic guideline on have been made so that access to the
the trust intranet. The impact of training has been policy takes three steps, it takes less
shared with other trusts with in the than a minute and it is also linked to
The alert card is now used for all network. an electronic alert. Finally it is located
haematology and some oncology in the policy section of the intranet.
patients on all three HEFT sites. For example at University Hospitals
Birmingham Foundation Trust (UHBFT) Ensuring that trusts have an accessible
The improvements in the HEFT alert the project team updated oncology policy or guideline in place which
card have been shared with other nursing staff on how to manage supports staff in the delivery of
trusts within the network that are patients with suspected neutropenic treatment is the main principle being
adopting or adapting the alert card to sepsis. UHBFT report the impact of spread throughout the network.
suit the needs of their patients.


Reducing delays through Patient
Group Directives (PGD) The OOH process from presentation to hospital
The longest pathway delay exists from
the point of medic assessment to the STEP 1 STEP 2 STEP 3 STEP 4 STEP 5
time the antibiotic is prescribed. Patient Patient Medic Nurse Patient
Baseline data showed 36% (5/11) of triaged is assessed prescribes administers admitted
patients experienced an average delay by a nurse by a medic antibiotics antibiotics to hospital
of 134 minutes at this point. A PGD is
being developed which will enable
specific nursing staff to prescribe and
administer a stat dose of antibiotics.
Once ratified the PGD will eliminate Improving communication Conclusion
duplication, reduce hand offs and lead between teams to support co Underlying the improvements and
to a decrease in delay to treatment. production learning achieved is a clear
A survey highlighted that 61% (27/44) understanding of the pathway in
Development of the PGD has been of acute staff did not know that there conjunction with hard work and drive
challenging, primarily due to the was a triage bleep holder on Ward 19. of staff members at all levels of the
number of teams involved in its In addition 66% (29/44) acute staff organisation to improving the
development. Additional support for had not been contacted by the triage provision of care for patients with
the PGD was gained by sharing bleep holder. This indicated that the neutropenic sepsis.
pathway data on the OOH pathway communication between teams was
performance and the impact of the not supporting co production.
PGD at Blackpool, Fylde and Wyre
Hospitals NHS Foundation Trust where Improvements and benefits
it provided a 69% improvement in achieved
door to antibiotics time. AMU staff receive a verbal hand over
from the triage bleep holder prior to
Development of an antibiotics box the patient presenting at their unit.
to improve access to treatment The verbal handover enables AMU to
Access to the right antibiotics has prepare for the patient’s arrival.
been achieved through the
development of an antibiotics drug The double sided triage form has been
box. The box is secure and lockable. replaced by the single sided UKONS
It contains appropriate antibiotics, form. Staff find this easier to complete
medical supplies required for the and understand. The completed form
treatment of neutropenic sepsis and a is faxed to AMU providing timely
paper version of the guideline. information supported by the verbal
hand over.
Once used the box is swopped with a
fully stocked replacement box situated Reducing barriers to effective
on the haematology/ oncology ward. communication between teams has
In conjunction with the PGD the box improved the flow of information and
will reduce the barriers faced by patients in the pathway. Improved
nursing staff to deliver the one hour communication has also promoted co
door to needle target. production as teams now support
each other in care delivery.


Winning Principle 1

Anglia Cancer Network
Commissioning and cost benefits of acute oncology:
Supporting spread across the Anglia Cancer Network

Commissioners and trusts now have NHS Improvement as being associated There is a good case for establishing
access to comparative information with these projects. Gross savings of network wide cost reporting on a
about costs of treating cancer patients £5.5m per annum in inpatients costs regular basis, harnessing the PbR data
in the network, enabling rates of have been identified as realisable as a which is already being collected
emergency and planned admissions, result of implementing CRS continuously by PCTs, and in some
lengths of stay and Payments by recommendations for these four cases by the SHA or its contractors, in
Results (PbR) costs to be identified and projects, most of which occurs in order to monitor benefits realisation.
compared for different tumour sites, acute oncology. This approach is being adopted across
providers and PCTs. This will help in the network to support the spread of
building business cases for Programme Budgeting gives a good the Winning Principles.
implementing nationally indicator of total cancer care costs per
recommended improvements, as well PCT, but does not provide
as identifying inefficiencies in opportunities to analyse cost at levels
treatment practice within the lower than PCT.
network.
PbR data readily available in all PCTs,
Published Programme Budgeting (PB) covering all surgical admissions and
data suggests the cost of treating many non-surgical treatments, can be
cancer in the Network is c£250m pa, combined across the Network giving
and Cancer Reform Strategy (CRS) important comparative data. This
data suggests that about 50% of this work requires financial and IT skills to
is Inpatient cost. Variations in PB cost be shared across the network and a
relative to incidence suggest gross shared commitment to information
savings of £30m pa across the exchange.
network are possible if the cost per
case of the three lowest cost PCTs Interest in using the tool which has
were applied to the three highest cost been developed, and interest in
PCTs. Specialist resources were increasing awareness of costs, is very
consequently commissioned to study high throughout the network.
detailed Payment by Results inpatient
data for cancer spells in the network, Existing contractual and financial
at a cost of c£40k. arrangements for cancer treatment
are not widely understood by cancer
PCTs have already reported savings of commissioners, especially in the non-
over £1m pa as a result of this PbR areas of chemotherapy and
analysis. These and future consequent radiotherapy, where availability of
productivity savings will enable activity and cost information differ
projects to be implemented in the potentially for each provider. There is
areas of acute oncology, 23 hour no consistent standard for whether to
breast, enhanced recovery and day treat chemotherapy treatment as
case chemotherapy, providing all of inpatient activity or not, or on how to
the benefits identified by the CRS and report it.


Anglia Cancer Network - Potential savings per project


Winning Principle 2
All patients should be on defined inpatient pathways based
on their tumour type and reasons for admission.

Aintree University Hospitals NHS Foundation Trust
Spreading the enhanced recovery principles in patients
undergoing colorectal, liver and upper GI surgery

The t rust is part of the Enhanced The project aimed to reduce length of LOS data collected through the DH
Recovery Partnership Programme. stay by the following: database for each patient is being
Enhanced Recovery pathways have used in Statistical Control Charts to
been introduced for patients • Liver pathway – reduce LOS for feedback improvement data to the
undergoing colorectal and liver 50% of patients to ≤ five days teams. The mean LOS has gone from
surgery. A pathway will also be • Colorectal pathway – reduce LOS 12.64 days to eight days following the
introduced for patients undergoing for 80% of patients ≤ five days launch of ERP (Source: Data submitted
upper GI surgery. The two aims of the • Upper GI pathway – reduce LOS for to the DH database for each patient
work are to improve the quality of 80% of patients ≤ nine days. admitted to ward 10 from 12/12/2009
care for patients and to reduce length to 13/04/2010).
of stay. The impact is being measured through
monitoring length of stay, readmission
rates and patient satisfaction surveys.

Reduction in length of stay has supported the closure of
five beds on the enhanced recovery ward

50

40
ERP Commenced
30
Length of Stay

20

10

0

-10

-20
Patients
Length of Stay The Mean (average)
Upper Control Limit Lower Control Limit
WINNING PRINCIPLE 2

From testing to spread: Sharing the knowledge and learning from organisations spreading the winning principles - case studies

From testing to spread: Sharing the knowledge and learning from organisations spreading the winning principles - case studies

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