Trust develops an integrated web-based pathway that supports extended hospital stay for children requiring long-term ventilation via tracheostomy, reducing length of stay

We developed an integrated web based care pathway which supports a service which aims to tackle inappropriate, extended hospital stay for children requiring long term ventilation via tracheosotmy (t-LTV). Our service offers clinical expertise, education, welfare and discharge coordination throughout London and South East England. We also provide a national web based integrated care pathway that supports the LTV network, and provides a forum for sharing information and standards. This integrated service has coincided with a decrease in the total hospital length of stay, and the number of days spent in hospital while being fit for discharge for children needing tr-LTV.

Challenges

•The PIC team at Royal Brompton Hospital identified children requiring t-LTV were occupying intensive care beds for longer than necessary.

•It is well documented that many children receiving long term ventilation (LTV) via tracheostomy remain in hospital for many months longer than necessary while a package of care is established in the home (Edwards, O’Toole & Wallis, 2004).

•Children on t-LTV remaining in hospital tend to be cared for in tertiary intensive care and high dependency units even when medically stable and ‘fit for discharge’.

•ICU is an inappropriate environment for children that no longer require that service (Murphy, 2008), detrimental to social and physical development (Noyes, 2002) and reduces capacity for elective and emergency admissions (NHS England, 2015).

•The local audit, ratified by the literature, identified that extended hospital stays are the result of a myriad of factors which include; lack of a defined discharge process, fragmented funding streams, difficulty in recruiting home care staff, a lack of knowledge and expertise to deliver the care required in a community setting and poor inter-agency communication (Edwards, O’Toole & Wallis, 2004; Smith & Hilliard, 2011).

Actions

•The Paediatric Intensive Care (PIC) team at Royal Brompton Hospital (RBH) conducted an internal audit of children discharged home on tr-LTV. Between 1 April 2004 and 31 March 2006 thirteen children were reviewed. Analysis of this cohort enabled the team to identify and map the barriers to achieving a safe and timely discharge from hospital to home. This clinical audit identified the need to capture information that would produce data to identify the reasons for delayed discharge, cost of hospitalisation, and to construct a new process to support timely hospital discharge for tr-LTV children

•We introduced a regional service to provide outreach clinical, educational, welfare and discharge support via a hub and spoke model under the name of ‘The Children’s Long Term Ventilation Service’.

•We developed and implemented an innovative web based pathway with integral workflow processing technology which has enabled a structured approach to the discharge pathway, and consistency of approach with the ability to track and report patient centred and population outcomes or delays along the hospital to home journey.

•We successfully disseminated our online integrated care pathway throughout NHS England and found that diffusing this innovation at pace and scale resulted in good adoption with 23 out of 24 LTV centres actively managing patients using this decision support tool. Dissemination of our web based pathway afforded us the opportunity to engage with our peers to create a network of LTV clinicians through which we promote best practice through sharing knowledge and evidence base.

Results

Reduced Bed days in PICU – right care in the right place at the right time

•Financial savings associated to reduced hospital stay

•Successful implementation of Integrated digital technology to guide a quality patient pathway

•Outcome data available real time for commissioners and users

Value

•We have successfully demonstrated significant reductions in hospital length of stay (LOS) for this cohort from 9.8 months (baseline from historical controls) to an average of 2.7 months.

•The reduction in bed days correlates with financial savings (£915,000 per patient (baseline) to £251,000 (2012-14) based on an average bed cost of £1500 per patient).

•We have evaluated user satisfaction from all accessing education finding 99% of attendees agreed or strongly agreed that their personal learning objectives had been met and 99% agreed or strongly agreed that the education had equipped them with enhanced knowledge and skills.

•We sought feedback through a service evaluation project using ‘Experienced Based Co-design’ methodology. We conducted semi-structured interviews with both families, which included parents as well as grandparents, and professionals in acute hospitals and community settings. All participants were extremely positive about the contribution of this model of care and feel that having a specialist team involved throughout the hospital to home journey enhanced their experience. The education programme in particular was credited as a key value of the service. Service improvement initiatives from this project have included improved written communication, including a new website, enhanced key worker role, provision of welfare support and development of a follow up pathway to provide a structured process for ongoing specialist care in the community.

In detail

It is well documented that many children receiving long term ventilation (LTV) via tracheostomy remain in hospital for many months longer than necessary while a package of care is established in the home. Furthermore children remaining in hospital tend to be cared for in tertiary intensive care and high dependency units even when medically stable and ‘fit for discharge’. The process of assessing needs, allocating funding and recruiting staff varies widely across the country, and there is inequity of service provision in the community. However, children on LTV are not a homogenous group and their underlying medical needs can be markedly different from one another. Literature suggests that extended hospital stays are the result of a myriad of factors which include; lack of a defined discharge process, fragmented funding streams, difficulty in recruiting home care staff and poor inter-agency communication.

Ambition

In 2006 the Paediatric Intensive Care (PIC) team at Royal Brompton Hospital (RBH) conducted an internal audit of children discharged home on tr-LTV. Between 1 April 2004 and 31 March 2006 thirteen children were reviewed. Analysis of this cohort enabled the team to identify and map the barriers to achieving a safe and timely discharge from hospital to home. This clinical audit identified the need to capture information that would produce data to identify the reasons for delayed discharge, cost of hospitalisation, and to construct a new process to support timely hospital discharge for tr-LTV children. This led to the staged development of a specially commissioned service for the discharge co-ordination of children on tr-LTV in London and the South East region.

The aim of the service is to move care closer to home for children on long term ventilation by providing specialist clinical support, education and discharge pathway management, augmented by the development of an online pathway and workflow tool, across London and South East England using ‘a hub and spoke’ model. In addition the Hospital to Home service delivers an actively managed web based integrated care pathway for LTV children that is now used by the majority of NHS England centres, and which has contributed to the development of a functional clinical network with shared purpose, best practice and standards. The aim of the service is to support safe care closer to home for children on long term ventilation based on the core objectives of an NHS England QIPP.

Quality

To provide a regional central resource and network to share best practice and solutions for children on tracheostomy-LTV, ensuring we keep the child and family at the heart of decision making.

Innovation

To work within a discharge framework using the Hospital to Home web based pathway with the aim of improving communication and interagency working across organisational boundaries for efficient patient pathways and flow.

Productivity

To work collaboratively with service providers across health and social care to enable safe and timely care at home, or closer to home, and reduce unnecessary hospital stay.

Prevention

To provide a central source of expertise that can diffuse specialist expertise throughout the network, to empower clinical teams caring for these children with complex needs by providing structured communication, care plans and specialist education and training delivered at the point of need.

Spread

We successfully disseminated our online integrated care pathway throughout NHS England and found that diffusing this innovation at pace and scale resulted in good adoption with 23 out of 24 LTV centres actively managing patients using this decision support tool. Dissemination of our web based pathway afforded us the opportunity to engage with our peers to create a network of LTV clinicians through which we promote best practice through sharing knowledge and evidence base. We now have the opportunity to analyse national t-LTV data to focus interventions to support continual service improvement.

Value

In addition to reduction in ICU and hospital length of stay and associated financial savings the support service itself has added significant value to both the family and professional experience. We evaluated family and professional experience of the hospital to home journey for children requiring long term ventilation via tracheotomy (tr-LTV) using an adapted experience based co-design (EBCD) approach. We conducted semi structured interviews with subsequent thematic analysis followed by co-design of identified service improvements with our sample.

We chose to use the user centrist approach of EBCD to evaluate our service because this methodology allowed us to not only evaluate service user experience but also work in partnership with them to make improvements where identified. Our service model is an innovative way of working and unique in that the support spans organisational boundaries. All participants were extremely positive about the contribution of this model of care and feel that having a specialist team involved throughout the hospital to home journey enhanced their experience.

The education program in particular was credited as a key value of the service. Service improvement initiatives from this project have included improved written communication, including a new website, enhanced key worker role and provision of welfare support to enhance health and social care integration for improved health and well-being. There is further development of a follow up pathway to provide a structured process for on-going specialist care into the community as we strive to share expertise and efficiency across services and disciplines.