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Central Middlesex Hospital: Brent Emergency Care and Diagnostic Centre

  • Last modified date:
    8 February 2007

A local hospital able to deal with emergency and routine cases on a 24-hour basis, and providing a single service for patients with chronic disease. Strong network links with surrounding health economy - to tertiary centre and to smaller hospitals.

Background

  • Central Middlesex Hospital, with Northwick Park Hospital, forms the North West London Hospitals Trust. It is a small DGH serving a population of around 220,000. The hospital has 243 beds and manages around 180 emergency admissions per week (10,000 a year). The Central Middlesex also hosts the Ambulatory Care and Diagnostic Centre (ACAD) that provides one-stop elective treatment services.

Challenges

  • In common with many hospitals of its size, Central Middlesex has comparatively small numbers of specialists, and junior and middle grade doctors in all the major specialties, in particular surgical discipline. Sustaining emergency care in the context of the requirements of the European Working Time Directive (EWTD), and increasing sub-specialisation, therefore presents a major challenge.

Aims & proposed changes to working patterns

  • The Brent Emergency Care and Diagnostic Centre (BECaD) is being developed as a service model to support a major hospital redevelopment. The aim is to provide a new model for the DGH that can provide sustainable assessment and treatment for the local catchment population. It involves a fundamental redesign of patient process and staff roles based on the use of care systems, pathways and protocols.

Service portfolio

  • Services provided at the BECaD will include acute medicine, surgery, gynaecology and trauma and orthopaedics and inpatient paediatrics but not consultant led obstetrics. Elective inpatient provision will be also be maintained for urology. Short-stay and day surgery will be provided for a full range of specialties from the Ambulatory Care and Diagnostic Centre (ACAD), Expert consulting services (replacing existing outpatient clinics) will be offered in all major medical and surgical sub specialties and in paediatrics. Services will be linked to specialist centres such as vascular surgery an a maxi-centre at Northwick Park, and cardiac services at St.Mary's Paddington.

Service model

  • The future service model depends on a high degree of service redesign and significant changes in working patterns. Ultimately Central Middlesex propose to make PRHOs and SHOs supernumerary, and change the working patterns of middle grades and consultants to achieve EWTD compliance as part of the redesign of the whole service model. Key features include
  • streaming within A&E
  • unified general medicine and A&E teams to provide an integrated acute assessment service with senior clinical leadership
  • patient-led single service for chronic disease
  • team based working providing protected emergency cover
  • strong differentiation between day and night working with an extended working day and hospital wide night team
  • Devolved management of surgical theatres and beds with out of hours working minimised in line with best clinical practice as per National Confidential Enquiry into Peri-Operative Deaths (NCEPOD) recommendations.

6. The A&E of the BECaD will have two front doors. NHS Direct and London Ambulance service will direct patients to the appropriate setting. Patients with minor injuries and complaints will be treated in the urgent treatment centre. This unit will be primary care led and staffed by a team of urgent care specialist including GPs and practice nurses as well as emergency nurse practitioners. There will also be built-in primary care follow-up including registration and significant social care input. Patients with more major complaints will be treated in the Major Assessment Centre which will become part of the new integrated acute assessment service.

Integrated acute assessment service

7. There will be a clear division in the hospital between the management of patients who are acutely ill (in the acute assessment service) and those in the recovery phase (in the step-down service. In both areas, medical and surgical patients will be treated together.

8. The acute assessment service will bring together A&E, Assessment Unit, ITU, CCU and HDU with acute medical, surgical and care of the elderly inpatient beds. This will involve merging the A&E team and the acute/critical care team, with 24 hour middle grade anaesthetic cover. Extending the working day (including for consultants) to minimise out of hours working and merging these frontline teams will deliver a consultant led system with middle grades covering a shorter night shift. The team will be supported by "major nurse practitioners".

9. The acute assessment area will be covered by medical consultants working for a 7-day period, in rotation, alongside A&E specialists and intensivists. The team will be able to call upon specialist opinions in surgery, T&O, gynaecology and urology. The aim will be to have early input from middle grade staff to provide an expert opinion. There will be 24-hour pathology and radiology support with extended day access to MRI, CT, ultrasound.

Chronic disease service

10. In the step-down service, primary care, intermediate care and step-down wards for older patients will be combined to provide a single service for patients in recovery. Staff in this service will have the opportunity to rotate between inpatient and community jobs, and case-management will ensure consistency of care before, during and after admissions.

Chronic disease service

11. A major feature of the BECaD is merging primary and secondary care to provide a single service for patients with chronic disease. This follows a disease management model, with patients taking a large part in determining their care and having direct access to specialists. Care will be provided under shared protocols and using shared information, with a greater menu of interventions. The outpatient department is replaced by an Expert Consulting Centre used by integrated teams.

Team based working in surgery to provide protected emergency cover

12. To ensure a rapid emergency response, surgery will be working on a team basis with a "surgeon of the day". A middle grade surgeon will also be assigned each day to booked work and separately to theatres. Work on rotas indicates that this alignment can be key to achieving a compliant approach.

Strong day/night differentiation with extended working day

13. At night, the on call nursing, medical and surgical team will merge to form one integrated team, allowing co-ordination of investigative effort. The team will be led by a middle grade physician and may include administrative support. The workload of the team will be reduced through core specialties working an extended day. This pooled resource will free up time for doctors to be used for more intensive training or rest periods. Ultimately this will make all medical and surgical SHO posts EWTD compliant.

14. Devolved management of surgical theatres and beds

15. Management of outpatients, elective in patient beds and theatre time will be devolved to the surgical teams within the Expert Consulting Centre led by a new Team Manager, a role currently being piloted within orthopaedics.Outstanding issues

16. The main issues around this example are likely to be the adequacy of out of hours surgical and anaesthetic cover. It will be important to establish that rotas provide adequate training; and that the range of surgical cover is sufficient.

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