A hospital trust’s program of analysis, training and delivery to improve care settings for emergency admissions could provide insight into the structure of services across an entire health economy. Lucy Reynolds, Duncan Harper and Peter Wilson report.

To understand real demand for elective and non-elective care, Plymouth Hospitals Trust (PHNT) and Plymouth’s commissioning team wanted to quantify the volume of planned and emergency patients within the trust who could have been treated in different care settings.

The NHS Devon, Plymouth and Torbay cluster commissioned Finnamore to work with Plymouth Hospital nurses to identify the scale of patients who could have been treated in more appropriate care settings. A five week programme was undertaken (see diagram 1, attached right).  

Culture change: shifting nursing perceptions

Identifying the scale of admissions that could be in different care settings required a committed team of nurses to survey patient records, input results for analysis and identify emerging issues. 

These nurses needed sufficient experience to make assessment decisions, and sufficient confidence to review decisions with clinicians. PHNT’s deputy director of nursing mobilised a number of very experienced nurses from educational and specialist roles in a very short space of time. 

The tight timeframe for training and delivery (four weeks) forced these nurses to postpone important “day job” educational activities (including junior doctor training), meaning that it was therefore natural for them to be sceptical about the value of this work initially.

Building knowledge

Through an initial training day, the nurses were introduced to care setting definitions and a structured survey tool, underpinned by concepts of better patient care.

While healthcare approaches typically focus on the patient pathway and what clinically needs to occur across its different stages, this training introduced an alternative language of care setting levels, based on acuity and need. Examples of different care settings are shown in figure 1 (attached right).

Care setting definitions enabled the nurses to categorise specific patient-level clinical plans into levels of care suitable for those actions, rather than focussing on the patient pathway exclusively. This provided them with sufficient knowledge to undertake the survey work, although scepticism still existed about applicability in practice.

Shifting mindsets

After a week of training and preparation, the nurses began conducting patient surveys (09.00 to 17.00, seven days a week for three weeks). This was supported by dedicated administrative assistance, and twice-daily team meetings:

  • Morning meeting:patient lists were reviewed, and workloads divided up by nurses. Nurses initially paired up to assist decision making, until individual confidence and consistency developed.
  • Wrap-up meeting:evening trouble-shooting sessions, with two functions: to review planned versus actual activity for the day, keeping delivery on-track and troubleshooting issues arising; to peer review decision making, ensuring consistent surveying across the team.

These wrap up meetings provided essential opportunities for ongoing learning and assimilation about appropriate care settings. Crucially, they also enabled nurses to share stories about the patients they had seen throughout the day who shouldn’t have been in the acute setting. This led to a vital shift in mindsets.

A similar mindset shift was experienced by PHNT’s deputy director of nursing, who managed and coordinated survey delivery. Initially sceptical due to the short turnaround and large scope of the audit, he attended an early workshop with Plymouth’s key care partners to review QIPP plans and initial survey findings:

This motivation led to the deputy director of nursing becoming a strong advocate for the work, and inspiring the nurses with a sense of the importance and relevance of the survey. 

This enthusiasm was combined with regular practical support from the PHNT Matron, Linda Field, who supervised the survey team and fielded practical questions from the nurse survey team. Regular recognition and thanks for the nurses’ work from the nursing leadership also helped to create a supportive environment and motivate the nurses.  

Understanding the patient’s perspective: what the nurses found 

As the survey progressed, the nurses encountered significant issues around inappropriate admissions and stays. Patients were being admitted for backaches; falls-related rehabilitation; catheter changes; administration of IV antibiotics; diarrhoea; or simply being ‘held’ in hospital while appropriate community care was arranged.

The main reason for these admissions was “perceived lack of available alternatives”. Other factors included consultant decision-making (and nurses’ reluctance to challenge this); inefficient discharging; and treatments not performed as planned.

The clear issue of patient care motivated the nurses, and these results transformed the nurses from a position of scepticism to one of full advocacy for care in the most appropriate setting.

Patient case study

This is an 84 year old who lives with her daughter near the hospital. She lacerated her head falling from bed, and her grandson called an ambulance. The crew couldn’t determine whether the fall was caused by “mechanical” reasons or something more serious, so transferred her to the Emergency Department at 7am.

In ED, she received stitches and was referred for further investigation by ED medics, who admitted her to the medical assessment unit. Here she was declared medically fit, but in need of a rapid response team review to assess if circumstances at home were appropriate. She was reviewed by an occupational therapist the following day and discharged.

This admission was avoidable. The patient’s needs could have been determined within the ED, and she could have been sent home with a “sitter” (possibly her grandson), with community care and OT support at home.

The results of this survey were profound. It identified that 21 per cent of PHNT’s non-elective admissions (31 per cent of non-elective beds) did not need to be at an acute level of care (see graph 1, attached right).

In addition, cohorts of patients were identified who were at a higher risk of being admitted to acute care when alternative settings were appropriate for their needs (see figure 2, attached right).

Ongoing work is now being undertaken between PHNT and its partners to use the findings of the nurses’ survey to change the shape of services across the local health economy. The survey work undertaken by PHNT’s nurses will now underpin local commissioning intentions and business planning to ensure that a real, structured approach to change is developed for the future.