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Programme Progress

Since the inception of the National Acute Medical Programme in 2010 and the publication of the seminal report there have been many achievements. Acute Medical Units (AMUs) in Model 4 Hospitals, Acute Medical Assessment Units (AMAUs) in Model 3 Hospitals and Medical Assessment Units (MAUs) in Model 2 Hospitals have been developed to implement the NAMP pathway for acute medical patients and support the delivery of this care.

 The NAMP hosts an annual conference to educate and train staff in areas of acute medicine see events section

2011 - 2014

2011- 2014 overall:

•  All acute Hospitals in Ireland reconfigured into Models 1-4

• Reduction of national medical average Length of Stay from 8.61 days (Jan 2009) to 6.8 days in 2014.

 The national benchmark of 25% same day discharges was achieved in 2014.

•  Implementation of National Early warning Score, COMPASS education programme and structured escalation communication tool (iSBAR) across 34 hospitals

• Formation of local and regional clinical and project governance teams involving multidisciplinary leadership in each acute hospital site

•  Completed diagnostic gap analysis across sites undertaking NAMP implementation against NAMP national targets

•  185 nurses in post in acute medicine

• Consolidated and disseminated programme methodology in relation to the 4 areas of interventions: Ambulatory Care, Medical Short Stay, Inpatient care & Frail older person care

• Delivered structured change management and performance improvement support to targeted acute hospital sites

• Programme delivered process improvement workshops, training and coaching. Harnessing innovation and leadership training across the acute emergency medical pathway

• Established Multidisciplinary clinical, professional advisory and working groups (Consultants, Nursing (2012) and Health and Social care professions)

• Reduction of 1.8 days in average length of stay nationally was achieved between 2009 and 2014

Working with the assistance of the national team, accelerated improvement projects have been identified in individual sites which have broadly fallen into the following categories:-

Operational

  • Visual hospital bed modelling (Beaumont hospital)
  • Navigation Hub development (Mater Hospital)
  • ICT solutions to track patient experience times (Tallaght)
  • Discharge planning and patient flow (Galway University Hospital Group)

Clinical

  • Nationally agreed referral criteria to AMAU (ICGP)
  • Accelerated process improvement events with targeted sites. Established governance structures. Key Stakeholders e.g.  SDU, other clinical programmes. Patient advocacy groups, ICGP
  • Allocation of 36 new Acute Physician Consultant posts 
  • Development of 3rd level postgraduate diploma, National Acute Medicine Nursing programme.
  • Development of Health and Social Care Professional Competency Framework.
  • Establishment of the Irish Society of Acute and Internal Medicine (ISAIM) – a multidisciplinary forum to support continuous professional development, promote shared learning and build and acute medicine community in Ireland
  • Establishment of the Acute Medicine Nurse Interest group (AMNIG)
  • Research and consultation to support development of an acute medicine nursing strategy conducted
  • Template for Writing Standard Operating Policies Designed and circulated
  • Development of nursing skills and competencies (core, specialist and enhanced / advanced) directory
  • Clinical Nurse Manager 2s appointed to AMAU’s & MAU’s 
  • Operational policies across all units completed in 2014
  • Total medical discharges up to the end of October 2014 increased by 28% compared to October 2010 figures. AMAU activity accounted for 33% of all medical patient discharges nationally in 2014.
  • Preliminary work was completed on the National Quality Assurance Information system (NQAIS) for medicine. This electronic tool supports data capture on medical patient activity to deliver further efficiencies and improved quality in acute medicine 
  • All 41 acute and single speciality hospitals (100%) have implemented the NEWS to some degree, and 98% of departments within those hospitals have implemented the NEWS. Over 5,000 staff have registered to complete their NEWS/Compass training through HSELand in addition to multiple structured classroom based multidisciplinary programmes run by Centres for Nursing & Midwifery Education and over 500 staff have completed the Train the Trainer programme including nurses, doctors and physiotherapists
  • A competency framework has been established for Health and Social Care Professionals working within the Acute Medicine environment
  • The National Clinical Guideline No. 1. The National Early Warning Score was updated in 2014 identifying a NEWS ≥ score of 4 (5 if patient on supplentary O2) as a trigger to screen for sepsis. 
  • The COMPASS / NEWS Programme is being included in the curricula of undergraduate medical and nursing third level institutions.
  • The COMPASS/NEWS e-learning programme development was completed
  • The NAMP linked with the Irish Maternity Early Warning System (IMEWS) project, which has been implemented in all 19 Maternity Units throughout the country and with the PEWS which is in development
  • The NAMP contributed to the work of the National Sepsis Steering Group Sepsis Screening & National Clinical Guideline for Communication (Handover) which has been identified as a priority by the Dept of Health for 2014

2015 - 2017

  • 273,668 Acute medical patients attended Acute Medical Units nationally, 57.2% were discharged home on the same day following assessment and treatment to complete their care
  • The Average LOS for AMU/AMAU/MAU patients was 5.4 days (excluding trim)
  • 37.4% of patients attending Acute medical units nationally were transferred there from the ED.
  • 63.1% of patients had patient experience time (PET) of less than 6 hours
  • 560 (460 WTE) Nurses working in Acute Medicine nationally 2016
  • NQAIS KPIs: Using NQAIS Medicine and site data received from hospitals, the NAMP team developed and agreed national KPIs for the measurement of AMAU performance in achieving model of care (MOC) implementation and the benefits that accrue in terms of bed days saved due to a reduced average length of stay and improved patient experience times
  • Site Visits: The NAMP team conducted site visits to all Model 4 hospital Acute Medical Units (AMUs) except for one during 2016 to review progress on implementation of the MOC, AMU staffing and access to diagnostics
  • Criteria Led Discharge: The Nursing Lead, with sponsorship of the Clinical Strategy and Programmes Division, supported a multi-disciplinary clinician led team in St Luke’s Hospital Kilkenny to test a model of Criteria Led Discharge (CLD), the learning from which will inform a wider national programme
  • Pilot of HSCP Common Screening Tool (CST): A number of pilots were carried out in 2016 and then CST adjusted as part of a PDSA cycle.  A guidance document, SOP and dataset to measure CST effectiveness were drafted in December 2016 and will be finalised in early 2018 – The Common Screening Tool is ready for publishing and will likely be incorporated into the Acute Floor Information System
  • The National Quality Assurance Improvement System (NQAIS) has been implemented into the programme as a tool for capturing data on medical patients. It was tested in the Mercy and Mater University Hospitals. NAMP commissioned Dublin Institute of Technology (DIT) to undertake mathematical modelling simulation of acute medical patient follow in collaboration with Tallaght Hospital
  • NAMP continues to gather and analyse monthly KPI data from AMAU/AMU/MAU sites and this information is shared with all acute physicians and hospital managers on a monthly basis.
  • The NAMP collaborated with other relevant National Clinical Programmes to develop clinical care pathways for common acute presentations in the Acute Medical Assessment Unit and ED; the delirium pathway has been implemented nationally and other pathways are expected to be implemented in late 2018
  • The NAMP team has been pivotal in the progression of the ‘Acute Floor’ concept, which originated in the NAMP model of care (2010). The ‘Acute Floor’ concept aims to facilitate a seamless provision of effective care across a range of specialities involved in the early management of acutely and critically ill patients. It also aims to provide early access to senior clinical decision makers which reduce delays in instituting necessary investigations and treatment thereby often preventing admission (Ambulatory Emergency Care) or reducing the length of inpatient admission
  • The NAMP team was also integral to the design and development of the forthcoming Acute Floor Information System (AFIS). This system will provide for the real time electronic recording of patient interventions in Emergency Departments, Acute Medical Assessment Units, Acute Surgical Assessment Units and Injury Units, resulting in a paper-lite environment for all unscheduled care provision in acute hospitals and one which will lend itself to meaningful analysis of flow and optimisation of care pathways
  • In collaboration with the HSE Deteriorating Patient Improvement Programme , CS&P and AHD the NAMP is refining the operation and monitoring of the National Early Warning Score (NEWS)
  • Director of Nursing NAMP Chair of National Clinical Guideline No1 (NEWS) review working group.
  • Acute Medicine Nurse Interest Group representation nominated to DoH / ONMSD National Quality Indicators for Nursing (Metrics) review group.
  • Pre site visit survey forms developed for nursing services which identify quality initiatives as examples of good practice for dissemination; staffing and skills mix, scope and scale of nursing influence in service design, delivery and governance, operational plans and staff development (clinical and managerial)
  • An evidence based publication setting out the skills and competencies required of acute medicine nurses at core, specialist and enhanced / advanced nurse practice level launched by Junior Minister for Health (Sept 2016) Casey, A., et al Setting the Direction: A development framework Supporting Practice Skills & Competencies in Acute Medical Assessment Units & Medical Assessment Units.  ONMSD AMP CS&PD, HSE, Dublin. 
  • Nationwide acute medicine nursing clinical education needs assessment survey conducted and analysed. Foundation education programme design and tendering for Level 8 NMBI accredited programme completed.  Funding allocated by ONMSD for all 560 acute medicine nurses to participate over three year period. 
  • Enhanced and extended roles undertaken by nurses include cannulation & phlebotomy and first dose I/V antibiotics
  • An expert Advisory Group chaired by the NAMP Director of Nursing, sponsored by the ONMSD was established to provide Guidance to Sites Developing Advanced Nurse Practitioners in Acute Medicine. Site visits identified a range of potential scopes of practice.  Draft KPIs for Advanced Nurse Practitioners submitted to DoH to advise policy development. Survey of all units identified readiness of candidates and sites for 49 Advanced Nurse Practitioners.
  • Multidisciplinary Master class (Business Case Development) for acute medicine teams provided  in association with ONMSD
  • Nursing Symposium attended by 120 nurses and Junior Minister Sept 2016 Dublin Castle.
  • Nursing Lead presented posters and oral presentations at: Nursing Symposium 2016; NES Scotland Fellowship (Quality and Patient Safety) programme; Integrated Care Conference (Irl); Society for Acute Medicine (Belfast). Results of education needs assessment also presented at SAM Edinburgh.
  • The NAMP runs annual conferences to enhance education and training see events page
  • The National Doctors and Training Programme received submissions from the NAMP on future manpower planning
  • The clinical lead NAMP is a member of and advises the Joint HSE and Department of Health (DoH) Emergency Department Taskforce
  • The Clinical Lead and Nurse Lead NAMP both sit on the DoH taskforce on Nurse Staffing and Skills Mix (Phase1) Medical and Surgical settings, and Phase 2 (Emergency Setting’s) steering groups.

2018

  • In 2018 86,951 newly registered acute medical patients were seen in Acute medical units nationally, 60.5% of those patients were assessed, treated & discharged on the same day. 345 of those patients were transferred to AMU/AMAU/MAU from the ED
  • The average Length of Stay for Acute medical patients was 5.5 days
  • The Health & Social Care Professionals interest group have published a survey on the current status of HSCP service delivery and access to diagnostics across model 3 & 4 hospitals.
  • The programme published its Ambulatory Care Framework across the Acute Floor with guidance on how to enhance and deliver Ambulatory Care for Ambulatory sensitive conditions seen in Acute Medical patients. This framework includes national data on clinical conditions seen in Acute Medical Patients across all hospitals, bed day usage of patients with respiratory, cardiovascular and neurological patients and current patient flow, same day discharge and bed day usage of all Acute Medical patients across all acute hospitals. (See programme documents for report without data)
  • The NAMP team are working with the National Doctors Training and Planning dept. in the HSE to undertake a review of all doctors working in Acute medicine nationally.
  • The programme is developing minimum requirements for Acute Medical Units within the Acute Floor.
  • Currently NQAIS data reports are shared quarterly to review KPI targets and performance of all hospitals with regard to Acute Medical patients.
  • The Acute Floor Model for Ireland has been published and approved by Senior Management and implementation is due to commence in pilot sites
  • There are now three (3) Registered Advanced Nurse Practitioner’s in Acute Medicine and twenty two (22) undergoing educational and clinical preparation.

Programme Accolades

  • Taoiseach’s Public Service Excellence Award (2012)
  • Healthcare Innovation Award (Biomnis) Patient Safety Category (2012)
  • Irish Medical Times Healthcare Award – Excellence in Healthcare Management (2012)
  • Society of Acute Medicine Conference (UK) poster submission received a commendation for the National Patient Observation Chart (Irl) project
  • European Union Commission selected the National Acute Medicine Programme along with the National Early Warning Score project as an innovative project from a large number of entries across Europe in 2012.  The submission was placed on their website

National Quality Assurance & Improvement System (NQAIS) Clinical

NQAIS Clinical was launched at the NAMP conference in October 2017 by Minister for Health Simon Harris TD.

It is an online reporting tool that analyses Hospital In-patient Enquiry (HIPE) data for patient discharges following their episode of care. It is possible to view patients from a diagnosis perspective with their principal reason for admission to hospital, and the most substantive health intervention they received i.e. the principal procedure they had performed, and the specialty of the clinician(s) who managed their care. This enables analysis of patients under the care of specific medical specialties, their reason for admission to hospital and/or what health intervention they received.

The system was designed collaboratively by the National Clinical Programmes, the Health Intelligence Unit HSE, nominated hospital group representatives, HSE, developed and supported by OpenApp, and is deployed under the governance framework of the national clinical programmes and supported by the National Clinical Advisor and Group Lead Acute Hospitals Division, HSE. The data hosted on the HSE’s Health Atlas website is administered by the Health Intelligence Unit, HSE.

NQAIS Clinical adopted a pan clinical programme approach to design and deliver a cohesive data informed support resource which leverages HIPE discharge records for use in delivery of quality improvement initiatives in the delivery of patient care in surgery, adult medicine, care of older persons, care of children, maternity, and neonates.

The overall aim of NQAIS Clinical is to provide clinical leadership with comparative performance metrics for the objective management of in-patient length of stay and same day discharge rates.  The application makes it easy to identify variance from top quartile teams’ performance and thereby allowing clinical management to identify where quality improvement initiatives will prove most beneficial. The QI methodology supports the transfer of learning from top quartile teams based on multi-disciplinary co-operation.

The system can aggregate and present metrics for inpatient length of stay (AvLOS), day case rates (%DC), inpatient day of surgery admission rates (%DOSA) and readmission rates. These metrics are dynamically available at hospital, clinical team, surgical specialty and procedure level, medical specialty and diagnosis level with supporting metrics and graphical representations of the metrics and their trending over time.

Users are presented with different dynamic views of HIPE data, relative comparative performance metrics and predictive indicators of what would happen to bed resource utilisation if they were in the top quartile of performance. They are able to interactively control the content of their reports using filters for any combination of the discharging hospital, month, diagnoses, procedures, specialty and age band and can review the content from a principal diagnosis, principal procedure, HIPE specialty or consultant team breakdown perspective.

Data sources:

The HIPE system is a health information system designed to collect medical and administrative data regarding inpatient and day case discharges from, and deaths in, acute public hospitals. Each HIPE discharge record represents one episode of care following admission to the given hospital for an individual patient, recording demographic, administrative, diagnoses, procedures and other related data.

NQAIS Clinical is available to clinicians and managers in all HSE funded hospitals, who agree to adhere to the data confidentiality requirements of the Health Service Executive (HSE) and the Healthcare Pricing Office (HPO) information policies and have the authorisation of the hospital(s) senior management or Clinical Director to use that hospital’s Hospital Inpatient Enquiry (HIPE) data.

Contact Programme Manager: Eilish Croke - eilish.croke@hse.ie

 

 

 

Clinical Strategy and Programmes Division