East and North Hertfordshire NHS Trust made dementia a priority when an internal review highlighted the need for improvements. The trust set up an enhanced nursing care team, which has improved patient care, safety and experience, while also saving the trust £144,000 in its first quarter against its forecast. This model has now been extended to include the care of adults and children with mental health problems.
East and North Hertfordshire NHS Trust identified the following challenges:
The trust recruited a group of band three clinical support workers and provided specialist training to provide one-to-one enhanced care to inpatients, as the internal review identified that this area of care required significant improvement. With the support of e-rostering, patient monitoring software and training, the enhanced nursing care team implemented a virtual roster, rotating staff every three hours, thereby covering more clinical areas and patients with less staff than previously required.
Wards are now required to undertake patient risk assessments based on their levels of risk, confusion and delirium. These assessments are sent to the team to assess how best to care for these patients. The level of care they provide depends on the patient’s risk. Care can range from patients receiving one-to-one care, to being placed in a bay with other high-risk patients who require constant monitoring with additional support, or they will put on Bay Watch, which is managed by ward staff establishing a tagging in and out system for a bay with lower-risk patients. This process is managed through the daily staffing and patient safety meeting, which provides oversight of the highest risk areas and appropriate deployment of staff.
The benefits of the three-hour rotations have been:
Technology was the key facilitator to this change in approach to enhanced care. Through its rostering system, which employees could access through their smartphones, the trust was able to deploy staff into the three-hour rotations. It also means that staff members can review where they are supposed to be working, allowing the team to respond in a timely manner.
Matron Emily Watts, from the enhanced nursing care team, who has analysed the team’s work, says: “Before the enhanced care team was established, the standard procedure was to book an unregistered nurse for a 11-and-a-half-hour shift for a specific patient, on a specific ward when a patient was identified with enhanced care needs.
“The flexibility of an in-house team ensures that members can be moved around the hospital covering more areas with less staff to manage and support our high-risk patients.”
The team undertakes a daily patient review to clarify the need for the enhanced care requirement, or advise if there are alternative ways to manage the patient. The flexibility of the team means it can move to where there is greatest need.
Before the introduction of the team, agency staff without specialist training would be booked to sit with the patients and patients were kept in their beds with the cot sides up to keep them safe. The team is now proactive in promoting patients’ independence and prevent deconditioning. Team members have the time to spend with the patients, ensure patients walk around if it is safe to do so and this improves patient dignity.
This closer monitoring and interaction with high-risk patients has resulted in a higher standard of care and has contributed to the reduction in length of patient stay in hospital and patient harm.
The trust has seen a bed days cost reduction of £25,000 between January and May 2017 (based on a cost per bed day of £500) through reducing the length of stay by approximately two days for patients with continuing healthcare needs after discharge from hospital. The team has enabled this through their comprehensive patient documents production, eliminating the need for wards to complete night-time diaries for a minimum period of 48 hours as part of the discharge assessment.
Since the team was established in January 2016, of the 1,538 patients referred to the team there have only been three reported falls to date. The graph below shows the reduction in falls, which is the result of a wider improvement programme of which the team was a part of at the time.
Overall, the clinical and financial benefits from e-rostering and the introduction of the team include improving the visibility of patient numbers, working staff, available staff, and patient acuity levels. It has enabled efficient deployment and re-deployment of staff at the right place and time, with each member aware of any changes such as admission or discharge of patients and staff can move accordingly, with the help of mobile alerts.
Liz Lees, former Director of Nursing at East and North Hertfordshire NHS Trust, said: “The most impressive thing about the team is that while there has been an increase in demand for enhanced care, it has reduced temporary staff spending and even decreased the cost of enhanced care. This has been done by flexibly deploying the team to meet the needs of the patients throughout the day to provide high-quality safe care to some of our most vulnerable patients.”
Regarding the use of temporary staff, matron Emily Watts says: “Where peaks in enhanced care needs occur that cannot be met by the substantive team or ward-based care, there will be the need for additional support from bank staff. To ensure that this demand can be met, work has taken place with NHS Professionals to establish a pool of bank staff with the right skills that can be used as required.”
Creating the extra capacity through the enhanced nursing care team has seen the trust reduce its agency spend dramatically. In quarter one of 2016-17 the temporary staff spend was £225,322, compared to quarter one in 2017-18 of £83,463. This indicates a cost reduction of £141,859 for the quarter.