Making Best Use of Inpatient Beds Project - National Priority Projects 07/08 Summary Document

NHS
NHS Improvement

CANCER

DIAGNOSTICS

Heart Improvement
HEART

Making Best Use
STROKE
of Inpatient Beds
National Priority Project

Making Best Use of Inpatient Beds is a national priority project of the Heart Improvement
Programme focusing on a variety of approaches to reducing avoidable inpatient bed days.

The project ran over the period June 2007 to March 2008.

Key learning from the project is available in the following formats:

1. Project summary
This document includes a description of the national project, supporting information
gained throughout the period and key learning from the project.

Project summaries include issues to address, actions taken and key outcomes from each
of the 12 projects participating in this work.

Contact details are included to provide additional information with regular updates
available on the website.

2. Presentations at National Conference 8 May 2008
Copies of presentations from the speakers at the conference are available on the website:
www.improvement.nhs.uk/heart

3. Web based resources
Project team members found this a very useful opportunity to share learning across the
different project areas. These are now available to share on the improvement website at:
www.heart.nhs.uk/priority_projects

These are categorised into four chapters:
1. Admission avoidance and timely readmission
2. Improving inpatient stay
3. Hospital/community interface
4. End of Life Care

Content includes:
• Case studies and improvement stories
• Protocols, procedures
• Operational policies
• Job descriptions
• Business cases
• Vox pops and video clips

Additional information will be included as it becomes available and existing materials
regularly updated.

Further information and updates email: info@improvement.nhs.uk

Making Best Use of Inpatient Beds 3

Contents
Introduction 4
Key Findings 6
Project Summaries 11
Plymouth Clinical Assessment Service (PCAS) 12
Heart Failure - Rotherham 13
Central Manchester Left Ventricular Systolic Dysfunction 15
Project in Primary Care
West Hertfordshire Brain Natriuretic Peptides (BNP) in 17
Secondary Care Project
Reducing Length of Inpatient Stay for Myocardial Infarction 18
and Acute Coronary Syndrome Patients - Lancashire
Cardiac Surgery Inter-hospital Transfer Project - North West London 20
Continuing Development of Cardiac Services in North Bristol 21
NHS Trust – Southmead Hospital and Frenchay Hospital
Reducing Non-elective Arrhythmia Inter-hospital Transfer Waits Through 22
the Implementation of an Internet-based Referral and Transfer
Management System - North Central London
Heart Failure Early Discharge - North West London 24
Reducing Avoidable Hospital Admissions by Providing Community 26
Support for Patients Referred Through the Single Contact Access
Nomination (SCAN) - Sheffield
Integrated Heart Failure Service Across All Organisational 27
Boundaries - Surrey
Making Best Use of Inpatient Beds - Sussex 28
Project Teams and Participating Sites 29

4 Making Best Use of Inpatient Beds

Introduction
Admission to hospital is essential for To improve health outcomes for
patients requiring surgery, some invasive
investigations and stabilisation of medical
conditions.
Following on from the work on
interhospital transfers1 there are still some
patients waiting for unnecessarily long
? people with long-term conditions
by March 2008 offering a
personalised care plan for the
most at risk vulnerable people;
and to reduce overall emergency
periods as an inpatient for surgery and bed days by 5% by 2008,
electrophysiological procedures. This is both through improved care
clinically suboptimal for the patients and in primary care and community
inefficient in terms of avoidable bed days. settings for people with
Waiting unnecessarily long periods for long-term conditions.
inpatient procedures and regular admissions
to hospital can be demoralising and stressful
for patients, their families and the staff who
care for them.
PSA12a3: Emergency bed days

The NHS Heart Improvement Programme
?
established a national project to work
The recent NICE Commissioning Guide with a number of local project teams.
highlights evidence to support effective
multidisciplinary specialist services for The aims of this work were:
people with chronic heart failure. These can
have a positive effect on patients’ life • To reduce the number of avoidable
expectancy and quality of life and help to emergency bed days
reduce recurrent hospital stays by 30–50%2. • To reduce overall length of stay
The Operating Framework requires • To develop alternative models
organisations to reduce these avoidable bed of care.
days by putting systems in place to support Twelve projects across the country took
people with long term conditions in the part in this work and from the outset we
community. recognised that many of the issues were
complex and that there was no single
solution.

1
Making moves Heart Improvement Programme April 2006 www.improvement.nhs.uk
2
Commissioning a heart failure service for the management of chronic heart failure www.nice.org.uk
3
Operating Framework 2007/08



The areas of work broadly divided into the
following:
• Prevention of admissions by improved
detection and management in the
community
• Redesign of the inpatient pathway
• Reduction in the frequency and
urgency of readmissions
• End of life care.



Key Findings



Key Findings

All 12 projects had very different approaches to Inter-hospital transfers
making best use of inpatient beds and, as such, • Treat and return policy implementation led to
were able to look at a variety of ways to achieve a reduction of an average by eight days stay
their results. The three areas addressed can for ACS patients awaiting angiography
broadly be defined as cardiology services, heart • Prioritisation and risk stratification agreement
failure services and inter-hospital transfers. The reached for targets that form part of the
findings include:- commissioning framework with a resultant
reduction in mean length of stay admission to
Cardiology services surgical transfer of 3.3 days per patient, and
• GPSI triage of cardiology referrals to effectively from work-up to surgical transfer of 7.25 per
manage patients led to a 66% reduction in patient
the referrals requiring cardiologist input in • Implementation of a web-based transfer
secondary care management system for electrophysiology
• Diagnostic testing performed and reported on patients showed a 55% reduction in total days
in less than ten working days using ‘Choose & waiting from the baseline.
Book’
• Transferring services from two hospitals to one Challenges
led to an average reduction in length of stay This work started in June 2007 and was
(LoS) for myocardial infarction (MI) and acute ambitious from the outset. Below are some of
coronary syndrome (ACS) patients of four the key challenges:
days.
• The complexity of the issues presenting at
Heart failure services local level required good information to
• BNP testing used to 'rule out' heart failure understand fully the issues that face service
reduced inappropriate medication and providers. Robust systems of data collection
requests for echo tests. Referral to and analysis were required and the initiation
cardiologists dropped by 30% of such systems was slower than originally
• BNP testing increased the percentage of anticipated.
people discharged from hospital with a • A variety of approaches to patient experience
diagnosis of heart failure confirmed by echo across the projects included surveys, patient
from 22% to 75% diaries and discovery interviews. The uptake of
• Electronic reporting of results reduced various methods was encouraging; however
duplication of tests achieving meaningful patient involvement
• Re-configuration of services enabled a continues to provide a challenge and will be a
reduction of heart failure admissions from 65 key element of future work.
to 21 per month and reduced length of stay • Demonstrating return on investment at a time
from 8.59 days to 4.5 days of early implementation of payment by results
• An audit indicated that optimal prescribing and development of the Improvement System
and titration of beta blockers could reduce gives added impetus to ensure that baseline
admissions by 142 per year. This equates to a data and methods of data collection and
16% reduction. The guidelines have been analysis are in place at the time of project
circulated to all GPs in one PCT inception. The nine month timeline
• A whole system integrated approach to heart attributable to the projects has largely been
failure cut admissions by more than 50% able to go some way to highlight and deliver
for people with heart failure in primary return on investment and it is anticipated
diagnosis position. The length of stay reduced that this will gain momentum in future
by four days from 11 to seven, which months and years.
represents a nearly 40% decrease and a 20% • Re-configuration at local level proved
reduction in the number of days waiting for challenging at times with competing agendas.
echo.



Return on Investment (ROI) The indicative savings shown may accrue to a
The development of NHS tariffs is ongoing and hospital provider but are not reflected in a
where possible projects have been encouraged reduction of cost to the commissioner through
to show ROI as an outcome measure. However, the tariff or contract mechanisms as they
the limited unbundling of diagnostics and the currently exist. Calculation of future tariffs will
relative insensitivity of tariffs at this stage of reflect changes in patient care.
their development to the effect of reducing
lengths of stay has been a limiting factor in These calculations are offered as an indicative
clearly identifying financial savings. short term saving and one which may be used
to stimulate local dialogue with the aim of
The following table sets out an example of ROI developing appropriate arrangements to re-
from one of the projects. The project aim was to invest savings as appropriate to improve care of
focus on emergency admissions and to identify patients along the whole pathway. This is
and reduce avoidable aspects of the patient stay premised on the understanding that the
and thereby to reduce the overall length of development of tariffs is not designed to prevent
hospital stay. A calculated cost per bed day of improvements in care from being realised.
£101 was based on the average of each non
elective spell tariff for heart failure (E18 and E19) The Heart Improvement Programme urges you
divided by their respective non elective stay trim to learn from this important work and discuss
point days to demonstrate an indicative return locally how you might apply some of the
on investment for each bed day saved against solutions to your own environment for the
the project baseline. benefit of local cardiac patients.

Mean LOS Admissions ROI £

Baseline:
April 8.59 65
May 8.81 66
June 5.36 64
Average 7.59 65

Project Reduction Bed days saved Bed day cost £

July 4.3 75 3.29 122
August 5.44 58 2.15 54
September 3.15 20 4.44 89
October 6.61 23 0.98 22
November 4.17 23 3.42 79
December 7.08 30 0.51 13
January 6.92 24 0.67 16
February 4.52 21 3.07 64
Total bed
days saved 623 101 62962



Key learning Other aspects includes:
With a range of clinical presentations, including • Good understanding of the complexity of all
heart failure, acute coronary syndrome and the issues, through effective base-lining
those awaiting surgical and electrical procedures, activities and ongoing data analysis is
by far the largest gain and the most challenging essential
was the heart failure group. Project team • Achieving earlier diagnosis ensures that
commitment has been impressive with feedback patients are on the right pathway of care at
highlighting the positive effects of peer support an earlier stage to achieve improved clinical
and national steerage. outcomes
• Increasing effective, appropriate and early
Of crucial importance is having an integrated medication, up-titrating and achieving
approach across the pathway of care. For cardiac maintenance dose, promotes symptom control
surgery patients explicit communication is and prevents emergency admission,
required, particularly between cardiology and particularly for heart failure patients
cardiac surgery departments, and between • Supporting partnership between patients and
secondary and tertiary care. Heart failure services health professionals, and where appropriate
require collaborative approaches particularly patient self management is necessary, to
between community and secondary care, achieve patient centred care
especially between nursing staff, and elderly • Using a systematic approach for booking and
medicine and cardiology. This underpins the transfer of patients helps reduce avoidable
opportunity for a co-ordinated and team based delays in the system
management style promoting a smoother • To help patients shape future services and
transition across organisations, departments and choice, their involvement is necessary from the
service providers for patients. outset
• Trust between organisations needs to be
The development of a supportive infrastructure developed to help avoid unnecessary
in primary care is essential when addressing duplication of diagnostic tests, particularly
admission avoidance, early discharge and when a patient needs to move between
reduction in readmissions. Commissioning service providers
expertise within the national team and locally • Education and training are crucial to the
has been beneficial to participating projects in implementation of change
this regard. • Greater flexibility of workforce and changing
roles can increase capacity and effectiveness of
service provision
• A greater focus on good working relationships
across the organisational interface will lead to
a reduction in frequency of admissions and
readmissions and will promote seamless care.



Moving forward/next steps Before discussing the specific projects it is
The online resource has been set up to important to acknowledge the huge
encapsulate useful information. This is a dynamic reductions in inpatient bed days realised to
tool for accessing a huge variety of useful date, for example through reducing
resources that will be continually developing unnecessary waits for urgent interhospital
following this initial launch and will provide an transfers for acute coronary syndrome and
opportunity for fast tracking innovative working. pathway redesign to meet elective targets.
Generally speaking the remaining work is
The next round of priority projects will include more challenging due to the competing
heart failure and surgery and will start in the pressures on elective and non elective services
summer of 2008 until 2010. and the increasing co-morbidity of patients.

Heart failure The NHS Heart Improvement Programme
Some of the projects above will continue acknowledge that NHS staff want systems to
through to the next stage of their work plan work seamlessly to help them provide the best
whilst other new projects will be recruited possible care for patients and that NHS
through the process of application. In particular, organisations need efficient and effective
we intend to work with networks and processes to make the best use of available
organisations on the issues below: beds.

• Prevalence and incidence For more information and to get involved
• Diagnosis please contact info@improvement.nhs.uk
• Treatment
• Maintenance
• Supportive and palliative care.

Underpinning the applications, we are
particularly interested to look at issues affecting
equity and access, information, audit and
coding, patient experience and workforce.

Surgery
Surgical work will focus on the whole pathway
of care including elective and non elective
management. This will bring together learning
from the 18 week pathway, making best use of
inpatient beds and the interhospital transfer
projects.



Project Summaries



Plymouth Clinical Assessment Service (PCAS)
Plymouth NHS Hospital Trust, Plymouth Teaching Primary Care Trust,
Private provider: Express Diagnostics
Peninsula Cardiac Managed Clinical Network (PCMCN)

Issues to address Key results/outcomes
General Practitioners’ with a Specialist Interest A pilot scheme was implemented (September
(GPSI) in Coronary Heart Disease (CHD) to triage 2007) of the Plymouth clinical assessment service
all cardiology referrals in order to ‘stem the flow’ (PCAS) which showed:
of referrals into the acute sector by sharing and
diversifying pathways, and provide more services • Only 34% of patients actually required
in the community e.g. NT Pro Brain Natriuretic referral to a cardiologist
Peptides (NT Pro BNP) to: • All patient's are booked through Choose
& Book and all diagnostic tests are
• Increase choice of provider, with quicker access performed and reported on in less than
to diagnostic tests and a quicker diagnosis of 10 working days
the disease • Results and reports are sent electronically to
• Enter the patient on the right pathway for the GPSIs and are available to cardiologists
their care, see the most appropriate person for • Those requiring clinical assessment from their
their care and be given medicines test result are booked into a community
management therapies much sooner to cardiology service and offered either a
improve their prognosis medicine management plan, referral to the
• Agree clearer pathways across organisational heart failure nurse or are referred back to their
boundaries GP for follow up.
• Set processes up electronically to ensure a
paperless trail to inform the referral to BNP - NT pro BNP has been used to 'rule out'
treatment time for the 18 week pathway heart failure since April 07. A total of 400
• Ensure speedy access to cardiologists for patients have been assessed using the test and
urgent cases from CHD GPSIs. found that:

Actions taken • 30% of patients were identified as 'not
• GPSIs were approached to ensure their having heart failure' reducing
agreement and a small scale triage study was inappropriate medication, request for
instigated to determine additional GPSI ECHO tests and referral to cardiologists
capacity required for triaging referral letters • early diagnosis has ensured patients are
(one hour of additional capacity per week was given appropriate medicines management
required for the GPSIs to perform a turn therapies which may translate into better
around time of less than five days). outcomes.
• Clear outcomes and priorities of these
meetings were established, delivered and All Plymouth GPs now use Choose & Book for all
evaluated by an inclusive PCAS project group. cardiology referrals and thus capture the
• Cardiologists met monthly with the GPSIs for Plymouth population within the Clinical
tutorials which also enabled speedier access Assessment Service. This will significantly
for urgent referrals. increase current referral figures and capacity
planning is underway to meet the demand.

Contact information
Chrissie Bennett
Email: Christine.bennett@phnt.swest.nhs.uk



Heart Failure
Rotherham PCT and Rotherham Hospital NHS Foundation Trust
North Trent Network of Cardiac Care

Issues to address 2007 to identify the scope for training and
Rotherham has a higher than national incidence developing primary care teams, to optimise their
of heart failure (HF) coupled with a high rate of prescribing practice and reduce the need for
emergency admissions and readmissions for hospital admissions. This highlighted significant
people with a primary diagnosis of HF. The main variation between primary care practices with an
aim of this project was to achieve a 5% overall low incidence of HF patients on beta
reduction in bed days for HF patients and to blockers licensed for HF and on the appropriate
develop a care package for people with three dose.
or more admissions per annum.
As a result of this work, titration guidelines have
• Avoidance of emergency admissions for been developed and disseminated widely to
patients with heart failure – one of the highest primary care teams. These are also available on
causes of admissions in Rotherham the PCT intranet.
• Getting patients onto the appropriate pathway
of care A series of protected learning time events aimed
• To ensure that admissions are timely and at GPs, practice nurses and other primary care
appropriate staff were held. This forms part of a rolling
• Education of staff in both secondary and programme of training and education.
primary care
• Support and joint working between secondary The beta blocker prescribing audit was
and primary care to improve the patient presented at the cardiovascular local
pathway implementation team (CVD LIT) meeting, and
• Improved communication across the whole also to primary care staff at the Protected
patient pathway Learning Time events in January 2008.
• Reduction in bed days for heart failure
patients. The main finding was that an indicated 142
admissions per year could be avoided by
Actions taken optimal prescribing and titration of beta
A time limited multidisciplinary project group blockers. This equates to a 16% reduction
was established to oversee the project. in HF admissions.

An admissions audit was performed from patient A six month telemedicine pilot for heart failure
records to identify patients with three or more patients will be completed in August 2008 when
admissions. A readmission evaluation form was a full evaluation will be carried out by Sheffield
developed including admission source, University. The pilot will compare the effects
medication on admission and noting changes and outcomes of 30 patients, trained and
made, diagnostic tests performed and discharge equipped to download vital signs data daily via
details. This baseline audit, carried out on 2006 the telephone line to a health care provider who
data, identified 53 patients in this category. will alert the GP or nurse when changes are
detected, with those of a control group. The aim
Beta blocker prescribing rates were recognised is to encourage patient self management and
as a significant indicator of successful patient reduce readmission rates and the number of
care and a correlation was identified from visits by specialist HF nurses.
research evidence between the increased use of
beta blockers in HF patients and a corresponding
reduction in hospital admissions. An audit of
beta blocker prescribing was carried out across
39 practices using practice registers in April



Key results/outcomes
• Two GP practices are due to commence a pilot
looking at ‘Enhancing the use of beta blockers
in heart failure patients – preventing non-
elective admissions and out patient referrals to
secondary care.’ It will be reviewed by the PCT
in October 2008.
• The titration guidelines are currently being
printed into booklet format and each GP will
receive a copy.
• Protected learning time events were organised
for GPs, focused on CVD, and many of the
workshops were targeted at heart failure.
• GP practice and community staff are being
kept up to date with evidence based
education and training
• This is part of a rolling programme of work for
patients with heart failure and will continue on
completion of the project.

Contact information
Ann Baines
Email: Ann.baines@rotherhampct.nhs.uk



Central Manchester Left Ventricular Systolic Dysfunction Project in Primary Care
Manchester Primary Care Trust
Greater Manchester and Cheshire Cardiac Network

The aim of the project was to establish a local 1. Audit of practice registers
enhanced service (LES) in primary care for people Out of the 41 GP practices in the central hub of
with left ventricular dysfunction (LVSD) to assess Manchester PCT, 29 practices responded.
impact on hospital admissions, length of stay
and patient experience. Below highlights some of the key results:

A staged approach was agreed to: Confirm the diagnosis of those patients with
read code G58
• Identify patients on practice systems with an • 66% of patients have their diagnosis
accurate diagnosis of LVSD confirmed by echocardiography
• Design and implement an education •12% of patients are awaiting an
programme for primary care clinicians to echocardiogram to confirm their diagnosis
ensure a high level of knowledge and skill
amongst participating practices Establish how many of these currently being
• Fully implement a LES to support specialist followed up in secondary care could be
services for people with LVSD and to raise the managed in the practice
level of care delivered to them in primary care. •There are potentially another 100 patients from
the practices that responded that could have
Actions taken their follow up in primary care
• As part of the LES, all 41 practices within
Central Manchester were asked to audit their Identify the number of new patients diagnosed
practice registers for patients with LVSD in the last year and consequently require up-
• Data was collected from all practices within titration of their medication
Central Manchester as well as practices • Last year there were 95 new patients
participating in the LES using the Tactical identified with a further 12 awaiting
Information System (TIS). This included length cardiology assessment
of stay (LoS) and admission/readmission rates • Out of these, only nine were followed up and
• Development of a training programme for the up-titrated in primary care, potentially leaving
enhanced service for LVSD to provide a possible 98 patients that could have been
participants with the knowledge & skills base treated in primary care.
sufficient to provide an enhanced service to
these patients 2. Data collection from Tactical Information
• A key component of the education System (TIS) - Data at the end of ten
programme focused on patient and public months
involvement. A pack was provided to staff Due to the two month time lag between activity
with useful references to follow up and teams and data collection, the March ‘08 data was not
proceeded with their chosen methodology available at time of publication.
over the course of the project, targeting
people appropriately from their heart failure This data will be incorporated onto the Greater
registers and utilising the cardiac network for Manchester and Cheshire website at
support. www.gmccardiacnetwork.nhs.uk in May 2008.



3. Educational programme for the enhanced
service for left ventricular systolic
dysfunction
The content for this programme was developed
by GPSI working closely with the Professor of
Cardiology from the local tertiary centre and his
team.

4. Patient involvement
Two practices are using ‘Discovery Interviews’ to
gain insight into the patient experience. This is
being utilised to shape future developments as
per local and national guidelines. Other practices
will be required to involve patients and this is
being followed up.

Contact information
Caroline Hewitt
Email: caroline.hewitt@gmccardiacnetwork.nhs.uk



West Hertfordshire Brain Natriuretic Peptides (BNP) in Secondary Care Project
West Herts Hospital Trust
Bedfordshire and Hertfordshire Heart and Stroke Network

Organisations involved Key results/outcomes
• Hemel Hempstead General Hospital (HHGH)
• Watford General Hospital (WGH) Before introduction After introduction
of BNP of BNP in HHGH
Issues to address
Assessing the effect of introducing urgent Brain Mean LoS for heart Mean Los for heart
Natriuretic Peptides (BNP) testing at one site failure primary failure primary
(Hemel Hempstead General Hospital) and diagnosis in the diagnosis first 3
comparing this to a neighbouring site which three months prior months with BNP at
does not perform BNP (Watford General to BNP: HHGH:
Hospital):
• HHGH 6.8 days • HHGH: 4.6 days
• Identifying patients with suspected heart • WGH 5.4 days (down 2.2 days)
failure • WGH: 5.6 days
• Confirming diagnosis earlier (up 0.2 days)
• Getting on to heart failure pathway (or other) Median LoS for Median LoS for
earlier heart failure primary heart failure
• Reducing in-patient echocardiograms diagnosis in the primary diagnosis in
• Increasing percentage of patients with primary three months prior the three months
heart failure discharge diagnosis confirmed by to BNP: with BNP in HHGH:
echo
• Reducing length of stay (LoS). • HHGH 2 days HHGH: 1.6 days
• WGH 4.3 days (down 0.4 days)
Actions taken with BNP
At Hemel Hempstead General Hospital (HHGH): WGH: 5.1 days
• Negotiated with the pathology lab to do (up 0.8 days)
urgent BNPs (result within 2 hours) for
Number of IP echoes Number of IP echoes
breathless patients being admitted with a
in HHGH: 48 in HHGH Feb 08: 68
query cardiac or definite cardiac cause for their
breathlessness Percentage of patients Percentage of patients
• Informed consultants and trained junior with HF diagnosis on with HF diagnosis on
doctors in the use of BNP discharge with discharge with
• BNP available from November 2007 diagnosis confirmed by diagnosis confirmed
• Organised for Pathology to send copies of BNP echo: 22% by echo: 75%
results to heart failure specialist nurse for her
to visit all patients with a positive result to
ensure echo and cardiology follow up This interim report demonstrates a reduction in
• Monitored BNP usage. both mean and median length of stay at Hemel
Hempstead General Hospital (HHGH), and a
At both Hemel Hempstead General Hospital slight increase at the neighbouring hospital site,
(HHGH) and Watford General Hospital (WGH) although the statistical significance has not yet
• Organised for data collections through IT been assessed. The results so far indicate that
• Baseline audits in Sept/Oct this has not reduced the number of inpatient
• Follow up audit in February 2008 and echos at this site, however the number of
collected/analysed data in March 2008. patients discharged with a diagnosis of heart
failure on discharge confirmed by echo has
increased from 22% to 75%.

Contact information
Candy Jeffries:
Email: Candy.Jeffries@bedfordshirepct.nhs.uk



Reducing Length of Inpatient Stay for Myocardial Infarction (MI)
and Acute Coronary Syndrome (ACS) Patients
East Lancashire Hospitals NHS Trust
Lancashire and South Cumbria Cardiac Network

Issues to address Actions taken
East Lancashire Hospitals Trust consisted of two • Mapping of MI and ACS care pathways
main District General Hospital sites 15 miles • Baseline information for the previous 12
apart, serving a population of 500 000 people. months of MI and ACS data was obtained
The trust had a disparate cardiology service, from healthcare resource groups (HRG).
consisting of 45 dedicated cardiac ward beds Prospectively, data was analysed
and 12 coronary care beds split across the two monthly in relation to length of stay,
sites, with two cardiologists at Burnley, and two readmission rate and bed days
at Blackburn, one of whom was a locum who • A flow tool that measured throughput
worked solely in the cardiac catheter lab. There through beds was obtained from critical care.
was no cardiology on call service, and the The flow tool was implemented on coronary
coronary care unit did not come under the care at both sites one month prior to the
management auspices of the cardiologists. move, and then was used to monitor activity
until 31 December
Patients who attended with MI were admitted • All cardiology inpatient services centralised on
onto a ward under the general physician of the to one site
day, rather than a cardiologist; and some • Treat and return policy instigated with tertiary
patients with ACS would complete their care centre for acute ACS patients. This
inpatient stay without seeing a cardiologist at meant that patients needing urgent
all. The catheter lab, based at the Blackburn site, angiography were identified to the tertiary
only performed procedures on ‘cold’ elective centre, taken for the procedure in a dedicated
patients. Acute ACS patients were referred to cardiac vehicle once the slot was available, and
the tertiary centre, remaining as in patients until returned to point of origin afterwards, without
the angiography had been done. The average becoming a tertiary centre inpatient. A web
wait for transfer to the tertiary centre was 15 based ‘whiteboard’ referral system was
days, but on occasion the wait could be as long created to facilitate this process
as 21 days. • Three interventional cardiologists recruited
(making a total of six cardiologists in total)
• Instigated 24/7 cardiology on call service
• Daily consultant ward rounds on cardiology
wards, coronary care and medical admissions
unit (MAU). MAU referral guidelines were
created by the cardiologists to identify and
accelerate referral of appropriate patients
• Instigated a pacemaker implantation service
• Catheter lab activity expanded to include low
risk inpatients. Balloon pump policy created,
training instigated, and ‘dummy run’
transfers trialled.




Number of Beds Average LOS MI/ACS LOS ACS patients awaiting
CCU Ward inpatients (days) angiography (days)

Baseline position 12 45 10 15

Position after 10 26 6 7
implementation

Notes 19 cardiology Average length of stay Average length of stay
beds removed reduced by 4 days reduced by 8 days

Contact information
Jennifer Watts
Email: Jennifer.watts@lsccn.nhs.uk



Cardiac Surgery Inter-hospital Transfer Project
Ealing Hospital NHS Trust
Imperial Healthcare NHS Trust (incorporating Hammersmith and St Mary’s sites)
The Royal Brompton and Harefield NHS Trust
North West London Cardiac Network

In July 2007 it became apparent that significant Transfer targets
delays were occurring for inpatients requiring Meetings have taken place and agreement
urgent transfer from a District General Hospital reached that the targets listed below will form
(DGH) into a tertiary centre for a surgical part of the commissioning framework for North
procedure. The reasons behind these delays West London. This is a significant step towards
were complex and varied, and related to bed ensuring that the aims of the project are met,
pressures, access to diagnostics and also to and that urgent surgical patients waiting for
work-up procedures. In July 2007, the web- transfer can go to the centre with the shortest
based Inter-Hospital Transfer (IHT) system waiting time.
showed that the average wait from admission to
transfer for an urgent inpatient surgical referral The targets agreed state that:
in North West London was 18 days. The project 1. 100% of high risk patients needing
was designed to address these issues and cardiac surgery should have been
focussed on Ealing NHS Trust and the tertiary transferred, and received their surgery,
centres it refers patients into (see above). within five days of the request for a fully
‘worked-up’ patient to be transferred
Actions taken 2. For intermediate risk patients, 90%
The project team looked at the entire patient should be transferred and have their
pathway for urgent surgical inpatients and surgery within five days
identified bottlenecks and agreed actions to 3. The risk scoring system devised and
take to address these issues. These bottlenecks approved by the North West London
fell into three main areas: Cardiac Network should be utilised
4. The North West London Cardiac
1. Pre-operative work-up Network’s web-based transfer system
2. Patient referral/tertiary care delays should be fully utilised by all trusts in
3. Clinical prioritisation and risk scoring North West London to monitor this
target
Three project meetings were held at which aims, 5. The web-based transfer system will be
approaches and actions were agreed. Actions used to flag the patient for transfer to
were undertaken outside the meeting in various another trust within North West London
areas: if a patient cannot be transferred and
operated on within five days.
• Development of a protocol for cardiothoracic
surgical work-up for patients to improve Transfer times from Ealing:
interhospital transfer to a tertiary care centre - A comparison of eight week audit data collected
Ealing NHS Trust at the beginning and end of the project shows
• Definition and agreement of standardised that the following savings are being made:
surgical work-up criteria
• Clinical prioritisation and risk scoring Mean wait from 3.3 days saved
• Audit of tertiary care bottlenecks and delays admission to per patient
• IHT system amended to facilitate cardiac surgical transfer
surgery work-up criteria.
Mean wait from 7.25 days saved
The network board was regularly updated on work-up complete per patient
the project’s progress and key issues were to surgical transfer
agreed there as appropriate.

Contact information
Jason Antrobus.
Email: Jason.antrobus@nhs.net



Continuing Development of Cardiac Services in North Bristol NHS Trust –
Southmead Hospital and Frenchay Hospital
Avon, Gloucestershire, Wiltshire and Somerset Cardiac and Stroke Network

Southmead and Frenchay Hospitals serve the Unfortunately, an outbreak of Noravirus
population of Bristol and the surrounding area, infection resulted in ward closures during the
supported by the Royal Bristol Hospital Tertiary course of the project, which had an impact on
Centre which is only a few miles away. There are the performance of the cardiology service.
currently two inpatient wards that receive However, despite this, the figures show that the
cardiac patients, supported by a coronary care improvements that had been made in the
unit. It became apparent that patients admitted system managed to prevent the performance of
with a primary cardiac diagnosis were subject to the service from deteriorating significantly from
a prolonged length of stay; that once admitted baseline levels.
patients transfer to a cardiac ward was delayed;
and that less than 60% were transferred to the In its first month, the catheter lab has seen and
care of a cardiologist. In addition, targets for the treated 100 patients. Further developments and
transfer of appropriate patients to the tertiary the continuation of this work are expected to
centre were not being achieved, and it was produce significant positive impacts on the
believed that opportunities to prevent patient current situation.
readmission after discharge were not being met.
Contact information
At the same time, there was a need to develop Nicola Hughes
appropriate pathways and guidelines for the Email: Nicola.Hughes@nbt.nhs.uk
imminent opening of a new catheter lab at the
Frenchay site.

Actions taken
• Developed and piloted a cardiac support nurse
role which actively pulled cardiac patients on
to the cardiac wards
• Developed a patient journal for cardiac
inpatients to records their thoughts regarding
their stay
• Operational policy and guidelines for the new
catheter lab were formulated
• Staff were very kindly supported and trained
by national specialist units
• Patient tracking system implemented
• Catheter lab opened on 18 February 2008,
providing angiography for low risk ACS
inpatients, a pacemaker insertion service and
PCI
• A second catheter lab is due to be opened
imminently
• A further cardiology consultant is due to join
the team in May
• Preparing for BCIS accreditation.



Reducing Non-elective Arrhythmia Inter-hospital Transfer Waits Through the
Implementation of an Internet-based Referral and Transfer Management System
The Heart Hospital (University College London Hospital), Barnet Hospital,
Chase Farm Hospital, North Middlesex Hospital, Royal Free Hampstead
Hospital, Whittington Hospital and North Central London Cardiac Network

Issues to address Actions taken
Patients who required treatment for a non- • A retrospective audit of time from admission
elective arrhythmia were referred by five North to referral, and from referral to IHT was
Central London (NCL) hospitals to the tertiary established (25 patients)
centre at University College London Hospital • Implementation of on-line IHT referral and
(UCLH). The referral was faxed from the acute transfer management system (Web Based
hospital to the catheter lab co-ordinator, and an Transfer System) at the end of August 2007 in
inter hospital transfer (IHT) arranged. Every stage the referring and receiving hospitals across the
of this process required lengthy medical North Central London sector. This incorporated
supervision. Anecdotally, long waits were a WBTS also a tracking and audit tool
reported but no robust audit system existed. • Initial training of the main users at all centres
during the month preceding going-live date
• Successful introduction of the web-based • Dedicated user support during office hours for
transfer system (WBTS) a further month
• Reduced length of stay for arrhythmia inter- • Further user training delivered between
hospital transfer (IHT) patients within North October and December 2007 for user change-
Central London over (mainly junior doctors)
• Improved communication between referring • In-house WBTS training and administration
and receiving centres as well as between staff functions given back to each hospital.
and patients Implementation of in-house WBTS champion
• Transparency of IHT wait, through on-line • Feedback lines of communication through
waiting lists WBTS champions
• Easily accessible length of stay data for all key • Cross-organisational team building and
stakeholders. problem solving through regular ‘Learn and
Share Events’
• Daily dedicated permanent pacemaker slots at
UCLH
• After implementation of WBTS a prospective
audit of waiting times was performed,
matching types and number of procedures of
baseline audit (25 patients)
• WTBS user satisfaction questionnaires used to
determine staff response to changes.

The key results are shown in the table below:

Admission to Referral to transfer Admission to
referral (total days) (total days) transfer (total days)

Baseline 193 155 348

WBTS cohort 87 140 227

Reduction from 55% 10% 35%
baseline in %



The user satisfaction questionnaires were
distributed to WBTS users including ward sisters,
receivers (personnel organising transfers at
receiving centres) and referring consultants.

These showed
• Referrers and ward sisters at the referring
centres reported greater transparency of the
IHT wait and improved communication
between the centres
• The information on the WBTS was believed to
have contributed to improved bed usage and
better team working across hospital
boundaries
• Referring consultants believed that the benefits
of the WBTS outweighed the increased work
load.

In addition, the 'live' waiting list has also
enabled all stakeholders to highlight
exceptionally long patient waiting times and at
times enabled intervention to limit these.
Greater participation of more stakeholders in the
IHT process also ensures better sustainability of
the transfer process within the NCL sector.

Contact information
Swetlana Wolf
Email: Swetlana.wolf@royalfree.nhs.uk



Heart Failure Early Discharge
Central Middlesex Hospital (part of North West London Hospitals NHS Trust)
Brent PCT (Wembley Centre for Health and Care and other Community Clinics)

Issues to address • Average length of stay was nine days
Patients with heart failure currently tend to stay • Patient’s follow up was conducted at the
in hospital longer than necessary because the cardiology or heart failure hospital clinic.
clinical staff must ensure that patients are All patients had one or more co-morbidities
completely stable before discharge. Because of with hypertension and diabetes being the
difficulty with continuity of care by junior most prevalent.
doctors, the period between the patient coming
off intravenous diuretics and being stabilised on Actions taken
oral medication is often prolonged. Also, A project steering group was set up with key
patients are kept in hospital longer than members (involving hospital and community
necessary because the medical staff realise that staff) to guide and inform the project. A process
they may not see them after discharge for some mapping exercise was conducted to review the
time because access to clinics is inflexible. existing care pathway and a baseline audit was
conducted for the first eight weeks. The
This project reviewed the existing pathway of following points outline the areas reviewed and
care and assessed length of stay and emergency developed within the project:
readmissions, the objective being to re-engineer
the pathway of care to reduce length of stay. • Early discharge protocol and proforma
Other areas reviewed were the existing developed by the heart failure (hospital and
cardiology services relationship with other community) and CCT
specialities such as general medicine, care of the • Promoting information for early discharge
elderly, respiratory, gastro, endocrine and the throughout the hospital and with other
collaborative care team (CCT). specialties
• Working closely with CCT to support the heart
Fifty data fields were included in the audit and a failure nurse with early discharge. Patients
further 30 for use from day one to ten of their were identified within A&E, CCU and wards to
care, which includes inpatient and community discuss possible early discharge
care episodes. The following points outline the • A questionnaire was sent out to patients who
most significant areas: were on the baseline audit asking to comment
on their recent admission and the service
• Twenty-four patients were identified for entry provided – this information was used to make
onto the baseline audit – our original target of changes to the pilot
30 patients couldn’t be reached due to the • The project was piloted for four months
patient criteria, which limited the patients that • Following the change in management process,
could be included. This was recognised as a a further 24 patients were audited and as with
risk to the pilot and it was agreed to the baseline audit, there were similar problems
investigate whether it would be possible to with recruitment. Prior to discharge of each
extend the project to include Brent patients patient an individual management plan was
admitted to Northwick Park Hospital put together to provide appropriate continuing
• Sixteen men and eight women who fitted the care and adjustments to medication
set criteria (patients treated with IV diuretics (continuing the stabilisation of the patient
with LV systolic dysfunction and not admitted which otherwise would have happened in
with ACS) were identified to include in the hospital). A combination of CCT, hospital heart
baseline. Six were <65 years and 18 were >65 failure nurses and community heart failure
years, this age split is typical of heart failure nurses was used depending on the patient’s
where the majority of patients tend to be requirements – home visiting or attendances at
elderly. hospital



• A patient personal notebook (previously
developed by North West London Cardiac
Network) was offered to patients on the pilot
to promote self-management of care
• CCT staff attended a heart failure nurses clinic
on a rotating basis as part of a training
schedule.

The length of stay of patients in the second
audit was eight days. Although the numbers of
patients in the study was not enough to allow
statistical analysis, the reduction in length of stay
was in the area predicted at the start of the
project (10%), and if born out in a larger study
would represent a significant saving.

Furthermore, this approach to patient care is
applicable to other specialties. The project did
provide some unexpected findings and more
qualitative than quantitative results.

The following points provide a brief outline of
the conclusions:

• Heart failure patients are often complex,
admitted with co-morbidities and social
issues which impact on being able to
provide early discharge
• Developed better links with other
specialties
• Developed a training schedule for CCT
and HF to educate A&E staff in
recognising HF symptoms and discharging
patients without admitting to hospital
• Patient follow-up was expanded to
incorporate different resources according
to need
• Further work to review emergency
readmissions for patients on pilot in next
six months to establish continuity of care
• Further work to estimate the resource cost
of providing the service to put against the
reduction in length of stay.

Contact information
Temo Donovan
Email: tdonovan@nhs.net



Reducing Avoidable Hospital Admissions by Providing Community Support for
Patients Referred Through the Single Contact Access Nomination (SCAN)
Sheffield Primary Care Trust;
Sheffield Teaching Hospitals NHS Foundation Trust
North Trent Network of Cardiac Care

Issues to address • Support and speed of response led by
SCAN is a referral system into and out of patient need
secondary care, initiated to provide support in • Utilises a mixture of urgent and non urgent
the community. response community services
• Local intelligence and directory of services
With the restructuring of the primary care trust used to signpost appropriately
(PCT) back into one PCT and the admission • Guidelines and protocols in place to underpin
avoidance work, the heart failure nurse service process and delivery
was reviewed and a new model introduced. • Identified gaps in service and skills
• Feedback loop in plan
Some of the aims were to: • New model enables two specialist nurses to
case find in secondary care, assess and refer
• Focus activity to reduce admissions and patients to community heart failure team.
maintain reduction in admissions
• Increase use of single contact access Key results/outcomes
nomination (SCAN) by primary and secondary • 300 cumulative heart failure referrals
care and develop further to enable into SCAN
patients/carers to self refer to SCAN for • Rate of GP referral increasing rapidly – 73
information/visit heart failure referrals in last quarter
• Review heart failure pathway in line with the • Evidence of patient satisfaction
18 week wait • Increased capacity through service redesign eg.
• Signpost patients to the appropriate service community staff nurses with special interest in
• Reduce discharge delays whilst patients wait heart failure take less complex patients with
for social services to provide care packages support from the specialist nurses
• Reduce variation in discharge information from • Reduced admissions and improved triage
heart failure service in secondary care to system
primary care. • Dedicated heart failure ward discussions
• Heart failure rehabilitation pilot
Actions taken • Early discussion in Telly Health
• Single point of access (SCAN) for nominations • Investment and support.
and management of the system in place from
primary, secondary care professionals, care Contact information
homes, social care, patients and carers. Colette Longford
Signposting by skilled senior nurses Email: collette.longford@sheffieldpct.nhs.uk
• Development of System One as an
administrative/management function as a
register for 'Very High Intensity Users’ (VHIUs)
• An additional three nurses from community
nursing appointed
• A change of role for secondary care nurses so
all inpatient and secondary care patients are
assessed and if appropriate, referred to the
community heart failure team. Education
provided for staff working on the medical
admissions unit. ‘link nurses’ developed and
criteria for case finding agreed



Integrated Heart Failure Service Across All Organisational Boundaries
Ashford and St Peters NHS Trust, North West Locality of Surrey PCT
(to be extended to South West Locality and Frimley Park)
Surrey Heart and Stroke Network

The aim of the project was to provide fully Key results/outcomes
integrated heart failure services across all • Establishment of local HF nurse activity
organisational boundaries to improve the clinical database. For Nov 07 – Jan 08
management of all heart failure patients. This demonstrates 72 avoided GP contacts,
included increasing referrals to the heart failure three avoided hospital admissions and
nurses and integrating the service with the GP one avoided A&E admissions
with special interest ‘heart function’ clinics. • Community Heart Failure Consultant
review – this was a four month audit of
Issues to address the direct access by HF nurses to
• Reduce heart failure admissions consultant opinion. Review indicates a
• Reduce length of stay (LoS) potential saving of 24 inpatient days and
• There were two heart failure nurses in old 15 outpatient attendances
North Surrey locality • Reduction of heart failure admissions from
• Successful BHF bid for heart failure nurses. 65 to 21 per month
Came into post July/September 06 (didn’t take • Reduction in LOS from average of 8.59
patients on until late 2006) days to 4.5 days
• Two to three weeks waits for inpatient echo • A strong heart failure steering group
with up to 16 week wait for outpatient echo committed to improving services
in secondary care • Improved access to consultant cardiology
• Links with palliative care team established but opinion
not consolidated • Improved patient management within the
• End of life stage – improved access to home and across organisational boundaries
palliative care and hospice. • Home ECG audit – expedited referral to
secondary care where appropriate for
Actions taken intervention/treatment. Improved medicines
• New consultant cardiologist with special management within the home. Reduced
interest in heart failure and imaging appointed unnecessary care/GP appointments. Increased
in April 06 reassurance for patients and carers
• Data collection to review heart failure • Improved links with palliative care and other
admissions for the first quarter in years 2006, community services
2007 and 2008 for comparison • Consistent documentation across localities
• Data collection to establish LoS from April to • Through audit and patient and public
March 2007/08 involvement, established sound evidence to
• Review documentation; new West Surrey wide inform business proposal for continuation of
clinical guidelines and patient information heart failure nurse led service
• Establishment of a heart failure nurse service • Engagement from network commissioning
across the whole of West Surrey to review group for continuation of service and spread
protocols to other localities across Surrey
• Establish a process for direct access to • New one stop echo/heart failure clinic run by
consultant cardiologist for his opinion with consultant cardiologist within secondary care.
complex patients for both heart failure and GP
with special interests (GPSI) Contact information
• Established links with palliative care Alex Bennett
• Access to network shared drive in order to Email: Abennett3@nhs.net
access information by all parties involved in
project
• Purchase of portable ECG machines for all
heart failure nurses across West Surrey
• Purchase of weighing scales to help inpatient
self-management
• Audit of patient satisfaction via questionnaire.



Making Best Use of Inpatient Beds
Conquest Hospital
Sussex Heart Network

Issues to address • Both Tai Chi rehabilitation programmes and
The Conquest Hospital inpatient heart failure hand-held records were available for heart
service offered an excellent package of care for failure patients
those patients who were referred to them, but • Teaching/education sessions for practice
the service became fragmented for the patients nurses/community nurses/acute nurses took
who were admitted to other consultant teams place
elsewhere in the hospital. Problems included: • Links with the hospice team and expansion of
the palliative and supportive care services were
• Delays in getting echos done developed and progressed.
• Heart failure team not being informed of the
patient admission Key results/outcomes
• Undue delays in medical admissions unit Jan 1998 – Dec 2007
(MAU) • 51.04% reduction in average no. of
• Patient not on the correct pathway for admissions/quarter with heart failure in
optimisation of care primary diagnosis position
• Longer length of stay (LoS) • 36.6% reduction in median LOS/quarter
• Unnecessary readmissions has decreased from 11 to seven days
• Lack of specialist support for patients • 23% reduction of deaths in hospital in
following their discharge. non-elective admissions with heart failure.

Actions taken Aug 2007 – Mar 2008
• Established a project steering group and • 20% reduction in number of days waiting
process mapped acute and community care for echo from date of referral to date
heart failure pathways of test.
• Baseline information data was obtained and
subsequent data was collected and analysed Please note that these results are calculated
• Early identification of heart failure admissions on incomplete HRG performance data.
through existing and enhanced methods.
These included a telephone hotline for heart Contact information
failure admissions with an accompanying Toni De Freitas
poster initiative, and an ‘alert’ feature on the Email: toni.defreitas@hastingsrotherpct.nhs.uk
hospital information system to highlight all
known patients and guidance around
contacting the heart failure team
• MAU consultants and their teams worked to
fast track patients to the heart failure acute
team, all cardiology inpatient admissions were
centralised to dedicated wards and early
access to echocardiogram on the ward was
facilitated
• Management plans were in place for all heart
failure patients following an acute heart failure
pathway, and optimised discharge and follow
up care were established
• Cross boundary communications were further
enhanced through multi-disciplinary team
discharge planning meetings, ward rounds for
heart failure acute teams, enhanced
community heart failure nurse links to wards
and the establishment of ward-link nurses



Project Team Members
and Participating Sites



Project Team Members and Participating Sites

Thelma Daly Temo Donovan
Avon, Gloucestershire, Wiltshire and Somerset North West London Cardiac Network
Cardiac and Stroke Network Brent, Central Middlesex Hospital and Brent tPCT
Bristol, Southmead Hospital, North Bristol NHS Trust
Chrissie Bennett
Nicola Hughes Peninsula Cardiac Managed Clinical Network
Avon, Gloucestershire, Wiltshire and Somerset Plymouth, Plymouth tPCT and Plymouth
Cardiac and Stroke Network Hospitals NHS Trust
Bristol, Southmead Hospital, North Bristol NHS Trust
Toni De Freitas
Candy Jeffries Sussex Heart Network
Bedfordshie & Hertfordshie Heart and Stroke Network Hastings, Conquest Hospital and Hastngs
Hemel Hempstead Hospital, West Herts NHS Trust and Rother PCT

Caroline Hewitt Alex Bennett
Greater Manchester and Cheshire Cardiac Network Surrey Heart and Stroke Network
Central Manchester, Central Manchester PCT, Central Woking, Surrey PCT and Ashford and
Manchester and Manchester Childrens University St Peter's NHS Trust
Hospitals NHS Trust and PBC Hub
Mimi Parker
Luke Coleman Surrey Heart and Stroke Network
Greater Manchester and Cheshire Cardiac Network Woking, Surrey PCT and Ashford and
Central Manchester, Central Manchester PCT, Central St Peter's NHS Trust
Manchester and Manchester Childrens University
Hospitals NHS Trust and PBC Hub National Team Members
Jennifer Watts
Lancashire and South Cumbria Cardiac Network Sheelagh Machin
Blackburn, East Lancashire NHS Trust, Blackburn Director, NHS Improvement
Royal Infirmary
Carolyn Heyes
Rita Briggs National Improvement Lead, NHS Improvement
Lancashire and South Cumbria Cardiac Network
Richard Longbottom
Blackburn, East Lancashire NHS Trust, Blackburn
Commissioning Advisor, NHS Improvement
Royal Infirmary

Ann Baines Jennifer Watts
North Trent Network of Cardiac Care - Rotherham Service Improvement Manager, NHS Improvement
Rotherham, Rotherham PCT and Rotherham NHS
Anne Coleman
Foundation Trust
Personal Assistant, NHS Improvement
Colette Longford
Jonathan Shribman
North Trent Network of Cardiac Care - Sheffield
National Clinical Lead, General Practitioner
Sheffield, Sheffield PCT and Sheffield Teaching
Hospitals NHS Trust David Walker
Swetlana Wolf National Clinical Lead, Consultant Cardiologist
North Central London Cardiac Network Steve Livesey
Hampstead, Royal Free Hospital NHS Trust and Heart National Clinical Lead, Consultant
Hospital Cardiothoracic Surgeon
Jason Antrobus
Ealing, Ealing Hospital NHS Trust, St Mary's Hospital
and Hammersmith Hospital


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improvement programme. With over eight
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Publication Ref: IMP/heart0004

Making Best Use of Inpatient Beds Project - National Priority Projects 07/08 Summary Document

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