Sharn Elton Ashish Shah Alison Shelley July 2016 Reducing zero day length of stay for people over the age of 75 in East and North Hertfordshire Sharn Elton Ashish Shah Alison Shelley July 2016

Overview of the current state The rate of 0 day length of stay (LoS) has increased from 16% to 22% over the last 4 years (37%) length of stay for > 23 hours reducing Year on Year since 2012/13 impact on acute hospitals negative patient experience The rationale behind this increase is complex increasing co-morbidities ageing population Significant numbers of patients occupying our hospital beds could be cared for in community settings availability of suitable services access

The Problem The Objective There are an increasing number of people over the age of 75 being admitted to hospital for a 0 day LoS which is adding to the unsustainable pressure on acute hospitals within East and North Hertfordshire (ENH). The Objective To stop any further increase in 0 day LoS for people over the age of 75 to reduce pressure on acute hospitals within ENH, by March 2017.

Root Cause Analysis (RCA)

Refining the Root Cause Initial RCA - decision to focus on the complex presentation and needs of our elderly population over 75 years of age Further data analysis re. most common reason for admission established urinary tract infections (UTI) Undertook a second RCA to review the reasons for admissions for those over the age of 75 with UTI specifically To Insert 2nd Fishbone How did we get here i.e. to hone in on the problem further

RCA – UTI Admissions

The Selected Strategy Second RCA identified 6 potential strategies Engaged with multi-agency stakeholder group (Rapid Response team) to identify the key strategy to take forward Strategies tested against four selection criteria affordability stakeholder buy-in level of impact replicability ‘Prevention and early identification’ strategy selected stakeholder group most energised by longevity of positive impact ease of replicability (other localities, conditions) Further work with stakeholders led to agreement to introduce a patient and carer education component support self-management and empowerment of patients and carers provision of direct access to community services

The Implementation Plan Action   Who When Status Identify a locality to work with AS / ST May 16 Complete Identify Patients with a history of 2 or more admissions in last 12 months with UTI June 16 Develop a UTI clinical management plan for each patient ST / CM Develop a simple fluid intake chart for home carers Develop a communications plan and educational advice sheet linked to the national ‘Beat the Heat’ campaign for the summer of 2016 CCG CT Provide initial ‘education’ appointment & direct access information for patients and carers for Rapid Response team RRT July – Sept 16 Initiated Conduct monthly progress reviews AS / RRT Arranged Conduct Focus Group with RR team to review progress - Oct’16 PT / RRT Oct 16 Key: AS – GP Lead ST – Rapid Response Team Project Manager CM – Community Matron RRT – Rapid Response Team CCG CT – CCG Communications Team PT – YALE Project Team

Evaluation Results Key performance indicators identified Methods - completion of UTI clinical management plans (process) - reduction of 0 day LoS admissions with UTI (outcome) - improved patient experience (outcome) Methods - review of mede-analytic data - patient survey Next Steps - share outcomes with Integrated Care Programme Board (ICPB) - if positive impact roll out across other East and North Herts localities Develop strategies for other medical conditions impacting 0 day LoS admissions Results 37 patients identified with 2 or more 0 day LoS admissions in the locality UTI clinical management plans / fluid intake charts / ‘beat the heat’ leaflets prepared Dedicated Community Matron identified in Rapid Response Team

Lessons Learnt The value of diversity of thought in strategic decision making The importance of leadership & trust Truly invest in the early stages of the decision making process need to spend significant time defining the problem and objective Root Cause Analysis phase is key Earlier stakeholder engagement richness of the conversation engagement and buy-in