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Review of Urgent Care, Critical Care, Stroke (Acute Phase) & TIA, and Vascular Services

Herefordshire Health Economy

Visit Date: 16th

& 17th

June 2010 Report Date: September 2010

Herefordshire WMQRS 2010a Final V1 20100917.doc 1

URGENT CARE, CRITICAL CARE, STROKE (ACUTE PHASE) & TIA, AND VASCULAR SERVICES

INDEX

Introduction ...................................................................................................................................................... 2

Key Points ......................................................................................................................................................... 3

Urgent Care..... ................................................................................................................................................ 4

Health Economy Overview .................................................................................................................. 4

Primary Care ....................................................................................................................................... 5

Acute Trust-Wide ................................................................................................................................ 8

Emergency Department ...................................................................................................................... 9

Acute Medical and Surgical Admissions ............................................................................................ 10

Stroke (Acute Phase) and TIA Services ............................................................................................................ 11

Critical Care .................................................................................................................................................... 12

Commissioning ............................................................................................................................................... 13

Appendix 1 Membership of Visiting Team ................................................................................................ 14

Appendix 2 Compliance with the Quality Standards ................................................................................. 15

Urgent Care – Primary Care: Minor Injuries Units.............................................................................. 15

Urgent Care – Primary Care: Primecare Walk-in Centre and GP out of hours .................................... 22

Urgent Care – Acute Trust Wide ........................................................................................................ 29

Urgent Care – Emergency Department .............................................................................................. 32

Urgent Care – Acute Medical and Surgical Admissions ( Admissions Ward) ...................................... 45

Urgent Care – Commissioning ........................................................................................................... 56

Stroke (Acute Phase) and TIA - Primary Care .................................................................................... 58

Stroke (Acute Phase) and TIA – Acute Trust ...................................................................................... 59

Stroke and TIA – Commissioning ....................................................................................................... 68

Critical Care ....................................................................................................................................... 70


INTRODUCTION

ABOUT WEST MIDLANDS QUALITY REVIEW SERVICE

West Midlands Quality Review Service (WMQRS) has been set up as a collaborative venture by NHS organisations in

the West Midlands to help improve the quality of health services by developing evidence-based Quality Standards,

carrying out developmental and supportive quality reviews - often through peer review visits, producing

comparative information on the quality of services and providing development and learning for all involved.

Expected outcomes are better quality, safety and clinical outcomes, better patient and carer experience,

organisations with better information about the quality of clinical services, and organisations with more confidence

and competence in reviewing the quality of clinical services. More detail about the work of WMQRS is available on

http://www.wmqi.westmidlands.nhs.uk/wmqrs/.

This report presents the findings of the review of Urgent Care, Critical Care, Stroke (Acute Phase) & TIA and Vascular

services based Herefordshire Hospitals NHS Trust and those commissioned by NHS Herefordshire, which took place

on 16th

& 17th

June 2010. The purpose of the visit was to review compliance with WMQRS Quality Standards for:

Urgent Care Services, Version 1.1, April 2010

Services for People with Stroke (Acute Phase) and Transient Ischaemic Attack, Version 1, April 2010

Services for People with Vascular Disease, Version 1, April 2010

Critical Care Services, Version 2, April 2010

These visits were organised by WMQRS on behalf of sponsoring networks/Care Pathway Groups: West Midlands

Urgent Care Pathway Group, West Midlands Partnership of Cardiac and Stroke Networks, West Midlands Vascular

Services Care Pathway Group and the Midlands Critical Care Networks

The purpose of these standards and the review programme is to help providers and commissioners of services to

improve clinical outcomes and patients’ experiences by improving the quality of services. The report also gives

external assurance of the care within the Health Economy which can be used as part of organisations’ Quality

Accounts. For commissioners, the report gives assurance of the quality of services commissioned and identifies

areas where developments may be needed.

The report reflects the situation at the time of the visit. The text of this report identifies the main issues raised

during the course of the visit. Appendix 1 lists the visiting ream which reviewed the services at Herefordshire health

economy. Appendix 2 contains the details of compliance with each of the standards and the percentage of

standards met.

ACKNOWLEDGMENTS

West Midlands Quality Review Service would like to thank the staff and patients of Herefordshire health economy

for their hard work in preparing for the review and for their kindness and helpfulness during the course of the visit.

Thanks are also due to the visiting team and their employing organisations for the time and expertise they

contributed to this review.

http://www.wmqi.westmidlands.nhs.uk/wmqrs/


KEY POINTS

1 The Herefordshire health economy was in a period of transition with plans to integrate acute and community

provider services. Reviewers found much shared understanding between the acute Trust and PCT and good

insight into the problems facing urgent care services in Herefordshire.

2 Minor injuries units (MIUs) were generally working well and there were good arrangements for the

coordination with other MIUs, but not with the Emergency Department. The Walk-in Centre and GP out of

hours services were also working well.

3 There were delays at a number of stages of the urgent care patient pathway. There was not yet health

economy-wide ownership of this problem with each service appearing to see the next service along the

pathway as the cause of their difficulties. Reviewers were concerned that the expectations and pace of

change were not yet sufficient to address the scale of the problems facing services in Herefordshire and that

there was not yet a whole-system approach to improving patient flow through the hospital.

4 Arrangements for document control of patient information, policies, procedures and guidelines were not

robust. Out of date guidelines were in use in both Minor Injuries Units and across the Trust.

5 Mental health support to urgent care services was excellent. Crisis intervention services came to assess

patients quickly at all times of day or night. This service was highly appreciated by staff within urgent care

services who were convinced that the responsiveness of mental health services avoided inappropriate

admissions to general medical wards.

6 Despite the problems with patient flow, the Emergency Department provided a good service from a pleasant

environment. There was a good vision for the future development of the service, which was driven by quality

and a clear view of patient pathways.

7 Staff in the Medical and Surgical Admissions Ward were working hard in difficult circumstances. The Trust

recognised that nurse staffing levels were low for the number and dependency of the patients and

investment in additional nursing staff was planned.

8 The stroke service had made significant progress but still faced difficulties. Arrangements for requesting CT

scans for patients with stroke were not robust. Staff were aware of the need to improve out-of-hours

thrombolysis and the Trust had plans to address this. There was only one stroke consultant and one vascular

technician. Rehabilitation service staffing was not sufficient to achieve the expected rehabilitation

assessment timescales. The pathway for the management of patients with TIA was not robust and high risk

TIA patients were not all receiving neuro-vascular assessment within 24 hours, especially at weekends.

9 The critical care service was working well from good facilities. The Trust was aware of the need to provide

clinical pharmacy input into the multi-disciplinary care of patients. Out of hours consultant cover was by

general anaesthetists and there was no evidence that they were undertaking Continuing Professional

Development of relevance to their work on the critical care unit.

Return to Index


URGENT CARE

HEALTH ECONOMY OVERVIEW

General Comments and Achievements

The Herefordshire health economy was in a period of transition with plans to integrate acute and community

provider services. Reviewers found much shared understanding between the acute Trust and PCT and good insight

into the problems facing urgent care services in Herefordshire. There was a good awareness of pressures on services

and risks which may result. Reviewers recognised that the changes being introduced were consuming significant

management time and that senior staff were therefore working under considerable pressure.

Immediate Risks: None

Concerns

1 Patient flow through the urgent care pathway

There were delays at many stages of the urgent care patient pathway. GP referrals were coming to the

Emergency Department when there was not capacity in the rest of the hospital. The Emergency Department

had a four bedded room the use of which changed depending on the pressures at any time. Achieving the

maximum four hour wait standard was causing difficulty. There was not yet health economy-wide ownership

of this problem with each service appearing to see the next service along the pathway as the cause of their

difficulties. On the day of the visit the Emergency Department was not busy but there were already three

patients waiting in the corridor. Reviewers considered that there was significant potential to tighten up

processes at each stage of the pathway and thereby improve the efficiency of flow and use of available

resources.

There were many plans for changes to the urgent care pathway but reviewers did not find robust

arrangements for the delivery of these plans. Reviewers were concerned that the expectations and pace of

change were not yet sufficient to address the scale of the problems facing services in Herefordshire and that

there was not a whole-system approach to improving patient flow through the hospital. Although senior

managers were aware of, for example, expected timescales for delivery of particular programmes, senior

clinical staff were not and it was not clear how they were being held to account for the programmes they

were expected to deliver. Reviewers also considered that the Trust and PCT Boards should ensure ongoing

monitoring of key indicators of the patient pathway during the time of transition.

2 Document Control

Several of the expected guidelines and protocols were informal and not documented, out of date or not in

the Trust format. The Patient Group Directives in the Minor Injuries Units were out of date. The2005 Junior

Doctors Handbook was still in use in the Minor Injuries Unit and was included in the Trust evidence folder

even though several of the guidelines were out of date. Reviewers recommended that this should be

withdrawn from use immediately. There were plans to re-write this Handbook and the Trust will need to


take into account the forthcoming (October) revision of the Resuscitation Council Guidelines. Much of the

patient information in the Trust did not comply with the Trust policy on patient leaflets. In some places there

were several versions of different leaflets. For example, the Emergency Department has four different

leaflets to be given to patients with diabetes. The Trust Major Incident Plan was dated 2007 with no review

date. This has previously been reviewed every two years.

Further consideration

1 Reviewers considered that the criteria for acceptance of patients by Minor Injuries Units may benefit from

review, including consideration of whether category C ambulance patients could be taken there. Reviewers

were told that the current criteria were inconsistent and that there was the potential for the Minor Injuries

Units to be seeing more patients.

Good practice

1 Mental health support to urgent care services was excellent. Crisis intervention services came to assess

patients quickly at all times of day or night. This service was highly appreciated by staff within urgent care

services who were convinced that the responsiveness of mental health services avoided inappropriate

admissions to general medical wards.

Return to Index

PRIMARY CARE

MINOR INJURIES UNITS

Herefordshire PCT provider services nurse-led Minor Injuries Units were situated at Ross and Leominster

Community Hospitals. The units were staffed by site-specific small teams of Emergency Nurse Practitioners (ENP)

who provided a 24 hour per day 7 days per week direct access service with 1 ENP per shift. The Minor Injury Unit at

Ledbury Health and Social Care Centre was managed by Shaw Healthcare but PCT protocols and policies were used.

The Ledbury unit manager was a member of the PCT Minor Injury Group which met regularly to review policies and

procedures and ensure consistency of care.

The Units assess and treat emergency patients who have sustained a ‘minor’ injury within the previous 48 hours. ‘In

hours’ medical support was provided by local GP’s and ‘out of hours’ medical support by Primecare. There was a

service level agreement in place for clinical advice to the units from Emergency Department medical and nursing

staff at Hereford County Hospital.

WMQRS agreed with Herefordshire PCT that the Minor Injuries Unit at Kington would not be reviewed at this stage.

This report therefore applies to all MIUs within Herefordshire except for the Kington Unit.



The visiting team went to the Minor Injuries Unit at Leominster Community Hospital and met staff from the MIU.

Staff were welcoming and demonstrated good teamwork. At Leominster the environment was good and the

surroundings were pleasant. There were good registers of training undertaken by staff and good links with GPs and

the local community. A ‘Patient and Carer’ road-show has recently been undertaken.

The Minor Injuries Units, excluding Kington, saw a total of 10584 patients in 2009/10 (4131 at Leominster , 3888 at

Ross on Wye and 2565 at Ledbury).

Immediate Risk: None

Concerns

1 Several guidelines and protocols were out of date, including Patient Group Directives, policies and the Junior

Doctor’s Handbook. Some of the policies were no longer clinically appropriate.

2 Reception staff were triaging patients without written guidelines.

Further Consideration

1 The ENPs, especially those working in smaller units, may benefit from spending some time in the Emergency

Department to ensure that their competence is being maintained.

2 Referral to ‘same day / next day’ clinics was taking place but without any written guidelines on the patients

who should be referred or the investigations which should take place prior to referral.

3 The responsibilities of the senior nurse and medical lead may benefit from being documented in job

descriptions.

4 There were differences between the MIUs in staff training and criteria for seeing patients. Reviewers

suggested that the MIU group should consider whether these should be standardised. Involvement of the

Emergency Department in these discussions may be helpful.

PRIMECARE WALK IN CENTRE AND GP OUT OF HOURS

The Herefordshire GP-Led Health Centre had been open since December 2009 in the Asda Building on Belmont Road

in Hereford. It was open from 8am to 8pm every day including weekends and bank holidays. The GP out of hours

service ran from 6 pm to 8 am from Monday to Friday, and all day Saturday, Sunday and Bank Holidays. Both

services were provided by Primecare.


The alignment of the walk-in centre and ‘out of hours’ service was working well and the services were seeing

between 200 and 1500 patients per week. Staff were pleasant and friendly and the service was efficiently organised.

Some aspects of the services were still developing but many of the Quality Standards were already met. Good


induction processes were in place. Documentation, training logs and audit programmes were robust. There was

evidence of good partnership working with the local health economy, including use of shared ‘Do Not Attempt

Resuscitation’ forms.


Concerns: None


1 There were Patient Group Directives in the ‘out of hours’ service but not yet in the walk-in centre. It may be

helpful to develop these now that nursing teams are in place.

2 The service did not yet meet the Quality Standard relating to availability of resuscitation drugs and

equipment because staff with appropriate competences may not always be available. The service should

continue its work towards meeting this Quality Standard.

Return to Index


ACUTE TRUST-WIDE


Staff were enthusiastic, committed and welcoming.

Patient reviewers commented that PALS appeared to be working well and good use was being made of volunteers.

Three weekly patient experience surveys were being undertaken, although it was not clear what happened to the

findings of these surveys. Patient reviewers found that patient information was not well organised and it was not

clear that patients would all be offered the information that was available.

Imaging Services

Imaging support to the urgent care pathway was good so long as patients were referred for imaging (see immediate

risk relating to the care of patients with stroke). Relationships with referring clinical teams were good. Extended

weekday and weekend working hours were in place and good use was made of PACS and voice recognition

software, including for reporting at home. CT and MRI scanners did not have the capacity needed, in particular, to

support the stroke pathway. CTPA was available on some weekends. There were some delays in plain film reporting.


Concerns

1 Patient ‘flow’ through the urgent care pathway: See health economy section of this report.

2 Document control: See health economy section of this report.

3 Policies and training relating to the Mental Capacity Act and Deprivation of Liberty Safeguards were not yet in

place. There were plans for training but no policy on which this training was to be based.

4 There was no protocol on the management of young people aged 16 to 18. It was not clear that young

people were offered choice over care in an adult or children’s setting. The Quality Standards for young

people choosing care in an adult setting were not yet being met.


1 Nurse managers did not seem to be aware that they could access the training records of their staff and

several nurse managers were unclear about the mechanisms for accessing funding for training. It may be

helpful to remind nurse managers of the current arrangements.

2 Processes for learning from complaints may benefit from review. Staff who met reviewers were not generally

aware of the process for learning from complaints and the Trust patient experience report did not refer to

the number of complaints received.

Good Practice: See health economy section of this report.

Return to Index


EMERGENCY DEPARTMENT


The Emergency Department provided a good service from a pleasant environment. There was a good vision for the

future development of the service, which was driven by quality and a clear view of patient pathways. There was

good leadership and a strong multi-disciplinary ethos. Awareness of the risks of sepsis was high and patients with

sepsis were being actively managed.


Concerns

1 Patient flow through the urgent care pathway: See health economy section of this report.

2 Data was not being collected for TARN or the national cardiac arrest database.

3 Links with the Wales Ambulance Service should be developed. The Emergency Department was not routinely

receiving ‘standby’ or alert calls from Welsh ambulances.


1 It may be helpful to strengthen links with minor injuries units in Herefordshire, including offering

opportunities for staff placements so that skills can be maintained.

Good Practice

1 The arrangements for caring for patients with trauma were good. Nursing staff were all ALS, ATLS and ILS

trained and consultant support was available very quickly.

Return to Index


ACUTE MEDICAL AND SURGICAL ADMISSIONS

The Admissions Ward was a 24 bedded unit with a mix of four bedded bays and single rooms, all with en-suite

bathroom facilities. One of the four bedded bays was allocated to “high care” patients. Medical and surgical

admissions came through the Ward, including GP referrals. If a bed was not available then GP referrals were routed

back to the Emergency Department.


This service was provided by committed staff who worked hard to provide good care in difficult circumstances. A

commendable range of improvement initiatives was being pursued.


Concerns

1 Nurse staffing levels were low for the number and dependency of the patients. Actual nurse staffing was

often below the expected level (4+2 / 4+2 / 3+1), which was itself low because of the high dependency care

provided. The Unit had 24 beds plus four high dependency beds and there were often more than four

patients needing high dependency care. The Trust was aware of this problem and was actively monitoring

staffing levels and patient dependency. Across the Trust, £1.8m investment in nurse staffing was planned for

the next two years.

2 Patient ‘flow’ through the urgent care pathway: See health economy section of this report.

3 Several guidelines and protocols were not documented. Staff were generally aware of what they needed to

do but these arrangements may not be robust.


1 Much work was taking place across the health economy on admission avoidance, including a home intra-

venous therapy service. There were also plans for the development of a Clinical Decisions Unit and for skill

mix development, including Advanced Nurse Practitioners, Physician Assistants and Acute Physicians.

Good Practice

1 Mental health services: See health economy section of this report.

Return to Index


STROKE (ACUTE PHASE) AND TIA SERVICES

ACUTE TRUST:


The stroke service had made significant progress. There was good leadership and good multi-disciplinary working. A

county-wide review had been undertaken and there were plans for investment in the service. Thrombolysis was

administered in the Emergency Department, patients were then transferred to the coronary care unit and then to

the stroke unit.

Immediate Risk:

1 The process for ensuring CT scanning of patient with suspected stroke within appropriate timescales was not

robust, especially at weekends.

Concerns

1 The service had only one stroke consultant. A senior member of the stroke team was therefore not available

on a daily basis to manage complications of thrombolysis (after discharge from the coronary care unit) and

review the care of patients who had been admitted as emergencies. During absences of the stroke consultant

the service was covered by care of the elderly consultants.

2 Thrombolysis was available only between 9am and 5pm Mondays to Fridays. A low proportion of patients

with stroke were receiving thrombolysis (in 2009 six patients were thrombolysed out of 339 patients with

stroke admitted to the hospital). The pathway for patients potentially eligible for thrombolysis who arrived

at the hospital outside of these hours was not clear. Reviewers were told of plans to appoint additional

emergency physicians and to undertake additional training for staff in the Emergency Department in order to

increase the times when thrombolysis is available. Timescales for implementation of these changes were not

clear.

3 The service had only one vascular technician and arrangements for cover during absences were not clear.

4 Rehabilitation Services

Rehabilitation assessment by physiotherapy, speech and language therapy and occupational therapy (if

required) within 24 hours of admission was not being achieved at weekends. Physiotherapy and occupational

therapy services were available Monday to Friday but limited speech and language therapy support was

available. No clinical psychology support was available for stroke patients.

5 The pathway for the management of patients with TIA was not robust. A TIA clinic was available five days a

week with ‘slots’ for CT scans for five patients per week. Patients with high risk TIA were not therefore being

able to receive a full neuro-vascular assessment within 24 hours.

6 The pathway for referral of patients for neuro-surgery was not clear.



1 There was no operational policy for the stroke service. Responsibilities for ensuring each stage of the patient

pathway was achieved within expected timescales were not clear. Reviewers suggested that this should be

developed soon with robust monitoring of implementation.

2 Some social work support was available but the numbers of patients was not considered sufficient to justify a

social worker with specific time allocated to their work on the Stroke Unit. Reviewers suggested that this

should be kept under review.

3 The Hereford service is a relatively small and it may be helpful to develop links with another stroke service

for support on educational and governance issues.

4 An audit of the care of patients with stroke and TIA in the Emergency Department was undertaken in 2009.

This recommended a repeat audit and reviewers supported this recommendation.

Good Practice

1 There was a good management plan document for patients with dysphagia.

2 There was a good TIA management plan document.

Return to Index

CRITICAL CARE


This was a well-equipped unit providing care in very good facilities. There was good nursing and medical leadership.

Staffing was relatively stable, with little turnover, and the middle-grade medical rota was relatively senior.

Concerns

1 There was no clinical pharmacy input into the multi-disciplinary care of patients. Pharmacists attended the

unit to check stock levels but not to advise on the care of patients.

2 Out of hours support to the critical care unit was provided by general anaesthetists and there was no

evidence that they were doing CPD of relevance to their work on the critical care unit.

3 There was no critical care delivery group, or similar mechanism, for the Trust to ensure that critical care

services link effectively with other services within the hospital.

4 The outreach service was only available between 08.00 – 18.00 on weekdays and 08.00 – 13.00 on weekends

and bank holidays.



1 The arrangements for supporting nurse training should be kept under review. There was no Practice

Development Lead and no plans to recruit to this post. The staff base was very stable but the service will

need to ensure that competences are maintained and, if there are new staff, that appropriate competences

are achieved.

2 Multi-disciplinary input to the ward round was limited. There was no allied health professional or pharmacy

(see above) involvement.

3 Nursing staff wash the vertical blinds in the unit. This may not be the best use of their time.

Good Practice

1 Ultrasound with echo-probe was available and two consultants were trained to use this.

2 Facilities for relatives were available in addition to the interview room.

Return to Index

COMMISSIONING

Urgent Care: See Health Economy section of this report

Critical Care: No specific commissioning issues were identified.

Vascular Services:

Vascular services for Herefordshire patients were reviewed as part of the Worcestershire health economy review.

The findings of this review are reported in the Worcestershire health economy report.1

Stroke (acute phase) and TIA Services:

A county-wide review of stroke services has been undertaken and there was good mapping of the expected number

of patients at each stage of the pathway.

Concern

1 There was not a clear commissioning plan for the full availability of stroke thrombolysis for Herefordshire

patients. Plans with expected dates for the achievement of a) other stroke-related Quality Standards

(especially QS CN-602) and b) neuro-vascular assessment of patients with high risk TIAs within 24 hours were

not evident.

1 WMQRS Urgent Care, Critical Care, Stroke (Acute Phase) & TIA and Vascular Services Final Report – Worcestershire Health Economy will be available via http://www.wmqi.westmidlands.nhs.uk/wmqrs/

http://www.wmqi.westmidlands.nhs.uk/wmqrs/


Return to Index

APPENDIX 1 MEMBERSHIP OF VISITING TEAM

Phil Milligan

Executive lead

Director of Operations Worcestershire Acute Hospitals NHS Trust

Bob Colclough Urgent Care Programme Manager NHS Stoke on Trent

Dr Aresh Anwar Divisional Medical Director University Hospitals Coventry & Warwickshire NHS Trust

Hilary Clemson Emergency Department Nurse Heart of England NHS Foundation Trust

Dr Mair Edmunds Associate Medical Director, Clinical Performance

University Hospitals Coventry & Warwickshire NHS Trust

Jane Tordoff Matron for Acute Surgery University Hospital of North Staffordshire NHS Trust

Stuart Shirley Hospital Ambulance Liaison Officer West Midlands Ambulance Service NHS Trust

Dr John Bleasdale Consultant, Lead Clinician Sandwell & West Birmingham Hospitals NHS Trust

Marian Foster Matron, Critical Care George Eliot Hospital NHS Trust

Heather Reading Senior Nurse - Outreach South Warwickshire NHS Foundation Trust

Jeff Osborne Service Improvement Lead Midlands Critical Care Network

Dr Amit Arora Consultant Stroke Physician University Hospital of North Staffordshire NHS Trust

Martine Pritchard Stroke Services Co-ordinator University Hospitals Coventry & Warwickshire NHS Trust

Gerald Robinson Patient Representative

Eileen Anderson Patient Representative

Helen Couth Head of Clinical Governance NHS Telford & Wrekin

Dr Frank Leahy Consultant Radiologist & Divisional Director for Imaging

Sandwell & West Birmingham Hospitals NHS Trust

Jennie Muraszewski General Manager- Surgical and Orthopaedic Directorates

Dudley Group of Hospitals NHS Foundation Trust

Tracy Gilmartin Head of Governance The Royal Orthopaedic Hospital NHS Foundation Trust (Birmingham)

Jane Eminson Acting Director West Midlands Quality Review Service

Sarah Broomhead Quality Manager West Midlands Quality Review Service

Lisa Carroll WMQRS Urgent Care Lead West Midlands Quality Review Service


HEREFORDSHIRE HEALTH ECONOMY

APPENDIX 2 COMPLIANCE WITH THE QUALITY STANDARDS

Analyses of percentage compliance with the Quality Standards should be viewed with caution as they give the same

weight to each of the Quality Standards whereas, in practice, their importance and the risks associated with not

meeting the Standard vary considerably. Also, the number of Quality Standards applicable to each service varied

depending on the nature of the service provided. Percentage compliance takes no account of ‘working towards’ a

particular Quality Standard and reviewers often comment that it is better to have a ‘No but’, where there is real

commitment to achieving a particular standard, than a ‘Yes but’ – where a ‘box has been ticked’ but the

commitment to implementation is lacking. With these caveats, table 1 summarises the percentage compliance for

each of the services reviewed.

Table 1 - Percentage of Quality Standards met

Service No. Applicable QS

No. QS Met % met

Urgent Care - Minor Injury Units 43 29 67

Urgent Care - Walk in Centre and GP Out of Hours 47 39 83

Urgent Care - Acute Trust-wide 13 10 77

Urgent Care - Emergency Department 78 59 76

Urgent Care - Acute Medical Units 74 43 58

Urgent Care - Urgent Care Commissioning 11 4 36

Urgent Care – Health Economy 266 184 69

Stroke and TIA – Primary Care 3 1 33

Stroke and TIA – Acute Trust 55 27 49

Stroke and TIA - Commissioning 6 3 50

Stroke and TIA – Health Economy 64 31 48

Critical Care 106 84 79

URGENT CARE – PRIMARY CARE: MINOR INJURIES UNITS

Ref. Quality Standard (QS) Met? Comments

AA-101 Information should be clearly displayed advising patients with potentially life-threatening conditions to report immediately to the receptionist.

Y

AA-102 Information for patients and carers about common conditions and health promotion should be available.

Y Leaflets on common conditions were available

AA-103 Information about NHS Direct and self-care options should be available.

Y



AA-199 The service should have: a. Mechanisms for receiving feedback from patients and carers about the treatment and care they received. b. A rolling programme of audit of a random sample of patients’ experiences of the service. c. Mechanisms for involving patients and carers in decisions about the organisation of the services.

N The MIUs were working with PALS to develop mechanisms for receiving feedback. There was a rolling programme of audit of patients' experiences but the arrangements for discussion of the findings were not clear. There were not yet mechanisms for involving patients and carers in decisions about the organisation of services. A road-show had taken place recently and feedback was awaited.

AA-201 The service should have a nominated medical and nurse lead with responsibility for ensuring implementation of the Quality Standards for Urgent Care Services. The medical and nurse lead should undertake regular clinical work within the service.

Y The roles were not yet included in job descriptions.

AA-202 All healthcare professionals should: a. Have sufficient knowledge of English to undertake the role expected of them b. If non-UK based, have had a risk assessment of their training and of their experience of working in the NHS c. Have contracts which require sharing of information about work undertaken for other organisations.

N Knowledge of English was covered in the PCT recruitment policy. There were no non-UK staff. HR policies did not yet include a requirement for sharing of information about work undertaken in other organisations.

AA-203 All healthcare professionals should have competences appropriate to their role in: a. Safeguarding of children and young people b. Safeguarding of vulnerable adults c. Recognition of the needs of vulnerable groups including young people, people with mental health problems, dementia, alcohol and substance misuse problems, learning disabilities and older people. d. Mental Capacity Act and Deprivation of Liberty Safeguards.

Y A good training database was available.



AA-204 At least one registered healthcare practitioner should be available at all times with competences in: a. adult and paediatric injury or illness examination and treatment b. history taking, examination and formulation of diagnosis and treatment plan c. assessment and management of vulnerable patients including young people, people with mental health problems, dementia, alcohol and substance misuse problems, learning disabilities and older people. d. acting as a first responder in the care of the acutely ill patient e. primary survey assessment f. life support at the level of Intermediate Life Support and Paediatric Life Support / Paediatric Intermediate Life Support (or equivalent) and management of immediate life-threatening situations until the ambulance arrives. (See note 3 for GP OOH services.) g. prescribing for common presenting conditions.

N This QS was met apart from g) prescribing for common conditions. No prescribing was undertaken. There were some PGDs but these appeared to be out of date.

AA-205 Sufficient registered healthcare professionals should be available for the expected number of patients. Where only one healthcare practitioner is needed for the expected number of patients, a lone worker policy meeting the requirements of QS AA-603 should be in use.

Y

AA-206 Where wound closure, plaster casting, cannulation and radiographic services are offered, healthcare practitioners should have appropriate competences including, for radiographic services, training in IRMER regulations.

Y No radiographic services were offered on site

AA-207 In services providing telephone assessment and advice, a member of staff with competences in giving telephone advice and using the validated assessment system should be available at all times

N/A

AA-208 There should be arrangements for quality assuring the recruitment of doctors. Providers of GP out of hours services are responsible for: a. recording the performers list all doctors b. verifying this with the named PCT as part of their recruitment procedures c. reminding doctors who are on the performers list of a PCT outside the area where they are providing an out of hours service that they should be on the list where they predominantly practice.

Y

AA-209 All staff should undertake a competence-based induction programme. For registered healthcare professionals, this induction should include a period of supervised work with a clinician employed by the same provider who has been trained in undertaking inductions.

N There was not yet a competence-based induction programme for MIU staff. There was general PCT induction and staff undertook some supernumerary shifts on the MIU.



AA-210 There should be a training and development plan for all staff. The competences expected of each role should be identified and the plan for achieving and maintaining these competences described. For staff in training, the level of supervision required should be specified.

Y This was met through KSFs and annual PDPs.

AA-301 Access for advice to Senior Decision Makers in local acute specialties should be available.

Y

AA-302 Access for advice to a mental health service Senior Decision Maker should be available.

Y Good support from mental health services was available.

AA-303 Access to an initial assessment by a competent mental health practitioner and to Mental Health Act assessment should be available.


AA-304 Staff should be able to access the following services at all times: a. Community nursing support, including admission avoidance and supported early discharge teams b. Mental Health Crisis Intervention Team c. Social services d. Youth services.

Y Community nursing support was available from district nurses to 10pm and thereafter from Primecare.

AA-401 Resuscitation drugs and equipment should be available and should be checked in accordance with local policy.

Y

AA-402 The following equipment should be available: a. ECG machine with ability to print or electronically transfer the ECG trace b. Plain x-ray facility.

Y

AA-403 An IT system capable of collecting data on activity levels and response times (QS AB-701) and supporting appropriate clinical audits (QS AB-702) should be available. There should also be the capability for secure email / transmission of information to GP surgeries.

Y

AA-404 If home visits are undertaken, the following drugs and equipment should be available: a. Portable resuscitation drugs and equipment b. Appropriate analgesia.

N/A

AA-501 Services providing telephone advice or assessment service should use a validated assessment system.

N/A

AA-502 Guidelines should be in use which ensure that patients are treated, transferred or referred to the most appropriate service, according to the health economy matrix of services at which different patient groups and conditions should be treated (QS AZ-601).

N Some protocols were available but these did not cover all services expected by the QS.

AA-503 Guidelines for reception staff on action for ‘front of the queue’ patients (QS AA-101) and advice to patients who do not fall within the patient groups or conditions that can be treated by the service (QS AZ-601) should be in use.

N There was not yet a written protocol for reception staff.



AA-504 Guidelines on the identification of immediate life-threatening conditions in adults and children should be in place. These guidelines should include resuscitation and handover to the ambulance service (or other appropriate acute service).

N Some algorithms were available in the main treatment room but the accompanying guidelines were out of date

AA-505 Clinical guidelines should be in use covering the assessment and management of common presenting conditions including: a. Chest pain b. Shortness of breath c. Cardiac Failure d. Headache e. Pneumonia f. Alcohol and substance misuse g. TIA and stroke h. Abdominal pain i. Retention of urine j. Cellulitis k. Gastro-intestinal bleeding l. Unstable blood sugars in diabetic patients m. Vaginal bleeding and common obstetric problems n. Venous thrombo-embolism prevention.

N The guidelines available (Junior Doctors Handbook and PGDs) were out of date and did not reflect current guidance.

AA-506 Access to evidence-based clinical guidelines for less common conditions should be available.

N As AA-505

AA-507 A procedure to ensure a timely response from the ambulance service, according to clinical need, should be in use.

Y

AA-508 A procedure for seeking advice and/or immediate referral where clinically indicated to the Emergency Department, Acute Medical Admissions Unit, Acute Surgical Admissions Unit, mental health service or other specialist facilities should be in use. This procedure should include notifying the service to which patients are referred and providing details of assessments undertaken.

Y

AA-509 A procedure for referral of patients to other services should be in use, including at least: a. Same day / next day services (see note 1) b. Health promotion and disease prevention programmes, including smoking cessation, contraception and sexual health services, brief intervention and other support services for those with alcohol and substance misuse problems. c. GP and other primary and community services d. Social services This procedure should include ensuring patients are given information about their condition.

Y Referral criteria and arrangements would benefit from being documented.



AA-510 A Medicines Management Policy should be in use which: a. Links to national or local formularies b. Includes arrangements for monitoring individual clinicians’ prescribing c. For nurse-led services, includes Patient Group Directives to support the treatment of common presenting conditions d. Specifies arrangements for access to pharmacist advice e. Covers arrangements for responsibility, reconciliation, record keeping and disposal requirements for the movement of drugs f. Covers access to palliative care drugs g. Ensures a complete, documented and coherent audit trail for controlled drugs, including those administered in the patient’s home and drugs returned for destruction.

N The Medicines Management Policy and PGDs were out of date.

AA-511 Guidelines, agreed with the specialist palliative care services serving the local population, should be in use covering, the management of patients with palliative care needs.

N/A

AA-599 Staff should be aware of local guidelines for end of life care.

Y There were good links with palliative care.

AA-601 Services providing telephone advice or assessment service should have a system in use which ensures: a. All calls are answered within 60 seconds of the end of the introductory message, which should normally be no more than 30 seconds long. Where there is no introductory message, all calls should be answered within 30 seconds. b. Patients are treated by the clinician best equipped to meet their needs and in the most appropriate location. Patients calling GP OOH services must, where it is clinical appropriate, be able to have a face-to-face consultation with a GP including, where necessary, at the patient’s place of residence. c. Telephone clinical assessment including identification of life-threatening conditions and, once identified, transfer of these calls to the ambulance service within three minutes. d. Start of definitive clinical assessment for urgent calls within 20 minutes of the call being answered by a person. e. Start of definitive clinical assessment for all other calls within 60 minutes of the call being answered by a person. f. At the end of the assessment, the patient is clear of the outcome including, where appropriate, the time-scale within which further action will be taken and the location of any face-to-face consultation.

N/A



AA-602 GP OOH services should have systems to ensure that face-to-face consultations are started within the following timescales after definitive assessment has been completed: • emergency – within 1 hour • urgent – within 2 hours • less urgent – within 6 hours.

N/A

AA-603 Services where staff work alone or undertake home visits should have a lone worker policy covering, at least, staff safety and security, the implications for medicines management and the system for calling additional help if required.

Y

AA-604 Arrangements for identifying people with advance care plans (QS AZ-705) and accessing the patient’s latest care plan should be in use.

N There was no process for identifying people with advance care plans at the MIU

AA-605 A system should be in place to notify the patient’s GP of any OOH consultations by 8.00 a.m. on the next working day.

Y Information was faxed to surgeries daily

AA-606 Representatives of the service should meet at least annually with the following local services to review links between the services and address any problems identified: a. Emergency Department/s b. Mental Health services.

Y

AA-607 The service should be part of the local health economy’s Urgent Care Group (QS AZ-701) or a sub-group thereof.

Y

AA-701 There should be regular collection of data and monitoring of: a. activity levels b. response times and locally agreed key performance indicators c. referrals to other services, including local Emergency Department/s d. compliance with national standards on clinical documentation.

Y

AA-702 The service should have a rolling programme of audit of compliance with evidence-based guidelines (QS AA-505/6).

N There was a rolling programme of audit for the community hospitals, but this did not yet include the MIUs

AA-703 The service should have a complaints procedure that is consistent with the principles of the NHS complaints procedure.

Y

AA-704 The service should have a system for reporting anonymised details of each complaint, including the way in which it has been handled, to the contracting PCT.

Y Complaints reports to committees were made through standard governance arrangements

AA-705 The service should have appropriate arrangements for reporting and investigating adverse incidents and ‘near misses’.

Y



AA-706 The service should have appropriate arrangements for clinical review of complaints, positive feedback, morbidity, mortality, transfers, critical incidents and ‘near misses’.

Y

AA-707 The services should be regularly comparing its achievement of key performance indicators with other similar providers.

N NRLS reporting figures and MIU data were available. These were considered as a whole PCT rather than for comparisons with other similar providers.

AA-799 All policies, procedures and guidelines should comply with the host organisation’s document control procedures.

N Several policies were out of date.

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URGENT CARE – PRIMARY CARE: PRIMECARE WALK-IN CENTRE AND GP OUT OF HOURS


AA-101 Information should be clearly displayed advising patients with potentially life-threatening conditions to report immediately to the receptionist.

Y

AA-102 Information for patients and carers about common conditions and health promotion should be available.

N Leaflets were in the process of being completed.

AA-103 Information about NHS Direct and self-care options should be available.

Y

AA-199 The service should have: a. Mechanisms for receiving feedback from patients and carers about the treatment and care they received. b. A rolling programme of audit of a random sample of patients’ experiences of the service. c. Mechanisms for involving patients and carers in decisions about the organisation of the services.

N Mechanisms were being developed further including a feedback process following home visits. Some patient feedback was obtained through follow up calls. Audit results were reported to the PCT.

AA-201 The service should have a nominated medical and nurse lead with responsibility for ensuring implementation of the Quality Standards for Urgent Care Services. The medical and nurse lead should undertake regular clinical work within the service.

Y

AA-202 All healthcare professionals should: a. Have sufficient knowledge of English to undertake the role expected of them b. If non-UK based, have had a risk assessment of their training and of their experience of working in the NHS c. Have contracts which require sharing of information about work undertaken for other organisations.

Y There was a comprehensive induction programme. Regular governance meetings were held and audits of GPs undertaken.



AA-203 All healthcare professionals should have competences appropriate to their role in: a. Safeguarding of children and young people b. Safeguarding of vulnerable adults c. Recognition of the needs of vulnerable groups including young people, people with mental health problems, dementia, alcohol and substance misuse problems, learning disabilities and older people. d. Mental Capacity Act and Deprivation of Liberty Safeguards.

Y

AA-204 At least one registered healthcare practitioner should be available at all times with competences in: a. adult and paediatric injury or illness examination and treatment b. history taking, examination and formulation of diagnosis and treatment plan c. assessment and management of vulnerable patients including young people, people with mental health problems, dementia, alcohol and substance misuse problems, learning disabilities and older people. d. acting as a first responder in the care of the acutely ill patient e. primary survey assessment f. life support at the level of Intermediate Life Support and Paediatric Life Support / Paediatric Intermediate Life Support (or equivalent) and management of immediate life-threatening situations until the ambulance arrives. (See note 3 for GP OOH services.) g. prescribing for common presenting conditions.

Y

AA-205 Sufficient registered healthcare professionals should be available for the expected number of patients. Where only one healthcare practitioner is needed for the expected number of patients, a lone worker policy meeting the requirements of QS AA-603 should be in use.

Y

AA-206 Where wound closure, plaster casting, cannulation and radiographic services are offered, healthcare practitioners should have appropriate competences including, for radiographic services, training in IRMER regulations.

N/A

AA-207 In services providing telephone assessment and advice, a member of staff with competences in giving telephone advice and using the validated assessment system should be available at all times

Y



AA-208 There should be arrangements for quality assuring the recruitment of doctors. Providers of GP out of hours services are responsible for: a. recording the performers list all doctors b. verifying this with the named PCT as part of their recruitment procedures c. reminding doctors who are on the performers list of a PCT outside the area where they are providing an out of hours service that they should be on the list where they predominantly practice.

Y

AA-209 All staff should undertake a competence-based induction programme. For registered healthcare professionals, this induction should include a period of supervised work with a clinician employed by the same provider who has been trained in undertaking inductions.

Y End of placement assessments were also undertaken.

AA-210 There should be a training and development plan for all staff. The competences expected of each role should be identified and the plan for achieving and maintaining these competences described. For staff in training, the level of supervision required should be specified.

Y

AA-301 Access for advice to Senior Decision Makers in local acute specialties should be available.

Y There was phone access to all acute Trust services

AA-302 Access for advice to a mental health service Senior Decision Maker should be available.


AA-303 Access to an initial assessment by a competent mental health practitioner and to Mental Health Act assessment should be available.


AA-304 Staff should be able to access the following services at all times: a. Community nursing support, including admission avoidance and supported early discharge teams b. Mental Health Crisis Intervention Team c. Social services d. Youth services.

Y Community nursing support was available from district nurses to 10pm and thereafter from Primecare.

AA-401 Resuscitation drugs and equipment should be available and should be checked in accordance with local policy.

N Staff were trained to BLS only and not all could cannulate. There was access to an AED and staff will access the hospital resuscitation team if required.

AA-402 The following equipment should be available: a. ECG machine with ability to print or electronically transfer the ECG trace b. Plain x-ray facility.

Y

AA-403 An IT system capable of collecting data on activity levels and response times (QS AB-701) and supporting appropriate clinical audits (QS AB-702) should be available. There should also be the capability for secure email / transmission of information to GP surgeries.

Y



AA-404 If home visits are undertaken, the following drugs and equipment should be available: a. Portable resuscitation drugs and equipment b. Appropriate analgesia.

N As – 401. There was good support from paramedics if required and, for security reasons, no drugs were carried in cars.

AA-501 Services providing telephone advice or assessment service should use a validated assessment system.

Y

AA-502 Guidelines should be in use which ensure that patients are treated, transferred or referred to the most appropriate service, according to the health economy matrix of services at which different patient groups and conditions should be treated (QS AZ-601).

Y

AA-503 Guidelines for reception staff on action for ‘front of the queue’ patients (QS AA-101) and advice to patients who do not fall within the patient groups or conditions that can be treated by the service (QS AZ-601) should be in use.

Y

AA-504 Guidelines on the identification of immediate life-threatening conditions in adults and children should be in place. These guidelines should include resuscitation and handover to the ambulance service (or other appropriate acute service).

Y

AA-505 Clinical guidelines should be in use covering the assessment and management of common presenting conditions including: a. Chest pain b. Shortness of breath c. Cardiac Failure d. Headache e. Pneumonia f. Alcohol and substance misuse g. TIA and stroke h. Abdominal pain i. Retention of urine j. Cellulitis k. Gastro-intestinal bleeding l. Unstable blood sugars in diabetic patients m. Vaginal bleeding and common obstetric problems n. Venous thrombo-embolism prevention.

Y

AA-506 Access to evidence-based clinical guidelines for less common conditions should be available.

Y

AA-507 A procedure to ensure a timely response from the ambulance service, according to clinical need, should be in use.

Y

AA-508 A procedure for seeking advice and/or immediate referral where clinically indicated to the Emergency Department, Acute Medical Admissions Unit, Acute Surgical Admissions Unit, mental health service or other specialist facilities should be in use. This procedure should include notifying the service to which patients are referred and providing details of assessments undertaken.

Y



AA-509 A procedure for referral of patients to other services should be in use, including at least: a. Same day / next day services (see note 1) b. Health promotion and disease prevention programmes, including smoking cessation, contraception and sexual health services, brief intervention and other support services for those with alcohol and substance misuse problems. c. GP and other primary and community services d. Social services This procedure should include ensuring patients are given information about their condition.

N a, c &d were met. Production of leaflets and health promotion information had yet to be completed.

AA-510 A Medicines Management Policy should be in use which: a. Links to national or local formularies b. Includes arrangements for monitoring individual clinicians’ prescribing c. For nurse-led services, includes Patient Group Directives to support the treatment of common presenting conditions d. Specifies arrangements for access to pharmacist advice e. Covers arrangements for responsibility, reconciliation, record keeping and disposal requirements for the movement of drugs f. Covers access to palliative care drugs g. Ensures a complete, documented and coherent audit trail for controlled drugs, including those administered in the patient’s home and drugs returned for destruction.

Y There were no PGDs in us in the Walk in Centre

AA-511 Guidelines, agreed with the specialist palliative care services serving the local population, should be in use covering, the management of patients with palliative care needs.

Y

AA-599 Staff should be aware of local guidelines for end of life care.

Y



AA-601 Services providing telephone advice or assessment service should have a system in use which ensures: a. All calls are answered within 60 seconds of the end of the introductory message, which should normally be no more than 30 seconds long. Where there is no introductory message, all calls should be answered within 30 seconds. b. Patients are treated by the clinician best equipped to meet their needs and in the most appropriate location. Patients calling GP OOH services must, where it is clinical appropriate, be able to have a face-to-face consultation with a GP including, where necessary, at the patient’s place of residence. c. Telephone clinical assessment including identification of life-threatening conditions and, once identified, transfer of these calls to the ambulance service within three minutes. d. Start of definitive clinical assessment for urgent calls within 20 minutes of the call being answered by a person. e. Start of definitive clinical assessment for all other calls within 60 minutes of the call being answered by a person. f. At the end of the assessment, the patient is clear of the outcome including, where appropriate, the time-scale within which further action will be taken and the location of any face-to-face consultation.

Y

AA-602 GP OOH services should have systems to ensure that face-to-face consultations are started within the following timescales after definitive assessment has been completed: • emergency – within 1 hour • urgent – within 2 hours • less urgent – within 6 hours.

Y Systems were in place and monthly audit reports were submitted to the PCT.

AA-603 Services where staff work alone or undertake home visits should have a lone worker policy covering, at least, staff safety and security, the implications for medicines management and the system for calling additional help if required.

N/A

AA-604 Arrangements for identifying people with advance care plans (QS AZ-705) and accessing the patient’s latest care plan should be in use.

Y

AA-605 A system should be in place to notify the patient’s GP of any OOH consultations by 8.00 a.m. on the next working day.

Y ADASTRA and Emis discharge summaries.

AA-606 Representatives of the service should meet at least annually with the following local services to review links between the services and address any problems identified: a. Emergency Department/s b. Mental Health services.

N Fortnightly meetings were held with A&E/ambulance service. A formal meeting with local mental health service had not yet taken places, though a GP with a interest in mental health was working with the service.

AA-607 The service should be part of the local health economy’s Urgent Care Group (QS AZ-701) or a sub-group thereof.

Y



AA-701 There should be regular collection of data and monitoring of: a. activity levels b. response times and locally agreed key performance indicators c. referrals to other services, including local Emergency Department/s d. compliance with national standards on clinical documentation.

Y

AA-702 The service should have a rolling programme of audit of compliance with evidence-based guidelines (QS AA-505/6).

N There was a monthly audit programme but no evidence of any action log

AA-703 The service should have a complaints procedure that is consistent with the principles of the NHS complaints procedure.

Y

AA-704 The service should have a system for reporting anonymised details of each complaint, including the way in which it has been handled, to the contracting PCT.

Y

AA-705 The service should have appropriate arrangements for reporting and investigating adverse incidents and ‘near misses’.

Y

AA-706 The service should have appropriate arrangements for clinical review of complaints, positive feedback, morbidity, mortality, transfers, critical incidents and ‘near misses’.

Y

AA-707 The services should be regularly comparing its achievement of key performance indicators with other similar providers.

N The service was planning to contact other providers with a view to implementing benchmarking and adopting best practice reviews.

AA-799 All policies, procedures and guidelines should comply with the host organisation’s document control procedures.

Y

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URGENT CARE – ACUTE TRUST WIDE


AC-301 The following support services should be available: a. interfaith support b. social workers c. interpreters d. advocacy services Information about these services should be available for patients and carers.

Y

AC-302 Hospitals with an Emergency Department, Acute Medical Admissions Unit (or equivalent) or Acute Surgical Admissions Unit (or equivalent) should have critical care services working towards meeting the WMQRS Quality Standards for Critical Care Services available on site.

Y

AC-303 Hospitals with an Emergency Department, Acute Medical Admissions Unit (or equivalent) or Acute Surgical Admissions Unit (or equivalent) should have anaesthesia services available on site, including: a. a consultant on call at all times and available within 30 minutes b. an anaesthetist of grade ST3 or above competent in rapid sequence induction available within 10 minutes.

Y

AC-304 An appropriately staffed emergency theatre should be available at all times.

Y

AC-305 Same day / next day rapid access services should be available for assessment of patients, including: a. Rapid access chest pain service b. Rapid access arrhythmia service c. Neuro-vascular assessment service d. Respiratory assessment service for patients with asthma and COPD e. Gastroenterology assessment service f. Hand clinic (weekdays only) g. Fracture clinic (weekdays only) h. Physiotherapy clinic (weekdays only).

N There was access to some clinics but not all those expected by the QS were available each day.

AC-306 Arrangements for accessing the senior decision makers in the Emergency Department, Acute Medical / Surgical Admissions Units (or equivalent) and relevant acute specialties should be agreed and communicated to primary care services (including GP OOH services, walk-in centres and urgent care centres) and ambulance services.

Y



AC-307 A group should coordinate the planning and delivery of urgent care services within the hospital. This group should include, at least, the clinical leads for the Emergency Department, Acute Medical / Surgical Admissions Units (or equivalent) and representatives from imaging, critical care, ambulance service, trauma and orthopaedics and mental health services.

Y

AC-308 Staff within the hospital should have access to a discharge service (discharge nurse or social worker) available to see patients within one hour and with: a. Information about and access to social services, district nursing, intermediate care beds, community matrons, falls teams and transport arrangements. b. Authority to organise these services for patients (within agreed guidelines). c. Access to occupational therapy services and authority to organise equipment and assessments (within agreed guidelines). d. Access to youth services. This service should be available at all times although arrangements may differ at different times of day.

N Lead nurses took responsibility for discharge with a 48 hr board for simple discharge and Band 3 support workers for help with Section 2 and 5 patients. It was not clear that Lead Nurses had the level of authority envisaged by this QS. There was no discharge liaison service and social work response was not within the timescales expected.

AC-309 Hospitals receiving patients with trauma should have a trauma team available at all times, including: a. Team Leader (Consultant) – available within 30 minutes b. Anaesthetist c. Anaesthetic Assistant (ODP) d. General Surgeon e. Orthopaedic Surgeon f. Emergency Department doctor (senior decision maker) g. Two Nurses. (Three if no anaesthetic assistant) h. Radiographer i. Scribe (Nurse or doctor).

Y



AC-310 Bed management arrangements should be in place which include: a. A system for monitoring patients who exceed the expected length of stay in the Clinical Decision Unit / Observation Ward. b. An system for getting patient to an appropriate destination within one hour of the decision to admit and an escalation policy covering action to be taken when this target is not achieved. c. A system for reporting compliance with admitting teams’ achievement of the one hour target for getting patients to an appropriate destination d. A system for ensuring that admitting teams review their compliance with the one hour target. e. A system for ensuring that patients are on an appropriate specialty ward within 24 hours of admission and for monitoring and reporting the number of patients for which this is not achieved. f. A system for monitoring the number of patients aged 16 to 18 on adult wards.

N Predictive capacity modelling was available and used extensively. This was not yet clearly linked to expected date of discharge and average length of stay.

AC-311 Arrangements should be in place whereby appropriate ambulance and GP admissions agreed by specialty teams are taken directly to the specialty concerned.

Y Bed capacity pressures could lead to patients needing admission being sent to the Emergency Department.

AC-312 The Trust should have plans to provide emergency response and medical management of major incidents.

Y The major incident plan was dated 2007 and was due for review.

AC-313 Trust-wide guidelines should be in place covering: a. Administration of blood and blood components b. Verification of death c. Organ donation d. Consent.

Y

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URGENT CARE – EMERGENCY DEPARTMENT


AE-101 Information should be clearly displayed advising patients with potentially life-threatening conditions to report immediately to the receptionist.

Y

AE-102 Information about NHS Direct and self-care options should be clearly displayed.

Y

AE-103 There should be a system of communicating waiting times to patients.

Y Information was also available in Polish.

AE-104 Information for patients and carers should be available for a variety of conditions including, at least: a. head injury b. fractures c. wounds d. pain relief e. chest infection f. asthma g. abdominal pain h. vaginal bleeding i. alcohol and substance misuse j. other common presenting conditions k. venous thrombo-embolism prevention l. health promotion, including smoking cessation, health eating, weight management, sexual and reproductive health, mental and emotional health and well-being. Information should cover: a. care and activities after discharge b. symptoms and action to take if unwell c. sources of further advice.

N There was no information available on chest infection or abdominal pain. Other leaflets were available but were not easy to find. There were duplicates of several leaflets, including four different leaflets on diabetes.

AE-105 Information about the following services should be easily available for patients and carers: a. interfaith support b. social services c. interpreters d. advocacy services.

N No information was available about social services.

AE -112 Patients being discharged home should be given a discharge letter. This letter should describe the condition, treatment given (if any) and future management plan. The contents of the letter should be discussed with the patient and, with the patient’s agreement, their carer/s and a copy should be sent to their GP.

N A discharge letter was not given regularly.



AE-113 Patients being admitted should have an initial management plan recorded in their medical notes. This plan should cover their diagnosis, or differential diagnosis, and management for, at least, the next four hours. The contents of the plan should be discussed with the patient and, with the patient’s agreement, their carer/s.

Y

AE-114 An appropriately decorated and furnished quiet room for bereaved relatives or relatives of critically ill patients should be available. This room should be close to the clinical area and should have a telephone for relatives’ use and facilities for providing drinks.

Y

AE-115 A bereavement support service should be available and information about this service should be offered to bereaved relatives.

Y

AE-199 The service should have: a. Mechanisms for receiving feedback from patients and carers about the treatment and care they received. b. Mechanisms for involving patients and carers in decisions about the organisation of the services.

Y A survey was undertaken in 2008 and another was planned.

AE-201 The Emergency Department should have a nominated lead consultant and nominated lead nurse with responsibility for ensuring implementation of the Quality Standards for Urgent Care Services relating to the Emergency Department. The lead consultant and lead nurse should undertake regular clinical work within the department.

Y

AE-202 A doctor trained in the specialty of Emergency Medicine at level ST4 or above or SAS grade 4 or above, should be available at all times and able to reach the Emergency Department within 10 minutes. This doctor must have competences in trauma, ATLS, ALS and advanced airway management.

Y There were three consultants and one Associate Specialist on the consultant rota. The middle grade rota comprises four substantive doctors and four long-term locums. The service made sure that less experienced middle grade staff were not on duty overnight.

AE-203 There should be sufficient senior decision makers within the Emergency Department to manage the expected number of patients.

Y The ED was caring for patients who should, ideally, go straight to the Medical Admissions Unit (see main report). Staff were therefore sometimes stretched.

AE-204 An Emergency Medicine consultant, associate specialist or SAS grade 9 or above doctor should be on call at all times and able to reach the Emergency Department within 30 minutes.

Y As AE-203



AE-205 There should be sufficient Emergency Department consultants, associate specialists or SAS grades 9 or above doctors to provide clinical cover within the Emergency Department for the expected number of patients.

Y As AE-203

AE-206 Sufficient junior doctors (FY1&2 or CT1-3), nurse practitioners and other registered practitioners with appropriate competences should be available to maintain the flow of patients through the Department and achieve waiting time targets for the expected number of patients. These staff should have appropriate competences in Emergency Medicine, including ILS, and be able to do a primary survey.

Y As AE-203

AE-207 There should be a shift leader / coordinator on each shift who has an overview of all patients and their stage of care, the flow of patients through the Department and responsibility for liaison with bed management. The shift leader / coordinator should have at least significant experience in urgent care at a senior level. In busy departments the shift leader / coordinator should be supernumerary and should not have clinical responsibility.

Y

AE-208 Sufficient nursing staff and support workers should be available to maintain the flow of patients through the Department and achieve waiting time targets for the expected number and dependency of patients. These staff should have competences appropriate for their work in the Emergency Department, including BLS.

Y

AE-209 Nurses rostered to work in the resuscitation area should have critical care competences and ILS.

Y

AE-210 At least one nurse per shift should have competences in initial assessment and treatment and undertaking and interpreting an early warning score assessment.

Y

AE-211 At least one nurse per shift should have competences in the assessment and management of people with mental health problems or dementia.

N There were plans for nurse training.

AE-212 At least one nurse per shift competent in undertaking nurse-led discharge should be rostered to the Clinical Decision Unit / Observation Unit.

N/A



AE-227 All healthcare professionals working in the Emergency Department or Acute Medical/Surgical Admissions Unit should have competences appropriate to their role in: a. protection of vulnerable adults, b. recognition of the needs of vulnerable groups including young people, people with mental health problems, dementia, alcohol and substance misuse problems, learning disabilities and older people. c. Mental Capacity Act and Deprivation of Liberty Safeguards.

N There were plans to start training in the next six weeks.

AE-228 Staff using point of care testing equipment and monitoring equipment should have competences in the use of this equipment.

Y Staff were being trained on the new blood gas machine. Good support was available from the pathology department.

AE-229 Staff undertaking ultrasound within the Emergency Department should have appropriate competences in undertaking this investigation.

Y

AE-230 Reception and administrative support should be available at all times.

Y

AE-231 There should be a training and development programme for all Emergency Department staff. The competences expected for each role should be identified and the plan for achieving and maintaining these competences described.

Y

AE-301 Laboratory services should be available, including: a. A system for rapid transport of pathology samples b. Availability of results within, at most, one hour c. O-ve blood immediately available to the Emergency Department d. Group-specific blood available within 15 minutes e. Fully cross-matched blood available within one hour.

Y



AE-302 Imaging services should be available, including initial reports available within one hour: a. 24/7 plain radiography with images available on digital PACS b. 24/7 ultrasound (within ED or from radiology) with referral guidelines for: i. Focused assessment with sonography for trauma (FAST) scan ii. Abdominal aortic aneurysm (AAA) diagnosis iii. Central venous access iv. Foreign body location c. 24/7 CT scanning with referral guidelines for head injury, stroke, pulmonary embolus, major trauma, abdominal pain. d. 24/7 access to MRI (on site or by referral) e. System of monitoring, recording and following up ‘missed’ x-rays and actions taken. This system must ensure that any ‘missed’ x-rays are identified and acted upon within locally agreed timescales. f. System for electronic transfer of images for specialist review (for example, to neurosurgery or vascular services).

N This standard was met except that the arrangements for monitoring, recording and following up missed x-rays and action taken were not robust. (There was a clinical discrepancy meeting but this would not cover 'missed' findings.) MRI was available 8am to 8pm Monday to Friday and some Saturday mornings and by referral at other times. See stroke report for issues relating to CT for patients with stroke.

AE-303 A consultant-led acute medicine service should be available on-site with a senior decision maker available for advice within 10 minutes and to review patients within 30 minutes.

Y

AE-305 A consultant-led general surgical service should be available on-site with a senior decision maker available for advice within 10 minutes and to review patients within 30 minutes. (ED & Acute Surgical Admissions only)

Y

AE-306 A consultant-led trauma and orthopaedics service should be available on-site, with a senior decision maker available for advice within 10 minutes and to review patients within 30 minutes.

Y



AE-307 Mental health services should be available, including: a. Access for advice to a mental health service Senior Decision Maker at all times. b. Appropriate initial assessment by a competent mental health practitioner within 30 minutes in urban areas and 60 minutes in rural areas. c. Appropriate initial assessment by a competent child and adolescent mental health practitioner within 30 minutes in urban areas and 60 minutes in rural areas for young people aged 16 to 18. d. Mental Health Act assessment by a Section 12 approved person within 60 minutes in urban areas and 120 minutes in rural areas. e. Mental health in-patient facility able to admit patients within one hour of decision to admit. f. Brief intervention service for people with alcohol and substance-misuse related attendance at the Emergency Department. g. Access to more specialised mental health services for children, young people and older people.

N The QS was not met for child and adolescent mental health services. Response by adult mental health services was good but was not always within the expected time limits.

AE-308 A consultant-led obstetrics and gynaecology service should, ideally, be available on-site, with a senior decision maker available for advice within 10 minutes and to review patients within 30 minutes. If this service is not on the same hospital site as the Emergency Department, there should be: a. robust pathways for the management of severe illness or injury b. ambulance by-pass agreements c. Clear arrangements for accessing advice d. procedures for rapid stabilisation and summoning retrieval teams e. procedures for dealing with common problems (see QS AE-509).

Y

AE-309 A consultant-led ENT service should, ideally, be available on-site, with a senior decision maker available for advice within 10 minutes and to review patients within 30 minutes. If this service is not on the same hospital site as the Emergency Department, there should be: a. robust pathways for the management of severe illness or injury b. ambulance by-pass agreements c. Clear arrangements for accessing advice d. procedures for rapid stabilisation and summoning retrieval teams e. procedures for dealing with common problems (see QS AE-509).

Y ENT services were not available on site but there were robust pathways and staff were aware of these.



AE-310 Allied health professional and other support staff should be available as follows: a. Physiotherapy (during normal working hours and access to advice at other times) b. Pharmacy (during normal working hours and arrangements for advice and supply of drugs at other times) c. Porters (24/7) d. Security staff (24/7) e. Cleaners (24/7).

Y A business case for additional physiotherapy and OT support was being prepared.

AE-401 Facilities meeting HBN22 should be available including: a. Resuscitation area (at least 4 bays if receiving trauma) b. Trolley area c. Ambulatory care area d. Reception and waiting area e. Rapid assessment and treatment area f. Quiet area for bereaved relatives or for confidential discussions with patients and relatives g. Clinical Decision Unit / Observation Ward (see note 1) h. Educational space i. Offices and secretarial space j. Dedicated facility for assessing patients with mental health problems k. Appropriate area to receive ambulance patients l. Viewing room.

Y Facilities are very good but there were only three resuscitation bays.

AE-404 Resuscitation drugs and equipment should be available and should be checked in accordance with Trust policy.

Y

AE-405 Facilities for ambulatory and central monitoring should be available.

Y Two 'high visibility' bays had monitoring equipment.

AE-406 Ultrasound should be immediately available to the resuscitation area.

Y

AE-407 Point of care testing for arterial blood gases, haemoglobin, electrolytes, urinalysis, glucose, lactate and pregnancy should be available.

Y A new machine had been purchased which includes lactate testing and staff were being trained in its use.

AE-408 Appropriate isolation facilities should be available. Y Three cubicles were available.

AE-409 Hospitals admitting major trauma or to which emergency patients are transferred (QS AE- & AF-508) should have a helicopter landing pad with easy access to the Emergency Department.

Y



AE-411 IT and records systems should be available. These should be: a. Linked to hospital patient administration and clinical records systems b. Capable of receiving electronic communication of data with ambulance services and general practice c. Capable of collecting activity data and generating reports with appropriately coded data.

Y There was a good medical records system and notes were usually available for ambulance patients by the time the patient arrived.

AE-501 Guidelines for reception staff on action for ‘front of the queue’ patients (QS AA-101) and patients who could consult primary care services or NHS Direct should be in use.

Y

AE-503 Guidelines on triage and initial assessment of patients should be in use. These should ensure initial assessment, including an ‘early warning score’, is undertaken by a competent healthcare practitioner within 30 minutes of the patient’s arrival in the Emergency Department. Subsequent monitoring should be based on the ‘early warning score’ assessment.

Y The 'amber' scoring system was used.

AE-505 Clinical guidelines on resuscitation and stabilisation should be in use.

Y

AE-507 The Trust policy on the care of critical care level 2/3 patients if level 2/3 care is not immediately accessible should be in use (see QS EQ-502).

N Guidelines for use in the event of a patient presenting to the Emergency Department were not all documented.

AE-508 Clinical guidelines covering direct transfer to an appropriate specialist service should be in use for, at least, each of the following services: a. Vascular services b. Burns services c. Stroke services d. Neuro-surgery services e. Spinal surgery services f. Cardiac services These guidelines should cover: a. Investigation and management of emergency patients b. Management of haemodynamically unstable patients c. Indications for seeking advice d. Indications and arrangements for emergency transfer e. Indications and arrangements for non-urgent referral f. Arrangements for transfer of cross-matched blood.

Y



AE-509 Clinical guidelines should be in use covering assessment and management of, at least: a. Infections, especially sepsis, meningitis b. Acute poisoning / drug overdose, including alcohol c. Metabolic disorders, especially diabetes d. Gastro-intestinal disorders, including GI bleeding, obstruction e. Cardiovascular disease, especially STEMI, acute cardiac failure, arrhythmias f. Venous thromboembolism, including prophylaxis, venous thrombosis and pulmonary embolism g. Respiratory disease, including asthma, COPD, infections h. Neurological disorders, including status epilepticus, stroke and TIA, subarachnoid haemorrhage, acute spinal cord compression, transient loss of consciousness i. Uro-genital disease, including acute renal failure, retention of urine, painful testis, colic j. Haematological disorders, including chronic anaemia, sickle cell crisis k. Mental health disorders, including depression, self-harm, dementia l. Head injury m. Hip fracture n. Spinal injury o. Head injury p. Pregnancy-related problems q. Trauma r. Burns and scalds s. Hand injuries.

N There were no guidelines covering respiratory assessment.

AE-510 Protocols should be in place for referral of patients to same day / next day services, including: a. Rapid access chest pain service b. Rapid access arrhythmia service c. Neuro-vascular assessment service d. Respiratory assessment service for patients with asthma and COPD e. Gastroenterology assessment service f. Hand clinic (weekdays only) g. Fracture clinic (weekdays only) h. Physiotherapy clinic (weekdays only) The protocols should cover indications for referral, investigations prior to referral, information to be sent with the patient, information to be given to patients and communication with the patient’s GP.

N There was access to a rapid chest pain service but this was not ‘next day’. There was no rapid access arrhythmia service. Neurovascular assessment was through TIA clinics and was not available at weekends. Respiratory assessment was available through the respiratory team.

AE-511 Guidelines on control of infection should be in use. Y



AE-512 Clinical guidelines should be in use covering: a. Sedation b. Antimicrobial use c. Pain management d. Management of fluids and electrolytes e. Management of acute confusional state.

Y

AE-513 In compliance with the “Saving Lives Campaign”, the principles of Care Bundles should be applied to the following High Impact Changes: No1: Central venous catheter care No2: Peripheral intravenous cannula care No4: Preventing surgical site infection No5: Care of ventilated patients No6: Urinary catheter care No7: Reducing the risk of C. Difficile.

N Written guidelines were not available.

AE-514 Guidelines, agreed with local paediatric services, should be in use covering indications for seeking advice on the care of young people aged 16 to 18.

Y

AE-515 Guidelines should be in use for directing patients to relevant health promotion and disease prevention programmes, including smoking cessation, contraception and sexual health services, and brief intervention and other support services for those with alcohol and substance misuse problems.

N Some information leaflets were available but not clear guidelines.

AE-516 In Emergency Departments with a CDU / Observation Ward, guidelines should be in use covering observation and assessment, risk stratification, investigations and admission criteria for, at least: a. Exclusion of acute coronary syndromes b. Severe sudden headache c. Renal colic d. Deep venous thrombosis / pulmonary embolus e. Syncope f. TIA assessment g. Head injury care h. Observation following alcohol intoxication i. Non-specific abdominal pain j. Management of self-harm and overdose k. Recovery from sedation l. Elderly patients requiring multi-disciplinary assessment m. Post-anaphylaxis observation n. Post-treatment of pneumothorax o. Mild to moderate asthma p. Low risk pneumonia q. Cellulitis r. Pain control after soft tissue trauma.

N/A



AE-517 Guidelines, agreed with the specialist palliative care services serving the local population, should be in use covering, the management of patients with palliative care needs.

Y

AE-599 Staff should be aware of local guidelines for end of life care.

Y

AE-603 An escalation plan to manage increased demand should be in place. This plan should include triggers and arrangements for increasing capacity.

Y

AE-604 A system should be in use for alerting and organising: a. Trauma Team (QS AC-309) b. Clinical and imaging staff for assessment of eligibility for thrombolysis (QS CE-501).

N There were good working relationships with WMAS. Links with the Wales Ambulance Service were not as good. Standby calls and trauma calls were not received from Wales Ambulance Service teams.

AE-605 Emergency Department staff should be able to speak directly to ambulance crews in order to ensure an appropriate clinical response is ready when patients arrive.

Y This QS was met but systems did not function well with the Wales Ambulance Service (see AE-605).

AE-606 A protocol on patient assessment should be in use which ensures: a. Definitive assessment has started within one hour of the patient’s arrival in the Emergency Department. b. Definitive assessment has been completed and a management plan identified, ideally within three hours of the patient’s arrival in the Emergency Department and, within four hours for all patients.

Y

AE-607 A system should be in use for acknowledging and reviewing pathology results.

Y

AE-608 A protocol should be in use covering communication with: a. patients, their carer/s and their GP b. services to which patients are being referred c. services to which patients are being transferred.

N There was no protocol covering the requirements of the standard.

AE-609 A protocol should be in use for identifying people with mental health problems, dementia or learning disabilities, violent patients, regular attenders, vulnerable adults and those nearing the end of life and for ensuring appropriate management from an early stage. The protocol should ensure, wherever possible that advance care plans are followed.

Y

AE-610 Young people aged 16 to 18 years should be offered choice of care in adult or children’s services, wherever appropriate and possible.

Y



AE-611 A protocol should be in use covering adherence with the Mental Capacity Act and the Deprivation of Liberty Safeguards.

N There was no evidence of a Trust policy covering MCA or DOLS. There was a PCT wide policy.

AE-612 The service should have structured arrangements for handover of patients at each change of responsible consultant, non-consultant medical staff, nursing staff and other staff.

N/A

AE-613 In Emergency Departments with a CDU / Observation Ward, there should be a CDU / Observation Ward operational policy covering, at least: a. Admission criteria b. Management plans, including provisional diagnosis, frequency and nature of observations, and discharge arrangements c. Frequency of review by Senior Decision-Maker d. Consultant review of all patients within 12 hours of admission e. Arrangements for liaison with social services and discharge services (QS AC-308).

N/A

AE-614 A protocol should be in use covering the management of violent and aggressive patients.

N There was no protocol but there was a local 'zero tolerance' policy.

AE-615 The service should have arrangements for liaison with falls prevention services, with the police on prevention of violence and with initiatives to reduce harm from alcohol or substance misuse.

Y

AE-616 A meeting with the ambulance service should be held at least annually to review the links with the Emergency Department and address any problems identified.

Y Monthly meetings were held.

AE-617 A meeting with local bereavement services should be held at least annually to review the links with the Emergency Department and address any problems identified.

N This did not happen but there were plans to start these meetings.

AE-618 A meeting with local Walk-in Centres, Minor Injuries Units and Urgent Care Centres should be held at least annually to review the links with the Emergency Department and address any problems identified.

Y Meetings were held. There was the potential for improving links to enhance staff training and to improve consistency between MIUs in the services offered.

AE-619 Arrangements should be in place with local mental health services for review of liaison arrangements and for addressing any problems identified.

Y Mental health services attend the monthly Directorate meetings.

AE-620 A process for ensuring action on the advice of the local Coroner should be in place.

Y



AE-701 Data should be submitted to appropriate national registers or audit programmes including: a. CEM annual audit programmes b. TARN (if accepting trauma) c. National cardiac arrest audit database.

N Data were submitted to the CEM annual audit programme but not to TARN or the national cardiac arrest audit database. TARN data were collected up to the last two years.

AE-702 There should be regular collection of data and monitoring of: a. Waiting times to see a doctor or Emergency Nurse Practitioner b. Waiting times for admission and achievement of national targets.

Y

AE-704 The services should have a rolling programme of audit of: a. compliance with evidence-based guidelines (QS AE-508/9) b. compliance with national standards on clinical documentation.

Y

AE-705 The service should have appropriate arrangements for clinical review of complaints, positive feedback, morbidity, mortality, transfers, critical incidents and ‘near misses’.

Y

AE-799 All policies, procedures and guidelines should comply with Trust document control procedures.

N Policies on the intranet were in a set format. There were several other policies which were not in this format. Some policies were out of date. Patient information was also not appropriately controlled

Back to Index


URGENT CARE – ACUTE MEDICAL AND SURGICAL ADMISSIONS ( ADMISSIONS WARD)


AF-107 There should be a system of communicating the name of the responsible consultant for the day to patients and carers.

Y In MAU the consultant name is displayed on ward and above the patient’s bed. In SAU the name of Consultant is displayed above the bed.

AF-108 Information for patients and carers should be available including, at least: a. head injury (surgical wards only) b. wounds (surgical wards only) c. pain relief d. chest infection e. asthma f. abdominal pain g. alcohol and substance misuse h. other common presenting conditions i. venous thrombo-embolism prevention j. health promotion, including smoking cessation, health eating, weight management, sexual and reproductive health, mental and emotional health and well-being. Information should cover: a. care and activities after discharge (for surgical services, this should include wound care) b. symptoms and action to take if unwell c. sources of further advice.

N There was limited information available - a,b,e,g,h, and for some of j. Some of the leaflets that were available were not version controlled.

AF-109 Information about the following services should be easily available for patients and carers: a. interfaith support b. social services c. interpreters d. advocacy services.

N There was no information about social service or advocacy services.

AF-110 Information for patients and carers about the Acute Medical / Surgical Admissions Unit should be available covering, at least: a. What patients need with them b. Visiting times c. Who will be looking after the patient (for example, staff groups, uniform colours) d. How to find out what is happening e. Who to talk to about concerns f. Moving on from the Unit.

Y There was a comprehensive leaflet.



AF -112 Patients being discharged home should be given a discharge letter. This letter should describe the condition, treatment given (if any) and future management plan. The contents of the letter should be discussed with the patient and, with the patient’s agreement, their carer/s and a copy should be sent to their GP.

Y Patients from the local groups who met with the reviewing team were not aware that this takes place.

AF-199 The service should have: a. Mechanisms for receiving feedback from patients and carers about the treatment and care they received. b. Mechanisms for involving patients and carers in decisions about the organisation of the services.

Y

AF-213 There should be a nominated lead consultant and nominated lead nurse with responsibility for ensuring implementation of the Quality Standards for Urgent Care Services relating to the Acute Medical / Surgical Admissions Unit. The lead consultant and lead nurse should undertake regular clinical work within the department.

Y

AF-214 A doctor trained in the specialty of Acute Medicine / Surgery at level ST3 or above or SAS grade 3 or above, should be available at all times and able to reach the Acute Medical / Surgical Admissions Unit within 10 minutes. This doctor must have competences in ALS.

Y The Trust had also approved a business case for the development of physicians assistants and ANPs

AF-215 An Acute Medicine / Surgery consultant, associate specialist or SAS grade 9 or above doctor should be on call at all times and able to reach the Acute Medical / Surgical Admissions Unit within 30 minutes.

Y

AF-216 There should be sufficient Acute Medicine / Surgery consultants, associate specialists or SAS grades 9 or above doctors to provide clinical cover within the Acute Medical / Surgical Admissions Unit for the expected number of patients.

Y The Trust was about to recruit two acute physicians

AF-217 Sufficient ‘Competent Clinical Decision-Makers’ (junior doctors (FY2 or CT1-3), nurse practitioners and other registered practitioners with appropriate competences should be available to maintain the flow of patients through the Unit. These staff should have appropriate competences in Acute Medicine / Surgery, including ILS.

Y

AF-218 Senior Decision-Maker and Competent Clinical Decision-Maker rotas should be organised to give reasonable continuity of care for patients.

Y



AF-219 There should be a shift leader / coordinator on each shift who has an overview of all patients and their stage of care, the flow of patients through the Unit and responsibility for liaison with bed management. The shift leader / coordinator should have significant experience in urgent care at a senior level. In busy departments the shift leader / coordinator should be supernumerary and should not have clinical responsibility.

N There was a shift leader who was not supernumerary. Reviewers were concerned that this made the role of the shift leader difficult to achieve especially as the overall the nursing staffing levels appeared low for the level of work undertaken on the unit. The Trust had plans to recruit additional nurses.

AF-220 Sufficient nursing staff and support workers should be available to maintain the flow of patients through the Unit and achieve waiting time targets for the expected number and dependency of patients. These staff should have competences appropriate for their work in the Acute Medical / Surgical Admissions Unit, including BLS.

N See concern in main report. Reviewers were also told that attendance on study days was sometimes cancelled due to poor staffing on the unit although staff were encouraged to attend training.

AF-221 Registered nursing staff should have competences in: a. ILS b. Doing a MEWS assessment, its interpretation and escalation as appropriate c. Recording an ECG d. Venepuncture e. IV drug administration f. Point of care testing g. Urinary catheterisation (male and female).

N The training records and discussion with staff would suggest that this standard was not met. Some staff had not undertaken recent training. From the rotas seen there was not always a nurse practitioner on duty.

AF-222 All healthcare support workers should have BLS and competences in acute medicine / surgery appropriate to the role they are undertaking.

N As AF-221

AF-223 At least one nurse on each shift should have enhanced skills in: a. ECG interpretation b. Cannulation c. Arterial blood gas analysis d. Swallowing screening (Acute Medicine only)

N Not all shifts were covered. There was not always a nurse practitioner on duty.

AF-224 At least one nurse per shift should have competences in the assessment and management of people with mental health problems or dementia.

N

AF-225 At least one nurse per shift should have competences in undertaking nurse-led discharge.

N The reviewers were told that nurse led discharge did not happen.

AF-226 In Units with a high dependency area, a minimum of one nurse who is studying for or has achieved a formal qualification in critical care should be available for every four level 2 patients.

N There were four HDU beds. See comment in main report.



AF-227 All healthcare professionals working in the Acute Medical / Surgical Admissions Unit should have competences appropriate to their role in: a. protection of vulnerable adults, b. recognition of the needs of vulnerable groups including young people, people with mental health problems, dementia, alcohol and substance misuse problems, or learning disabilities and older people. c. Mental Capacity Act and Deprivation of Liberty Safeguards.

N Mental health and vulnerable adults training did not appear to be taking place. There were, however, good links with the Mental Health Team.

AF-232 Staff undertaking ultrasound within the Acute Medical / Surgical Admissions Unit should have appropriate competences in undertaking this investigation.

N

AF-233 A ward clerk / administrative support should be available at all times.

N There was ward clerk cover from 08.00 to 15.30 Monday to Friday & 15.00 to 20.00 on Monday, Tuesday and Friday. Weekend cover was from 08.00 to 14.00. There was no cover outside these hours.

AF-234 There should be a training and development programme for all Acute Medical / Surgical Admissions Unit staff. The competences expected for each role should be identified and the plan for achieving and maintaining these competences described.

N A competency booklet was being developed.

AF-301 Laboratory services should be available, including: a. A system for rapid transport of pathology samples b. Availability of results within, at most, one hour c. O-ve blood immediately available to the Emergency Department d. Group-specific blood available within 15 minutes e. Fully cross-matched blood available within one hour.

Y

AF-302 Imaging services should be available, including initial reports available within one hour: a. 24/7 plain radiography with images available on digital PACS b. 24/7 ultrasound with referral guidelines for: i. Central venous access ii. Chest Drain Insertion c. 24/7 CT scanning with referral guidelines for stroke, pulmonary embolus, abdominal pain. d. 24/7 access to MRI (on site or by referral) e. System of monitoring, recording and following up ‘missed’ x-rays and actions taken. This system must ensure that any ‘missed’ x-rays are identified and acted upon within locally agreed timescales. f. System for electronic transfer of images for specialist review (for example, to neurosurgery or vascular services).

N The standard was not fully met. Not all CT radiographers were capable of doing CTPA. There was no formal system for monitoring, recording and following up missed x-rays.

MRI was available 8-8 Monday - Friday and some Saturdays and by referral at other times. Spinal cord injuries go to Bristol.

AF-304 Access to echocardiography, bronchoscopy and gastroscopy should be available at all times.

Y



AF-305 Acute Medical Admissions only: A consultant-led general surgical service should be available on-site with a senior decision maker available for advice within 10 minutes and to review patients within 30 minutes. (ED & Acute Surgical Admissions only)

Y

AF-306 A consultant-led trauma and orthopaedics service should be available on-site, with a senior decision maker available for advice within 10 minutes and to review patients within 30 minutes.

Y

AF-307 Mental health services should be available, including: a. Access for advice to a mental health service Senior Decision Maker at all times. b. Appropriate initial assessment by a competent mental health practitioner within 30 minutes in urban areas and 60 minutes in rural areas. c. Appropriate initial assessment by a competent child and adolescent mental health practitioner within 30 minutes in urban areas and 60 minutes in rural areas for young people aged 16 to 18. d. Mental Health Act assessment by a Section 12 approved person within 60 minutes in urban areas and 120 minutes in rural areas. e. Mental health in-patient facility able to admit patients within one hour of decision to admit. f. Brief intervention service for people with alcohol and substance-misuse related attendance at the Emergency Department. g. Access to more specialised mental health services for children, young people and older people.

Y The reviewers were particularly impressed with the access and response from the team. (see good practice)

AF-310 Allied health professional and other support staff should be available as follows: a. Physiotherapy (during normal working hours and access to advice at other times). Physiotherapy staff should have time allocated in the job plan for their work on the Acute Medical / Surgical Admissions Unit. b. Speech therapy (during normal working hours and access to advice at other times). c. Dietetics (during normal working hours and access to advice at other times). d. Pharmacy (during normal working hours and arrangements for advice and supply of drugs at other times) e. Porters (24/7) f. Security staff (24/7) g. Cleaners (24/7).

Y The MAU was on the first floor and therefore any security issues were managed by the porters who had undertaken conflict resolution training and would call the Police if required.



AF-402 Facilities meeting HBN4 should be available . The number of trolleys, beds and chairs should be appropriate to the needs of patients, with the ability to flex capacity for expected fluctuations in numbers and dependency of patients. Appropriate isolation facilities should be available.

Y

AF-403 Acute Medical Admissions only: A dedicated facility for assessing patients with mental health problems should be available.

N There was no dedicated facility on the MAU.

AF-404 Resuscitation drugs and equipment should be available and should be checked in accordance with Trust policy.

y

AF-405 Facilities for ambulatory and central monitoring should be available.

N There was access to ambulatory monitoring.

AF-407 Point of care testing for arterial blood gases, haemoglobin, electrolytes, urinalysis, glucose, lactate and pregnancy should be available.

Y

AF-410 Acute Medical Admissions Units only: Facilities for continuous positive airways pressure and non-invasive / non-intubated ventilation should be available.

Y

AF-411 IT and records systems should be available. These should be: a. Linked to hospital patient administration and clinical records systems b. Capable of receiving electronic communication of data with ambulance services and general practice c. Capable of receiving electronic transfer of data from the Emergency Department d. Capable of collecting activity data and generating reports with appropriately coded data.

N The IT system was linked to the hospital administration system but not capable electronic communication of data with ambulance services and general practices.

AF-412 Same sex accommodation should be available for all patients except those in high dependency areas.

Y

AF-502 Guidelines on admission to the Acute Medical / Surgical Admissions Unit should be in use. These guidelines should cover admission criteria, the process for documenting information given, alternatives to admission and process for directing elsewhere if not admitted, tracking patients expected, investigations to be done before admission and handover of clinical information.



AF-503 Guidelines on triage and initial assessment of patients should be in use. These should ensure initial assessment, including an ‘early warning score’, is undertaken by a competent healthcare practitioner within 30 minutes of the patient’s arrival in the Acute Medical / Surgical Admissions Unit.

Y

AF-504 All patients should have a clear written monitoring plan stating the frequency of observations. Monitoring should be based on the ‘early warning score’ assessment and should be no longer than four hourly.

y

AF-505 Clinical guidelines on resuscitation and stabilisation should be in use.

Y

AF-506 Guidelines on triggering referral to the critical care outreach team should be in use.

Y

AF-507 The Trust policy on the care of critical care level 2/3 patients if level 2/3 care is not immediately accessible should be in use (see QS EQ-502).

y

AF-508 Clinical guidelines covering direct transfer to an appropriate specialist service should be in use for, at least, each of the following services: a. Vascular services b. Stroke services c. Cardiac services These guidelines should cover: a. Investigation and management of emergency patients b. Management of haemodynamically unstable patients c. Indications for seeking advice d. Indications and arrangements for emergency transfer e. Indications and arrangements for non-urgent referral f. Arrangements for transfer of cross-matched blood.

y



AF-509 Clinical guidelines should be in use covering assessment and management of, at least: Acute Medical and Surgical Admissions Units a. Infections, especially sepsis, meningitis b. Gastro-intestinal disorders, including GI bleeding, obstruction c. Venous thromboembolism, including prophylaxis, venous thrombosis and pulmonary embolism d. Uro-genital disease, including acute renal failure, retention of urine, painful testis, colic e. Pregnancy-related problems Acute Medical Admissions Units only f. Acute poisoning / drug overdose, including alcohol g. Metabolic disorders, especially diabetes h. Cardiovascular disease, especially STEMI, acute cardiac failure, arrhythmias i. Respiratory disease, including asthma, COPD, infections j. Neurological disorders, including status epilepticus, stroke and TIA, subarachnoid haemorrhage, acute spinal cord compression, transient loss of consciousness k. Haematological disorders, including chronic anaemia, sickle cell crisis l. Mental health disorders, including depression, self-harm, dementia Acute Surgical Admissions Units only m. Limb ischaemia n. Pancreatitis o. Post-operative haemorrhage p. Upper abdominal pain q. Wound infection and dehiscence.

N This QS was met by medicine but not by the surgical unit as the surgical guidelines were not available (m to q). The Trust had plans to review all medical and surgical guidelines from August 2010.

AF-510 Protocols should be in place for referral of patients to same day / next day services, including: a. Rapid access chest pain service b. Rapid access arrhythmia service c. Neurovascular assessment service d. Respiratory assessment service for patients with asthma and COPD e. Gastroenterology assessment service f. Physiotherapy clinic (weekdays only) The protocols should cover indications for referral, investigations prior to referral, information to be sent with the patient, information to be given to patients and communication with the patient’s GP.

N There was access to a rapid chest pain service but this was not ‘next day’. There was no rapid access arrhythmia service. Neurovascular assessment was through TIA clinics and was not available at weekends. Respiratory assessment was available through the respiratory team.

AF-511 Guidelines on control of infection should be in use. Y



AF-512 Clinical guidelines should be in use covering: a. Sedation b. Antimicrobial use c. Pain management d. Management of fluids and electrolytes e. Management of acute confusional state f. Pre-operative management (acute surgical admissions only).

N There were no guidelines for the management of fluids and electrolytes and the management of acute confusional state.

AF-513 In compliance with the “Saving Lives Campaign”, the principles of Care Bundles should be applied to the following High Impact Changes: 1: Central venous catheter care 2: Peripheral intravenous cannula care 4: Preventing surgical site infection (Acute Surgical Admissions only) 5: Care of ventilated patients 6: Urinary catheter care 7: Reducing the risk of C. Difficile.

Y

AF-514 Guidelines, agreed with local paediatric services, should be in use covering indications for seeking advice on the care of young people aged 16 to 18.

N Written guidelines were not available. However, agreed there were arrangements for discussion with paediatricians on an individual case basis.

AF-515 Guidelines should be in use for directing patients to relevant health promotion and disease prevention programmes, including smoking cessation, contraception and sexual health services, and brief intervention and other support services for those with alcohol and substance misuse problems.

N There was very good information for alcohol services and information on smoking cessation.

AF-517 Guidelines, agreed with the specialist palliative care services serving the local population, should be in use covering, the management of patients with palliative care needs.

Y

AF-599 Staff should be aware of local guidelines for end of life care.

Y



AF-601 The Unit should have an operational policy covering, at least: a. Arrangements for giving advice to GPs and recording the advice given. b. Admission of patients from the Emergency Department within one hour of the decision to admit. c. Ensuring all patients have an estimated date of discharge as part of their initial management plan (QS AF-505) d. Acute Medical Admissions: Consultant review of all patients within 12 hours of admission. Acute Surgical Admissions: Consultant review of all patients within 24 hours of admission. e. Arrangements for the care of patients aged 16 to 18 years old, which should include flexible visiting, care in a side room. f. Notification to maternity services of admission of a pregnant woman (16+ weeks gestation) with a non-obstetric problem g. Arrangements for liaison with social services and discharge services (QS AC-308) h. Arrangements for follow up clinics.

N There was no policy covering a,b&e

AF-602 A protocol on patient assessment should be in use which ensures: a. Definitive assessment has started within four hours of the patient’s arrival in the Acute Medical / Surgical Admissions Unit b. Definitive assessment has been completed within 12 hours of the patient’s arrival in the Acute Medical / Surgical Admissions Unit.

N The SOP did not cover this.

AF-603 An escalation plan to manage increased demand should be in place. This plan should include triggers and arrangements for increasing capacity.

Y

AF-607 A system should be in use for acknowledging and reviewing pathology results.

Y

AF-608 A protocol should be in use covering communication with: a. patients, their carer/s and their GP b. services to which patients are being referred c. services to which patients are being transferred.

N There was no protocol covering the requirements of the standard.

AF-609 A protocol should be in use for identifying people with mental health problems, dementia or learning disabilities, violent patients, regular attenders, vulnerable adults and those nearing the end of life and for ensuring appropriate management from an early stage. The protocol should ensure, wherever possible that advance care plans are followed.

Y



AF-611 A protocol should be in use covering adherence with the Mental Capacity Act and the Deprivation of Liberty Safeguards.

N There was no evidence of a Trust policy covering MCA or DOLS. There was a PCT wide policy.

AF-612 The service should have structured arrangements for handover of patients at each change of responsible consultant, non-consultant medical staff, nursing staff and other staff.

Y

AF-614 A protocol should be in use covering the management of violent and aggressive patients.

Y

AF-615 The service should have arrangements for liaison with falls prevention services, with the police on prevention of violence and with initiatives to reduce harm from alcohol or substance misuse.

Y

AF-616 A meeting with the ambulance service should be held at least annually to review the links with the Acute Medical / Surgical Admissions Unit address any problems identified.

Y

AF-617 A meeting with local bereavement services should be held at least annually to review the links with the Acute Medical / Surgical Admissions Unit and address any problems identified.

N An annual meeting with local bereavement services had not yet taken place.

AF-619 Arrangements should be in place with local mental health services for review of liaison arrangements and for addressing any problems identified.

Y There were good links with the Mental Health Team (see also the Good Practice section of the report)

AF-620 A process for ensuring action on the advice of the local Coroner should be in place.

Y

AF-703 There should be regular collection of data and monitoring of target times for: a. admission of patients from the Emergency Department (QS AF-601) b. start and completion of definitive assessment (QS AF-602).

N There was no evidence available

AF-704 The services should have a rolling programme of audit of: a. compliance with evidence-based guidelines (QS AF-509) b. compliance with national standards on clinical documentation.

N A Trust-wide audit programme was available but this did not cover surgical aspects of care as these guidelines were not available (QS AF-509).

AF-705 The service should have appropriate arrangements for clinical review of complaints, positive feedback, morbidity, mortality, transfers, critical incidents and ‘near misses’.

Y



AF-799 All policies, procedures and guidelines should comply with Trust document control procedures.

N Policies on the intranet were in a set format. There were several other policies which were not in this format.

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URGENT CARE – COMMISSIONING


AZ-101 Information should be available regularly for the public about urgent care services available, including NHS Direct, including on-line services, and self-care options, and the indications for accessing different services.

Y

AZ-102 A programme of community awareness should be run, specifically targeted at schools and young people, to encourage appropriate use of urgent care services.

N This was not a priority group for targeting information for NHS Herefordshire.

AZ-501 The local health economy Urgent Care Group should have agreed the guidelines on admission of patients to the Acute Medical / Surgical Admissions Unit/s.

Y

AZ-601 The local health economy Urgent Care Group should have agreed the patient groups or conditions who should be cared for by different services. The matrix of services and patient groups / conditions should be explicit about: a. any ambulance by-pass arrangements, including arrangements for patients with suspected: i. Vascular emergencies ii. Major burns iii. Major trauma iv. Hyper-acute stroke v. STEMI vi. Patients needing neuro-surgery b. direct referrals to community services, mental health services, social services, district nurses, intermediate care services and community teams / matrons.

N There was no formal matrix. Some pathways are clear but some staff were unaware of the options available, especially those relating to admission avoidance.

AZ-701 A local health economy Urgent Care Group should meet regularly involving representatives from primary care services, Emergency Department, Acute Medical Admissions Unit (or equivalent), Acute Surgical Admissions Unit (or equivalent), ambulance service, social services, intermediate care services and mental health services. There should be either patient members of the Group or formal mechanisms for ensuring public and patient involvement.

Y



AZ-702 The local health economy Urgent Care Group should regularly monitor: a. Usage of different services and variations by general practice b. Any delays in transfer of patients to appropriate care settings c. Achievement of agreed quality and outcome indicators for each service.

Y

AZ-703 The local health economy Urgent Care Group should agree an annual health economy-wide plan for urgent care services. This plan should cover: a. Previous years’ activity, quality (including achievement of Quality Standards), outcomes and funding levels for each urgent care service b. Expected activity, quality (including achievement of Quality Standards), outcomes and funding levels for each urgent care service for the forthcoming year c. Progress against the health-economy-wide actions in the previous plan d. Agreed health-economy-wide actions to improve urgent care services in the forthcoming year.

N The health economy was actively working towards achievement of this QS through its ‘Transformation Board’.

AZ-704 The local health economy Urgent Care Group should have agreed arrangements for sharing information about vulnerable groups of the population who are likely to attend urgent care services regularly or who are approaching the end of life.

N There was an Information-sharing agreement and an over-arching information sharing policy between PCT, HHT and Council, but this was not specific to urgent care, covering those who are likely to attend urgent care services regularly.

AZ-705 The local health economy Urgent Care Group should have agreed arrangements for advanced care planning for vulnerable groups of the population who are likely to attend urgent care services regularly or who are approaching the end of life and ensuring that all urgent care services have access to the advance care plans.

N Some work on advanced care planning and health economy-wide training had already taken place. Further work was planned as part of the proposed integration with community services.

AZ-706 The local health economy Urgent Care Group should ensure that information is circulated regularly to primary care services covering at least: a. Access to senior decision makers (QS AC-306) b. Same day / next day services (QS AC-305).

N Some information was available

AZ-708 The local health economy Urgent Care Group should have considered whether any joint audits of urgent care across providers of services are needed and, if so, should ensure these audits are undertaken and agreed actions are implemented.

N There was no evidence of consideration of joint audits.

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STROKE (ACUTE PHASE) AND TIA - PRIMARY CARE


CA-101 Information should be offered to all patients referred to the Neuro-Vascular Assessment Service covering, at least: a. Brief description of the condition b. Arrangements for neuro-vascular assessment with clear indication of timescales c. What to do if symptoms recur d. Advice not to drive until the neuro-vascular assessment e. Availability of further information, including through NHS Direct.

N Information was only available for a, e.

CA-501 Guidelines on the primary care management of patients with suspected stroke should be in use covering at least: a. Assessment of patients with suspected stroke, including the use of a validated tool such as FAST b. Immediate management c. Referral information, including date and time of onset of symptoms and date and time of first contact.

Y

CA-502 Guidelines on the primary care management of patients with suspected TIA should be in use covering at least: a. Assessment of patients with suspected TIA, including undertaking an ABCD2 score b. Immediate management, including indications for aspirin or alternative anti-platelet agent c. Indications for referral to the Neuro-Vascular Assessment Service within 24 hours for high risk (currently ABCD2 score of 4 and above, multiple TIAs or minor stroke) or within seven days for low risk patients d. Referral information, including date and time of onset of symptoms, and date and time when symptoms resolved e. Information to be given to patients and carers referred to the Neuro-Vascular Assessment Service (QSCA-101) f. Indications for admission g. Arrangements for referral to lifestyle management services h. Arrangements for one month follow up of well-being, cognitive impairment and impact on work.

N A good stroke pathway was available, though it was not clear if this was available in primary care services.


STROKE (ACUTE PHASE) AND TIA – ACUTE TRUST


CC-201 There should be a nominated lead consultant and nominated lead nurse / allied health professional with responsibility for ensuring implementation of the Quality Standards for Services for People with Stroke (Acute Phase) and TIA.

Y

CE-501 Clinical guidelines should be in use in the Emergency Department covering: Patients with suspected stroke a. Assessment of patients with suspected stroke using ROSIER b. Immediate management c. Transfer of patients to an appropriate Thrombolysis Centre or Stroke Unit (QSAE-508) d. Referral information, including date and time of onset of symptoms, and date and time of first contact. Patients with suspected TIA a. Assessment, including undertaking an ABCD2 score b. Immediate management, including indications for aspirin or alternative anti-platelet agent c. Indications for referral to the Neuro-Vascular Assessment Service within 24 hours for high risk (currently ABCD2 score of 4 and above, multiple TIAs or minor stroke) or within seven days for low risk patients d. Referral information, including date and time of onset of symptoms and date and time when symptoms resolved e. Indications for admission f. Information to be given to patients and carers (QSCZ-102) if the patient is to be discharged before their neuro-vascular assessment.

N The service had a singlehanded consultant and therefore this standard was difficult to meet. The Trust will need to consider how a 24hour response can be provided for high risk patients admitted when the consultant is on leave.

CN-101 Information should be offered to all patients and carers covering at least: a. Stroke, its causation and potential impact b. Investigations and treatment options available c. Research trials available (if any) d. Driving advice and DVLA notification e. Promoting good health, including diet, exercise and smoking cessation f. Stroke service staff and facilities available g. Who to contact with queries or for advice h. Symptoms and action to take if become unwell i. Access to benefits advice j. Support groups available k. Expert Patients Programme (if available) l. How to influence local services (QSCN-199) m. Where to go for further information, including NHS Direct and useful websites.

Y



CN-102 Information about the following services should be easily available for patients and carers: a. Interfaith support b. Social services c. Interpreters d. Advocacy services.

N The standards was met apart from information about social services

CN-103 Information for patients and carers about the Stroke Service should be available covering, at least: a. What patients need with them b. Visiting times c. Who will be looking after the patient (for example, staff groups, uniform colours) d. How to find out what is happening e. Facilities for relatives f. Who to talk to about concerns g. Moving on from the Unit.

N All the information was seen apart from (g).

CN-105 Patients being discharged home should be given a discharge letter. This letter should describe the condition, treatment given (if any) and future management plan. The contents of the letter should be discussed with the patient and, with the patient’s agreement, their carer/s and a copy should be sent to their general practitioner.

Y

CN-199 The Stroke Service should have: a. Mechanisms for receiving feedback from patients and carers about the treatment and care they receive. b. Mechanisms for involving patients and carers in decisions about the organisation of the services.

Y Surveys were undertaken. Reviewers would suggest that the department should consider explicit action plans to ensure that the survey results contribute to a process of continuous improvement.

CN-201 Thrombolysis Centres: A senior healthcare professional with specialist training and experience in stroke diagnosis and stroke thrombolysis should be available on site at all times.

N The Trust was aware of the need to develop a 24/7 service.

CN-202 Thrombolysis Centres: A consultant stroke specialist should be available at all times.

N A Stroke Consultant was only available Monday to Friday 9am to 5pm.

CN-203 Stroke Units: A consultant stroke specialist should be available on weekdays. A senior member of the stroke team should be available on all days when emergency admissions are accepted and the following day.

N A Stroke Consultant was only available Monday to Friday 9am to 5pm. There was no dedicated specialist registrar, and no consistent weekend cover.



CN-204 An Acute Stroke Unit should be available, staffed by nurses and HCAs with appropriate competences in care of patients with stroke. The competence framework should cover at least: a. Management of acutely ill and deteriorating patients b. High dependency care c. Swallowing screening d. Complications associated with stroke thrombolysis (Thrombolysis Centres only) e. Mobilisation f. Tube feeding.

Y The Stroke Unit used the online STARS competency framework. Competence records were kept in the professional development department.

CN-205 At least one healthcare professional on each shift should have competences in swallowing screening.

Y 60% of staff were trained to do swallowing assessments, and more training was planned.

CN-206 At least one nurse on each shift should have competences in the management of acutely ill and deteriorating patients.

N This QS was not yet met, however, there was a plan to address this.

CN-207 A member of staff with responsibility for coordination and for liaison with other services should be available and there should be arrangements for cover for this role.

N There was no coordinator. The reviewers were told that this was under review within the countywide stroke pathway work.

CN-208 There should be a training and development plan for all members of the Stroke Team. The competences expected of each role should be identified and the plan for achieving and maintaining these competences described.

Y

CN-301 CT scanning should be available on-site at all times. The service should be staffed by healthcare professionals with training and expertise in performing and interpreting brain CT scans and should meet The Royal College of Radiologists Standards for quality assurance of CT.

Y The process to request at CT scan out of hours had many steps. The development of a protocol might help to streamline this process and increase the time to access. This should allow with 24/7 scanning to be achieved for more patients.

CN-302 The following services should be available daily: a. Physiotherapy b. Speech and language therapy (for both swallowing assessment and communication) c. Occupational Therapy

N There was access to all services during normal week-day hours although only 0.1 wte speech and language therapist time was available. There was only a respiratory service available at weekends.

CN-303 The following services should be available for patients with stroke: a. Dietetics (including staff with competences in nutritional screening) b. Psychological support c. Social work.

N There was no access to psychological support. Social work support was available for patients with stroke, though no dedicated sessions due to the limited numbers of stroke patients.



CN-304 Level 3 critical care facilities should be available on the same hospital site.

Y

CN-501 Clinical guidelines on the management of patients with stroke should be in use covering: a. Clinical assessment, including assessment of cognitive and perceptive problems b. Choice of imaging, including indications for CT, MRI, carotid Doppler and more complex imaging investigations c. Indications for thrombolysis or early anticoagulation treatment d. Other investigations e. Pharmacological treatment, including aspirin or alternative anti-platelet agent f. Intensity of daily therapy g. Indications and arrangements for referral to vascular services for consideration of carotid endarterectomy h. Indications and arrangements for referral to neuro-surgery i. Indications for referral to critical care j. Indications for referral to lifestyle management services (dietician, smoking cessation, psychology).

N There were no guidelines covering a, d, or j although in practice nurses do complete MUST and BMI scores. Reviewers were impressed with the progress the team has made so far with the development of other guidelines.

CN-502 Thrombolysis Centres: A thrombolysis protocol should be in use covering: a. Delivery and management of thrombolysis b. Management of post-thrombolysis complications.

N There was a thrombolysis protocol but this did not cover the management of post-thrombolysis complications.

CN-503 Clinical guidelines should be in use covering the immediate management of patients with: a. Intracerebral haemorrhage b. Sub-arachnoid haemorrhage c. Arterial dissection d. Central venous thrombosis.

N There were no guidelines covering a or d,

CN-504 Clinical guidelines should be in use covering the management of: a. Hypertension b. Obesity c. High cholesterol d. Atrial fibrillation e. Diabetes f. Fever

N The standard was nearly met. A clinical guideline covering the management of obesity had yet to be developed.



CN-505 The following protocols should be in use: a. Recognition of deteriorating patients and transfer to intensive care b. Provision of high dependency care, including communication with critical care services c. Prevention and management of venous thrombosis d. Nutrition and feeding, including tube feeding e. Mobilisation f. Physiological and neurological monitoring.

Y

CN-506 Discharge planning guidelines should be in use covering, at least: a. Discharge to Stroke Unit closer to the patient’s home (Thrombolysis Centres only) b. Discharge to stroke rehabilitation facility c. Discharge home with support from specialist stroke rehabilitation services d. Communication with the patient’s GP.

Y

CN-598 A protocol on driving advice should be in use, covering establishing the type of licence and giving appropriate advice on DVLA notification.

Y

CN-599 The stroke service should be aware of local guidelines for end of life care.

Y

CN-601 An alert system should be in use which ensures rapid availability of clinical and imaging staff for assessment of eligibility for thrombolysis.

Y The ambulance service alerted the Emergency Department.



CN-602 An operational policy should be in use which ensures: a. Brain imaging for urgent patients, including those where thrombolysis is being considered, within 30 minutes of admission and, at the latest, within 60 minutes of admission b. Thrombolysis within 60 minutes of admission in appropriate patients (Thrombolysis Centres only) c. Brain imaging for all patients, within four hours of admission and, at the latest, within 24 hours of admission d. Swallowing screening within four hours of admission and prior to administration of any drinks, food or oral medication e. Specialist swallowing assessment within 24 hours of admission (if indicated on admission screening) f. Rehabilitation assessment by physiotherapy, speech and language therapy and occupational therapy (if required) within 24 hours of admission g. Assessment by other members of the specialist rehabilitation team (QSCN-303), if required, within five days of admission h. Referral for carotid endarterectomy within one week of onset of symptoms, if indicated i. Care plans are in place for all patients and reviewed regularly.

N There was no operational policy in use covering the requirements of the standard.

CN-603 A ward round or review of all patients by a senior member of the stroke team should take place daily.

N There was only one Stroke Consultant and no Specialist Registrar

CN-604 A multi-disciplinary team meeting to review the care of patients with stroke should be held at least weekly involving at least: a. Stroke specialists b. Stroke coordinator (QSCN-207) c. Rehabilitation services (QSCN-302 & CN-303).

N There was no MDT meeting as there was no stroke coordinator and limited specialist in-patient rehabilitation provision.

CN-605 A neuro-radiology multi-disciplinary team meeting should be held at least weekly.

N Occasional meetings did occur but were not formalised or at the expected frequency.

CN-609 Arrangements should be in place for multi-disciplinary discussion of patients’ suitability for surgery involving a stroke specialist, radiologist, vascular surgeon and stroke coordinator or lead nurse.

N The vascular surgeon did not take part in the MDT but saw patients separately.

CN-701 The service should have a system of monitoring time from onset of symptoms and progress through the patient pathway for all patients.

Y



CN-702 There should be regular collection of the national data set and monitoring of activity and outcome indicators.

Y

CN-703 The service should have an annual programme of audit of compliance with evidence-based guidelines.

Y

CN-704 The service should have arrangements for review of complaints, positive feedback, morbidity, mortality and critical incidents. This should include review of patients where thrombolysis was indicated but not administered within three hours of onset of symptoms.

Y

CN-705 The service should produce an annual report summarising activity, compliance with quality standards and clinical outcomes. The report should identify actions required to meet expected quality standards and progress since the previous year’s annual report.

N/A It was less than a year since the WMQRS Quality Standards were finalised and so this QS is not yet applicable. However the team had produced annual reports in the past and future reports will now cover the requirements of the standard

CN-706 The service should be an active member of the West Midlands Stroke Research Network.

Y

CN-707 The service should offer an educational session on the assessment of patients with stroke to local GPs at least annually.

Y

CN-708 Thrombolysis Centres: The service should coordinate an educational session for referring Stroke Units on the assessment and treatment of patients with stroke at least annually. This session should include: a. Review of the care of patients where thrombolysis was indicated but not administered within three hours of onset of symptoms. b. Review of arrangements for discharge of patients to local Stroke Units.

N/A There were no referring Stroke Units

CN-709 Stroke Units: The service should participate in the educational session run by the Thrombolysis Centre to which patients are usually referred.

N/A There were no referring Stroke Units

CN-799 All policies, procedures and guidelines should comply with Trust document control procedures.

N The documents should be reviewed to ensure that they are current and have take into account latest national guidance.



CP-101 Information should be offered to all patients with a confirmed TIA covering at least: a. Transient Ischaemic Attack, its causation and potential impact b. Investigations and treatment options available c. Research trials available (if any) d. Driving advice and DVLA notification e. Promoting good health, including diet, exercise and smoking cessation f. Symptoms and action to take if become unwell g. Follow-up arrangements h. Who to contact with queries or for advice i. How to influence local services (QSCP-199) j. Where to go for further information, including NHS Direct and useful websites.

Y

CP-102 All patients with a confirmed TIA should have their management plan discussed with them. Patients should be offered a written, individual management plan. Arrangements should be in place to ensure a copy of this plan is received by the patient’s GP within one week of the neuro-vascular assessment.

Y The reviewers were impressed with the quality and comprehensive nature of the TIA management plan.

CP-103 Information for patients about interpreter services should be available.

Y

CP-199 The Neuro-Vascular Assessment Service should have: a. Mechanisms for receiving feedback from patients and carers about the treatment and care they receive. b. Mechanisms for involving patients and carers in decisions about the organisation of the services.

Y

CP-201 A Neuro-Vascular Assessment Service should be available daily with at least: a. A healthcare professional who is a member of the stroke team and has competences in neurovascular assessment b. Ultrasound duplex devices and a member of staff with competences in vascular ultrasound c. A consultant stroke physician available for advice.

N a) There was a single handed technician b) Ad hoc cover from visiting neurologist c) Single stroke consultant

CP-301 MRI / MRA with diffusion weighted imaging and gradient echo sequences should be available within 24 hours for patients at high risk of subsequent stroke and within seven days for those at lower risk. CT / CTA should be available for patients where MRI is contra-indicated.

N MRI/MRA with gradient echo but not diffusion was available Monday - Friday (8-8) but not currently at weekends. CTA was not available with current scanner. CT scans available within 24hrs and available 24/7 but referral processes were not robust.

CP-302 Access to lifestyle management services, including dietician, smoking cessation and psychology services, should be available.

N No psychology support was available. Other aspects of the QS were met.



CP-501 Clinical guidelines should be in use within the Neuro-Vascular Assessment Service covering: a. Clinical assessment b. Choice of imaging, including indications for carotid Doppler, CTA and MRA c. Other investigations, including blood tests, echo and 24 hour ECG d. Pharmacological treatment, including initiation of aspirin, statins and blood pressure management (see note 2) e. Indications for admission f. Indications for referral to lifestyle management services (dietician, smoking cessation, psychology) g. Indications for referral to vascular services for consideration of carotid endarterectomy h. Indications for referral to cardiology services, including arrhythmia services. i. Arrangements for one month follow up of well-being, cognitive impairment and impact on work (if undertaken by Neuro-Vascular Assessment Service).

N Guidelines were in development

CP-598 A protocol on driving advice should be in use, covering establishing the type of licence and giving appropriate advice on DVLA notification.

Y

CP-609 Arrangements should be in place for multi-disciplinary discussion of patients’ suitability for surgery involving, at least, a stroke physician, radiologist and vascular surgeon.

N See comments at CN605/609

CP-701 The service should offer an educational session on the assessment of TIA to local general practitioners at least annually.

Y

CP-702 There should be regular collection of data and monitoring of activity and outcome indicators.

Y

CP-703 The service should have an annual programme of audit of compliance with evidence-based guidelines.

N

CP-704 The service should have arrangements for review of complaints, positive feedback, morbidity, mortality and critical incidents.

N The review of issues relating to TIAs were not included in these meetings

CP-705 The service should produce an annual report summarising activity, compliance with quality standards and clinical outcomes. The report should identify actions required to meet expected quality standards and progress since the previous year’s annual report.

N/A It was less than a year since the WMQRS Quality Standards were finalised and so this QS was not yet applicable. However the team had produced annual reports in the past and future reports will now cover the requirements of the standard



CP-799 All policies, procedures and guidelines should comply with Trust document control procedures.

N The documents should be reviewed to ensure that they are current and have take into account latest national guidance.

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STROKE AND TIA – COMMISSIONING


CZ-101 Information should be available for the public on recognising and identifying the symptoms of stroke and TIA, such as FAST, and action to take.

Y

CZ-102 Information for patients referred to Neuro-Vascular Assessment Services should be agreed and distributed to all local GPs, Walk-in Centres, Urgent Care Centres, Minor Injuries Units, Emergency Departments and Acute Medical Admissions Units.

N Not all the information was available or had been distributed. The information available at the time of the visit was of a good standard.

CZ-501 Guidance should be agreed and distributed to all primary care services covering at least: a. Assessment of patients with suspected stroke, including the use of a validated tool such as FAST b. Immediate management c. Referral information, including date and time of onset of symptoms and date and time of first contact.

Y

CZ-502 Guidance should be agreed and distributed to all primary care services covering at least: a. Assessment of patients with suspected TIA, including undertaking an ABCD2 score b. Immediate management, including indications for aspirin or alternative anti-platelet agent c. Indications for referral to the Neuro-Vascular Assessment Service within 24 hours for high risk (currently ABCD2 score of 4 and above, multiple TIAs or minor stroke) or within seven days for low risk patients d. Referral information, including date and time of onset of symptoms and date and time when symptoms resolved e. Information to be given to patients and carers referred to the Neuro-Vascular Assessment Service (QSCZ-101) f. Indications for admission g. Arrangements for referral to lifestyle management services h. Arrangements for one month follow up of well-

N Some guidance and information was available. Neurovascular assessment within 24hrs for high risk patients had not yet been established.



being, cognitive impairment and impact on work.

CZ-601 PCTs should have agreed the configuration of the following services for their population: a. Neuro-Vascular Assessment Services b. Stroke Units c. Thrombolysis Centres.

N A county-wide review of stroke services was in progress at the time of the visit. Implementation of a thrombolysis pathway 7 days a week will be part of this work.

CZ-701 PCTs should have agreed the action plan resulting from the Stroke Service Annual Report (QSCN-705).

N/A It was less than a year since the WMQRS Quality Standards were finalised and so this QS was not yet applicable.

CZ-702 PCTs should have agreed the action plan resulting from the Neuro-Vascular Assessment Services Annual Report (QSCP-705).

N/A It was less than a year since the WMQRS Quality Standards were finalised and so this QS was not yet applicable

CZ-703 PCTs should ensure that educational sessions for general practitioners in the management of patients with stroke and TIA take place at least annually.

Y


CRITICAL CARE


EC-201 Lead consultant and lead nurse A nominated lead consultant and lead nurse who also provide critical care services should be responsible for critical care services within the Trust.

Y

EC-501 Occupancy of critical care unit/s Average bed occupancy in units providing level 2 and 3 critical care should not normally exceed 85%.

N Occupancy was regularly 85 to 90%.

EC-701 Trust-wide critical care group Each Trust should have a critical care delivery group or equivalent involving at least: a. the lead consultant and lead nurse for each critical care area b. a representative of the Outreach Team c. member of the Trust Executive Board responsible for critical care.

N There were plans for a group to be established.

EC-702 Critical incident reporting As part of the Trust-wide system, there should be a mechanism for analysing critical incidents. This mechanism should involve critical care unit/s and the outreach team.

Y

EC-703 Annual analysis of services Within the last year the Trust should have undertaken an annual analysis of services, including: a. night-time discharges b. non-clinical transfers c. hours of level 2 and 3 care in inappropriate settings d. time when one bed is available to receive a level 3 patient e. occupancy levels f. workload of outreach team g. future plans for service developments.

Y

EC-704 Annual analysis of services – action plan The annual analysis of services should have been discussed at the Trust critical care delivery group (or equivalent) and an agreed action plan developed.

N See EC-701

EC-705 Hospital bed management There should be clear links between the critical care unit and the hospital bed management system, including escalation procedures.

Y



EC-706 Satisfaction survey A survey of patients’ and/or relatives’ satisfaction with the Trust’s critical care services should have been undertaken, discussed at the Trust-wide critical care delivery group (or equivalent) and at least one action agreed.

Y

EC-799 Document control All policies, procedures and guidelines should comply with Trust document control procedures.

Y

EN-101 Pre-admission Arrangements should be in place for offering pre-admission visiting, leaflets or videos for patients and relatives prior to relevant elective admissions.

N The arrangements for elective admissions did not include information about critical care.

EN-102 Admission (1) For admissions, relatives should, where possible, be welcomed by a member of staff within 15 minutes of their arrival in the unit and given a brief summary of what may happen in the next two hours.

Y

EN-103 Admission (2) A doctor and/or nurse should, where possible, discuss the patient’s condition with the family within two hours of their arrival in the unit. This discussion should be documented in the patient’s notes.

Y



EN-104 Information Culturally sensitive information should be available for families covering at least: a. admission b. organisation of the unit, including availability of single sex facilities c. direct telephone number(s) d. parking e. visiting arrangements f. facilities for making drinks and light refreshments g. accommodation and facilities for overnight stay h. ‘hotel’ charges i. facilities for children and people with disabilities who are visiting j. how to contact the unit k. usual arrangements for communication about the patient’s condition l. how to arrange a discussion with a doctor about the patient’s condition m. availability of interpreters n. involvement of families in care, including participation in the delivery of care and presence during interventions o. discharge p. follow-up arrangements, including a contact number for advice q. access to benefits advice and social services. r. availability of other support services (for example, chaplains, help with care of relatives and pets) s. useful websites, support groups and other sources of information.

N This QS was met except for k, l, n, p, q and r.

EN-105 Refreshments Relatives should be able to access drinks and light refreshments within the hospital at all times.

Y

EN-106 Facilities for overnight stay Access to residential accommodation with at least one bedroom for relatives from the unit should be available. This should include telephone and shower facilities and access for people with disabilities.

Y

EN-107 Patient communication Appropriate communication aids should be available to enable patients to communicate with their family and with staff.

Y

EN-201 Nurse staffing (1) The unit’s nursing establishment and nursing rosters should be appropriate to the anticipated number of level 2 and level 3 patients.

Y Nursing staff worked flexibly to meet fluctuations in the number and dependency of patients.



EN-202 Nurse staffing (2) In units with 6 or more beds, there should be at least one supernumerary nurse in charge on each shift.

N/A

EN-203 Nurse staffing: continuity of care Nursing staff allocations should be organised to give reasonable continuity of care and flexibility between care of level 2 and level 3 patients.

Y

EN-204 Nurse staffing: monitoring Arrangements should be in place for monitoring and reviewing sickness, vacancy and turnover levels of nursing staff providing bedside patient care

Y Reviewers did not see any records but were told that this was being maintained.

EN-205 Nurse training (1) All nursing staff should either have or be working towards competences in critical care appropriate to their role within the unit.

Y

EN-206 Nurse training (2) On each shift there should be a minimum of one nurse who is studying for or has achieved a formal qualification in critical care for every four level 2 patients / every two level 3 patients.

Y

EN-207 Administrative and clerical support Administrative and clerical support should be adequate for the number of beds and the usual level of care provided.

Y

EN-208 Professional development team There should be a professional development team responsible for continuing professional development of nursing, HCAs and ancillary staff providing critical care services. This team should be involved in delivering level 1, 2 and 3 programmes of education, training and development.

N Level 3 training was provided externally. The arrangements for ensuring all appropriate staff had level 1 and 2 competences were not robust. There was no professional development team and no alternative mechanism for achieving this QS.

EN-209 Rotation Suitably qualified nurses on the critical care unit should have the opportunity to rotate into the outreach team.

N There was no formal rotation of nursing staff



EN-210 Consultant staffing: weekday daytime On weekdays there should be at least 1 ITU trained or experienced consultant every 8 beds usually providing level 3 care / every 16 beds usually providing level 2 care. This consultant’s sole role for the day should be the care of critically ill patients and s/he should not have responsibilities elsewhere. An ITU trained or experienced consultant is someone who has a CST/CCST or equivalent in critical care or someone who undertakes regular day-time sessions on the critical care unit. All ITU trained and experienced consultants should be undertaking regular CPD of relevance to their work on the critical care unit.

Y

EN-211 Consultant staffing: evenings, nights and weekends There should be at least one ITU trained or experienced consultant available for each unit at evenings, nights and weekends.

N Night and weekend cover was by general anaesthetists. It was not clear that CPD of relevance to their work on the ICU was being undertaken.

EN-212 Other medical staffing There should be at least 1 non-consultant doctor dedicated to critical care services for every 8 beds usually providing level 3 care / every 16 beds usually providing level 2 care. This doctor’s sole role for the day should be the care of critically ill patients and s/he should not have responsibilities elsewhere.

Y

EN-213 Other medical staff: training All non-consultant medical staff should have or be working towards competences appropriate to their role on the unit. All non-consultant medical staff should be undertaking regular, relevant CPD.

Y

EN-214 Medical staff: continuity of care Medical staff rotas should be organised to give reasonable continuity of care.

Y

EN-215 Induction All new critical care staff should have induction programmes. For medical staff, this induction must include their responsibilities in relation to the outreach team.

Y

EN-216 Training All staff employed in the critical care unit should have an assessment of their training needs at induction and annually thereafter as part of their annual appraisal.

Y



EN-217 Staff support Policies should be in place covering: a. family-friendly working / rostering arrangements for all staff b. safety and security of staff c. access to occupational health and other support mechanisms for all staff d. professional mentorship or support for all clinical staff (which could include clinical supervision).

Y

EN-218 Team building The unit should encourage and enable team building activities.

Y

EN-301 24 hour access 24 hour access should be available to: a. on-site imaging service b. endoscopy service c. physiotherapy d. pharmacy e. pathology services f. spiritual care g. domestic cleaning.

Y

EN-302 Daily sessional support Daily sessional support should be available from: a. physiotherapy b. pharmacy c. nutritional support

N Sessional support was available from physiotherapy and dietetics but not from pharmacy.

EN-303 Links with other services Effective links should be in place with: a. occupational therapy b. speech and language therapy c. acute pain management d. counselling services e. bereavement services f. interpreters / cultural liaison services g. clinical psychology h. social services i. transplant services

N There was limited access to OT, counselling, clinical psychology and social services.

EN-304 Laboratory communication Units should have agreed arrangements for rapid transfer of samples to laboratories and availability of results: Urgent within 1 hour Routine within 2 hours.

Y



EN-305 Pharmacy communication Units should have agreed arrangements for ensuring: Availability of non-stock drugs within 1 hour Availability within 1 hour of additional stock items at times of peak demand.

Y See main report.

EN-401 Bed spaces There should be at least 20m2 for each bed and 2.5m of unobstructed corridor space beyond the working area.

Y

EN-402 Isolation facilities There should be: a. at least one single room for every six beds in open areas, or b. agreed arrangements for minimising the risk of cross infection.

Y

EN-403 Mattresses and bed frames All units should have access to mattresses and bed frames that are appropriate for the clinical needs of the patients.

Y

EN-404 Piped oxygen and air There should be at least four oxygen and two air outlets for each bed.

N 3 oxygen and 3 air outlets were available for each bed.

EN-405 Electricity supply At least 24 electricity sockets per bed should be available. At least three of these sockets should have an uninterruptible power supply.

Y

EN-406 Scavenging Scavenging points should be situated in all areas where anaesthetic gases or vapours may be used.

N/A

EN-407 Suction Each bed should have at least two suction outlets. In addition, each unit should have two portable suction devices.

Y

EN-408 Telephones The following telephones should be available: a. at least 1 per patient area capable of being moved to each bedside b. main nurses’ station phones appropriate to the size of the unit and with sufficient capacity to handle an emergency incident. c. one in each office d. relatives room (internal phone).

N There was no portable phone



EN-409 Intubation equipment An intubation tray equipped for immediate use should be available in each unit.

Y

EN-410 Emergency ventilation Emergency ventilation equipment, including a self-inflating bag, should be available at each bed.

Y

EN-411 Monitors (1) Each bed space should have the capacity for: a. ECG, respiration, saturation and non-invasive blood pressure monitoring b. transducing 3 pressure traces c. temperature monitoring at 2 sites d. access to facilities to measure cardiac output.

Y

EN-412 Monitors (2) The monitors listed in A2.11 should be available in a modular unit capable of integration with A&E, theatre and portable monitoring systems.

Y

EN-413 Pumps (bedside) For a level III admission each bedside should have access to at least: a. One feed infuser b. Two volumetric infusers c. Four syringe drivers.

Y

EN-414 Pumps (unit) Each unit should have easy access to: a. A rapid infusion device b. Patient controlled analgesia devices as required.

Y

EN-415 Ventilators (level 3 care) There should be one ventilator immediately available for each bed space normally used for level 3 care. For each 10 bed spaces there should be one extra ventilator available in case of breakdowns. All ventilators should be less than 10 years old.

Y

EN-416 Ventilators (level 2 care) Units providing level 2 care should have a mechanism for accessing additional ventilatory assistance at times of peak demand.

Y

EN-417 Patient chairs One patient chair should be available for: a. every 4 beds normally used for level 3 care b. every 2 beds normally used for level 2 care.

Y



EN-418 Relatives chairs There should be 2 non-wheel, non-fabric, stackable chairs for every bed space.

Y

EN-419 Seating for staff Each bed space should have one stool or non-fabric chair for staff use.

Y

EN-420 Lighting All patient areas should have: a. Adequate lighting with brightness control b. Procedure lamps c. Night lighting, preferably at a low height. Ideally, patient and staff areas should have natural lighting and patients should be able to see out of the windows.

Y

EN-421 CPAP CPAP capability should be available for each bed space

Y

EN-422 Non-invasive ventilation Each unit should have non-invasive ventilation available in appropriate numbers for the case-mix of the unit.

Y

EN-423 Continuous renal replacement therapy device In critical care units that perform Renal Replacement Therapy (RRT), every four beds potentially used for level 3 care should have one continuous renal replacement therapy device. Isolated units providing level 1 and 2 care should have access to a continuous renal replacement therapy device.

Y

EN-424 Defibrillators There should be one defibrillator for each patient care area, dedicated for use in that area.

Y

EN-425 Sinks One sink should be available for every two beds in open areas and for every bed in a single room.

Y

EN-426 Infection control Gloves, aprons, hand hygiene gel, a sharp disposal bins and a clinical waste bin should be available at each bed space. Hand hygiene gel should be available at the unit entrance.

Y

EN-427 Laundry The unit should have clean bed linen, towels, curtains and patient gowns/clothing available at all times. Adequate arrangements should be in place for laundering staff working clothes.

Y



EN-428 Air management All patient areas, including single rooms, should have air conditioning capable of both heating and cooling. There should be at least the following air changes per hour: Single rooms 15 Other patient areas 3 Lab and ‘dirty’ areas 5 Staff areas 2.

Y

EN-429 Other facilities Other facilities should be available and comply with nationally recognised standards: a. Sluice b. Clean and dirty preparation areas c. Storage for waste, bulk equipment and bedside equipment d. Laboratory e. Relatives areas (at least two rooms) f. Offices g. On call rooms h. Staff rest area i. Seminar room j. Entry phone and security arrangement k. Internet access.

Y

EN-430 Manual handling Each unit should have: a. one hoist capable of lifting 150kg b. one hoist capable of lifting over 150kg c. appropriate manual handling devices for lifting haemofiltration fluids and other heavy loads.

Y

EN-431 Resuscitation drugs Resuscitation drugs should be available and checked in accordance with the Trust’s resuscitation committee policy.

Y

EN-432 Blood fridge The unit should have access to a blood refrigerator.

Y

EN-433 Patients’ bathroom An appropriately equipped patients’ bathroom should be available in all units normally providing level 2 care. Units normally providing level 3 care only should have access to such a facility.

Y



EN-501 Unit Guidelines (1) Appropriate multidisciplinary guidelines should be in use within the unit, covering at least: a. consent to treatment b. infection control c. nutrition d. medicines management e. pain management f. nursing care (for example, mouth and bowel care) g. withdrawal and limitation of treatment h. organ donation. i. Rehabilitation after critical illness

Y

EN-502 Unit Guidelines (2) Appropriate multidisciplinary guidelines should be in use within the unit, covering at least: a. sedation b. brain stem death c. spinal injuries d. traumatic head injury e. sepsis f. antimicrobial use g. tracheostomy care

N This QS was met except for c and d. There were good links with specialist centres for care of such patients.

EN-503 Saving Lives Campaign In compliance with the “Saving Lives Campaign” the principles of Care Bundles should be applied to address the following High Impact Changes: No1: Central venous catheter care No2: Peripheral intravenous cannula care No3: Renal dialysis catheter care No4: Preventing surgical site infection No5: Care of ventilated patients No6: Urinary catheter care No7: Reducing the risk of C. Difficile.

Y

EN-601 Admission The unit should have agreed arrangements for admission of patients covering at least: a. types of patient admitted b. referral process c. assessment of patients d. review by a consultant within 12 hours.

Y

EN-602 Consultant rounds There should be a consultant-led multi-disciplinary ‘round’ of the critical care unit at least daily.

N The ward rounds did not include a pharmacist or regular input from the dietitian.



EN-603 Visiting arrangements There should be an agreed policy on visiting arrangements. This should include: a. the first time relatives see the patient b. arrangements for visiting dying patients c. arrangements for children to visit.

N A draft policy was available but this had not yet been ratified.

EN-604 Communication with families The unit should have written guidelines on communication with patients and families, including respect for patients’ privacy and confidentiality.

N There was no guideline. Plans were in place to develop this

EN-605 Feedback from patients and families The unit should have a system for reviewing and learning from patients’ and families’ complaints and letters of thanks.

N No formal process was in place.

EN-606 Specialist team liaison Arrangements should be in place for liaison with appropriate specialist teams involved in the care of patients on the unit.

Y

EN-607 Handover The unit should have structured arrangements for handover of patients at each change of responsible consultant, non-consultant medical staff, nursing staff and other staff.

Y

EN-608 Care plans For each patient there should be a multidisciplinary daily plan of care that is updated each day. This should include the expected level of monitoring and mobilisation.

N Plans of care were uni-disciplinary and sequential.

EN-609 Discharge The unit should have agreed arrangements for discharge of patients covering at least: a. Preparation for discharge b. Including medical and nursing summaries of clinical information in patients’ notes prior to discharge from the unit.

Y

EN-610 Long-term follow up The unit should have agreed arrangements for long term follow-up of patients discharged from the unit.

N There were no agreed arrangements for long term follow up.

EN-611 Death certification Arrangements should be in place to ensure availability of a death certificate and release of the body within 24 hours of death (exceptions may be made at weekends and bank holidays), except where the coroner is involved.

Y



EN-612 GP notification of death Following a patient’s death, arrangements should be in place to notify their GP by the end of the next working day.

Y

EN-613 Communication with primary care There should be agreed arrangements for communication with primary care, which should include communication of follow-up arrangements.

N There were no formal arrangements for communication with primary care.

EN-614 Updating The unit should have a mechanism in place to review and disseminate published scientific evidence relating to critical care.

Y

EN-615 Multi-disciplinary meetings There should be an agreed structure of multi- and uni- disciplinary meetings to ensure that all staff are involved in the running of the unit. These meetings should include appropriate arrangements for review of morbidity, mortality, transfers and outcomes.

N Multi-disciplinary meetings did not take place. Quarterly ITU morbidity and mortality meetings took place and meetings between nursing and clinical leads.

EN-616 Equipment maintenance The unit should have agreed arrangements for maintaining an overview of service contracts for equipment and for ensuring regular maintenance. Responsibility for equipment maintenance should be clearly defined.

Y

EN-617 Cleanliness The unit should be clean and tidy.

Y

EN-618 Capacity management The unit should have systems in place to monitor and manage capacity and patient flows. These systems should include: a. Arrangements for flexing level 2 and 3 capacity b. Monitoring delayed discharges and refused admissions c. Escalation policy.

Y

EN-619 Care of Children The unit should comply with the standards relating to general intensive care for children in Section C, Standards for The Care of Critically Ill and Critically Injured Children in the West Midlands (Version 3).

Y

EN-701 Audit Regular, multi-disciplinary audit should take place within the unit. This should cover the whole audit cycle, including implementing and auditing changes in practice.

Y



EN-702 Activity and staffing data Critical care unit data should be collected routinely on: a. nursing staff allocation b. patients’ level of care c. available capacity.

Y

EN-703 Bed register The unit should contribute data to the network bed management system or the live bed register.

Y

EN-704 ICNARC data The unit should collect and submit ICNARC data in accordance with ICNARC quality standards for collection and submission and participate in the ICNARC case mix programme.

Y

EN-705 CCMDS The unit should collect and submit the critical care minimum dataset.

Y

EP-101 Short-term follow-up There should be agreed arrangements for routine follow-up of patients who have been discharged from the critical care unit. These arrangements should cover: a. information b. support and advice on physical and psychological problems c. referral to other support services d. visits to the unit.

Y

EP-201 Outreach team There should be an outreach team (or equivalent) able to cover all areas where level 1 care may be provided. This team should be available 24 hours a day and comprise a minimum of one nurse per shift per hospital site.

N Outreach was only available between 08.00 – 18.00 weekdays and 08.00 – 13.00 weekends and bank holidays.

EP-202 Medical lead A named critical care consultant should have lead responsibility for ensuring medical support is available to the outreach team.

Y

EP-203 Qualifications All nurses working in the outreach team should have a formal qualification in critical care and two years critical care experience after achieving this qualification.

Y



EP-501 Operational policy The outreach team should have an agreed operational policy. This should cover, at least: a. admission b. retrieval c. communication with and accessing multi-disciplinary support and advice from the critical care service. d. referral to critical care services e. communication mechanisms f. responsibility of outreach and ‘parent’ teams g. referral for long-term follow-up h. education and training.

N The operational policy did not include b, g, and h

EP-502 Triggering Referral The mechanism for referral to the outreach team should be easily available on adult wards and in other potential risk areas.

Y

EP-701 Data collection A minimum data set should be collected.

Y Data were collected on paper and inputted later. Consideration should be given to collecting data at point of care.

EQ-501 Transfer policy The network transfer guidelines and policy should be in use within the hospital.

Y

EQ-502 ‘Outlier’ policy The Trust should have a policy covering the care of level 2/3 patients if level 2/3 care is not immediately available. This policy must ensure that a level 2/3 patient is cared for by a member of staff with appropriate critical care skills and that, if the patient is in an isolated environment, this member of staff is never unaccompanied. The policy must cover: a. nursing staff b. medical cover c. access to equipment d. communication with the critical care unit e. process for clinical and managerial escalation with specified time limits f. any area-specific variations to the above reflecting the differing needs of, for example, A&E, wards and theatres.

Y This was included in the ITU operational policy. The process for clinical and managerial escalation with specified time limits would benefit from review

EQ-701 Transfer audit The hospital should be submitting copies of transfer forms to the network office for inclusion in the network transfer audit.

Y



EQ-702 Level 1 competency There should be an agreed process for ensuring that nurses and junior medical staff working in potential risk areas have training in the recognition and immediate management of acutely ill and deteriorating patients.

Y The team had also presented their process nationally.

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