1. 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

2. 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

3. 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.

4. Root Cause Analysis (RCA)

5. 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

6. RCA – UTI Admissions

7. 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

8. 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

9. 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

10. 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