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Page 2 of 84 Proposed Intra-NALHN Service Plan – February 2016
Document Control Date: 03/2/2016 Release:
Author:
NALHN Executive
Owner:
NALHN Executive
Document Number: A224729
Note: This document is only valid on the day it was printed
Revision History
Revision Date Previous Revision Date
Summary of Changes Changes Marked
3/2/16 New draft
Approvals This document requires the following approvals. A signed copy should be placed in the project files.
Name Signature Title Date of Issue Version Dr Elaine Pretorius Clinical Lead Transforming
Health, NALHN
Michael Francese Executive Sponsor, Transforming Health, NALHN
Jenny Browne Director Finance, NALHN
Scott McMullen
Chief Operating Officer, NALHN
Jackie Hanson Chief Executive Officer, NALHN
Distribution This document has been distributed to: Name Title Date of Issue Version
Page 3 of 84 Proposed Intra-NALHN Service Plan – February 2016
Disclaimer
The content of this plan was developed by relevant stakeholders drawing on specialty knowledge,
information and data that was available at the time. Information contained in this plan may require
further refinement and / or realignment based on further improvements that may occur between
the time the plan was documented and the commissioning of the services or compromises that may
need to be made in order to provide a safe service.
Assumptions
The development of Service Plans for Lyell McEwin Hospital (LMH) and Modbury Hospital (ModH)
are based on a number of assumptions:
Service Plans
o The Service plan is a point in time document and as such is intended to be a living
document that will be revisited and updated along the Transforming Health journey.
Activity and workforce
o Modelling is based on commissioned activity in accordance with the Service Level
Agreement (SLA) between Department for Health and Ageing (DHA) and Northern
Adelaide Local Health Network (NALHN).
o Specific assumptions relating to service delivery are identified in the relevant
sections of this plan. Workforce modelling has been based on these assumptions.
o The development of the NALHN Service Plans was based on 2014/15 activity actuals
for patient profiles and applied 2015/16 commission activity where significant
differences between actuals and commissioned emerged.
o Agreed consistent approach to modelling and theatre utilisation/ scheduling and is
standardised to 4 hour theatre session lists.
o Outpatient Activity will be modelled for every service plan.
Management of deteriorating patients, patient transfers and clinical documentation
o Management of deteriorating patients will be well defined through Medical
Emergency Team (MET) and Rapid Response Teams (RRT).
o Hospital-at-Night functions and emergency management response team will support
clinical practice and processes.
o A system will be in place to address patient movement for rapid transfer and
ambulance support.
Page 4 of 84 Proposed Intra-NALHN Service Plan – February 2016
o NALHN will maintain controls, checks and balances in both electronic and paper-
based information management and data governance for patient identification and
transfers.
Clinical Support Services and Infrastructure
o Interdependencies and infrastructure for Clinical Support Services are built in to
models of care.
Infection Control
o The universal principles relating to Infection Control will continue to support clinical
practice.
Central Flow Unit in patient transfers
o The Central Flow Unit will continue to act as NALHN’s strategic capacity and patient
flow management centre.
Training and Accreditation
o NALHN will continue to engage with the relevant Colleges and Professional Bodies to
ensure training and development requirements are met.
Corporate Services
o Corporate functions across NALHN will be considered as a whole of system
approach.
While these assumptions are important to acknowledge, they do not override or compromise the
overarching model of care principles - best care first time, every time, ensuring patients are treated
closer to home where possible - and commitment to the Transforming Health journey.
Page 5 of 84 Proposed Intra-NALHN Service Plan – February 2016
Contents Disclaimer ...................................................................................................................................................... 3
Assumptions.................................................................................................................................................. 3
1. Introduction .............................................................................................................................................. 8
2. Purpose ..................................................................................................................................................... 8
3. NALHN’s commitment to improving the patient journey ..................................................................... 8
4. Population of interest ............................................................................................................................ 10
5. Activity and Service Moves .................................................................................................................... 12
5.1 Intra NALHN – overview of changes ............................................................................................... 12
5.2 CALHN to NALHN .............................................................................................................................. 14
6. Models of Care ....................................................................................................................................... 14
6.1 NALHN Emergency and Critical Care Services ................................................................................ 14
Emergency Departments (including EECU/ ED Short Stay) ............................................................. 15
Rapid Response Team ........................................................................................................................ 16
NALHN Intensive Care Unit................................................................................................................ 18
NALHN Hospital at Home .................................................................................................................. 19
6.2 NALHN Surgical Services .................................................................................................................. 19
Referral pathways .............................................................................................................................. 21
Preadmissions..................................................................................................................................... 21
Discharge and follow up .................................................................................................................... 21
Restorative care and rehabilitation .................................................................................................. 22
Emergency care .................................................................................................................................. 22
Clinical deterioration ......................................................................................................................... 23
Elective Surgical Waiting lists ............................................................................................................ 23
Theatres .............................................................................................................................................. 23
Surgical Sub Specialties ...................................................................................................................... 23
Orthopaedics .................................................................................................................................. 23
Urology ........................................................................................................................................... 27
ENT .................................................................................................................................................. 27
Vascular Surgery............................................................................................................................. 27
Page 6 of 84 Proposed Intra-NALHN Service Plan – February 2016
General Surgery ............................................................................................................................. 28
Upper GIT surgery .......................................................................................................................... 28
Breast Endocrine ............................................................................................................................ 28
Plastics and reconstructive surgery .............................................................................................. 28
Gynaecology ................................................................................................................................... 29
6.3 NALHN Medical Services .................................................................................................................. 29
Medical Sub Specialties ..................................................................................................................... 29
General Medicine (including Short Stay General Medicine Unit)............................................... 29
Cardiology ....................................................................................................................................... 31
Respiratory Medicine..................................................................................................................... 32
Gastroenterology service .............................................................................................................. 33
Diabetes and Endocrinology ......................................................................................................... 33
Neurology and Stroke Services ..................................................................................................... 34
Renal Services................................................................................................................................. 35
Haematology and Medical Oncology............................................................................................ 36
Chronic Disease Management Unit .............................................................................................. 36
7. Interdependencies- clinical support summary ..................................................................................... 37
8. Interdependencies- non clinical support summary ............................................................................. 39
9. Infrastructure - summary ....................................................................................................................... 40
10. Staff education / training required for implementation ................................................................... 41
11. Workforce – FTE summary by service................................................................................................. 42
12. Activity – summary by service ............................................................................................................. 49
Division Medical Sub Specialties ........................................................................................................... 49
Overall summary ................................................................................................................................ 49
Current state....................................................................................................................................... 50
Future state ........................................................................................................................................ 53
Surgical Activity ...................................................................................................................................... 56
Overall summary: ............................................................................................................................... 56
Current state....................................................................................................................................... 56
Page 7 of 84 Proposed Intra-NALHN Service Plan – February 2016
Future state ........................................................................................................................................ 60
13. Risk management ................................................................................................................................. 65
Page 8 of 84 Proposed Intra-NALHN Service Plan – February 2016
1. Introduction
The SA Health Transforming Health agenda outlines the direction for the delivery of health services
across South Australia. Transforming Health aims to provide the best care, first time, every time. To
achieve this, there also needs to be significant work undertaken in unlocking existing capacity within
hospitals by improving the effectiveness and efficiency of care provided.
For NALHN, LMH will develop into a major adult tertiary hospital for the north as planned, supported
by ModH as a centre for elective surgery, rehabilitation and sub-acute services. LMH will continue to
provide paediatric surgery and paediatric medicine as part of a statewide governance service with
the Women’s and Children’s Hospital and Flinders Medical Centre. LMH neonatal services will also
be part of a statewide governance service and will continue to provide complex care to acutely ill
newborns with the Special Care Nursery increasing in complexity and volume.
In addition to the internal NALHN service profile changes, Transforming Health also outlines the
movement of services between Local Health Networks (LHNs) to support the principle of care
provided as close to home as possible. This will require a significant change in the service profile of
both sites, and associated transfer of activity and resources to support this.
2. Purpose
The purpose of the NALHN Transforming Health Intra NALHN Consolidated Service Plan is to provide
a clear understanding of the type and volume of services, and necessary supporting infrastructure,
to be provided across NALHN as part of the intra NALHN service profile changes. It also provides an
overview of the transfers associated with the CALHN to NALHN activity transfer process.
3. NALHN’s commitment to improving the patient journey
‘Improving the Patient Journey. Everybody Matters’ encourages all staff to play an active role in
improving the patient journey and reminds us of the core values and behaviours we must uphold to
ensure the needs of our patients remain at the forefront of our day-to-day work.
As an organisation that embraces ‘Improving the Patient Journey. Everybody Matters’, we will
continue to move from:
work being organised through the needs of the business;
changes being reactive to patient demands;
information being presented only from the staff point of view;
Page 9 of 84 Proposed Intra-NALHN Service Plan – February 2016
staff feeling not empowered to initiate change; and
being a silo working culture.
Through ‘Improving the Patient Journey. Everybody Matters’ we ensure:
we view our organisation through the lens of people who actually use our services;
the provision of information is planned and two way;
pathways are mapped to illustrate experience and patient experience data is collected and
acted upon;
service users are part of the decision making process and our organisation can demonstrate
that this leads to improvement;
work is based around the patient journey, providing more consistent and integrated care;
there is a positive learning approach to complaints handling, and complaints and
compliments are shared widely; and
patients are supported to be partners in their care and share decisions.
The five elements that make up and contribute to ‘Improving the Patient Journey. Everybody
Matters’1 is patient-focused and supported by a number of values, behaviours and standards. These
include:
Patient and Family Centred Care
Accessible, Integrated and Coordinated Care
Working as a Team
Acting on Feedback
Safe and Reliable Care
1 Link for Improving the Patient Journey http://dev.health.sa.gov.au/cnahs_dev/InsideNorthern/ImprovingthePatientJourneyEverybodyMatters/tabid/904/Default.aspx,
Page 10 of 84 Proposed Intra-NALHN Service Plan – February 2016
4. Population of interest
There were 369,484 people living in the NALHN area as at the last (published) census in 2011. The
primary catchment for NALHN is the northern Adelaide metropolitan region comprising three Local
Government Areas (LGA) in their entirety, the City of Playford, the City of Salisbury and the City of
Tea Tree Gully, and part of a fourth, the City of Port Adelaide Enfield. In addition a substantial
number of people who access services in the NALHN come from outside the geographic boundaries
of the LHN, including people from rural, remote, interstate and overseas locations. A significant
number of residents from within the NALHN currently access health services in other LHNs within
the state. The proportion of patients accessing services in other LHNs is dependent on the specific
service required. In some instances this is appropriate as they are highly specialised, state-wide
services, however the intention is that for the majority of services, NALHN should be capable of
providing in excess of 85% of the care required for the local population.
The Northern area of Adelaide is currently the highest population growth area in SA. This will mean
that by 2026 it is expected a quarter of the state’s total population is expected to live in the
northern metropolitan catchment2.
NALHN has a younger age structure to that of South Australia as a whole and although there will be
an increase in the percentage of older persons in the NALHN region, the region will maintain its
status as the youngest region until 2026. Although the total proportion of older people in NALHN is
lower that the state average, the growth in this age group in NALHN is greater that the growth rate
for the state as a whole.
The NALHN is characterised by significant disadvantage with regard to health and wellbeing, as it
contains some of the most disadvantaged parts of the state. As a whole, residents of NALHN rate
lower on population health measures than residents of other LHNs, and are also more likely to have
chronic disease or risk factors for chronic disease.
The proportion of Aboriginal or Torres Strait Islander people living in the NALHN in 2011 (1.9% of the
NALHN population) is consistent with the state as a whole (1.9%). However, some SLAs in the NALHN
had some of the highest metropolitan proportions of Aboriginal and Torres Strait Islander people.
Although there is diversity, the NALHN Aboriginal and Torres Strait Islander population, as a group,
rate much lower on most measures of population health relative to the whole population. Since
2 Population projections for South Australia. Projection, May 2011, Medium series based on Census 2006.
Page 11 of 84 Proposed Intra-NALHN Service Plan – February 2016
2005, an estimated 55% of all refugee new migrants in South Australia have settled in the LGA’s of
Playford, Salisbury, Tea Tree Gully, Gawler, Mallala and part of Port Adelaide Enfield. This
percentage equated to a total of 2,905 people in 2006 and increased by 178% to 8,061 people in
2011. This settlement trend is expected to continue3.
Demand increases are not only related to population growth. The NALHN is characterised by
significant disadvantage with regard to health and wellbeing, as it contains some of the least affluent
parts of the state. The social and economic factors influencing the health services within the NALHN
include, but are not limited to the following:
High level of obesity and co-morbidities per volume of patients
High level of limited literacy (year 10 level)
Low socio-economic status
The area has a greater avoidable causes of death when compared with the rest of South Australia
High level of psychosocial distress level associated with the level of disadvantage
High prevalence of smoking and physical inactivity
High level of single parent families, people receiving unemployment benefits and disability
pensioners.
There is one General Practitioner per 1,400 or more people and of particular note is the high
proportion of the sole GPs. This impacts on the number and availability of after-hours GP services
and the number of presentations to the LMH and ModH’s Emergency Departments after hours4.
3 Northern Adelaide Medicare Local (NAML) 2015 4 Australian Bureau of Statistics Census Data – August 2011. (Accessed on line 31
st July 2012)
4 http://www.dpti.sa.gov.au/__data/assets/pdf_file/0006/177936/Population_Change_Fact_Sheet_2014.pdf
Page 12 of 84 Proposed Intra-NALHN Service Plan – February 2016
5. Activity and Service Moves
5.1 Intra NALHN – overview of changes
Surgical services
ModH will become the elective surgery centre for the north and north east, providing 23-hour and
day elective procedures. An expanded one stop breast service will give women access to a breast
surgeon, radiologist and a breast care nurse in the same location. Emergency, complex and multi-day
surgery will be focused to LMH, including a 24/7 orthopaedic trauma surgery service.
Emergency services
ModH will continue to operate an ED 24 hours a day, 7 days a week, staffed by specialists, and the
majority of patients who present will continue to be seen at the hospital. If patients need ongoing,
specialist care not available at ModH, they will be stabilised before being transferred to another
hospital. A short stay unit will be established to assist management of admissions from ED.
Medical services
Establishment of an acute medical short stay unit at ModH providing care for up to 48 hours, with
patients who have higher acuity needs or require greater than 48 hours inpatient care transferred to
LMH. Gastroenterology outpatient service and elective endoscopies will now be provided at ModH.
A new cardiac catheter laboratory will be built at LMH.
Rehabilitation services
ModH will become the major rehabilitation centre for the north and north east, with a new gym,
hydrotherapy pool and therapy spaces, increasing inpatient rehab beds to a total of 52. As a result
cardiology, some medical and some surgical inpatient beds will move to LMH with Level 3 at ModH
redeveloped to accommodate the additional rehabilitation beds.
This redevelopment will be undertaken in two phases and will require the decanting of each wing
during the redevelopment phase. Each phase will take approximately three to four months to
complete. Bays on level 2 will also require decanting to enable any underfloor work to be completed.
The decanting also includes activity movement between Modbury and Lyell McEwin Hospitals.
Diagrams 1 and 2 below outline the moves between ModH and LMH and the moves within ModH.
Activity currently accommodated in 3 East will transfer to LMH Ward 1B. It is anticipated this
decanting of 3 East will occur by early March 2016. It is anticipated the decanting of 3 West will
occur by June 2016.
Page 13 of 84 Proposed Intra-NALHN Service Plan – February 2016
Diagram 1: Modbury to LMH Activity Movements
Diagram 2: Intra-Modbury Activity Movement
Page 14 of 84 Proposed Intra-NALHN Service Plan – February 2016
5.2 CALHN to NALHN
As part of Transforming Health, detailed planning work is under way to increase the services
available across NALHN and enable more residents of the northern and north eastern suburbs to be
treated closer to home. This includes new capital investment in both the LMH and ModH and service
realignments across a range of services to transfer the activity currently occurring in CALHN that
relates to northern residents into NALHN.
During the first half of 2016 activity from selected CALHN services will transition to NALHN. Below is
a list of in scope services:
Orthopaedics
Stroke
Cardiology
Vascular
Renal medicine
Urology
Medical oncology
Upper GIT
Endocrinology
Haematology
Breast surgery
ENT
6. Models of Care
This section outlines the service models for those units and specialties impacted by the site profile
changes and activity moves.
6.1 NALHN Emergency and Critical Care Services
The NALHN emergency and critical care services will operate as a single service – multi site model
under the governance of the Critical Care Division. This model is necessary to ensure the services
provided are safe and of a high quality, that staff have the opportunity to provide a range of complex
and non-complex procedures, and that trainees are offered a breadth of experience. The single
service model will also provide greater consistency of care across the two sites by providing common
policies, procedures and patient pathways.
Page 15 of 84 Proposed Intra-NALHN Service Plan – February 2016
Emergency Departments (including EECU/ ED Short Stay)
The NALHN will continue to provide FACEM (Fellow of the Australian College of Emergency
Medicine) led EDs at both LMH and ModH, 24 hours, seven days a week. The EDs will receive, triage,
stabilise and manage adult and paediatric patients who present with a range of conditions including;
medical and surgical emergencies; paediatric and obstetric emergencies; post trauma and acute
mental health. Strong links will continue to be maintained with the SA Ambulance Service, MedStar,
CALHN, SALHN and WCLHN for the transfer of patients requiring high acuity state-wide services (e.g.
burns, spinal injuries, cardiothoracic, complex vascular and neurosurgery and out of hours stroke).
Patients requiring inpatient specialist services not available at the ModH site will be transferred to
where the service is provided either at LMH or an alternative LHN.
LMH ED will have the capability to stabilise major trauma patients who cannot be transported
directly to the Major Trauma Services at the RAH (>16years) or WCH (<16years).
Strategies which support patient flow through the ED will continue to be implemented to assist in
achieving national ED targets.
The Extended Emergency Care Unit (EECU) /ED Short Stay Unit (EDSSU) will address the needs of
patients who do not require an inpatient admission to hospital but need extended observation
and short-term treatment, or who are waiting for test results to confirm that they can be
discharged. EDSSU will adhere to specific admission and discharge criteria and policies as per ED led
model below.
Key Principles for admission to EECU/EDSSU include:
Clinically stable AND
Anticipated to require a period of observation or treatment less than 24hours, or
In some circumstances are pending transfer to another facility.
LMH currently has an EECU in place. The EDSSU will be established at ModH co-located with the
Short Stay General Medicine Unit (SSGMU). It is proposed that a purpose built 30 bed short stay
unit (EDSSU and SSGMU) be constructed adjacent to the ModH ED. Timeframe to be determined.
The ED continues to be supported by an allied health team comprising Physiotherapy, Occupational
Therapist, Social Work and other specialties as required and together with the ED discharge liaison
nurse form the Emergency Medical Assessment Team (EMAT) from Monday to Friday.
Page 16 of 84 Proposed Intra-NALHN Service Plan – February 2016
Rapid Response Team
In response to the change in profile of ModH, a RRT will be established to manage deteriorating
patients on site for stabilisation and / or transfer out. A RRT is a designated group of healthcare
clinicians who are available quickly to deliver critical care expertise in response to clinical
deterioration (MET/ Code Blue) of a patient located within the hospital (excluding emergency
department patients). It is proposed that the Rapid Response Team will commence following the
closure of the High Dependence Unit at ModH.
There are three key features of the RRT members:
They must be available to respond immediately when called, and not be constrained by
competing responsibilities.
They must be on site and accessible.
They must have the critical care skills necessary to assess and respond.
The key roles of the RRT are:
Assess and stabilise the patient condition.
Communicate to the home treating team.
Educate and support the direct care staff.
Recommend / assist with patient transfer to a higher level of care as required.
The RRT will have two registered nurses rostered per shift over 24 hours. This is to ensure back up is
available for simultaneous MET calls and if the first RRT nurse is managing a deteriorating patient
waiting for up transfer.
There will be a designated RRT medical officer 24 hours a day. In addition, it is proposed that the
Medical RRT member assumes the position of medical team leader overnight at ModH, supporting
junior medical staff and nursing staff as required. Medical oversight of the service will initially reside
with NALHN intensive care, with RRT activity being continuously monitored and ongoing governance
reassessed within six months from commencement.
The initial response to a deteriorating patient is via a MET call / Code Blue as described in the NALHN
Rapid Detection and Response Procedure.
If the patient is unstable and requires short term critical care support until an up transfer
can occur, the patient will be transferred to ED and managed by the RRT medical Team
Leader (TL) and RRT nurse. Only patients requiring up transfer (to LMH or other facility) will
be managed in the ED until transfer can occur. Transfer to the ED is at the direction of the
Page 17 of 84 Proposed Intra-NALHN Service Plan – February 2016
RRT medical TL following discussion with the ICU / MET Consultant and the home team. The
Senior ED Consultant must be notified prior to transfer to ED.
If the patient does not require up transfer they will remain on the ward where the RRT
medical TL will discuss situation with the patient’s home team and adjust treatment plan as
required. The RRT nurse will assist and support the ward nursing staff with ongoing
management.
If the patient requires short term monitoring but not an up transfer, the RRT TL will liaise
with the home team and the medical registrar for potential to manage in the Short Stay
General Medicine Unit.
The RRT will be based in the ED (includes MET 1 and MET 2 nurses and ICU Registrar) and will meet
at the beginning of each shift with the Medical Registrar (team huddle).
The MET Consultant will provide an overview of the service for the day and will:
Undertake a daily ward round of Modbury Hospital either in person or via telephone with
MET TL (ICU registrar)
Be available for telephone consultations
Attend the site if required (e.g protracted MET call, airway concerns)
Assist in communication with other facilities if LMH unable to provide relevant service and
ensure appropriate transfer occurs
RRT Team Leader (ICU Registrar) will:
Lead the MET huddle
o Identify individual roles and responsibilities at MET
o Identify and discuss any patients of concern
o Discuss capacity within ED and LMH ICU
o Identify ward patient cohorts / redevelopment floor plan changes
Attend and lead all MET
Discuss all MET calls with Home team Consultant and MET consultant
Review ‘patients of concern’ at the request of the MET nurse and liaise with home teams as
necessary
Contribute to education relevant to role
Page 18 of 84 Proposed Intra-NALHN Service Plan – February 2016
RRT 1 Nurse:
Primary role will be to attend MET calls. RRT 1 will remain with patient until no longer required. This
includes ongoing care of deteriorating patient until transfer complete. MET 1 role will be expanded
to include:
Equipment checks including 4 MET trolley’s spread throughout the Hospital
Data collection for monitoring and evaluation
i. Patient reviews post MET
ii. Patient reviews – not MET
iii. MET calls
iv. Patient transfer to Short Stay General Medicine Unit
v. Patient transfer to LMH ICU or other
vi. Time frames for Medstar
vii. Incident reporting (SLS)
viii. Assessing and monitoring of “patients of concern”. Handover of such patients will be
handed over from shift to shift
ix. RDR chart auditing
RRT 2 Nurse:
Will respond to MET calls when the RRT 1 nurse is still on a previous MET call or RRT 1 requires
additional assistance due to skills or staff deficits on wards (especially at night and for calls outside
the ward areas). RRT 2 nurse will be supernumerary for the first three months to facilitate transition
and evaluation but thereafter will be included in the ED nursing staffing numbers.
Communication:
Communication will be via mobile phones and pagers. The pagers will notify of any Code Blue calls
and of other codes happening in the hospital and the phones enable direct communication between
team members.
Note: the RRT nurses will be required to regularly rotate into LMH ICU to maintain skills and
experience. In addition, all RRT/ MET nursing and medical staff require ALS 2 training.
Attachment 1 outlines the RRT process.
NALHN Intensive Care Unit
NALHN intensive care services will be provided from the LMH ICU which underwent an expansion as
part of the LMH Stage C redevelopment. The LMH ICU is a separate and self-contained section of the
hospital, staffed and equipped for the management of patients with established life-threatening
Page 19 of 84 Proposed Intra-NALHN Service Plan – February 2016
reversible or potentially reversible, organ failure or with a high risk of life-threatening organ failure.
The ICU provides specialist expertise and facilities for the support of patients and their families,
utilising the skills of medical, nursing and other allied health staff qualified and experienced in the
management of critically ill patients. The ICU provides a closed model of care with admission into
the ICU and care of the patients whilst in the unit under the medical governance of the intensive
care consultants. Neonatal and paediatric are excluded from general adult ICUs. Critically ill
paediatric patients will be stabilised and assessed for transfer to the Women’s and Children’s
Hospital.
There will be an ongoing requirement for LMH ICU to support the ModH in the care of deteriorating
patients. For the patient that is rapidly deteriorating the ModH RRT will respond followed by a direct
admit to the ICU at the LMH.
NALHN Hospital at Home
The NALHN Hospital at Home (H@H) service facilitates early discharge from ward areas reducing
length of stay, hospital avoidance by accepting patients directly from ED, and complete hospital/ED
avoidance by accepting patients from the community if known by an inpatient Consultant. NALHN
H@H functions as a ‘virtual ward’ where inpatients of the LMH or ModH reside outside of the
organisation in their home, nursing home, or temporary place of residence. All H@H patients are in
an acute phase of illness and require acute nursing intervention and access to a collaboration of
services offered within an acute care organisation, whose care needs cannot be met by outside
community service.
The H@H services at LMH and ModH is an integrated service, with LMH as the main base from
where the service is coordinated. ModH will continue to maintain a limited service on-site providing
a liaison role to elicit and assess referrals and potentially provide treatment. The LMH site is
supported by a medical assessment clinic 3 days per week to facilitate review of medical patients,
with medical ‘off site’ reviews when appropriate. H@H also has access to treatment rooms to assess
the deteriorating patient as an alternative to the ED.
6.2 NALHN Surgical Services
The NALHN surgical services will operate as a single service – multi site model under the governance
of the Division of Surgical Specialties and Anaesthetics, and for Gynaecology under the governance
of the Women and Children’s Division. Under this model there will be greater consistency of care
across the two sites by providing common policies, procedures and patient pathways, staff will have
the opportunity to provide a range of complex and non- complex procedures, and trainees will be
Page 20 of 84 Proposed Intra-NALHN Service Plan – February 2016
offered a breadth of experience. It is expected that staff, both medical and nursing will rotate across
sites as clinically required and appropriate.
ModH will be the location within NALHN to provide elective same day and 23 hour surgery for
routine, non-complex patients and procedures for the following types of surgical services:
Non- complex elective same day and 23 hour surgery, specifically including laparoscopic
procedures, for non-complex gynaecology patients.
Upper limb procedures and simple lower limb orthopaedic procedures (knee arthroscopies,
ACL reconstructions etc.), for non-complex patients.
Hernia repairs, appendectomies, cholecystectomies, major and minor bladder, breast,
transurethral and perianal and pilonidal procedures for non-complex patients.
Ear, Nose and Throat (ENT) surgery for adult patients.
Emergency management of patients presenting to the Emergency Department, with cases
requiring urgent operative management or inpatient management transferred to the LMH.
ModH surgical registrar cover will remain unchanged.
Inpatient management of non-complex patients requiring non-operative fracture
management who are suitable for medical or geriatric management, e.g. osteoporotic crush
fractures
A One Stop Breast Care Clinic where assessment, radiological intervention and biopsy (if
required) can occur at one visit.
Outpatient services, including but not limited to orthopaedics (including review of fractures
and non-operative fracture management), general surgery, urology, breast endocrine, ENT,
general gynaecology and colposcopy.
Ward consults for patients admitted under other specialties during office hours.
Stomal therapy and the acute pain service provided currently at ModH will operate from LMH due to
the changing profile of surgical procedures being undertaken at ModH. Tele support will be available
and consult by appointment.
The LMH will provide a 24/7 surgical service and gynaecology service inclusive of all of NALHN’s
multiday elective and emergency surgery, as well as providing emergency and non–routine same day
and complex and non-routine 23 hour elective surgery. All paediatric activity, obstetric activity and
an early pregnancy advisory service will continue to be provided at LMH as per current NALHN
model for these services.
Page 21 of 84 Proposed Intra-NALHN Service Plan – February 2016
To support the alignment of services between the two sites, and to accommodate the additional
multiday activity at LMH; low risk, non-complex same day and 23 hour activity will be flowed from
LMH to ModH as appropriate, noting that a small volume of same day and 23 hour activity will
remain at LMH to allow for patient complexity.
Outpatient clinics will remain at ModH, however whilst the clinics are provided at one site the
surgery may need to occur at a different location to the outpatient appointment. This will be the
case for multi-day surgery and complex patients requiring 23 hour or day surgery. LMH will continue
to provide outpatient services for surgery, as well as emergency management of patients presenting
to the Emergency Department. Under the single service – multi site model all outpatient referrals
will be triaged centrally and allocated an appointment at either LMH or ModH site.
Referral pathways
Referral pathways into the NALHN surgical services and gynaecology services will remain largely
unchanged. External referrers will continue to send referrals to their existing NALHN hospitals.
Establishment of a single referral point is the preferred model. The intent is to support patients
attending clinics at their nearest hospital, however this single review of referrals would allow for
patients requiring sub specialty review to be directed to the appropriate sub specialty clinic which,
for low volume sub specialties, may only be delivered from one site.
Internal referrals for inpatient admission (primarily from ED) will be directed to the most appropriate
site for follow up, for instance, an ED referral requiring surgery will be referred to the appropriate
inpatient ward for direct admission or other appropriate clinical speciality that is provided at LMH,
otherwise the patient may need referral to another LHN.
Preadmissions
NALHN will implement a single model of care for preadmission clinics. There are specific procedures
that are identified as requiring a face to face assessment (primarily joint replacements), however
beyond this a risk stratification approach will be used based on patient or procedure complexity.
Whilst ideally patients will attend their preadmission clinic appointment at the site of surgery this is
not a requirement and will be influenced by patient preference and physical capacity of the site.
Discharge and follow up
For elective surgical patients the principles for discharge and follow up will remain unchanged, i.e.
post discharge follow up outpatient appointment will be organised or patient advised to have follow
up with their GP. For surgical or gynaecology patients discharged from ED there may be referral to a
relevant surgical access clinic or standard outpatient clinic or to their GP for follow up.
Page 22 of 84 Proposed Intra-NALHN Service Plan – February 2016
Restorative care and rehabilitation
Rehabilitation pathways within NALHN will be enhanced by the expanded rehabilitation services to
be provided at ModH, including the orthogeriatric patient pathway (statewide model currently
under development). ModH will play a pivotal role in providing restorative care and rehabilitation
services for surgical patients, both via the Geriatric Evaluation and Management Unit, and via
rehabilitation services. Surgical consults for patients within those services at ModH will still occur.
Emergency care
The emergency pathway for ModH emergency surgical patients (non gynaecology and non
orthopaedics) is outlined in Attachment 2. During normal business hours (Monday to Friday, 7:30am
to 5:00pm), there will be an onsite on-call surgical registrar available at ModH to respond to
emergency consults. Additional support where required will occur via Surgical Consultants onsite
either in OPD or theatre.
After hours (Monday to Friday, 5.00pm to 10pm and weekends to midday) an on-site, on-call
Surgical Registrar will be available to respond to Emergency Department consults where required.
After 10pm weekdays and midday weekends a remote on- call registrar will be available along with
consultant support if required. As per current arrangements, an on call consultant roster will be in
place for ModH.
An emergency on call return to theatre team will be established as a trial to support the 23 hour
model of surgery at ModH. This will provide additional support to enable attending consultants to
return existing elective 23 hour patients to theatre in a timely manner if required. This is to be
reviewed 6 months post implementation.
To further support emergency care of patients presenting to ModH, the Division of Surgical
Specialties and Anaesthetics will restructure the current outpatient sessions to enable quick access
following an ED presentation. It is envisaged that 2 emergency appointments will be allocated from
the total surgical outpatient clinic footprint at ModH each day
For gynaecology related presentations to ModH ED requiring urgent management (e.g. proven
ovarian pathology or PID and significant menorrhagia or early pregnancy conditions) will require
transfer to LMH with direct admission to the Women’s Health Unit after consultation with the on call
registrar. The emergency pathway for ModH gynaecological patients is outlined in Attachment 3.
For orthopaedic related presentations it is anticipated the LMH will provide a 5 day a week
emergency orthopaedic theatre (with possible extension to an additional half day weekend session),
Page 23 of 84 Proposed Intra-NALHN Service Plan – February 2016
which would minimise the requirement for after hours theatre to those patients who require urgent
operative management (e.g. significant blood loss, neurovascular compromise, compartment
syndrome, life or limb threatening sepsis, severe open fractures). For fractures requiring non urgent
operative management, the existing model of discharge from ED, quick review in fracture clinic, and
orthopaedic “mop up” lists will continue.
The orthopaedic service will have an after hours on call for ModH via phone to the LMH on call.
Attachment 4 outlines the orthopaedic pathways for ModH presentations (Level 1 and 2 trauma
patients, isolated limb trauma, ambulant injured). It is proposed that this change will take effect
from March 2016.
Clinical deterioration
For patients who undergo elective same day or 23 hour surgery at ModH who become unexpectedly
unwell post operatively will be managed via the deteriorating patient pathway outlined in
Attachment 5. For those patients requiring an unplanned return to operating theatre out of hours
this will occur at ModH by recalling theatre team.
Elective Surgical Waiting lists
NALHN will move from the current two site approach to managing elective waiting lists to a single
model. It is proposed that this change will take effect from March 2016. Current positions on wait
lists will be maintained as far as possible.
Theatres
Following the intra NALHN service changes the total elective theatre requirements at ModH will be
2.6 theatres per day Monday to Friday. For LMH elective theatre requirements will be 4.5 theatres
per day and emergency theatre requirements 1.8 theatres per day. It is proposed that this change
will take effect from March 2016.
Surgical Sub Specialties
Orthopaedics
A comprehensive orthopaedic surgery service will need specialised Extended/ Advance scope Allied
Health positions and specialist nursing roles. Following the service moves, further analysis and
consultation will be undertaken on what the Allied Health requirements are, informed by the SA
Health Transforming Health Allied Health project currently underway. Allied Health led outpatient
clinics will continue to be provided at both sites to match patient flows. Robust referral pathways to
Page 24 of 84 Proposed Intra-NALHN Service Plan – February 2016
non operative treatment for those conditions where there is evidence that conservative treatment is
as effective as operative management will be explored for elective outpatient clinics.
Specialist nursing roles may include Clinical Practice Consultant or Nurse Practitioner to manage,
coordinate and facilitate: pre- and post-operative case management of arthroplasty patients
(including active list management of patients awaiting arthroplasty); Neck of Femur management
including pathway development and case management; and Orthopaedic trauma resource.
Pathways
The main categories of orthopaedic patients who present to EDs and how they will be managed are
as follows:
Level 1 and 2 trauma patients (also refer to Attachment 4a for flowchart):
o Patients who require obvious input from specialties not available at LMH (either wholly
or for emergency purposes) will bypass NALHN and go directly to the RAH. No internal
NALHN patient pathways will be needed to manage these patients;
o Patients who present to the LMH ED, either via SAAS or private car will be assessed by
ED staff and either identified as needing services not available in NALHN and be on
transferred as required, or can be managed within the LMH and be admitted to the
general sub-speciality bed card with orthopaedic management as required. Patients
presenting to ModH will be assessed by ED staff and transferred to the most appropriate
hospital. Trauma transfers are always from ED to ED.
Isolated limb trauma patients (also refer to Attachment 4b for flowchart):
o For patients picked up by SAAS, where there is obvious surgical input required (e.g.,
fractured neck of femur, open fractures, severely angulated limbs, neurovascular
compromise etc.), these patients will be triaged by SAAS and present directly to LMH for
ED assessment and admission to the orthopaedic team. A number of patients may also
present via private car/ walk in.
o Patients who present directly to ModH will be transferred to LMH following ED
assessment and management, with the expectation of this being a direct admission to
the ward.
Ambulant injured patients (also refer to Attachment 4c for flowchart):
o Patients requiring non-operative management will be managed within the ED at which
they present (LMH or ModH), provided with relevant assistive devices (plaster, slings,
braces, crutches etc.) and referred to the on-site orthopaedic fracture clinic for follow
Page 25 of 84 Proposed Intra-NALHN Service Plan – February 2016
up within one week. This patient pathway will remain largely unchanged from current
practice. There will be a proportion of these patients that will require admission under
orthopaedics.
o Patients requiring non-urgent operative management will be stabilised and provided
with initial management within the ED at which they present (e.g., plaster, brace,
crutches etc.) and referred to the on-site orthopaedic fracture clinic for review and
confirmation of operative management requirements including booking to the relevant
theatre list if required. ED staff will be responsible for triaging these referrals and
ensuring patients have next business day review if they suspect operative management
is required. At LMH there are currently Resident Medical Officer (RMO) slots to facilitate
this. ModH will proceed to implement review slots within their existing fracture clinics.
o Patients requiring urgent operative management – a small number of walk in patients
may require urgent operative management (e.g. for patients who have neurovascular
compromise or who have a compartment syndrome). For patients who present to the
LMH, they will be managed via the same emergency processes as for the single limb
trauma patients. For patients in this category who present to ModH, their initial
assessment, management and stabilisation will be provided by the ModH ED. The ED
will be responsible for undertaking relevant neurovascular observations and liaising
with the NALHN (LMH) orthopaedic on-call staff to discuss patient management and
transfer to LMH for operative management. The transfer to LMH will be facilitated by
direct admission transfers to minimise any duplication within EDs.
Paediatric Fracture Management o Paediatric patients who present to either LMH or ModH EDs with a fracture will be
assessed and managed by the ED.
o Patients who do not require operative management or sedation will be managed within
the ED at which they present, and referred to the on-site fracture clinic, consistent with
current practice.
o Paediatric patients requiring operative management, who fulfil the following criteria,
are suitable for transfer or admission to LMH:
Aged 5 or over
No HDU/ ICU requirement (based on either comorbidities or extent of
injury)
No confirmed or suspected spinal injury
Page 26 of 84 Proposed Intra-NALHN Service Plan – February 2016
Injury within the capabilities of LMH Orthopaedic Team
o Patients not meeting any of the above criteria will be transferred to the Women’s and
Children’s Hospital (WCH) (or RAH in the event of a spinal injury in a patient over 16
years of age).
Orthogeriatric care
The statewide orthogeriatric (fractured neck of femur) pathway is currently in development and will
include an expectation of surgery the day of or the day after presentation to emergency, except in
cases where a delay in surgery is clinically indicated. To facilitate this and support the volume of
activity to be managed by LMH (inclusive of potential increased road transfers from Country Health
South Australia (CHSA)) a dedicated orthopaedic emergency theatre will be established. Initially this
theatre is will operate at 50% capacity, and will increase to full capacity as activity from CALHN to
NALHN increases. Weekend cases will initially be managed via on-call, however these volumes will
be monitored and if required the option of establishing a dedicated weekend list will be explored.
Additional emergency theatre will support the existing scheduled elective sessions.
The early involvement of a specialist geriatric team, under a shared model of care is also expected to
improve the clinical outcomes for this cohort of patients as well as create improvements in length of
stay. There are three broad categories of patients which are anticipated:
Nursing home patients - these patients are ideally suited to a short post-operative stay and
then return to their residential care facility, with geriatric input facilitating this. The overall
inpatient management is expected to remain with orthopaedics.
Non-complex patients - this cohort is expected to have a short-medium post-operative stay,
with referrals to GEM or rehabilitation services for some patients. Geriatric input will assist
with early identification of patients requiring sub-acute care, and also facilitate earlier
transfer to these services. The acute post-operative management of this cohort is expected
to remain with orthopaedics. Those patients requiring sub-acute care will be transferred to
the relevant clinical unit.
Complex patients with additional co morbidities, including dementia and delirium - these
patients represent a complex group with longer length of stay. It is anticipated the initial
post-operative management will be within orthopaedics, however these patients will need
to transfer to geriatrics (with ongoing orthopaedic input as required) early post-operatively
to ensure the most appropriate specialist input into their complex associated medical
conditions.
Page 27 of 84 Proposed Intra-NALHN Service Plan – February 2016
As part of the statewide model of care in development, the expectation is that discharge planning
for patients with a fractured NOF will be completed by day 2 post operatively.
Orthopaedic elective surgery
The broad principles for the orthopaedic elective patient pathway, including potential for the
introduction of Allied Health substitution clinic, is presented in Attachment 6. Elective outpatient
clinics need robust referral pathways to non-operative treatment for those conditions where there is
evidence that conservative treatment is as effective as operative management. The range of services
required includes podiatry, orthotics, physiotherapy and occupational therapy.
Urology
The majority of 23 hour and same day urology procedures will occur at ModH. This includes but is
not limited to non complex major and minor bladder procedures; transurethral and urethral
procedures; and cystoscopes. All multi day and emergency will occur at the LMH along with a small
volume of same day and 23 hour surgery to allow for patient complexity. Emergency urology activity
will be undertaken at LMH. Refer to Attachment 2 for the emergency pathway for surgical patients
presenting to ModH. Ongoing discussions are occurring between CALHN and NALHN to support a
hub and spoke model.
ENT
The NALHN ENT service will continue to provide most adult same-day and 23 hour elective surgery at
ModH, with all paediatric surgery provided at the LMH. Emergency ENT activity will be undertaken
at LMH. Refer to Attachment 2 for the emergency pathway for surgical patients presenting to ModH.
Paediatric ENT services will remain at the LMH within a Hub and Spoke model, LMH being a spoke of
the Women’s and Children’s Hospital (W&CH). A central referral point will be established with the
W&CH. All paediatric ENT referrals will be triaged by the W&CH and referred to the LMH where
appropriate.
Vascular Surgery
Post CALHN to NALHN activity transfer the NALHN Vascular Services will provide an inpatient consult
service and day surgery procedures over a 5 day model, Monday to Friday. A dedicated Vascular
Surgeon will be onsite at NALHN hospitals daily. Whilst initially the service will provide same-day
procedures only, any patients requiring an overnight stay will be under the medical governance of
the Diabetes and Endocrine team, as is the current arrangement. All patients requiring a vascular
consult after hours will be directly transferred to the Royal Adelaide Hospital.
Page 28 of 84 Proposed Intra-NALHN Service Plan – February 2016
General Surgery
All multi-day and complex procedures will remain or occur at LMH due to complexity. All post-
operative infections requiring an inpatient stay will flow from ModH to the LMH. Consultation will
occur over the next 12 months regarding an integrated surgical service.
Upper GIT surgery
Complex cholecystectomy some will remain or occur at LMH, however major cholecystectomy and
other major non-complex 23 hour elective surgery will continue at ModH. Upper GIT inpatient
activity will be transferred as part of the CALHN to NALHN activity transfer. This will enable the
development of sub specialist pancreatic and/or liver expertise enhancing the current model of care.
Breast Endocrine
The majority of all 23 hour and same-day procedures will occur at ModH, including major malignant
breast disorders. All multi-day activity will occur at the LMH. A One Stop Breast Care Clinic will be
established at ModH once a week for new patients to provide prompt assessment and treatment of
patients with a suspected diagnosis of breast cancer. This clinic will provide all the required elements
of a triple assessment during a single visit enabling:
a basis for definitive diagnosis in the majority of patients
reassurance with no need for further attendance in most patients with non-malignant
conditions; and
information for multidisciplinary meeting (MDM) treatment planning prior to review of
those diagnosed to have cancer
The proposed pathway for patients attending the One Stop Breast Care Clinic is outlined in
Attachment 7.
All NALHN Breast Endocrine surgeons will rotate through the clinic. Given that biopsy results will
only be available within 24 to 48 hours following a visit to the Clinic patients will be seen in other
Breast Endocrine outpatient clinics to ensure timely follow up. A central triage process will be
developed with triaging of referrals to occur twice a week.
Plastics and reconstructive surgery
The small volume of day and 23hr surgery plastics and reconstructive surgery undertaken in NALHN
will continue to be provided. More complex surgery will be referred to CALHN as LMH does not
provide this. Refer to Attachment 2 for the emergency pathway for surgical patients presenting to
ModH.
Page 29 of 84 Proposed Intra-NALHN Service Plan – February 2016
Gynaecology
As part of the one service multi site model the Women and Children’s Division will establish rapid
access appointments at ModH to facilitate discharge from ED for non-urgent gynaecological patients
and ensure timely review. The Division will also consolidate the existing early pregnancy service at
LMH to a dedicated unit, with all threatened miscarriage patients referred to this unit for follow up
and continuity of care.
6.3 NALHN Medical Services
The NALHN medical services operate under the governance of the Medical Sub Specialties Division.
This Division provides inpatient and outpatient services in a number of sub-specialties. All specialties
and Obstetric Medicine are multi-site. Nurse-led clinics form an important part of service delivery.
The Chronic Disease Management Unit provides management of chronic disease with a focus on
hospital avoidance and frequent-utiliser strategies.
Medical Sub Specialties
General Medicine (including Short Stay General Medicine Unit)
General Medicine will move away from the traditional take system under the current 5 medical units
at LMH to 3 medical units. The consolidation of services will allow the Division to move toward a 7
day service and reallocate resources, specifically junior medical staff to sub-specialties where junior
medical staff has traditionally been scant. This approach will include daily ward morning rounds by
consultant and criteria led discharge. This approach will contribute significantly to equitable
dispersion of activity, earlier senior decision-making and hospital avoidance. The General Medicine
pathway is outlined in Attachment 8. Ward reconfiguration and movements are outlined under
Section 5.
Allied Health including dietetics, occupational therapy, physiotherapy, speech pathology, social
work, and orthotics and podiatry service will be provided to the 3 general medicine units at LMH.
Resources will be relocated to the LMH from the ModH to support the intra NALHN moves with staff
rotating across sites.
Deteriorating patient:
It is proposed that pathways for deteriorating patients at ModH will be either to the 4 higher
intensity nursing beds, termed Medical Assessment Beds, or transferred to LMH (refer to
Attachment 9 for draft flow chart). LMH processes for deteriorating patients will continue.
Outpatients:
Page 30 of 84 Proposed Intra-NALHN Service Plan – February 2016
General Medicine outpatient clinics will continue to be available at ModH and LMH. To facilitate
early morning ward rounds it is proposed that the outpatient clinics at both sites be scheduled for
the afternoon.
Short Stay General Medicine Unit (SSGMU) at ModH The model for this unit will be consistent with the LMH acute medical unit (AMU) model, providing
care for up to 48 hours. Patients who have higher acuity needs or require greater than 48 hours care
will be transferred to LMH. Evidence from the LMH AMU model demonstrates more appropriate and
timely care, with more rapid assessment, earlier diagnosis and treatment due to early review by
senior medical officer (consultant physician and/or senior medial registrar); reduction in
unnecessary admission and investigations; and reduced LOS. Allied Health will work across the
SSGMU and the EDSSU.
The key components of the ModH SSGMU include:
Management responsibility lies with Division of Medical Sub Specialities
18 short stay medical beds
General medicine patients will be assessed and admitted in the SSGMU
After patients are assessed in the SSGMU, their estimated LOS will be determined and those
with an estimated LOS <48 hours will remain in the unit. For patients deemed to require >48
hours of inpatient care, will be transferred to LMH general medicine units (24 hours 7 days a
week) to the appropriate inpatient ward
Seven day, 24 hours service with features at least once daily consultant led ward rounds
Multiple decision making points over 24 hour period
Focus on multidisciplinary early assessment, proactive planning and intervention
Nursing staff rostered as per business rules and allied health team with sufficient numbers of
experienced non-rotational staff dedicated to the unit
Clerical support for extended hours
Patients can remain in the unit for a maximum of 48 hours with the aim to make a decision
about discharge or transfer to inpatient medical units at LMH as soon as possible
Exclusion Criteria:
Where existing patient admission pathways exist they will continue (i.e. chest pain, ICU, stroke,
gastroenterology, etc).
Acute general medical patients whose clinical condition would be best managed in a General
Medicine inpatient bed at LMH or palliative care at ModH. These are patients who have:
Page 31 of 84 Proposed Intra-NALHN Service Plan – February 2016
An anticipated LOS>48 hours with a diagnosis and comprehensive treatment plan in place
(prolonged admission)
Patients requiring palliative care measures in the terminal phase of the illness
Psychiatric illness but no psychiatric package in place to facilitate leaving the SSGMU within
48 hours
Patients who do not have a disposition destination on discharge
Patients requiring non-invasive ventilation or HDU/ICU interventions
Patients present with acute surgical or orthopaedic conditions
Patients who are best managed under subspecialty units
Deteriorating patient:
It is proposed that pathways for deteriorating patients will be either to the Medical Assessment Beds
at ModH or transferred to LMH.
Cardiology
Chest pain is a common presentation to LMH and ModH ED’s and is a NALHN priority area for
productivity improvement to ensure efficiencies and flow through the ED’s and improved inpatient
length of stay. A NALHN Chest Pain Pathway has been developed (refer to Attachments 10 and 11
for detail). High risk chest pain patients will go to LMH. ModH will continue to provide a 24 hour
walk-in service for low risk chest pain with pathway to LMH if assessed as requiring higher care and
intervention. Rapid Assessment clinics for early stress tests and review will be established. Ward
reconfiguration and movements are outlined under Section 5.
To support the chest pain pathway LMH will provide a central Chest Pain Unit (CPU) service. The aim
of the CPU is to provide a cost effective efficient service to manage patients presenting with chest
pain with the goal to transfer patients out of ED within 120 minutes of presentation and to reduce
length of stay by timely diagnostics (eg High Sensitive Troponin) and management intervention.
The CPU will be located in the LMH AMU. Initially the CPU will be a stand-alone unit with minimal
supports from the AMU nursing staff, however over time this service will become a more integrated
service. Clinical and operational governance of the CPU resides with the Division of Medical Sub-
Specialties and at an operational level the Medical Head of Unit for Cardiology and the Cardiology
Clinical Service Co-ordinator (CSC).
Scope of the Chest Pain Unit - in scope:
Low risk chest pain - if index pain began >6hrs from triage is now resolved
Page 32 of 84 Proposed Intra-NALHN Service Plan – February 2016
Low risk chest pain - if index pain began <6hrs from triage (ALOS 8-12 hrs)
Medium risk chest pain - discriminate degree at assessment
Out of scope:
Chest pain resulting from a diagnosed non-cardiac cause; eg mechanical injury/ pneumonia/
pulmonary embolism
Out-of-Hospital Cardiac Arrest (OOHCA)
Cardiogenic Shock and haemodynamic instability
Acute Pulmonary Oedema (APO) and other forms of decompensated heart failure
Anterior ST-Elevation Myocardial Infarction (STEMI)
Non-STEMI
Unstable Angina
Moderate to high risk Acute Coronary Syndrome (ACS)
Physically dependent patient
Cardiovascular Intervention Suite (CVIS) LMH:
To support the transfer of activity from CALHN to NALHN a second CVIS at LMH will be
commissioned. The procedures that would be in scope for the second CVIS are still being confirmed,
however may include procedures relating to vascular, electrophysiological cardiac services and
STEMI to support vascular, stroke and cardiology.
Respiratory Medicine
Respiratory (in particular COPD) is a NALHN priority area for productivity improvement to ensure
efficiencies and flow through the ED’s and improved inpatient length of stay. The COPD group are
over represented in the patients who frequently utilise ED and medical beds. Pathways for the acute
exacerbation of COPD have been developed (refer to draft in Attachment 12). This will contribute to
more appropriate admission criteria and hospital avoidance and the Respiratory service’s
engagement with the Chronic Disease Management Unit (CDMU) and ED.
Respiratory patients will be able to access the SSGMU at ModH if their care needs are assessed as
meeting the criteria for this unit. It is anticipated that all sub-specialties will rotate to Modbury
Hospital with daily Consultant ward rounds 7 days per week. The 24 bed Ward 2D at LMH will be a
mixed ward for the sub-specialties of respiratory, gastroenterology, endocrine and renal.
Page 33 of 84 Proposed Intra-NALHN Service Plan – February 2016
Respiratory Quick Access Clinics (QACs) are planned, in addition to close engagement with the
CDMU. Modbury Hospital requires additional input. The home oxygen service will be transferred to
LMH. Pathways to pulmonary rehabilitation are outlined in the acute exacerbation to COPD
pathway to ensure optimal access. Non Invasive Ventilation (NIV) is the next evolution of the
inpatient service. With the infrastructure and equipment now in place at LMH; the next step is the
process of developing an education plan to support nursing and junior medical staff. It is anticipated
CN time will be utilised to resource this program for 12 months.
Gastroenterology service
The service model for the NALHN Gastroenterology service is based on the principle of one NALHN
Gastroenterology Service provided across the two sites of LMH and ModH with a wait list at ModH
and a wait list at LMH. Gastroenterology outpatient services and elective endoscopies will be
provided at ModH. The service will remain at the same location in the Gastroenterology suite at
ModH continuing to utilise the gastroenterology theatre and recovery area. Inpatient activity for the
SRG Gastroenterology will not be transferred as part of the CALHN to NALHN activity transfer.
In 2016 improving administrative processes and utilising consultant FTE adequately will be
progressed and consolidated, in particular:
Redistribution of nurse sedationist vs High Risk Anaesthetics lists to allow for more High
Risk lists to be undertaken
Target of 80% list utilisation
Active management of Colonoscopy wait list
Increased consult lists for referrals
Referral pathways and referral criteria to General Practitioners
Inpatient and outpatient consultation service at Modbury Hospital
Limited nurse sedationist lists at Modbury Hospital
NALHN self-sufficiency in the provision of Gastroenterology services
Model for scope cleaning - currently reviewing the model, exploring the use of Technicians
to provide this function.
Diabetes and Endocrinology
The service model for the NALHN diabetes services aims to emulate progressive models on the
eastern seaboard, with clinics managed by specialist diabetes teams. Multiple clinics occur at the
same time including walk-in clinics and rapid access clinics with senior medical input throughout the
Page 34 of 84 Proposed Intra-NALHN Service Plan – February 2016
day. This model facilitates reduced waiting times for new patient appointments, improved access for
patients who require rapid care for urgent cases and avoidable hospital admissions. Clinics are
located at LMH and GP Plus Superclinic Modbury.
Further diabetes inpatient activity will be transferred as part of the CALHN to NALHN activity
transfer. This activity will be absorbed into Ward 2D at LMH which will be a mixed ward for the sub-
specialties of respiratory, gastroenterology, endocrine and renal.
Neurology and Stroke Services
Stroke is a NALHN priority area for productivity improvement to ensure efficiencies and flow through
the ED’s, improved inpatient length of stay and earlier initiation of rehabilitation whilst awaiting
transfer to sub acute rehabilitation. A NALHN Stroke Pathway has been developed (refer to
Attachment 13). Stroke inpatient activity will be transferred as part of the CALHN to NALHN activity
transfer. This activity will be absorbed into Ward 1E at LMH which will be a mixed ward for the sub-
specialties of general medicine and neurology. In addition, the hours of stroke thrombolysis will
extend from the current 0800-1600, to 2000.
The following areas and actions have been identified to improve the efficiency of the NALHN Stroke
Service:
Areas Actions
1. Service approach Principles, vision, goals:
Engagement of staff in the development of common vision,
goals and principles to guide the service.
Service name:
Engagement of staff in the development and promotion of a
service name.
2. Multidisciplinary review Trial of an additional formal weekly MDT meeting at LMH.
Explore appropriate: membership of MDT; meeting time;
agenda format; method of recording meeting outcomes.
Explore opportunities for video-conferencing between NALHN
sites.
Continuation of informal daily stroke team brief.
3. Percutaneous endoscopic
gastrostomy (PEG) pathway
for patients admitted with
Development and implementation of enhanced PEG pathways
including timeframe for PEG.
A PEG pathway (refer to Attachment 14). has been developed
for patients admitted with stroke and is outlined on the
Page 35 of 84 Proposed Intra-NALHN Service Plan – February 2016
stroke NALHN PPG OWI02147 Percutaneous endoscopic gastrostomy
(PEG) pathway for patients admitted with stroke.
4. Referral on admission Inclusion of prompt for referral on admission in Admission
Checklist.
Promotion of referral on admission (within 24 hours.)
5. Pathway to rehabilitation Exploration of slow and fast stream pathways-
Mild-moderate (2-3 days); Severe (7 days)
Changes to MDT frequency, format, etc may assist movement
through pathway.
6.TIA Minor stroke pathway Clarify opportunities for implementation of proposed pathway.
A TIA nurse has been appointed and nurse-led clinics are being
established.
Renal Services
Renal Medicine is a specialty providing management of chronic renal failure and dialysis, as well as
inpatient care for acute renal failure, acute glomerular disease and nephrotic syndrome. Renal
failure complicates many conditions, especially Diabetes, Vascular Disease and Hypertension.
Renal inpatient activity will be transferred as part of the CALHN to NALHN activity transfer. NALHN
currently is unable to provide inpatient dialysis. This activity will be absorbed into Ward 2D at LMH
which will be a mixed ward for the sub-specialties of Respiratory, Gastroenterology, Endocrine and
Renal. This will enable:
Existing LMH patients that require expert Renal care, or inpatient dialysis to be managed by the
Renal Team, thus improving the quality of care delivered and reducing the associated morbidity
and mortality currently identified within the division.
The ability to manage the care of patients who are currently managed within CALHN. This
includes patients admitted for non-complex renal diagnoses (as the tertiary renal service for
CNARTS, RAH will continue to manage complex and unwell renal patients) as well as patients
admitted to CALHN for non-renal diagnoses (e.g., respiratory conditions) who require dialysis
during their inpatient stay.
No direct admission from ED to a Renal bed card will be allowed.
The service to also support patients with renal conditions who require surgery to have their
procedures performed at LMH rather than RAH.
Page 36 of 84 Proposed Intra-NALHN Service Plan – February 2016
Haematology and Medical Oncology
The transfer of haematology and medical oncology inpatient activity as part of the CALHN to NALHN
activity transfer will enable NALHN patients to be managed within the network, however is not
enough to maintain a stand-alone Haematology bed card. This activity will be absorbed into Ward 1D
at LMH which will be a mixed ward with General Medicine and Oncology disciplines, and will enable:
an increase in current cancer treatments being undertaken
inpatient chemo to be undertaken
4 additional oncology chairs will be introduced to support this
the following activity to move back to NALHN:
o RBC disorders as described in DRG transfers
o Increase in activity currently done in NALHN
o Low grade lymphomas and myelomas.
Chronic Disease Management Unit
The priorities within this unit are hospital avoidance, case identification, case management and
coordinated care of all chronic disease programs (refer to Attachment 15 for an overview of the
unit). By the end of the 2015/2016 financial year, it is planned that this unit will be fully established
and have a profile within the organisation with chronic disease being managed in a structured
manner. The clinical leads in Allied Health, Nursing and Medicine are facilitating:
Entry and exit criteria for the chronic disease programs
Creating single referral point for all chronic disease management
Developing screening tools for high risk individuals
Meeting with General Practitioners and start developing Shared Care Models
Strengthening Hospital Avoidance strategies
Incorporating End of Life Project
Page 37 of 84 Proposed Intra-NALHN Service Plan – February 2016
7. Interdependencies- clinical support summary
NALHN Service Associated with intra NALHN
Level of required clinical capability Source - SA Health Clinical Capability Services Framework (2015)
Critical Care Services
Interdependency LMH ED (based on Level 5)
ModH ED (based on Level 3 -4)
Anaesthetic on site Level 5 on site Level 3 - 4
Children’s anaesthetic on site Level 4 on site Level 4
Cardiac care unit on site Level 5 accessible Level 4
Cardiac diagnostic & interventional on site Level 5 accessible Level 4
Cardiac medicine on site Level 5
Intensive care on site level 5 accessible Level 4
Children’s intensive care accessible Level 4
Medical on site Level 5 accessible Level 3; on site Level 4
Children’s medical accessible Level 4 accessible Level 4
Medical imaging on site Level 5 on site Level 1-4
Mental Health on site Level 5 accessible Level 4
Mental Health (child & youth) accessible Level 4 accessible Level 4
Nuclear medicine on site Level 4
Children’s nuclear medicine accessible Level 4
Pathology on site Level 4 accessible 3-4
Perioperative on site Level 5 accessible Level 3; on site Level 4
Pharmacy on site Level 5 on site Level 3-4
Surgical on site Level 5 accessible Level 3; on site Level 4
Children’s surgical accessible Level 4 accessible Level 4
Interdependency LMH ICU Anaesthetic on site Level 5
Cardiac medicine accessible Level 5
Medical on site Level 5
Medical imaging on site Level 4
Mental health accessible Level 5
Pathology accessible Level 4
Page 38 of 84 Proposed Intra-NALHN Service Plan – February 2016
NALHN Service Associated with intra NALHN
Level of required clinical capability Source - SA Health Clinical Capability Services Framework (2015)
Perioperative on site Level 5
Pharmacy on site Level 5
Renal accessible Level 5
Surgical on site Level 5
NALHN Service Associated with intra NALHN
Surgical Services
Interdependency LMH impact
ModH impact
Anaesthetic Emergency; multi day;
preadmission
Same day; 23 hour;
preadmission
Theatres Sterilising Unit
Post Anaesthetic Recovery Unit
Sterilising Unit
Post Anaesthetic
Recovery Unit
ED Bypass or transfer process Bypass or transfer
process
Intensive care Increased activity Change of service
profile
Medical imaging Imaging intensifier increase;
Ultrasound increase
CT scans increase
Interventional radiology for
emergency activity
Greater access to
ultrasound,
mammograms, CT
Pathology Histology;
Phlebotomist
Histology access for
one stop breast care
clinic
Perioperative Increased activity
Pharmacy Increased activity;
Increased volume primarily for
high volume, low cost
prophylactic antibiotics;
Clinical pharmacy requirements
to support the additional
Clinical pharmacy
requirements
Page 39 of 84 Proposed Intra-NALHN Service Plan – February 2016
NALHN Service Associated with intra NALHN
surgical multi day activity at
LMH
Allied Health Comprehensive Allied Health services including dietetics, occupational therapy, orthotics, physiotherapy, speech pathology, podiatry and social work to provide ward based services.
Outpatient clinics Clinic types Clinic types
NALHN Service Associated with intra NALHN
Medical Services
Interdependency LMH & ModH impact
ED Bypass or transfer process
Intensive care Site profile changes
Medical imaging Patient identifier / documentation across sites
Pathology Phlebotomy rounds to match proposed future ward
configuration;
Access to High Sensitivity Troponin
Pharmacy Clinical pharmacy requirements to support the move
from ModH (3East) to LMH (1B).
Allied Health Comprehensive Allied Health services including dietetics, occupational therapy, orthotics, physiotherapy, speech pathology, podiatry and social work to provide ward based services.
Outpatient clinics Clinic types and timing
8. Interdependencies- non clinical support summary
Intra NALHN
Hotel Services ICT Transfers
Cleaning
Imprest
Linen requirements
Orderly support
Waste removal
A process has been established with
ICT to identify ICT requirements and
timing / lead in times. This will be
ongoing to encompass the CALHN
NALHN transition.
Medical records
transfers between sites;
PAS – UR numbers SAAS transfers
Page 40 of 84 Proposed Intra-NALHN Service Plan – February 2016
9. Infrastructure - summary
NALHN Service Associated with intra NALHN [Space / minor /major works / Equipment]
Critical Care Services (note: equipment to be moved from 1 West as appropriate)
Purpose built short stay unit at ModH – proposed end 2016
H@H space at ModH
Four fully equipped MET trollies either located centrally at RRT
home base or strategically located around the hospital.
- One trolley will be suited to responding to external MET
calls. This trolley will have a Propaq Defibrillator which is
lighter
Communication devices (pagers and mobile phones)
The following equipment will be available (most likely in ED):
Transport ventilator oxylog (2 in hospital)
Non-invasive ventilators (2) in hospital)
Telemedicine technology functionality would be highly valuable to
enable consultations between LMH ICU and ModH.
Surgical Services Infrastructure available/required at each site to support changes to
service location, roles and model of care.
2nd II available at LMH to support theatres although staffing for
second is required. Future service changes will require third II.
Breast Endocrine – gamma probes and nerve monitor already
available.
Consider future growth for interventional radiology.
Consider outpatient audiology booth requirements for ENT.
Equipment – broad requirements have been identified. Detailed
analysis is currently being undertaken.
Patient mobility aids and ADL equipment at both sites.
Office space – to be confirmed
Medical Services Location of stress test at ModH and space for admin officer
Minor works associated with establishment of chest pain unit at
LMH
Minor works required to enable the location of a Stress Test Lab to
service the chest pain unit at LMH
Page 41 of 84 Proposed Intra-NALHN Service Plan – February 2016
NALHN Service Associated with intra NALHN [Space / minor /major works / Equipment]
Equipment for Stress Test at LMH: already purchased.
Utilise existing bed side monitors
Cardiac AED
All other equipment to be utilised from AMU
10. Staff education / training required for implementation
The three principles that underpin staff education and training in readiness for implementation
include:
People work safely in their workplace
Patient safety is not compromised
The work environment is safe
To facilitate this the following will occur:
Operational procedures and work instructions will be updated so they are suitable for the
new environment
All staff to complete their work unit induction and any other specialised training required
Communication and providing access to online tools
Allocate super user/s who will deliver train the trainer unit orientation across both sites
Page 42 of 84 Proposed Intra-NALHN Service Plan – February 2016
11. Workforce – FTE summary by service
The following only includes FTE associated with this NALHN consolidated service plan.
INTRA NALHN TRANSFERS 2015-16 labour budget (in scope cost centres only) Current Staffing -
Total Total Future State
(Intra NALHN)
Northern Adelaide LHN - in scope cost centres 1,163.16 1,126.70
Lyell McEwin Hospital 778.05 863.60
Critical Care - LMH 325.99 330.99
LMH EMERGENCY SERVICE 212.60 212.60
ENDP 30.50 30.50
MD02 18.40 18.40
MDP1 6.00 6.00
MDP2 47.60 47.60
MDX1 1.53 1.53
RN01 85.43 85.43
RN2A 8.46 8.46
RN2C 7.11 7.11
RN3A 1.17 1.17
RN4A 6.40 6.40
LMH ICU/HDU 102.25 102.25
ASO3 1 1
MD02 8.22 8.22
MDP2 14.50 14.50
RN01 63.26 63.26
RN2A 5.19 5.19
RN2C 8.91 8.91
RN3A 1.17 1.17
LMH HOME HOSPITAL 11.14 16.14
AS02 0.60 0.84
ENDP 0.77 0.77
RN2A 1.03 2.06
RN2C 7.57 10.13
RN3A 1.17 1.17
RN4A 0 1.17
Medical Administration - LMH 21.64 23.64
Medical Sub-Specialties - LMH 139.16 183.44
LMH CHEST PAIN ASSESSMENT - -
ASO2 0 -
MDP2 0 -
RN3A 0 -
LMH CARDIOLOGY 14.80 15.80
Page 43 of 84 Proposed Intra-NALHN Service Plan – February 2016
AHP1 0.20 0.20
AHP2 1.00 1.00
ASO2 2.4 2.40
CAMD 0 -
MD02 4.20 4.20
MDP1 1.00 1.00
MDP2 6.00 7.00
Lmh Chest Pain Unit - 1.00
RN4A 0 0
RN3A 0 0
RN01 0 0
ENDP 0 0
MDP2 0 1
LMH GASTROENTEROLOGY 24.90 25.90
ASO2 3.00 3.00
ENDP 4.10 4.10
MD02 4.40 4.40
MDP2 4.00
5.00
RN01 6.21 6.21
RN2A 0.91 0.91
RN2C 1.14 1.14
RN3A 1.14 1.14
LMH GENERAL MEDICINE 74.83 76.83
ASO2 2.00 2.00
ASO3 2.00 2.00
MD02 8.50 8.50
MDP1 11.00 11.00
MDP2 51.00 53.00
MOV3 0.33 0.33
LMH Ward - Ward 1B - 36.28
ASO2 0 1.00
ENDP 0 11.67
RN01 0 16.28
RN2A 0 2.57
RN2C 0 3.59
RN4A 0 1.17
Lmh Infectious Diseases 2.10 3.10
MD02 2.10 2.10
MDP2 0 1.00
LMH NEUROLOGY 4.30 4.30
MD02 3.00 3.00
TGO1 1.30 1.30
LMH ONCOLOGY 13.66 14.66
ASO2 1.00 1.00
Page 44 of 84 Proposed Intra-NALHN Service Plan – February 2016
ASO3 1.00 1.00
MD02 2.20 2.20
MDP2 2.00 3.00
RN01 3.17 3.17
RN2A 0.58 0.58
RN2C 3.13 3.13
RN3A 0.58 0.58
LMH THORACIC MEDICINE 4.57 5.57
MD02 1.80 1.80
MES2 0.80 0.80
MES4 0.80 0.80
RN2A 1.17 1.17
MDP2 0 1
Surgical Specialties & Anaesthetics - LMH 292.37 321.54
LMH ANAESTHESIA 57.70 60.22
ASO3 1.00 1.00
ENDP 5.66 5.72
MD02 16.98 16.98
MDP2 16.67 16.67
MDP3 1.00 1.00
MDP4 0.50 0.50
RN01 10.91 13.64
RN2A 1.26 1.27
RN2C 2.58 2.29
RN3A 1.14 1.15
LMH Acute Pain Service 1.63 1.65
RN2C 0.46 0.47
RN3A 1.17 1.18
Lmh Surgical & Acute Admin 10.15 11.39
ASO2 1.80 2.00
ASO3 2.20 2.20
MD02 0.80 0.80
RN2C08 0 1.04
RN3A 2.32 2.32
RN5A 3.03 3.03
LMH CSSD 13.62 13.62
AS04 1.00 1.00
WHA5 10.94 11.94
WHA6 1.68 1.68
LMH RECOVERY 18.87 22.13
RN01 12.07 14.75
RN2A 1.26 1.78
RN2C 4.40 4.45
RN3A 1.14 1.15
Page 45 of 84 Proposed Intra-NALHN Service Plan – February 2016
WHA4 0 0
LMH OPERATING THEATRE 58.70 65.22
ASO2 6.68 7.79
ASO3 1.00 1.00
EN01 1.26 1.27
ENDP 5.66 5.96
RN01 31.43 36.48
RN2A 5.53 5.59
RN3A 1.14 1.14
WHA4 1.00 1.00
WHA5 5.00 5.00
LMH PRE ADMISSION CLINICS 6.06 8.56
RN01 3.67 6.17
RN2A 1.22 1.22
RN3A 1.17 1.17
LMH BREAST ENDOCRINE 6.70 6.70
MD02 2.00 2.00
MDP1 1.00 1.00
MDP2 2.00 2.00
MDP3 1.00 1.00
RN3A 0.70 0.70
LMH COLORECTAL 8.90 7.90
MD02 2.90 2.90
MDP1 2.00 1.00
MDP2 3.00 3.00
MDP3 1.00 1.00
LMH WARD 2F-SAME DAY UNIT 10.30 8.44
ENDP 2.41 1.46
RN01 5.28 3.88
RN2A 0.84 0.74
RN2C 1.20 1.21
RN3A 0.57 1.15
LMH WARD 2FX (PERMANENT WARD) 12.13 16.59
ENDP04 0 1.81
RN01 10.90 12.82
RN2A 0.77 0.78
RN3A 0.46 1.18
LMH STOMAL THERAPY 1.17 2.35
RN3A 1.17 2.35
LMH WARD 2B 38.88 45.17
EN01 8.78 9.52
ENDP 5.19 5.89
RN01 18.59 23.38
RN2A 5.14 5.20
Page 46 of 84 Proposed Intra-NALHN Service Plan – February 2016
RN3A 1.18 1.18
LMH WARD 2E 31.67 35.63
ENDP 8.13 8.22
RN01 16.79 20.60
RN2A 5.58 5.64
RN3A 1.17 1.17
LMH ORTHOPAEDIC SURGERY 9.59 9.69
MD02 2.00 3.10
MDP1 2.00 2.00
MDP2 3.35 3.35
MDP4 2.00 1.00
MOV3 0.24 0.24
LMH UPPER GI 6.30 6.30
MD02 1.90 2.30
MDP1 2.00 2.00
MDP2 2.00 2.00
MOV3 0.40 0.00
Modbury Hospital 384.00 267.09
Critical Care - Mod 151.45 116.22
Mod Emergency Department 110.36 110.36
ASO2 1.00 1.00
ENDP 9.42 9.42
MD02 12.50 12.5
MDP1 5.00 5.00
MDP2 17.26 17.26
MDP4 9.24 9.24
RN01 44.85 44.85
RN2A 2.75 2.75
RN2C 4.88 4.88
RN3A 1.17 1.17
RN4A 2.29 2.29
MOD WARD - CRITICAL CARE UNIT 36.33 -
ASO2 1.00 0
ENDP 1.03 0
RN01 14.61 0
RN2A 2.12 0
RN2C 11.4 0
RN3A 1.17 0
MD02 0.00 0
MDP2 5.00 0
MOD OUTREACH & H@H 4.76 -
RN2A 1.03 0
RN2C 2.56 0
RN4A 1.17 0
Page 47 of 84 Proposed Intra-NALHN Service Plan – February 2016
RAPID RESPONSE TEAM - 5.86
RN01 0 3.41
RN2C 0 2.45
Medical Sub-Specialties - Mod 98.25 46.61
MOD GENERAL MEDICINE - CLIN SERV 22.40 12.40
MD02 1.80 1.80
MDP1 9.00 3.00
MDP2 11.00 7.00
MOV3 0.60 0.60
Mod Ward - Medical 3E 37.78 -
ASO2 2.50 0.00
ENDP 11.67 0.00
RN01 16.28 0.00
RN2A 2.57 0.00
RN2C 3.59 0.00
RN4A 1.17 0.00
Mod Ward - Short Stay Unit - 34.21
ASO2 0 2.40
ENDP 0 7.89
RN01 0 20.93
RN3A 0 1.81
RN4A 0 1.18
MOD WARD - MEDICAL 3W 38.07 -
ASO2 1.00 0.00
ENDP 11.67 0.00
RN01 16.28 0.00
RN2A 2.57 0.00
RN2C 3.59 0.00
RN3A 1.79 0.00
RN4A 1.17 0.00
Surgical Specialties & Anaesthetics - Mod 134.30 103.26
MOD STOMAL THERAPY 1.17 -
RN3A 1.17 0.00
Mod Anaesthetics - Nursing 8.76 4.48
RN01 5.87 2.33
RN2A 1.28 0.78
RN2C 1.03 0.78
RN3A 0.58 0.59
MOD ANAESTHESIOLOGY - CLIN SERV 14.08 14.08
MD02 5.55 5.55
MDP2 7.40 7.40
MOV3 1.13 1.13
MOD OPERATING THEATRE 27.49 23.58
ASO2 4.78 4.78
Page 48 of 84 Proposed Intra-NALHN Service Plan – February 2016
ENDP 0.51 1.29
RN01 9.48 8.30
RN2A 2.57 0.00
RN2C 8.98 8.04
RN3A 1.17 1.17
MOD ACUTE PAIN SERVICE 1.22 -
RN3A 1.22 0.00
Mod Pre Admission Clinic - Nursing 2.44 -
RN01 1.22 0.00
RN2C 1.22 0.00
MOD WARD - DAY PROCEDURE UNIT 7.33 12.32
ENDP 1.22 2.48
RN01 3.42 7.15
RN2A 0.49 0.49
RN2C 0.98 0.98
RN3A 1.22 1.22
MOD GENERAL SURGERY - CLIN SERV 21.62 20.88
MDP1 4.00 3.00
MDP2 13.00 13.00
MDP3 1.00 1.76
MDO2 1.62 1.62
MOV2 0.50 0.00
MOV3 1.50 1.50
Mod Recovery - Nursing 9.97 9.54
RN01 7.14 6.71
RN2A 1.22 1.22
RN2C 1.03 1.03
RN3A 0.58 0.58
MOD WARD - SURGICAL 21.06 0.80
ASO2 1.00 0.80
ENDP 5.19 0.00
RN01 9.35 0.00
RN2A 1.61 0.00
RN2C 2.69 0.00
RN3A 1.22 0.00
MOD WARD - 23 HOUR 12.96 11.38
ASO2 1.80 1.80
ENDP 2.57 2.33
RN01 6.73 6.16
RN2A 0.77 0.25
RN2C 1.09 0.84
MOD ORTHOPAEDIC SURGERY - CLIN SERV 6.20 6.20
MDP2 5.00 5.00
MOV3 1.2 1.20
Page 49 of 84 Proposed Intra-NALHN Service Plan – February 2016
PALLIATIVE CARE 0 1.00
MDP1 0.00 1.00
An Expression of Interest process will be finalised for all on-going non-Medical staff directly affected
by the service change. Any on-going employee who may become unattached will be placed into an
on-going position in accordance with the relevant industrial instrument.
There will be no surplus on-going employeeat the conclusion of all the intra-NALHN moves.
12. Activity – summary by service
The following tables outline the current activity and indicative future state based on the medicine
and surgical models of care outlined in previous sections. Activity is based on NALHN 2014/15
inpatient data set (ISAAC).
Division Medical Sub Specialties
Overall summary
Table 1: Summary NALHN 2014/15 activity for Division Medical Sub Specialties at LMH and ModH
2014/15 Actuals seps per site
LMH ModH Total
<48 hours 5,688 2,052 7,740
>48 hours 6,754 2,719 9,473
Grand Total 12,442 4,771 17,213
Table 2: Summary future state NALHN Division Medical Sub Specialties at LMH and ModH
Future state seps per site based on model of care
LMH ModH Total
<48 hours 5,839 4,416 10,255
>48 hours 9,471 0 9,471
Grand Total 15,310 4,416 19,726
Page 50 of 84 Proposed Intra-NALHN Service Plan – February 2016
Current state
Table 3: Current Activity for the LMH by Division Medical Sub Specialties
Page 51 of 84 Proposed Intra-NALHN Service Plan – February 2016
Seps Bed Days ALOS Seps Bed Days ALOS
01 - CARDIOLOGY 1,235 1,459 1.18 867 4,552 5.25
02 - INTERVENTIONAL CARDIOLOGY 444 558 1.26 584 2,577 4.41
03 - CARDIOTHORACIC SURGERY 7 9 1.29 16 142 8.88
04 - RESPIRATORY MEDICINE 709 965 1.36 1,551 8,713 5.62
05 - GASTROENTEROLOGY 298 359 1.20 337 1,850 5.49
06 - GIT ENDOSCOPY 79 109 1.38 183 1,445 7.90
07 - NEUROLOGY 504 603 1.20 813 6,597 8.11
08 - NEUROSURGERY 20 24 1.20 49 463 9.45
09 - ENDOCRINOLOGY 249 308 1.24 242 1,431 5.91
10 - RENAL FAILURE 62 73 1.18 106 818 7.72
12 - HAEMATOLOGY 231 252 1.09 135 739 5.47
13 - ENT 6 6 1.00 8 35 4.38
14 - OPHTHALMOLOGY 9 10 1.11 9 41 4.56
15 - MEDICAL ONCOLOGY 51 64 1.25 185 1,607 8.69
17 - RHEUMATOLOGY 46 37 0.80 58 354 6.10
18 - DERMATOLOGY 17 19 1.12 18 64 3.56
19 - HEAD & NECK SURGERY 1 1 1.00 1 12 12.00
20 - DENTISTRY 5 4 0.80 11 66 6.00
21 - UPPER GIT SURGERY 0 0 2 19 9.50
22 - COLORECTAL SURGERY 0 0 3 25 8.33
23 - ORTHOPAEDICS 81 94 1.16 180 1,397 7.76
24 - UROLOGY 20 23 1.15 23 175 7.61
25 - VASCULAR SURGERY 32 27 0.84 48 377 7.85
26 - GENERAL MEDICINE 1,122 1,221 1.09 1,086 8,124 7.48
27 - GENERAL SURGERY 103 126 1.22 146 901 6.17
28 - BREAST SURGERY 0 0 0 0
29 - PLASTIC & RECONSTRUCTIVE SURGERY 1 0 0.00 3 31 10.33
30 - GYNAECOLOGY 1 2 2.00 3 26 8.67
31 - OBSTETRICS 285 289 1.01 12 53 4.42
34 - TRACHEOSTOMY 2 2 1.00 26 369 14.19
35 - DRUG & ALCOHOL 39 48 1.23 18 93 5.17
36 - BURNS 1 1 1.00 0 0
37 - PSYCHIATRY 28 33 1.18 23 118 5.13
38 - ACUTE REHABILITATION 0 0 0 0
39 - UNGROUPABLE 0 0 8 101 12.63
Grand Total 5,688 6,726 1.18 6,754 43,315 6.41
<48H
Division of MSS - 2014/15 Actual Activity (LMH)
>48H
Page 52 of 84 Proposed Intra-NALHN Service Plan – February 2016
Table 4: Current Activity for the ModH by Division Medical Sub Specialties
Seps Bed Days ALOS Seps Bed Days ALOS
01 - CARDIOLOGY 720 835 1.16 381 2,055 5.39
02 - INTERVENTIONAL CARDIOLOGY
03 - CARDIOTHORACIC SURGERY 3 24 8.00
04 - RESPIRATORY MEDICINE 283 374 1.32 718 4,219 5.88
05 - GASTROENTEROLOGY 86 109 1.27 142 995 7.01
06 - GIT ENDOSCOPY 6 83 13.83
07 - NEUROLOGY 215 260 1.21 314 2,339 7.45
08 - NEUROSURGERY 14 18 1.29 29 164 5.66
09 - ENDOCRINOLOGY 55 77 1.40 98 513 5.23
10 - RENAL FAILURE 26 33 1.27 24 141 5.88
12 - HAEMATOLOGY 136 149 1.10 70 401 5.73
13 - ENT 3 4 1.33 7 40 5.71
14 - OPHTHALMOLOGY 2 3 1.50 3 10 3.33
15 - MEDICAL ONCOLOGY 18 22 1.22 64 545 8.52
17 - RHEUMATOLOGY 10 13 1.30 26 158 6.08
18 - DERMATOLOGY 3 3 1.00 5 30 6.00
19 - HEAD & NECK SURGERY
20 - DENTISTRY 1 2 2.00 2 11 5.50
21 - UPPER GIT SURGERY 1 3 3.00
22 - COLORECTAL SURGERY
23 - ORTHOPAEDICS 44 56 1.27 135 1,092 8.09
24 - UROLOGY 8 9 1.13 19 86 4.53
25 - VASCULAR SURGERY 5 5 1.00 14 126 9.00
26 - GENERAL MEDICINE 348 390 1.12 544 4,703 8.65
27 - GENERAL SURGERY 49 62 1.27 83 660 7.95
28 - BREAST SURGERY 1 12
29 - PLASTIC & RECONSTRUCTIVE SURGERY 2 21 10.50
30 - GYNAECOLOGY
31 - OBSTETRICS 1 1 1.00
34 - TRACHEOSTOMY
35 - DRUG & ALCOHOL 16 23 1.44 10 40 4.00
36 - BURNS
37 - PSYCHIATRY 9 13 1.44 15 76 5.07
38 - ACUTE REHABILITATION 1 4
39 - UNGROUPABLE 2 36 18.00
Grand Total 2,052 2,461 1.20 2,719 18,587 6.84
<48H >48H
Division of MSS - 2014/15 Actual Activity (ModH)
Page 53 of 84 Proposed Intra-NALHN Service Plan – February 2016
Future state
Table 5: Future state for the LMH by Division Medical Sub Specialties
Seps Bed Days ALOS Seps Bed Days ALOS
01 - CARDIOLOGY 1,245 1,468 1.18 1,248 6,055 4.85
02 - INTERVENTIONAL CARDIOLOGY 444 558 1.26 584 2,577 4.41
03 - CARDIOTHORACIC SURGERY 7 9 1.29 19 162 8.50
04 - RESPIRATORY MEDICINE 715 969 1.36 2,269 11,890 5.24
05 - GASTROENTEROLOGY 298 359 1.20 479 2,637 5.50
06 - GIT ENDOSCOPY 79 109 1.38 189 1,519 8.04
07 - NEUROLOGY 527 626 1.19 1,127 8,491 7.53
08 - NEUROSURGERY 20 24 1.20 78 585 7.50
09 - ENDOCRINOLOGY 250 310 1.24 340 1,806 5.31
10 - RENAL FAILURE 62 73 1.18 130 923 7.10
12 - HAEMATOLOGY 310 332 1.07 205 1,035 5.05
13 - ENT 6 6 1.00 15 65 4.30
14 - OPHTHALMOLOGY 9 10 1.11 12 47 3.88
15 - MEDICAL ONCOLOGY 56 69 1.23 249 2,062 8.28
17 - RHEUMATOLOGY 47 38 0.81 84 479 5.70
18 - DERMATOLOGY 18 20 1.11 23 87 3.76
19 - HEAD & NECK SURGERY 1 1 1.00 1 12 12.00
20 - DENTISTRY 5 4 0.80 13 74 5.69
21 - UPPER GIT SURGERY 0 0 3 22 7.33
22 - COLORECTAL SURGERY 0 0 3 25 8.33
23 - ORTHOPAEDICS 84 96 1.14 315 2,288 7.26
24 - UROLOGY 22 23 1.05 42 233 5.54
25 - VASCULAR SURGERY 32 27 0.84 62 482 7.77
26 - GENERAL MEDICINE 1,141 1,241 1.09 1,630 12,197 7.48
27 - GENERAL SURGERY 103 126 1.22 229 1,441 6.29
28 - BREAST SURGERY 0 0 1 11 10.50
29 - PLASTIC & RECONSTRUCTIVE SURGERY 1 0 0.00 5 51 10.10
30 - GYNAECOLOGY 1 2 2.00 3 26 8.67
31 - OBSTETRICS 285 289 1.01 12 53 4.42
34 - TRACHEOSTOMY 2 2 1.00 26 369 14.19
35 - DRUG & ALCOHOL 39 48 1.23 28 118 4.21
36 - BURNS 1 1 1.00 0 0
37 - PSYCHIATRY 29 34 1.17 38 172 4.51
38 - ACUTE REHABILITATION 0 0 1 4 4.00
39 - UNGROUPABLE 0 0 8 101 12.63
Grand Total 5,839 6,874 1.18 9,471 58,094 6.13
<48H >48H
Division of MSS - Future State (LMH)
Page 54 of 84 Proposed Intra-NALHN Service Plan – February 2016
Table 6: Future state for the ModH by Division Medical Sub Specialties
Division of MSS - Future State (ModH)
<48H >48H
Seps Bed Days ALOS Seps Bed Days ALOS
01 - CARDIOLOGY 1,078 1,378 1.28 0 0 0.00
02 - INTERVENTIONAL CARDIOLOGY 03 - CARDIOTHORACIC SURGERY 3 5 1.50 0 0 0.00
04 - RESPIRATORY MEDICINE 972 1,413 1.45 0 0 0.00
05 - GASTROENTEROLOGY 225 318 1.41 0 0 0.00
06 - GIT ENDOSCOPY 6 9 1.50 0 0 0.00
07 - NEUROLOGY 489 683 1.40 0 0 0.00
08 - NEUROSURGERY 42 60 1.43 0 0 0.00
09 - ENDOCRINOLOGY 146 213 1.46 0 0 0.00
10 - RENAL FAILURE 50 69 1.38 0 0 0.00
12 - HAEMATOLOGY 127 174 1.37 0 0 0.00
13 - ENT 10 15 1.45 0 0 0.00
14 - OPHTHALMOLOGY 5 8 1.50 0 0 0.00
15 - MEDICAL ONCOLOGY 73 107 1.47 0 0 0.00
17 - RHEUMATOLOGY 31 45 1.45 0 0 0.00
18 - DERMATOLOGY 7 10 1.36 0 0 0.00
19 - HEAD & NECK SURGERY 20 - DENTISTRY 3 5 1.67 0 0 0.00
21 - UPPER GIT SURGERY 22 - COLORECTAL SURGERY 23 - ORTHOPAEDICS 175 255 1.46 0 0 0.00
24 - UROLOGY 25 38 1.50 0 0 0.00
25 - VASCULAR SURGERY 19 26 1.37 0 0 0.00
26 - GENERAL MEDICINE 749 1,000 1.34 0 0 0.00
27 - GENERAL SURGERY 129 182 1.41 0 0 0.00
28 - BREAST SURGERY 1 2 1.50 0 0 0.00
29 - PLASTIC & RECONSTRUCTIVE SURGERY 1 2 1.50 0 0 0.00
30 - GYNAECOLOGY 31 - OBSTETRICS 1 1 1.00 0 0 0.00
34 - TRACHEOSTOMY 35 - DRUG & ALCOHOL 26 38 1.46 0 0 0.00
36 - BURNS 37 - PSYCHIATRY 23 35 1.50 0 0 0.00
38 - ACUTE REHABILITATION 39 - UNGROUPABLE
Grand Total 4,416 6,086 1.38 0 0 0.00
Page 55 of 84 Proposed Intra-NALHN Service Plan – February 2016
Table 7: ModH Activity for Division Medical Sub Specialties flowing to LMH
Modbury >48HR Activity flowing to LMH
>48 Hours
Row Labels Seps Bed Days ALOS
01 - CARDIOLOGY 368 1,411 3.83
02 - INTERVENTIONAL CARDIOLOGY
03 - CARDIOTHORACIC SURGERY 3 20 6.50
04 - RESPIRATORY MEDICINE 695 3,035 4.37
05 - GASTROENTEROLOGY 139 761 5.47
06 - GIT ENDOSCOPY 6 74 12.33
07 - NEUROLOGY 297 1,686 5.68
08 - NEUROSURGERY 28 117 4.18
09 - ENDOCRINOLOGY 92 347 3.77
10 - RENAL FAILURE 24 105 4.38
12 - HAEMATOLOGY 70 296 4.23
13 - ENT 7 30 4.21
14 - OPHTHALMOLOGY 3 6 1.83
15 - MEDICAL ONCOLOGY 60 401 6.68
17 - RHEUMATOLOGY 22 101 4.59
18 - DERMATOLOGY 5 23 4.50
19 - HEAD & NECK SURGERY
20 - DENTISTRY 2 8 4.00
21 - UPPER GIT SURGERY
22 - COLORECTAL SURGERY
23 - ORTHOPAEDICS 134 884 6.60
24 - UROLOGY 19 58 3.03
25 - VASCULAR SURGERY 14 105 7.50
26 - GENERAL MEDICINE 420 2,189 5.21
27 - GENERAL SURGERY 80 516 6.45
28 - BREAST SURGERY 1 11 10.50
29 - PLASTIC & RECONSTRUCTIVE SURGERY 1 8 7.50
30 - GYNAECOLOGY
31 - OBSTETRICS
34 - TRACHEOSTOMY
35 - DRUG & ALCOHOL 10 25 2.50
36 - BURNS
37 - PSYCHIATRY 15 54 3.57
38 - ACUTE REHABILITATION
39 - UNGROUPABLE
Grand Total 2,515 12,266 4.88
Page 56 of 84 Proposed Intra-NALHN Service Plan – February 2016
Surgical Activity
Overall summary:
Table 8: Summary NALHN Surgical Activity for 2014/15 at LMH and ModH by care type and length of stay category
14/15 Actuals Seps per site based on care type and LOS category
LMH ModH Total
Elective Emergency Elective Emergency
Multiday sub total 771 2,917 425 1,427 5,540
23HR sub total 724 715 683 474 2,596
Same day sub total 2,007 319 1,095 143 3,564
Grand total 3502 3951 2203 2044 11700
Table 9: Summary future state NALHN Surgical activity at LMH and ModH, by care type and length of stay category (intra NALHN)
Future state Seps per site based on care type and LOS category
LMH ModH Total
Elective Emergency Elective Emergency
Multiday sub total 1,178 3,718 N/A N/A 4,896
23HR sub total 358 1,109 1,043 N/A 2,510
Same day sub total 908 462 1,961 N/A 3,331
Grand total 2,444 5,289 3,004 N/A 10,737 Note: 2014/15 Gastro and GIT endoscopy total separations for the LMH of 644 multi-day, 233 for same-day and 86 for 23 hour has been removed in future state as this activity is now under the governance of the Division of Medicine. Activity undertaken at ModH for Gastro and GIT Endoscopy is included as this is undertaken by General Surgery.
Current state
Table 10: Current Multi-day Activity for the LMH by Division of Surgery 2014/15
LMH Multi-day Surgical Activity 2014/15 Elective Emergency
SRGs Separations Bed Days ALOS Separations Bed Days ALOS
01 - CARDIOLOGY
6 25 4.2 02 - INTERVENTIONAL CARDIOLOGY 1 12 12.0 3 18 6.1 03 - CARDIOTHORACIC SURGERY
04 - RESPIRATORY MEDICINE
22 137 6.2 05 - GASTROENTEROLOGY 6 10 1.6 505 1926 3.8 06 - GIT ENDOSCOPY 12 17 1.4 121 777 6.4 07 - NEUROLOGY
2 7 3.3 08 - NEUROSURGERY 2 2 0.9 10 35 3.5 09 - ENDOCRINOLOGY
6 20 3.3 10 - RENAL FAILURE
43 212 4.9 12 - HAEMATOLOGY 6 20 3.4 15 57 3.8 13 - ENT 6 9 1.6
15 - MEDICAL ONCOLOGY 2 9 4.5 21 106 5.0 17 - RHEUMATOLOGY
21 95 4.5 18 - DERMATOLOGY
8 18 2.2
Page 57 of 84 Proposed Intra-NALHN Service Plan – February 2016
Table 11: Current Multi-day Activity for ModH by the Division of Surgery 2014/15
Multi-day Surgical Activity 2014/15 ModH
Elective Emergency
SRG Separations Bed Days ALOS Separations
Bed Days ALOS
01 - CARDIOLOGY 2 6 3.1 02 - INTERVENTIONAL CARDIOLOGY
03 - CARDIOTHORACIC SURGERY 1 1 1.4
04 - RESPIRATORY MEDICINE 1 2 1.7 9 35 3.9 05 - GASTROENTEROLOGY 2 5 2.4 292 1005 3.4 06 - GIT ENDOSCOPY 10 33 3.3 28 126 4.5 07 - NEUROLOGY 1 5 5.0 2 9 4.6 08 - NEUROSURGERY 2 11 5.4 3 12 4.0 09 - ENDOCRINOLOGY 1 4 4.1 4 16 3.9 10 - RENAL FAILURE 1 1 1.3 1 6 5.5 12 - HAEMATOLOGY 3 7 2.4 10 44 4.4 13 - ENT 39 73 1.9 38 115 3.0 15 - MEDICAL ONCOLOGY 8 28 3.4 17 - RHEUMATOLOGY 1 2 2.0 16 61 3.8 18 - DERMATOLOGY 2 1 0.7 1 2 2.2 19 - HEAD & NECK SURGERY 10 24 2.4 1 2 2.1 20 - DENTISTRY 3 5 1.7 21 - UPPER GIT SURGERY 24 62 2.6 59 254 4.3 22 - COLORECTAL SURGERY 35 272 7.8 39 384 9.9 23 - ORTHOPAEDICS 175 875 5.0 356 2771 7.8 24 - UROLOGY 40 106 2.7 9 39 4.4 25 - VASCULAR SURGERY 4 21 5.3 17 130 7.7 26 - GENERAL MEDICINE 7 37 5.3 113 391 3.5 27 - GENERAL SURGERY 38 119 3.1 399 1406 3.5 28 - BREAST SURGERY 14 40 2.9 1 2 1.7 29 - PLASTIC & RECONSTRUCTIVE SURGERY 13 36 2.7 8 47 5.9 30 - GYNAECOLOGY 6 13 2.2 31 - OBSTETRICS 1 3 2.8 34 - TRACHEOSTOMY
36 - BURNS 1 1 1.4
39 - UNGROUPABLE 1 17 16.7
Grand Total 425 1740 4.1 1427 6929 4.9
19 - HEAD & NECK SURGERY 15 39 2.6 20 - DENTISTRY
21 - UPPER GIT SURGERY 71 204 2.9 257 1189 4.6 22 - COLORECTAL SURGERY 170 1442 8.5 130 1611 12.4 23 - ORTHOPAEDICS 253 1071 4.2 330 2544 7.7 24 - UROLOGY 105 264 2.5 280 876 3.1 25 - VASCULAR SURGERY
8 180 22.5 26 - GENERAL MEDICINE 4 15 3.7 168 711 4.2 27 - GENERAL SURGERY 70 279 4.0 884 3487 3.9 28 - BREAST SURGERY 32 78 2.4 18 52 2.9 29 - PLASTIC & RECONSTRUCTIVE SURGERY 11 25 2.3 16 53 3.3 30 - GYNAECOLOGY 3 4 1.2 21 52 2.5 31 - OBSTETRICS
9 28 3.1 34 - TRACHEOSTOMY
5 146 29.2 36 - BURNS
39 - UNGROUPABLE 2 6 3.1 8 98 12.2
Grand Total 771 3506 4.5 2917 14461 5.0
Page 58 of 84 Proposed Intra-NALHN Service Plan – February 2016
Table 12: Current 23 hour Activity for the LMH for the Division of Surgery 2014/15
Table 13: Current 23 hour Activity for ModH for the Division of Surgery 2014/15
ModH 23 hour Emergency and Elective 2014/15 Elective Emergency
SRGs Separations Bed Days ALOS Separations
Bed Days ALOS
01 - CARDIOLOGY
1 1 0.9 03 - CARDIOTHORACIC SURGERY 3 3 1.1
04 - RESPIRATORY MEDICINE
1 1 0.8 05 - GASTROENTEROLOGY 5 5 1.0 75 71 0.9 06 - GIT ENDOSCOPY 5 5 1.0 4 4 0.9 07 - NEUROLOGY
1 1 0.9 08 - NEUROSURGERY 2 2 1.1 2 2 0.8 09 - ENDOCRINOLOGY
10 - RENAL FAILURE 12 - HAEMATOLOGY 2 2 1.1 2 2 1.1
13 - ENT 323 348 1.1 24 23 1.0 14 - OPHTHALMOLOGY 1 1 1.0
15 - MEDICAL ONCOLOGY 3 3 1.0 2 2 0.9 17 - RHEUMATOLOGY
6 5 0.9 18 - DERMATOLOGY
3 3 1.1 19 - HEAD & NECK SURGERY 10 11 1.1
20 - DENTISTRY 3 3 1.1 1 1 1.0
LMH 23 hour Emergency and Elective 2014/15 Elective Emergency
SRGs Separations Bed Days ALOS Separations Bed Days ALOS
01 - CARDIOLOGY
2 2 0.8 03 - CARDIOTHORACIC SURGERY 4 5 1.1 1 1 1.0 04 - RESPIRATORY MEDICINE
3 2 0.7 05 - GASTROENTEROLOGY 1 1 0.9 73 67 0.9 06 - GIT ENDOSCOPY 5 5 1.0 7 8 1.1 07 - NEUROLOGY
2 2 0.8 08 - NEUROSURGERY 4 4 1.1 3 3 0.9 09 - ENDOCRINOLOGY
1 1 0.9 10 - RENAL FAILURE 2 2 1.0 15 15 1.0 12 - HAEMATOLOGY 6 7 1.1 2 1 0.6 13 - ENT 56 60 1.1 3 3 1.0 14 - OPHTHALMOLOGY
15 - MEDICAL ONCOLOGY 2 2 1.1 1 1 0.8 17 - RHEUMATOLOGY
7 7 0.9 18 - DERMATOLOGY 2 2 1.2 7 6 0.9 19 - HEAD & NECK SURGERY 49 54 1.1
20 - DENTISTRY 21 - UPPER GIT SURGERY 124 132 1.1 16 16 1.0
22 - COLORECTAL SURGERY 35 39 1.1 33 31 0.9 23 - ORTHOPAEDICS 176 196 1.1 90 91 1.0 24 - UROLOGY 82 91 1.1 124 111 0.9 25 - VASCULAR SURGERY
2 1 0.6 26 - GENERAL MEDICINE 3 3 1.0 108 98 0.9 27 - GENERAL SURGERY 59 64 1.1 196 174 0.9 28 - BREAST SURGERY 106 114 1.1 5 4 0.9 29 - PLASTIC & RECONSTRUCTIVE SURGERY 4 4 1.1 8 7 0.8 30 - GYNAECOLOGY 2 2 1.1 4 4 0.9 31 - OBSTETRICS 1 1 0.9 2 2 0.8 37 - PSYCHIATRY
39 - UNGROUPABLE 1 1 1.1 Grand Total 724 789 1.1 715 656 0.9
Page 59 of 84 Proposed Intra-NALHN Service Plan – February 2016
21 - UPPER GIT SURGERY 40 44 1.1 4 5 1.2 22 - COLORECTAL SURGERY 14 15 1.0 21 20 0.9 23 - ORTHOPAEDICS 140 158 1.1 79 77 1.0 24 - UROLOGY 19 21 1.1 7 7 1.0 25 - VASCULAR SURGERY 1 1 1.0 3 3 0.9 26 - GENERAL MEDICINE 7 7 1.0 90 84 0.9 27 - GENERAL SURGERY 83 88 1.1 141 134 1.0 28 - BREAST SURGERY 7 7 1.1
29 - PLASTIC & RECONSTRUCTIVE SURGERY 14 14 1.0 3 3 1.0 30 - GYNAECOLOGY
3 3 1.0 31 - OBSTETRICS
1 1 0.8 37 - PSYCHIATRY 1 1 0.9
39 - UNGROUPABLE Grand Total 683 740 1.1 474 451 1.0
Note: 23 hour defined as those patients whose LOS is 29hours or under and where the admission and discharge date are different.
Table 14: Current Same-day Activity at the LMH and ModH by Division of Surgery 2014/15
ModH LMH Same-day Separations by Site 2014/15 Elective Emergency Elective Emergency
SRGs Seps ALOS Seps ALOS Seps ALOS Seps ALOS
01 - CARDIOLOGY
1 0.5 1 0.1 2 0.2
04 - RESPIRATORY MEDICINE
3 0.2
05 - GASTROENTEROLOGY 16 0.3 31 0.4 51 0.3 21 0.4
06 - GIT ENDOSCOPY 43 0.2 182 0.1
07 - NEUROLOGY 3 0.2
1 0.2 1 0.4
08 - NEUROSURGERY 4 0.3 1 0.6 11 0.3 1 0.6
09 - ENDOCRINOLOGY
1 0.3
10 - RENAL FAILURE 7 0.2
6 0.2 9 0.4
12 - HAEMATOLOGY 3 0.3 2 0.3 11 0.3 2 0.4
13 - ENT 121 0.3 3 0.3 26 0.3 14 - OPHTHALMOLOGY 1 0.2
409 0.2 1 0.6
15 - MEDICAL ONCOLOGY 5 0.2 4 0.4 40 0.2 18 - DERMATOLOGY 23 0.2 5 0.4 17 0.3 4 0.4
19 - HEAD & NECK SURGERY 11 0.2
4 0.3 20 - DENTISTRY 7 0.3
1 0.4 21 - UPPER GIT SURGERY 36 0.4
83 0.5 1 0.6
22 - COLORECTAL SURGERY 30 0.3 6 0.5 89 0.3 23 0.4
23 - ORTHOPAEDICS 311 0.3 23 0.3 324 0.3 53 0.4
24 - UROLOGY 230 0.2 7 0.3 384 0.2 38 0.4
25 - VASCULAR SURGERY 4 0.4 2 0.1 2 0.3 26 - GENERAL MEDICINE 8 0.3 14 0.3 88 0.3 74 0.4
27 - GENERAL SURGERY 87 0.4 35 0.3 139 0.4 67 0.4
28 - BREAST SURGERY 16 0.3 1 0.4 64 0.3 8 0.3
29 - PLASTIC & RECONSTRUCTIVE SURGERY 127 0.3 3 0.2 72 0.3 13 0.4
30 - GYNAECOLOGY 1 0.3 1 0.3 2 0.0 35 - DRUG & ALCOHOL
1 0.7
37 - PSYCHIATRY 1 0.4
Grand Total 1095 0.3 143 0.4 2007 0.3 319 0.4
Page 60 of 84 Proposed Intra-NALHN Service Plan – February 2016
Future state
Table 15: 23 Hour Elective Activity at ModH based on intra NALHN transfers
23 Hr Elective Activity at ModH (intra NALHN transfers)
SRGs Seps ALOS Bed Days
13 – ENT 263 1.1 283
00 – ORTHOPAEDICS 200 1.1 225
21 - UPPER GIT SURGERY 131 1.1 140
27 - GENERAL SURGERY 114 1.1 122
28 - BREAST SURGERY 90 1.1 96
24 – UROLOGY 81 1.1 90
19 - HEAD & NECK SURGERY 47 1.1 51
22 - COLORECTAL SURGERY 39 1.1 43
29 - PLASTIC & RECONSTRUCTIVE SURGERY 14 1.1 15
26 - GENERAL MEDICINE 8 1.0 8
12 – HAEMATOLOGY 6 1.2 7
03 - CARDIOTHORACIC SURGERY 6 1.0 6
08 – NEUROSURGERY 5 1.0 5
05 – GASTROENTEROLOGY 5 1.0 5
15 - MEDICAL ONCOLOGY 5 1.0 5
06 - GIT ENDOSCOPY 4 1.0 4
20 – DENTISTRY 2 1.1 3
18 – DERMATOLOGY 2 1.2 2
10 - RENAL FAILURE 2 1.0 2
30 – GYNAECOLOGY 134 1.1 143
39 – UNGROUPABLE 1 1.1 1
14 – OPHTHALMOLOGY 1 1.0 1
25 - VASCULAR SURGERY 1 1.0 1
31 – OBSTETRICS 1 0.9 1
37 – PSYCHIATRY 1 0.9 1
Total 1175 1.1 1259
Table 16: Same day Elective Surgical Separations ModH
MPH Same- Day Elective Activity
SRG Separations
05 – GASTROENTEROLOGY 13 06 - GIT ENDOSCOPY 34 13 – ENT 118 19 - HEAD & NECK SURGERY 12 21 - UPPER GIT SURGERY 95 22 - COLORECTAL SURGERY 95 23 – ORTHOPAEDICS 508 24 – UROLOGY 491 27 - GENERAL SURGERY 181 28 - BREAST SURGERY 64 29 - PLASTIC & RECONSTRUCTIVE SURGERY 159 26 - GENERAL MEDICINE 77 25 - VASCULAR SURGERY 5
Page 61 of 84 Proposed Intra-NALHN Service Plan – February 2016
12 – HAEMATOLOGY 11 08 – NEUROSURGERY 12 01 – CARDIOLOGY 1 04 - RESPIRATORY MEDICINE 0 07 – NEUROLOGY 3 09 – ENDOCRINOLOGY 0 10 - RENAL FAILURE 10 14 – OPHTHALMOLOGY 0 15 - MEDICAL ONCOLOGY 36 18 – DERMATOLOGY 32 20 – DENTISTRY 0 30 – GYNAECOLOGY 613 35 - DRUG & ALCOHOL 0 37 – PSYCHIATRY 1
Grand Total 2571
Note: includes Women’s and Children’s Division activity under gynaecology
Table 17: ModH Multi-day Elective Activity Flowing to LMH
ModH Multi-day Activity to transfer to LMH Elec (intra NALHN transfers)
Elective
SRGs Separations ALOS Bed Days Minus ICU
03 - CARDIOTHORACIC SURGERY 1 1.4 1
04 - RESPIRATORY MEDICINE 1 1.7 2
05 - GASTROENTEROLOGY 2 2.4 5
06 - GIT ENDOSCOPY 10 3.3 33
07 - NEUROLOGY 1 5.0 5
08 - NEUROSURGERY 2 5.4 11
09 - ENDOCRINOLOGY 1 4.1 4
10 - RENAL FAILURE 1 1.3 1
12 - HAEMATOLOGY 3 2.4 7
13 - ENT 39 1.9 73
17 - RHEUMATOLOGY 1 2.0 2
18 - DERMATOLOGY 2 0.7 1
19 - HEAD & NECK SURGERY 10 2.4 24
21 - UPPER GIT SURGERY 24 2.6 62
22 - COLORECTAL SURGERY 35 7.8 272
23 - ORTHOPAEDICS 175 5.0 875
24 - UROLOGY 40 2.7 106
25 - VASCULAR SURGERY 4 5.3 21
26 - GENERAL MEDICINE 7 5.3 37
27 - GENERAL SURGERY 38 3.1 119
28 - BREAST SURGERY 14 2.9 40
29 - PLASTIC & RECONSTRUCTIVE SURGERY 13 2.7 36
36 - BURNS 1 1.4 1
Grand Total 425 4.1 1740
Page 62 of 84 Proposed Intra-NALHN Service Plan – February 2016
Table 18: ModH Multi-day Emergency Activity Flowing to LMH
Table 19: Multi-day Emergency Activity at LMH (excluding flows from ModH)
ModH Multi-day Activity to transfer to LMH
SRG
Emergency
Seps ALOS Bed Days Minus ICU
01 - CARDIOLOGY 2 3.1 6 03 - CARDIOTHORACIC SURGERY
04 - RESPIRATORY MEDICINE 9 3.9 35 05 - GASTROENTEROLOGY 292 3.4 1005 06 - GIT ENDOSCOPY 28 4.5 126 07 - NEUROLOGY 2 4.6 9 08 - NEUROSURGERY 3 4.0 12 09 - ENDOCRINOLOGY 4 3.9 16 10 - RENAL FAILURE 1 5.5 6 12 - HAEMATOLOGY 10 4.4 44 13 - ENT 38 3.0 115 15 - MEDICAL ONCOLOGY 8 3.4 28 17 - RHEUMATOLOGY 16 3.8 61 18 - DERMATOLOGY 1 2.2 2 19 - HEAD & NECK SURGERY 1 2.1 2 20 - DENTISTRY 3 1.7 5 21 - UPPER GIT SURGERY 59 4.3 254 22 - COLORECTAL SURGERY 39 9.9 384 23 - ORTHOPAEDICS 356 7.8 2771 24 - UROLOGY 9 4.4 39 25 - VASCULAR SURGERY 17 7.7 130 26 - GENERAL MEDICINE 113 3.5 391 27 - GENERAL SURGERY 399 3.5 1406 28 - BREAST SURGERY 1 1.7 2 29 - PLASTIC & RECONSTRUCTIVE SURGERY 8 5.9 47 30 - GYNAECOLOGY 6 2.2 13 31 - OBSTETRICS 1 2.8 3 36 - BURNS
39 - UNGROUPABLE 1 16.7 17
Grand Total 1427 4.9 6929
LMH Multi-day Activity (not including ModH Flows)
Emergency
SRG Separations ALOS Bed Days Minus ICU
01 - CARDIOLOGY 6 4.2 25
02 - INTERVENTIONAL CARDIOLOGY 3 6.1 18
04 - RESPIRATORY MEDICINE 22 6.2 107
07 - NEUROLOGY 2 3.3 7
08 - NEUROSURGERY 10 3.5 34
09 - ENDOCRINOLOGY 6 3.3 17
10 - RENAL FAILURE 43 4.9 208
12 - HAEMATOLOGY 15 3.8 54
13 - ENT
Page 63 of 84 Proposed Intra-NALHN Service Plan – February 2016
Table 20: Multi-day Elective Activity at LMH (excluding flows from ModH)
LMH Multi-day Activity (not including ModH Flows)
Elective
SRG Separations ALOS Bed Days Minus ICU
01 - CARDIOLOGY 02 - INTERVENTIONAL CARDIOLOGY 1 12.0 12
04 - RESPIRATORY MEDICINE 07 - NEUROLOGY 08 - NEUROSURGERY 2 0.9 2
09 - ENDOCRINOLOGY 10 - RENAL FAILURE 12 - HAEMATOLOGY 6 3.4 19
13 - ENT 6 1.6 9
15 - MEDICAL ONCOLOGY 2 4.5 9 17 - RHEUMATOLOGY
18 - DERMATOLOGY 19 - HEAD & NECK SURGERY 15 2.6 31
21 - UPPER GIT SURGERY 71 2.9 198 22 - COLORECTAL SURGERY 170 8.5 1377
23 - ORTHOPAEDICS 253 4.2 1058
24 - UROLOGY 105 2.5 255 25 - VASCULAR SURGERY
26 - GENERAL MEDICINE 4 3.7 15
27 - GENERAL SURGERY 70 4.0 266
28 - BREAST SURGERY 32 2.4 77 29 - PLASTIC & RECONSTRUCTIVE SURGERY 11 2.3 25
30 - GYNAECOLOGY 3 1.2 4
31 - OBSTETRICS 34 - TRACHEOSTOMY 39 - UNGROUPABLE 2 3.1 6
Grand Total 753 4.6 3363
15 - MEDICAL ONCOLOGY 21 5.0 106
17 - RHEUMATOLOGY 21 4.5 95
18 - DERMATOLOGY 8 2.2 18
19 - HEAD & NECK SURGERY 21 - UPPER GIT SURGERY 257 4.6 1138
22 - COLORECTAL SURGERY 130 12.4 1513
23 - ORTHOPAEDICS 330 7.7 2518
24 - UROLOGY 280 3.1 871
25 - VASCULAR SURGERY 8 22.5 178
26 - GENERAL MEDICINE 168 4.2 706
27 - GENERAL SURGERY 884 3.9 3432
28 - BREAST SURGERY 18 2.9 52
29 - PLASTIC & RECONSTRUCTIVE SURGERY 16 3.3 52
30 - GYNAECOLOGY 21 2.5 52
31 - OBSTETRICS 9 3.1 28
34 - TRACHEOSTOMY 5 29.2 55
39 - UNGROUPABLE 8 12.2 91
Grand Total 2291 5.1 11373
Page 64 of 84 Proposed Intra-NALHN Service Plan – February 2016
Table 21: Total 23 hour elective activity at LMH based on intra NALHN transfers
23 Hr Elective Activity at LMH (intra NALHN transfers)
SRGS Seps ALOS Bed Days
03 - CARDIOTHORACIC SURGERY 1 1.1 1
06 - GIT ENDOSCOPY 1 1.0 1
12 - HAEMATOLOGY 2 1.1 2
13 - ENT 115 1.1 123
19 - HEAD & NECK SURGERY 11 1.1 12
20 - DENTISTRY 1 1.1 1
21 - UPPER GIT SURGERY 42 1.1 45
24 - UROLOGY 17 1.1 19
26 - GENERAL MEDICINE 1 1.0 1
27 - GENERAL SURGERY 27 1.1 29
28 - BREAST SURGERY 22 1.1 24
29 - PLASTIC & RECONSTRUCTIVE SURGERY 3 1.0 3
23 - ORTHOPAEDICS 116 1.1 130
Total 358 1.1 393
Table 22: Total 23 hour emergency activity at LMH based on intra NALHN transfers
23 hour Emergency Activity at LMH (intra NALHN transfers)
SRGs
Emergency
Seps ALOS Bed Days minus ICU
01 - CARDIOLOGY 3 0.9 3
03 - CARDIOTHORACIC SURGERY 1 1.0 1
04 - RESPIRATORY MEDICINE 4 0.7 3
05 - GASTROENTEROLOGY 75 0.9 71
06 - GIT ENDOSCOPY 4 0.9 4
07 - NEUROLOGY 3 0.5 2
08 - NEUROSURGERY 5 0.8 4
09 - ENDOCRINOLOGY 1 0.9 1
10 - RENAL FAILURE 15 1.0 15
12 - HAEMATOLOGY 4 0.8 3
13 - ENT 27 1.0 26
15 - MEDICAL ONCOLOGY 3 0.9 3
17 - RHEUMATOLOGY 13 0.9 12
18 - DERMATOLOGY 10 0.9 9
19 - HEAD & NECK SURGERY 0 0.0 0
20 - DENTISTRY 1 1.0 1
21 - UPPER GIT SURGERY 20 1.0 20
22 - COLORECTAL SURGERY 54 0.9 51
23 - ORTHOPAEDICS 169 1.0 168
24 - UROLOGY 131 0.9 118
25 - VASCULAR SURGERY 5 0.8 4
26 - GENERAL MEDICINE 198 0.9 181
27 - GENERAL SURGERY 337 0.9 307
28 - BREAST SURGERY 5 0.9 4
29 - PLASTIC & RECONSTRUCTIVE SURGERY 11 0.9 10
30 - GYNAECOLOGY 7 1.0 7
31 - OBSTETRICS 3 0.8 2
Page 65 of 84 Proposed Intra-NALHN Service Plan – February 2016
Table 23: Total Same-day Separations at LMH based on intra NALHN transfers
Same-day Elective and Emergency Separations at LMH (intra NALHN transfers)
Elective Emergency
SRGs Seps Seps 13 - ENT 29 3 19 - HEAD & NECK SURGERY 3 0 21 - UPPER GIT SURGERY 24 1 22 - COLORECTAL SURGERY 24 29 23 - ORTHOPAEDICS 127 76 24 - UROLOGY 123 45 27 - GENERAL SURGERY 45 102 28 - BREAST SURGERY 16 9 29 - PLASTIC & RECONSTRUCTIVE SURGERY 40 16 26 - GENERAL MEDICINE 19 88 25 - VASCULAR SURGERY 1 2 12 - HAEMATOLOGY 3 4 08 - NEUROSURGERY 3 2 01 - CARDIOLOGY 0 3 04 - RESPIRATORY MEDICINE 0 3 07 - NEUROLOGY 1 1 10 - RENAL FAILURE 3 9 14 - OPHTHALMOLOGY 410 1 15 - MEDICAL ONCOLOGY 9 4 18 - DERMATOLOGY 8 9 20 - DENTISTRY 8 0 35 - DRUG & ALCOHOL 0 1 37 - PSYCHIATRY 0 0 30 - GYNAECOLOGY 758 175 31 - OBSTETRICS 1 0 05 - GASTROENTEROLOGY 3 31 06 - GIT ENDOSCOPY 8 0
Grand Total 1666 615 Notes: includes Women’s and Children’s Division activity under gynaecology, including the Family Advisory Clinic.
13. Risk management
A full risk register has been established for the NALHN Transforming Health program. The risk
register sets out risks under the following broad categories:
Workforce
Public Perceptions
Program Delivery
Benefits Realisation
Clinical Commissioning
Governance and Compliance
Grand Total 1109 0.9 1029
Page 66 of 84 Proposed Intra-NALHN Service Plan – February 2016
ICT
Procurement
Assets and Infrastructure
The risk register outlines two risks of significant concern to NALHN:
the ability to transfer and SA Ambulance Service’s capacity due to the numbers of transfers
NALHN’s ICT capacity.
NALHN is currently working with SAAS and SA Health’s ICT to assist in mitigating and minimising
these risks.
Page 67 of 84 Proposed Intra-NALHN Service Plan – February 2016
ATTACHMENT 1
MET TL to discuss with duty ICU or MET consultant
TRANSFER TO MH ED (PENDING TRANSFER TO LMH) TRANSFER TO MH Short-Stay STAND DOWN
MT TL to documentNew treatment planFrequency of observationEscalation pathwayInvestigationsReview time frameAssess response to treatment and liaise with HT consultant. If deteriorates while in Short Stay, recall MET (and duty MET consultant).
MET nurses to Assist with stabilisation. Assist ward staff with ongoing
management Handover to short stay ward and review as
required
MET TL to
Stabilise for transfer to LMH
Lead clinical management
Refer to receiving team at LMH
Arrange transfer with MedSTAR or SAAS
MET nurses to Assist with stabilisation Assist transfer to ED Support and manage patient in ED (remain with
patient) Prepare patient for transfer to LMH
TRANSFERRED TO LMH ICU or CCU or other ward (as appropriate)
Does the patient still meet RDR Red or Purple Zone Criteria or have unresolved clinical
concern about the patient?
End of MET call assessment
Does the patient needintervention or are organ supports not
available at MH?
Does the patient needintervention or are organ supports not
available at MH?
CONSIDERATIONS
Suitability for escalation Comorbidities/7 step pathway
Suitability to remain in MH Current clinical requirements/Potential for further deterioration
MET TL to discuss with Home Team / Covering consultant
YES
YES NO
YES NO
NO
RAPID RESPONSE TEAM
Page 82 of 84 Proposed Intra-NALHN Service Plan – February 2016
ATTACHMENT 13
Potential Stroke Pathway - NALHN
Patient presents to ED with stroke symptomsReferral to Allied Health through Oacis on admission
CODE Stroke 8.00am-8.00pm
Walk-in to ED after 8.00pm
Rapid transfer to RAH for
thrombolysis
Patient Admitted to Stroke Service Assessment and Care
AH Assessment – Nursing – malnutrition screen (MUST) 24hrs SP – 24 hours: PH/OT – 24 hours;
Dietician – MUST ≥ 2/Enteral Nutrition/poor oral intake ; SW – 48 hours as requested
Medical Assessment - Identify risk factors for secondary prevention. (investigations -Blood/ telemetry/ MRI/ CT/echo)
Monitoring - ongoing improvement deficitsRehabilitation, secondary prevention
and palliationMultidisciplinary (MDT) rehabilitation assessment ( twice weekly)
Rehabilitation service notifiedRehabilitation review
Initiate post acute management and discharge planning on presentation
Consultation with patient, family and GP
AH (SP) swallow screen and assessment Treatment if needed
Minor stroke- TIA
After hours- Admitted to stroke service
TIA nurseNotify Stroke Service
Patient Admitted to
Ward
If medically stable
discharged to home
TIA Clinic for follow-up after
24 hours
End of life management Medically stable
Facilitate discharge planning and follow-up Assessment as required: (ACAT/ Rehabilitation/ TCP
Patient remains in stroke unit as long as required
Mild to Moderate stroke severity - 2-3 days
Suitable for RITH or day
rehabilitation
Unsuitable for RITH or day
rehabilitation
Severe stroke - 7 days
Long term palliation
- Hospice or community
Inpatient rehabilitation or TCP
Patient NET (see PEG pathway)
YES
Ongoing assessment (including MDT), therapy and care
NOInpatient/
Interhospital transfer
Medically un-stable
Note:Blue
indicates potential pathway
categories
Patient admitted to AMU. (If no inpatient stroke beds or
if telemetry required) YES