Requires improvement
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Overall, we rated the responsiveness of the critical care to the individual patient’s needs as requiring improvement because there was a high bed occupancy across critical care with delays in the discharge of one in three patients admitted to critical care. As a result, patients were being discharged out of the unit during the night from both the Intensive Care Unit and Neuro-Critical Care Unit. There was a poor flow through the hospital which contributed to the delayed discharges from the unit due to a lack of bed capacity throughout the hospital. Patients discharged out-of-hours were reviewed by the rapid response team on the ward on the same night of discharge with continued reviews the following day. Whilst we found no evidence of high bed occupancy and delayed discharges having a significant impact on elective or emergency admissions to either unit, they did have an impact on patient experience, which was well recognised by staff and senior management alike and was on the risk register.
We saw examples of the modification of services offered to meet the needs of local people, captured through twice yearly focus groups. Through this focus group, real change had been implemented including improving the transition of care from Intensive Care Unit to the ward, establishment of a quiet/interview room for doctors to speak to relatives on the Neuro-Critical Care Unit, re-design of the relative’s room and the design and pilot of an application for a mobile tablet to help patients with a tracheostomy in place to communicate.
Patients discharged from the critical care unit were invited to a follow up clinic to review their progress. A summary of this consultation is then provided to the patient’s general practitioner to facilitate on-going care within the
community. Through the use of patient diaries, staff were able to document the patient journey through critical care. This was reviewed during their follow up appointment to aide memory and recall.
We saw innovative practices aimed at helping patients communicate with staff including trolleys with various communication aides like letter boards, pictures, words and the aforementioned mobile tablet application. Relatives visiting their loved ones in hospital were allowed flexible visiting hours and given discounts coupons for parking charges.
Patient complaints were dealt with promptly through organised meetings with the patient liaison team and written replies back to patients.
Service planning and delivery to meet the needs of local people
• Staff and patients on the unit worked collaboratively to identify the needs of local people and design services to correspond to this. An interview/quiet room had
recently been fitted on the premises within the Neuro-Critical Care Unit to provide a private
environment for staff to speak to relatives. The relative’s room was also refurbished to ensure comfortable seating for carer’s.
• On the Intensive Care Unit, a junior doctor jointly developed an application for a mobile tablet called “My ICU Voice” to enable patients who had a tracheostomy in place to communicate with staff. Funding for the tablets was jointly secured through the trust and through a charitable donation. We saw the use of this application during our inspection which was an example of outstanding practice in response to patient needs.
• One relative shared with us that they found the “fact sheets” that had been printed out and left for relatives in their waiting room as helpful and informative for them during their time in critical care.
Meeting people’s individual needs
• The unit had good links with the learning disabilities nurse. The nurse was being called pro-actively when a patient was identified to have a learning disability and an individualised care plan being formulated as a result. We observed this on the Intensive Care Unit where the staff identified that a person who had come to them unconscious had woken up and staff recognised that they had a learning disability and would require the support of the specialist nurse.
• All patients on the Intensive Care Unit and Neuro-Critical Care Unit were asked to complete a depression scoring
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tool during their rehabilitation period to identify specialist requirements in a timely manner. Patients who were identified as requiring further assessment were referred to the psychiatry team and their progress was reviewed during the follow up clinics.
• Patients were invited to a follow up clinic with plans in place to include a clinical psychologist within the service offered. We followed patients through this service and found it to be an extremely well run service. Feedback was collated within the clinic and was very positive and detailed the caring nature of the nurse running it and the support they have received as a result.
• Patient diaries were developed across the service. Staff filled in details of daily events, which patients got to take home. This helped patients orientate themselves with the care they were provided and featured strongly in the positive feedback received. The patient diaries were reviewed during their follow up clinic appointment. • The Speech and Language Therapy team (SALT) had
designed and implemented a trolley system that contained various communication aides to help patients communicate with staff. This included letter boards, individual alphabets, words and pictures. • Within this trolley there were different types of call
buzzers that patients could use to alert staff to particular needs. For example, on Neuro-Critical Care Unit, a buzzer was developed to be attached on to the side of a patient’s head, if they had lost function of their arms.
• On both critical care units, staff were flexible about visiting times. Relatives told us that, on the day of admission they were allowed to be with their loved one all through the night. They never felt pressured to leave the ward and were provided refreshments through the night.
• Relatives of patients admitted to hospital were also given car parking discounts to allow for them to visit their relatives more frequently.
• Patients were offered a variety of meals on the
Intermediate Dependency Area to meet specific dietary requirements. For example, we saw patients being offered Halal and Kosher meals on request.
Access and flow
• Length of stay and delayed discharges had a significant impact on the flow of patients from the critical care unit. The hospital bed occupancy was at 98% at the time of our inspection which impacted on the timely discharges of patients to the ward areas. .
• Trust wide, length of stay for patients and delayed discharges was seen as a significant risk to flow. This was having an adverse impact on the critical care unit with more than 1 in 3 patients on both units having a delay in discharge over the calendar year in 2014. Thrice a day, the bed capacity was reviewed trust wide and on the critical care units. . Patients on the unit ready for discharge were identified early; however this was not having a significant impact on aiding patient flow. • Bed occupancy for the critical care service was high. In
March 2015, bed occupancy on the Intensive Care Unit was 93% and 95% on the Neuro-Critical Care Unit. In February, the average occupancy was 113% on the Intensive Care Unit and 109% on Neuro-Critical Care Unit. This meant that patients were occasionally being provided care by the critical care team in areas outside of the critical care unit.
• Data was being collected locally to ascertain the impact on of bed occupancy on delays in admission of patients on to the unit and cancellations of operations owing to lack of critical care beds. During January and February 2015, the Intensive Care Unit had 14 elective admissions in each month. There were no cancellations of any elective surgery in either month owing to an unavailability of beds.
• During the last six months, two emergency surgical procedures were cancelled owing to the lack of
availability of a critical care bed. Data reviewed between February and March 2015 showed there were 152 patients admitted to the Intensive Care Unit. All of these patients were admitted within four hours of a decision taken to admit, in line with the Faculty of Intensive Care Medicine / Intensive Care Society Core Standards for Intensive Care Units (Edition 1) standards. In April, two patients have had to wait longer than four hours for admission. On the Neuro-Critical Care Unit, 163 patients were admitted in February and March 2015. All patients were admitted within four hours of a decision to admit. In December 2014, it was documented in the admissions book that one patient had to wait for 18 hours in the emergency department for admission and one patient waited for four hours in January. The trust clarified that
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on review of the patients’ medical records they believed that the patient only waited for two hours once the decision had been made to admit to an intensive care bed..
• An internal audit was carried out within the Intensive Care Unit between January to March 2014. The notes of 102 patients were reviewed. The median time to admission to the JF unit from referral was 102 minutes. • As a result of the difficulties in flow, patients were also
being discharged later on in the day. In March 2015, 16 out of 65 patients (25%) on the Neuro-Critical Care Unit and 15 out of 54 (28%) were discharged between 22:00 and 07:59. In February, 36% of patients on the
Neuro-Critical Care Unit and 21% on the Intensive Care Unit were discharged out of hours. .
• Patients discharged out-of-hours were reviewed by the rapid response team on the ward on the same night of discharge with continued reviews the following day. However the delays overnight did have an impact on patient experience, which was well recognised by staff and senior management alike and was on the risk register.
• In March 2015, there were three non-clinical transfers out from the Neuro-Critical Care Unit to the John Farman Unit. There were no non-clinical transfers from the Intensive Care Unit in this month.
Learning from complaints and concerns
• Over the last year, critical care services at Addenbrooke’s hospital have received only one formal written
complaint. Feedback, provided informally to the department included anxiety around the discharge process for patients and the transition to ward based care. In response to this, the staff have started planning discharges in advance including preparing patients for the transition to ward based care.
• Complaints that came through the Patient Advice and Liaison service (PALs) were flagged up to the consultant staff and would have a lead nurse and doctor assigned to the complaint. Meetings were organised with the family to attempt local resolution. Minutes were taken during these meetings and a formal written response provided to the families.