Northern Adelaide Local Health Network (NALHN) Adelaide Local Health Network (NALHN) ... Michael Francese Executive Sponsor, ... and Northern Adelaide Local Health Network

Northern Adelaide Local Health Network (NALHN)

Proposed Intra-NALHN

Service Plan

February 2016

Page 2 of 84 Proposed Intra-NALHN Service Plan – February 2016

Document Control Date: 03/2/2016 Release:

Author:

NALHN Executive

Owner:

NALHN Executive

Document Number: A224729

Note: This document is only valid on the day it was printed

Revision History

Revision Date Previous Revision Date

Summary of Changes Changes Marked

3/2/16 New draft

Approvals This document requires the following approvals. A signed copy should be placed in the project files.

Name Signature Title Date of Issue Version Dr Elaine Pretorius Clinical Lead Transforming

Health, NALHN

Michael Francese Executive Sponsor, Transforming Health, NALHN

Jenny Browne Director Finance, NALHN

Scott McMullen

Chief Operating Officer, NALHN

Jackie Hanson Chief Executive Officer, NALHN

Distribution This document has been distributed to: Name Title Date of Issue Version


Disclaimer

The content of this plan was developed by relevant stakeholders drawing on specialty knowledge,

information and data that was available at the time. Information contained in this plan may require

further refinement and / or realignment based on further improvements that may occur between

the time the plan was documented and the commissioning of the services or compromises that may

need to be made in order to provide a safe service.

Assumptions

The development of Service Plans for Lyell McEwin Hospital (LMH) and Modbury Hospital (ModH)

are based on a number of assumptions:

Service Plans

o The Service plan is a point in time document and as such is intended to be a living

document that will be revisited and updated along the Transforming Health journey.

Activity and workforce

o Modelling is based on commissioned activity in accordance with the Service Level

Agreement (SLA) between Department for Health and Ageing (DHA) and Northern

Adelaide Local Health Network (NALHN).

o Specific assumptions relating to service delivery are identified in the relevant

sections of this plan. Workforce modelling has been based on these assumptions.

o The development of the NALHN Service Plans was based on 2014/15 activity actuals

for patient profiles and applied 2015/16 commission activity where significant

differences between actuals and commissioned emerged.

o Agreed consistent approach to modelling and theatre utilisation/ scheduling and is

standardised to 4 hour theatre session lists.

o Outpatient Activity will be modelled for every service plan.

Management of deteriorating patients, patient transfers and clinical documentation

o Management of deteriorating patients will be well defined through Medical

Emergency Team (MET) and Rapid Response Teams (RRT).

o Hospital-at-Night functions and emergency management response team will support

clinical practice and processes.

o A system will be in place to address patient movement for rapid transfer and

ambulance support.


o NALHN will maintain controls, checks and balances in both electronic and paper-

based information management and data governance for patient identification and

transfers.

Clinical Support Services and Infrastructure

o Interdependencies and infrastructure for Clinical Support Services are built in to

models of care.

Infection Control

o The universal principles relating to Infection Control will continue to support clinical

practice.

Central Flow Unit in patient transfers

o The Central Flow Unit will continue to act as NALHN’s strategic capacity and patient

flow management centre.

Training and Accreditation

o NALHN will continue to engage with the relevant Colleges and Professional Bodies to

ensure training and development requirements are met.

Corporate Services

o Corporate functions across NALHN will be considered as a whole of system

approach.

While these assumptions are important to acknowledge, they do not override or compromise the

overarching model of care principles - best care first time, every time, ensuring patients are treated

closer to home where possible - and commitment to the Transforming Health journey.


Contents Disclaimer ...................................................................................................................................................... 3

Assumptions.................................................................................................................................................. 3

1. Introduction .............................................................................................................................................. 8

2. Purpose ..................................................................................................................................................... 8

3. NALHN’s commitment to improving the patient journey ..................................................................... 8

4. Population of interest ............................................................................................................................ 10

5. Activity and Service Moves .................................................................................................................... 12

5.1 Intra NALHN – overview of changes ............................................................................................... 12

5.2 CALHN to NALHN .............................................................................................................................. 14

6. Models of Care ....................................................................................................................................... 14

6.1 NALHN Emergency and Critical Care Services ................................................................................ 14

Emergency Departments (including EECU/ ED Short Stay) ............................................................. 15

Rapid Response Team ........................................................................................................................ 16

NALHN Intensive Care Unit................................................................................................................ 18

NALHN Hospital at Home .................................................................................................................. 19

6.2 NALHN Surgical Services .................................................................................................................. 19

Referral pathways .............................................................................................................................. 21

Preadmissions..................................................................................................................................... 21

Discharge and follow up .................................................................................................................... 21

Restorative care and rehabilitation .................................................................................................. 22

Emergency care .................................................................................................................................. 22

Clinical deterioration ......................................................................................................................... 23

Elective Surgical Waiting lists ............................................................................................................ 23

Theatres .............................................................................................................................................. 23

Surgical Sub Specialties ...................................................................................................................... 23

Orthopaedics .................................................................................................................................. 23

Urology ........................................................................................................................................... 27

ENT .................................................................................................................................................. 27

Vascular Surgery............................................................................................................................. 27


General Surgery ............................................................................................................................. 28

Upper GIT surgery .......................................................................................................................... 28

Breast Endocrine ............................................................................................................................ 28

Plastics and reconstructive surgery .............................................................................................. 28

Gynaecology ................................................................................................................................... 29

6.3 NALHN Medical Services .................................................................................................................. 29

Medical Sub Specialties ..................................................................................................................... 29

General Medicine (including Short Stay General Medicine Unit)............................................... 29

Cardiology ....................................................................................................................................... 31

Respiratory Medicine..................................................................................................................... 32

Gastroenterology service .............................................................................................................. 33

Diabetes and Endocrinology ......................................................................................................... 33

Neurology and Stroke Services ..................................................................................................... 34

Renal Services................................................................................................................................. 35

Haematology and Medical Oncology............................................................................................ 36

Chronic Disease Management Unit .............................................................................................. 36

7. Interdependencies- clinical support summary ..................................................................................... 37

8. Interdependencies- non clinical support summary ............................................................................. 39

9. Infrastructure - summary ....................................................................................................................... 40

10. Staff education / training required for implementation ................................................................... 41

11. Workforce – FTE summary by service................................................................................................. 42

12. Activity – summary by service ............................................................................................................. 49

Division Medical Sub Specialties ........................................................................................................... 49

Overall summary ................................................................................................................................ 49

Current state....................................................................................................................................... 50

Future state ........................................................................................................................................ 53

Surgical Activity ...................................................................................................................................... 56

Overall summary: ............................................................................................................................... 56

Current state....................................................................................................................................... 56


Future state ........................................................................................................................................ 60

13. Risk management ................................................................................................................................. 65


1. Introduction

The SA Health Transforming Health agenda outlines the direction for the delivery of health services

across South Australia. Transforming Health aims to provide the best care, first time, every time. To

achieve this, there also needs to be significant work undertaken in unlocking existing capacity within

hospitals by improving the effectiveness and efficiency of care provided.

For NALHN, LMH will develop into a major adult tertiary hospital for the north as planned, supported

by ModH as a centre for elective surgery, rehabilitation and sub-acute services. LMH will continue to

provide paediatric surgery and paediatric medicine as part of a statewide governance service with

the Women’s and Children’s Hospital and Flinders Medical Centre. LMH neonatal services will also

be part of a statewide governance service and will continue to provide complex care to acutely ill

newborns with the Special Care Nursery increasing in complexity and volume.

In addition to the internal NALHN service profile changes, Transforming Health also outlines the

movement of services between Local Health Networks (LHNs) to support the principle of care

provided as close to home as possible. This will require a significant change in the service profile of

both sites, and associated transfer of activity and resources to support this.

2. Purpose

The purpose of the NALHN Transforming Health Intra NALHN Consolidated Service Plan is to provide

a clear understanding of the type and volume of services, and necessary supporting infrastructure,

to be provided across NALHN as part of the intra NALHN service profile changes. It also provides an

overview of the transfers associated with the CALHN to NALHN activity transfer process.

3. NALHN’s commitment to improving the patient journey

‘Improving the Patient Journey. Everybody Matters’ encourages all staff to play an active role in

improving the patient journey and reminds us of the core values and behaviours we must uphold to

ensure the needs of our patients remain at the forefront of our day-to-day work.

As an organisation that embraces ‘Improving the Patient Journey. Everybody Matters’, we will

continue to move from:

work being organised through the needs of the business;

changes being reactive to patient demands;

information being presented only from the staff point of view;


staff feeling not empowered to initiate change; and

being a silo working culture.

Through ‘Improving the Patient Journey. Everybody Matters’ we ensure:

we view our organisation through the lens of people who actually use our services;

the provision of information is planned and two way;

pathways are mapped to illustrate experience and patient experience data is collected and

acted upon;

service users are part of the decision making process and our organisation can demonstrate

that this leads to improvement;

work is based around the patient journey, providing more consistent and integrated care;

there is a positive learning approach to complaints handling, and complaints and

compliments are shared widely; and

patients are supported to be partners in their care and share decisions.

The five elements that make up and contribute to ‘Improving the Patient Journey. Everybody

Matters’1 is patient-focused and supported by a number of values, behaviours and standards. These

include:

Patient and Family Centred Care

Accessible, Integrated and Coordinated Care

Working as a Team

Acting on Feedback

Safe and Reliable Care

1 Link for Improving the Patient Journey http://dev.health.sa.gov.au/cnahs_dev/InsideNorthern/ImprovingthePatientJourneyEverybodyMatters/tabid/904/Default.aspx,

http://dev.health.sa.gov.au/cnahs_dev/InsideNorthern/ImprovingthePatientJourneyEverybodyMatters/tabid/904/Default.aspx

http://dev.health.sa.gov.au/cnahs_dev/InsideNorthern/ImprovingthePatientJourneyEverybodyMatters/tabid/904/Default.aspx


4. Population of interest

There were 369,484 people living in the NALHN area as at the last (published) census in 2011. The

primary catchment for NALHN is the northern Adelaide metropolitan region comprising three Local

Government Areas (LGA) in their entirety, the City of Playford, the City of Salisbury and the City of

Tea Tree Gully, and part of a fourth, the City of Port Adelaide Enfield. In addition a substantial

number of people who access services in the NALHN come from outside the geographic boundaries

of the LHN, including people from rural, remote, interstate and overseas locations. A significant

number of residents from within the NALHN currently access health services in other LHNs within

the state. The proportion of patients accessing services in other LHNs is dependent on the specific

service required. In some instances this is appropriate as they are highly specialised, state-wide

services, however the intention is that for the majority of services, NALHN should be capable of

providing in excess of 85% of the care required for the local population.

The Northern area of Adelaide is currently the highest population growth area in SA. This will mean

that by 2026 it is expected a quarter of the state’s total population is expected to live in the

northern metropolitan catchment2.

NALHN has a younger age structure to that of South Australia as a whole and although there will be

an increase in the percentage of older persons in the NALHN region, the region will maintain its

status as the youngest region until 2026. Although the total proportion of older people in NALHN is

lower that the state average, the growth in this age group in NALHN is greater that the growth rate

for the state as a whole.

The NALHN is characterised by significant disadvantage with regard to health and wellbeing, as it

contains some of the most disadvantaged parts of the state. As a whole, residents of NALHN rate

lower on population health measures than residents of other LHNs, and are also more likely to have

chronic disease or risk factors for chronic disease.

The proportion of Aboriginal or Torres Strait Islander people living in the NALHN in 2011 (1.9% of the

NALHN population) is consistent with the state as a whole (1.9%). However, some SLAs in the NALHN

had some of the highest metropolitan proportions of Aboriginal and Torres Strait Islander people.

Although there is diversity, the NALHN Aboriginal and Torres Strait Islander population, as a group,

rate much lower on most measures of population health relative to the whole population. Since

2 Population projections for South Australia. Projection, May 2011, Medium series based on Census 2006.


2005, an estimated 55% of all refugee new migrants in South Australia have settled in the LGA’s of

Playford, Salisbury, Tea Tree Gully, Gawler, Mallala and part of Port Adelaide Enfield. This

percentage equated to a total of 2,905 people in 2006 and increased by 178% to 8,061 people in

2011. This settlement trend is expected to continue3.

Demand increases are not only related to population growth. The NALHN is characterised by

significant disadvantage with regard to health and wellbeing, as it contains some of the least affluent

parts of the state. The social and economic factors influencing the health services within the NALHN

include, but are not limited to the following:

High level of obesity and co-morbidities per volume of patients

High level of limited literacy (year 10 level)

Low socio-economic status

The area has a greater avoidable causes of death when compared with the rest of South Australia

High level of psychosocial distress level associated with the level of disadvantage

High prevalence of smoking and physical inactivity

High level of single parent families, people receiving unemployment benefits and disability

pensioners.

There is one General Practitioner per 1,400 or more people and of particular note is the high

proportion of the sole GPs. This impacts on the number and availability of after-hours GP services

and the number of presentations to the LMH and ModH’s Emergency Departments after hours4.

3 Northern Adelaide Medicare Local (NAML) 2015 4 Australian Bureau of Statistics Census Data – August 2011. (Accessed on line 31

st July 2012)

4 http://www.dpti.sa.gov.au/__data/assets/pdf_file/0006/177936/Population_Change_Fact_Sheet_2014.pdf

http://www.dpti.sa.gov.au/__data/assets/pdf_file/0006/177936/Population_Change_Fact_Sheet_2014.pdf


5. Activity and Service Moves

5.1 Intra NALHN – overview of changes

Surgical services

ModH will become the elective surgery centre for the north and north east, providing 23-hour and

day elective procedures. An expanded one stop breast service will give women access to a breast

surgeon, radiologist and a breast care nurse in the same location. Emergency, complex and multi-day

surgery will be focused to LMH, including a 24/7 orthopaedic trauma surgery service.

Emergency services

ModH will continue to operate an ED 24 hours a day, 7 days a week, staffed by specialists, and the

majority of patients who present will continue to be seen at the hospital. If patients need ongoing,

specialist care not available at ModH, they will be stabilised before being transferred to another

hospital. A short stay unit will be established to assist management of admissions from ED.

Medical services

Establishment of an acute medical short stay unit at ModH providing care for up to 48 hours, with

patients who have higher acuity needs or require greater than 48 hours inpatient care transferred to

LMH. Gastroenterology outpatient service and elective endoscopies will now be provided at ModH.

A new cardiac catheter laboratory will be built at LMH.

Rehabilitation services

ModH will become the major rehabilitation centre for the north and north east, with a new gym,

hydrotherapy pool and therapy spaces, increasing inpatient rehab beds to a total of 52. As a result

cardiology, some medical and some surgical inpatient beds will move to LMH with Level 3 at ModH

redeveloped to accommodate the additional rehabilitation beds.

This redevelopment will be undertaken in two phases and will require the decanting of each wing

during the redevelopment phase. Each phase will take approximately three to four months to

complete. Bays on level 2 will also require decanting to enable any underfloor work to be completed.

The decanting also includes activity movement between Modbury and Lyell McEwin Hospitals.

Diagrams 1 and 2 below outline the moves between ModH and LMH and the moves within ModH.

Activity currently accommodated in 3 East will transfer to LMH Ward 1B. It is anticipated this

decanting of 3 East will occur by early March 2016. It is anticipated the decanting of 3 West will

occur by June 2016.


Diagram 1: Modbury to LMH Activity Movements

Diagram 2: Intra-Modbury Activity Movement


5.2 CALHN to NALHN

As part of Transforming Health, detailed planning work is under way to increase the services

available across NALHN and enable more residents of the northern and north eastern suburbs to be

treated closer to home. This includes new capital investment in both the LMH and ModH and service

realignments across a range of services to transfer the activity currently occurring in CALHN that

relates to northern residents into NALHN.

During the first half of 2016 activity from selected CALHN services will transition to NALHN. Below is

a list of in scope services:

Orthopaedics

Stroke

Cardiology

Vascular

Renal medicine

Urology

Medical oncology

Upper GIT

Endocrinology

Haematology

Breast surgery

ENT

6. Models of Care

This section outlines the service models for those units and specialties impacted by the site profile

changes and activity moves.

6.1 NALHN Emergency and Critical Care Services

The NALHN emergency and critical care services will operate as a single service – multi site model

under the governance of the Critical Care Division. This model is necessary to ensure the services

provided are safe and of a high quality, that staff have the opportunity to provide a range of complex

and non-complex procedures, and that trainees are offered a breadth of experience. The single

service model will also provide greater consistency of care across the two sites by providing common

policies, procedures and patient pathways.


Emergency Departments (including EECU/ ED Short Stay)

The NALHN will continue to provide FACEM (Fellow of the Australian College of Emergency

Medicine) led EDs at both LMH and ModH, 24 hours, seven days a week. The EDs will receive, triage,

stabilise and manage adult and paediatric patients who present with a range of conditions including;

medical and surgical emergencies; paediatric and obstetric emergencies; post trauma and acute

mental health. Strong links will continue to be maintained with the SA Ambulance Service, MedStar,

CALHN, SALHN and WCLHN for the transfer of patients requiring high acuity state-wide services (e.g.

burns, spinal injuries, cardiothoracic, complex vascular and neurosurgery and out of hours stroke).

Patients requiring inpatient specialist services not available at the ModH site will be transferred to

where the service is provided either at LMH or an alternative LHN.

LMH ED will have the capability to stabilise major trauma patients who cannot be transported

directly to the Major Trauma Services at the RAH (>16years) or WCH (<16years).

Strategies which support patient flow through the ED will continue to be implemented to assist in

achieving national ED targets.

The Extended Emergency Care Unit (EECU) /ED Short Stay Unit (EDSSU) will address the needs of

patients who do not require an inpatient admission to hospital but need extended observation

and short-term treatment, or who are waiting for test results to confirm that they can be

discharged. EDSSU will adhere to specific admission and discharge criteria and policies as per ED led

model below.

Key Principles for admission to EECU/EDSSU include:

Clinically stable AND

Anticipated to require a period of observation or treatment less than 24hours, or

In some circumstances are pending transfer to another facility.

LMH currently has an EECU in place. The EDSSU will be established at ModH co-located with the

Short Stay General Medicine Unit (SSGMU). It is proposed that a purpose built 30 bed short stay

unit (EDSSU and SSGMU) be constructed adjacent to the ModH ED. Timeframe to be determined.

The ED continues to be supported by an allied health team comprising Physiotherapy, Occupational

Therapist, Social Work and other specialties as required and together with the ED discharge liaison

nurse form the Emergency Medical Assessment Team (EMAT) from Monday to Friday.


Rapid Response Team

In response to the change in profile of ModH, a RRT will be established to manage deteriorating

patients on site for stabilisation and / or transfer out. A RRT is a designated group of healthcare

clinicians who are available quickly to deliver critical care expertise in response to clinical

deterioration (MET/ Code Blue) of a patient located within the hospital (excluding emergency

department patients). It is proposed that the Rapid Response Team will commence following the

closure of the High Dependence Unit at ModH.

There are three key features of the RRT members:

They must be available to respond immediately when called, and not be constrained by

competing responsibilities.

They must be on site and accessible.

They must have the critical care skills necessary to assess and respond.

The key roles of the RRT are:

Assess and stabilise the patient condition.

Communicate to the home treating team.

Educate and support the direct care staff.

Recommend / assist with patient transfer to a higher level of care as required.

The RRT will have two registered nurses rostered per shift over 24 hours. This is to ensure back up is

available for simultaneous MET calls and if the first RRT nurse is managing a deteriorating patient

waiting for up transfer.

There will be a designated RRT medical officer 24 hours a day. In addition, it is proposed that the

Medical RRT member assumes the position of medical team leader overnight at ModH, supporting

junior medical staff and nursing staff as required. Medical oversight of the service will initially reside

with NALHN intensive care, with RRT activity being continuously monitored and ongoing governance

reassessed within six months from commencement.

The initial response to a deteriorating patient is via a MET call / Code Blue as described in the NALHN

Rapid Detection and Response Procedure.

If the patient is unstable and requires short term critical care support until an up transfer

can occur, the patient will be transferred to ED and managed by the RRT medical Team

Leader (TL) and RRT nurse. Only patients requiring up transfer (to LMH or other facility) will

be managed in the ED until transfer can occur. Transfer to the ED is at the direction of the


RRT medical TL following discussion with the ICU / MET Consultant and the home team. The

Senior ED Consultant must be notified prior to transfer to ED.

If the patient does not require up transfer they will remain on the ward where the RRT

medical TL will discuss situation with the patient’s home team and adjust treatment plan as

required. The RRT nurse will assist and support the ward nursing staff with ongoing

management.

If the patient requires short term monitoring but not an up transfer, the RRT TL will liaise

with the home team and the medical registrar for potential to manage in the Short Stay

General Medicine Unit.

The RRT will be based in the ED (includes MET 1 and MET 2 nurses and ICU Registrar) and will meet

at the beginning of each shift with the Medical Registrar (team huddle).

The MET Consultant will provide an overview of the service for the day and will:

Undertake a daily ward round of Modbury Hospital either in person or via telephone with

MET TL (ICU registrar)

Be available for telephone consultations

Attend the site if required (e.g protracted MET call, airway concerns)

Assist in communication with other facilities if LMH unable to provide relevant service and

ensure appropriate transfer occurs

RRT Team Leader (ICU Registrar) will:

Lead the MET huddle

o Identify individual roles and responsibilities at MET

o Identify and discuss any patients of concern

o Discuss capacity within ED and LMH ICU

o Identify ward patient cohorts / redevelopment floor plan changes

Attend and lead all MET

Discuss all MET calls with Home team Consultant and MET consultant

Review ‘patients of concern’ at the request of the MET nurse and liaise with home teams as

necessary

Contribute to education relevant to role


RRT 1 Nurse:

Primary role will be to attend MET calls. RRT 1 will remain with patient until no longer required. This

includes ongoing care of deteriorating patient until transfer complete. MET 1 role will be expanded

to include:

Equipment checks including 4 MET trolley’s spread throughout the Hospital

Data collection for monitoring and evaluation

i. Patient reviews post MET

ii. Patient reviews – not MET

iii. MET calls

iv. Patient transfer to Short Stay General Medicine Unit

v. Patient transfer to LMH ICU or other

vi. Time frames for Medstar

vii. Incident reporting (SLS)

viii. Assessing and monitoring of “patients of concern”. Handover of such patients will be

handed over from shift to shift

ix. RDR chart auditing

RRT 2 Nurse:

Will respond to MET calls when the RRT 1 nurse is still on a previous MET call or RRT 1 requires

additional assistance due to skills or staff deficits on wards (especially at night and for calls outside

the ward areas). RRT 2 nurse will be supernumerary for the first three months to facilitate transition

and evaluation but thereafter will be included in the ED nursing staffing numbers.

Communication:

Communication will be via mobile phones and pagers. The pagers will notify of any Code Blue calls

and of other codes happening in the hospital and the phones enable direct communication between

team members.

Note: the RRT nurses will be required to regularly rotate into LMH ICU to maintain skills and

experience. In addition, all RRT/ MET nursing and medical staff require ALS 2 training.

Attachment 1 outlines the RRT process.

NALHN Intensive Care Unit

NALHN intensive care services will be provided from the LMH ICU which underwent an expansion as

part of the LMH Stage C redevelopment. The LMH ICU is a separate and self-contained section of the

hospital, staffed and equipped for the management of patients with established life-threatening


reversible or potentially reversible, organ failure or with a high risk of life-threatening organ failure.

The ICU provides specialist expertise and facilities for the support of patients and their families,

utilising the skills of medical, nursing and other allied health staff qualified and experienced in the

management of critically ill patients. The ICU provides a closed model of care with admission into

the ICU and care of the patients whilst in the unit under the medical governance of the intensive

care consultants. Neonatal and paediatric are excluded from general adult ICUs. Critically ill

paediatric patients will be stabilised and assessed for transfer to the Women’s and Children’s

Hospital.

There will be an ongoing requirement for LMH ICU to support the ModH in the care of deteriorating

patients. For the patient that is rapidly deteriorating the ModH RRT will respond followed by a direct

admit to the ICU at the LMH.

NALHN Hospital at Home

The NALHN Hospital at Home (H@H) service facilitates early discharge from ward areas reducing

length of stay, hospital avoidance by accepting patients directly from ED, and complete hospital/ED

avoidance by accepting patients from the community if known by an inpatient Consultant. NALHN

H@H functions as a ‘virtual ward’ where inpatients of the LMH or ModH reside outside of the

organisation in their home, nursing home, or temporary place of residence. All H@H patients are in

an acute phase of illness and require acute nursing intervention and access to a collaboration of

services offered within an acute care organisation, whose care needs cannot be met by outside

community service.

The H@H services at LMH and ModH is an integrated service, with LMH as the main base from

where the service is coordinated. ModH will continue to maintain a limited service on-site providing

a liaison role to elicit and assess referrals and potentially provide treatment. The LMH site is

supported by a medical assessment clinic 3 days per week to facilitate review of medical patients,

with medical ‘off site’ reviews when appropriate. H@H also has access to treatment rooms to assess

the deteriorating patient as an alternative to the ED.

6.2 NALHN Surgical Services

The NALHN surgical services will operate as a single service – multi site model under the governance

of the Division of Surgical Specialties and Anaesthetics, and for Gynaecology under the governance

of the Women and Children’s Division. Under this model there will be greater consistency of care

across the two sites by providing common policies, procedures and patient pathways, staff will have

the opportunity to provide a range of complex and non- complex procedures, and trainees will be


offered a breadth of experience. It is expected that staff, both medical and nursing will rotate across

sites as clinically required and appropriate.

ModH will be the location within NALHN to provide elective same day and 23 hour surgery for

routine, non-complex patients and procedures for the following types of surgical services:

Non- complex elective same day and 23 hour surgery, specifically including laparoscopic

procedures, for non-complex gynaecology patients.

Upper limb procedures and simple lower limb orthopaedic procedures (knee arthroscopies,

ACL reconstructions etc.), for non-complex patients.

Hernia repairs, appendectomies, cholecystectomies, major and minor bladder, breast,

transurethral and perianal and pilonidal procedures for non-complex patients.

Ear, Nose and Throat (ENT) surgery for adult patients.

Emergency management of patients presenting to the Emergency Department, with cases

requiring urgent operative management or inpatient management transferred to the LMH.

ModH surgical registrar cover will remain unchanged.

Inpatient management of non-complex patients requiring non-operative fracture

management who are suitable for medical or geriatric management, e.g. osteoporotic crush

fractures

A One Stop Breast Care Clinic where assessment, radiological intervention and biopsy (if

required) can occur at one visit.

Outpatient services, including but not limited to orthopaedics (including review of fractures

and non-operative fracture management), general surgery, urology, breast endocrine, ENT,

general gynaecology and colposcopy.

Ward consults for patients admitted under other specialties during office hours.

Stomal therapy and the acute pain service provided currently at ModH will operate from LMH due to

the changing profile of surgical procedures being undertaken at ModH. Tele support will be available

and consult by appointment.

The LMH will provide a 24/7 surgical service and gynaecology service inclusive of all of NALHN’s

multiday elective and emergency surgery, as well as providing emergency and non–routine same day

and complex and non-routine 23 hour elective surgery. All paediatric activity, obstetric activity and

an early pregnancy advisory service will continue to be provided at LMH as per current NALHN

model for these services.


To support the alignment of services between the two sites, and to accommodate the additional

multiday activity at LMH; low risk, non-complex same day and 23 hour activity will be flowed from

LMH to ModH as appropriate, noting that a small volume of same day and 23 hour activity will

remain at LMH to allow for patient complexity.

Outpatient clinics will remain at ModH, however whilst the clinics are provided at one site the

surgery may need to occur at a different location to the outpatient appointment. This will be the

case for multi-day surgery and complex patients requiring 23 hour or day surgery. LMH will continue

to provide outpatient services for surgery, as well as emergency management of patients presenting

to the Emergency Department. Under the single service – multi site model all outpatient referrals

will be triaged centrally and allocated an appointment at either LMH or ModH site.

Referral pathways

Referral pathways into the NALHN surgical services and gynaecology services will remain largely

unchanged. External referrers will continue to send referrals to their existing NALHN hospitals.

Establishment of a single referral point is the preferred model. The intent is to support patients

attending clinics at their nearest hospital, however this single review of referrals would allow for

patients requiring sub specialty review to be directed to the appropriate sub specialty clinic which,

for low volume sub specialties, may only be delivered from one site.

Internal referrals for inpatient admission (primarily from ED) will be directed to the most appropriate

site for follow up, for instance, an ED referral requiring surgery will be referred to the appropriate

inpatient ward for direct admission or other appropriate clinical speciality that is provided at LMH,

otherwise the patient may need referral to another LHN.

Preadmissions

NALHN will implement a single model of care for preadmission clinics. There are specific procedures

that are identified as requiring a face to face assessment (primarily joint replacements), however

beyond this a risk stratification approach will be used based on patient or procedure complexity.

Whilst ideally patients will attend their preadmission clinic appointment at the site of surgery this is

not a requirement and will be influenced by patient preference and physical capacity of the site.

Discharge and follow up

For elective surgical patients the principles for discharge and follow up will remain unchanged, i.e.

post discharge follow up outpatient appointment will be organised or patient advised to have follow

up with their GP. For surgical or gynaecology patients discharged from ED there may be referral to a

relevant surgical access clinic or standard outpatient clinic or to their GP for follow up.


Restorative care and rehabilitation

Rehabilitation pathways within NALHN will be enhanced by the expanded rehabilitation services to

be provided at ModH, including the orthogeriatric patient pathway (statewide model currently

under development). ModH will play a pivotal role in providing restorative care and rehabilitation

services for surgical patients, both via the Geriatric Evaluation and Management Unit, and via

rehabilitation services. Surgical consults for patients within those services at ModH will still occur.

Emergency care

The emergency pathway for ModH emergency surgical patients (non gynaecology and non

orthopaedics) is outlined in Attachment 2. During normal business hours (Monday to Friday, 7:30am

to 5:00pm), there will be an onsite on-call surgical registrar available at ModH to respond to

emergency consults. Additional support where required will occur via Surgical Consultants onsite

either in OPD or theatre.

After hours (Monday to Friday, 5.00pm to 10pm and weekends to midday) an on-site, on-call

Surgical Registrar will be available to respond to Emergency Department consults where required.

After 10pm weekdays and midday weekends a remote on- call registrar will be available along with

consultant support if required. As per current arrangements, an on call consultant roster will be in

place for ModH.

An emergency on call return to theatre team will be established as a trial to support the 23 hour

model of surgery at ModH. This will provide additional support to enable attending consultants to

return existing elective 23 hour patients to theatre in a timely manner if required. This is to be

reviewed 6 months post implementation.

To further support emergency care of patients presenting to ModH, the Division of Surgical

Specialties and Anaesthetics will restructure the current outpatient sessions to enable quick access

following an ED presentation. It is envisaged that 2 emergency appointments will be allocated from

the total surgical outpatient clinic footprint at ModH each day

For gynaecology related presentations to ModH ED requiring urgent management (e.g. proven

ovarian pathology or PID and significant menorrhagia or early pregnancy conditions) will require

transfer to LMH with direct admission to the Women’s Health Unit after consultation with the on call

registrar. The emergency pathway for ModH gynaecological patients is outlined in Attachment 3.

For orthopaedic related presentations it is anticipated the LMH will provide a 5 day a week

emergency orthopaedic theatre (with possible extension to an additional half day weekend session),


which would minimise the requirement for after hours theatre to those patients who require urgent

operative management (e.g. significant blood loss, neurovascular compromise, compartment

syndrome, life or limb threatening sepsis, severe open fractures). For fractures requiring non urgent

operative management, the existing model of discharge from ED, quick review in fracture clinic, and

orthopaedic “mop up” lists will continue.

The orthopaedic service will have an after hours on call for ModH via phone to the LMH on call.

Attachment 4 outlines the orthopaedic pathways for ModH presentations (Level 1 and 2 trauma

patients, isolated limb trauma, ambulant injured). It is proposed that this change will take effect

from March 2016.

Clinical deterioration

For patients who undergo elective same day or 23 hour surgery at ModH who become unexpectedly

unwell post operatively will be managed via the deteriorating patient pathway outlined in

Attachment 5. For those patients requiring an unplanned return to operating theatre out of hours

this will occur at ModH by recalling theatre team.

Elective Surgical Waiting lists

NALHN will move from the current two site approach to managing elective waiting lists to a single

model. It is proposed that this change will take effect from March 2016. Current positions on wait

lists will be maintained as far as possible.

Theatres

Following the intra NALHN service changes the total elective theatre requirements at ModH will be

2.6 theatres per day Monday to Friday. For LMH elective theatre requirements will be 4.5 theatres

per day and emergency theatre requirements 1.8 theatres per day. It is proposed that this change

will take effect from March 2016.

Surgical Sub Specialties

Orthopaedics

A comprehensive orthopaedic surgery service will need specialised Extended/ Advance scope Allied

Health positions and specialist nursing roles. Following the service moves, further analysis and

consultation will be undertaken on what the Allied Health requirements are, informed by the SA

Health Transforming Health Allied Health project currently underway. Allied Health led outpatient

clinics will continue to be provided at both sites to match patient flows. Robust referral pathways to


non operative treatment for those conditions where there is evidence that conservative treatment is

as effective as operative management will be explored for elective outpatient clinics.

Specialist nursing roles may include Clinical Practice Consultant or Nurse Practitioner to manage,

coordinate and facilitate: pre- and post-operative case management of arthroplasty patients

(including active list management of patients awaiting arthroplasty); Neck of Femur management

including pathway development and case management; and Orthopaedic trauma resource.

Pathways

The main categories of orthopaedic patients who present to EDs and how they will be managed are

as follows:

Level 1 and 2 trauma patients (also refer to Attachment 4a for flowchart):

o Patients who require obvious input from specialties not available at LMH (either wholly

or for emergency purposes) will bypass NALHN and go directly to the RAH. No internal

NALHN patient pathways will be needed to manage these patients;

o Patients who present to the LMH ED, either via SAAS or private car will be assessed by

ED staff and either identified as needing services not available in NALHN and be on

transferred as required, or can be managed within the LMH and be admitted to the

general sub-speciality bed card with orthopaedic management as required. Patients

presenting to ModH will be assessed by ED staff and transferred to the most appropriate

hospital. Trauma transfers are always from ED to ED.

Isolated limb trauma patients (also refer to Attachment 4b for flowchart):

o For patients picked up by SAAS, where there is obvious surgical input required (e.g.,

fractured neck of femur, open fractures, severely angulated limbs, neurovascular

compromise etc.), these patients will be triaged by SAAS and present directly to LMH for

ED assessment and admission to the orthopaedic team. A number of patients may also

present via private car/ walk in.

o Patients who present directly to ModH will be transferred to LMH following ED

assessment and management, with the expectation of this being a direct admission to

the ward.

Ambulant injured patients (also refer to Attachment 4c for flowchart):

o Patients requiring non-operative management will be managed within the ED at which

they present (LMH or ModH), provided with relevant assistive devices (plaster, slings,

braces, crutches etc.) and referred to the on-site orthopaedic fracture clinic for follow


up within one week. This patient pathway will remain largely unchanged from current

practice. There will be a proportion of these patients that will require admission under

orthopaedics.

o Patients requiring non-urgent operative management will be stabilised and provided

with initial management within the ED at which they present (e.g., plaster, brace,

crutches etc.) and referred to the on-site orthopaedic fracture clinic for review and

confirmation of operative management requirements including booking to the relevant

theatre list if required. ED staff will be responsible for triaging these referrals and

ensuring patients have next business day review if they suspect operative management

is required. At LMH there are currently Resident Medical Officer (RMO) slots to facilitate

this. ModH will proceed to implement review slots within their existing fracture clinics.

o Patients requiring urgent operative management – a small number of walk in patients

may require urgent operative management (e.g. for patients who have neurovascular

compromise or who have a compartment syndrome). For patients who present to the

LMH, they will be managed via the same emergency processes as for the single limb

trauma patients. For patients in this category who present to ModH, their initial

assessment, management and stabilisation will be provided by the ModH ED. The ED

will be responsible for undertaking relevant neurovascular observations and liaising

with the NALHN (LMH) orthopaedic on-call staff to discuss patient management and

transfer to LMH for operative management. The transfer to LMH will be facilitated by

direct admission transfers to minimise any duplication within EDs.

Paediatric Fracture Management o Paediatric patients who present to either LMH or ModH EDs with a fracture will be

assessed and managed by the ED.

o Patients who do not require operative management or sedation will be managed within

the ED at which they present, and referred to the on-site fracture clinic, consistent with

current practice.

o Paediatric patients requiring operative management, who fulfil the following criteria,

are suitable for transfer or admission to LMH:

Aged 5 or over

No HDU/ ICU requirement (based on either comorbidities or extent of

injury)

No confirmed or suspected spinal injury


Injury within the capabilities of LMH Orthopaedic Team

o Patients not meeting any of the above criteria will be transferred to the Women’s and

Children’s Hospital (WCH) (or RAH in the event of a spinal injury in a patient over 16

years of age).

Orthogeriatric care

The statewide orthogeriatric (fractured neck of femur) pathway is currently in development and will

include an expectation of surgery the day of or the day after presentation to emergency, except in

cases where a delay in surgery is clinically indicated. To facilitate this and support the volume of

activity to be managed by LMH (inclusive of potential increased road transfers from Country Health

South Australia (CHSA)) a dedicated orthopaedic emergency theatre will be established. Initially this

theatre is will operate at 50% capacity, and will increase to full capacity as activity from CALHN to

NALHN increases. Weekend cases will initially be managed via on-call, however these volumes will

be monitored and if required the option of establishing a dedicated weekend list will be explored.

Additional emergency theatre will support the existing scheduled elective sessions.

The early involvement of a specialist geriatric team, under a shared model of care is also expected to

improve the clinical outcomes for this cohort of patients as well as create improvements in length of

stay. There are three broad categories of patients which are anticipated:

Nursing home patients - these patients are ideally suited to a short post-operative stay and

then return to their residential care facility, with geriatric input facilitating this. The overall

inpatient management is expected to remain with orthopaedics.

Non-complex patients - this cohort is expected to have a short-medium post-operative stay,

with referrals to GEM or rehabilitation services for some patients. Geriatric input will assist

with early identification of patients requiring sub-acute care, and also facilitate earlier

transfer to these services. The acute post-operative management of this cohort is expected

to remain with orthopaedics. Those patients requiring sub-acute care will be transferred to

the relevant clinical unit.

Complex patients with additional co morbidities, including dementia and delirium - these

patients represent a complex group with longer length of stay. It is anticipated the initial

post-operative management will be within orthopaedics, however these patients will need

to transfer to geriatrics (with ongoing orthopaedic input as required) early post-operatively

to ensure the most appropriate specialist input into their complex associated medical

conditions.


As part of the statewide model of care in development, the expectation is that discharge planning

for patients with a fractured NOF will be completed by day 2 post operatively.

Orthopaedic elective surgery

The broad principles for the orthopaedic elective patient pathway, including potential for the

introduction of Allied Health substitution clinic, is presented in Attachment 6. Elective outpatient

clinics need robust referral pathways to non-operative treatment for those conditions where there is

evidence that conservative treatment is as effective as operative management. The range of services

required includes podiatry, orthotics, physiotherapy and occupational therapy.

Urology

The majority of 23 hour and same day urology procedures will occur at ModH. This includes but is

not limited to non complex major and minor bladder procedures; transurethral and urethral

procedures; and cystoscopes. All multi day and emergency will occur at the LMH along with a small

volume of same day and 23 hour surgery to allow for patient complexity. Emergency urology activity

will be undertaken at LMH. Refer to Attachment 2 for the emergency pathway for surgical patients

presenting to ModH. Ongoing discussions are occurring between CALHN and NALHN to support a

hub and spoke model.

ENT

The NALHN ENT service will continue to provide most adult same-day and 23 hour elective surgery at

ModH, with all paediatric surgery provided at the LMH. Emergency ENT activity will be undertaken

at LMH. Refer to Attachment 2 for the emergency pathway for surgical patients presenting to ModH.

Paediatric ENT services will remain at the LMH within a Hub and Spoke model, LMH being a spoke of

the Women’s and Children’s Hospital (W&CH). A central referral point will be established with the

W&CH. All paediatric ENT referrals will be triaged by the W&CH and referred to the LMH where

appropriate.

Vascular Surgery

Post CALHN to NALHN activity transfer the NALHN Vascular Services will provide an inpatient consult

service and day surgery procedures over a 5 day model, Monday to Friday. A dedicated Vascular

Surgeon will be onsite at NALHN hospitals daily. Whilst initially the service will provide same-day

procedures only, any patients requiring an overnight stay will be under the medical governance of

the Diabetes and Endocrine team, as is the current arrangement. All patients requiring a vascular

consult after hours will be directly transferred to the Royal Adelaide Hospital.


General Surgery

All multi-day and complex procedures will remain or occur at LMH due to complexity. All post-

operative infections requiring an inpatient stay will flow from ModH to the LMH. Consultation will

occur over the next 12 months regarding an integrated surgical service.

Upper GIT surgery

Complex cholecystectomy some will remain or occur at LMH, however major cholecystectomy and

other major non-complex 23 hour elective surgery will continue at ModH. Upper GIT inpatient

activity will be transferred as part of the CALHN to NALHN activity transfer. This will enable the

development of sub specialist pancreatic and/or liver expertise enhancing the current model of care.

Breast Endocrine

The majority of all 23 hour and same-day procedures will occur at ModH, including major malignant

breast disorders. All multi-day activity will occur at the LMH. A One Stop Breast Care Clinic will be

established at ModH once a week for new patients to provide prompt assessment and treatment of

patients with a suspected diagnosis of breast cancer. This clinic will provide all the required elements

of a triple assessment during a single visit enabling:

a basis for definitive diagnosis in the majority of patients

reassurance with no need for further attendance in most patients with non-malignant

conditions; and

information for multidisciplinary meeting (MDM) treatment planning prior to review of

those diagnosed to have cancer

The proposed pathway for patients attending the One Stop Breast Care Clinic is outlined in

Attachment 7.

All NALHN Breast Endocrine surgeons will rotate through the clinic. Given that biopsy results will

only be available within 24 to 48 hours following a visit to the Clinic patients will be seen in other

Breast Endocrine outpatient clinics to ensure timely follow up. A central triage process will be

developed with triaging of referrals to occur twice a week.

Plastics and reconstructive surgery

The small volume of day and 23hr surgery plastics and reconstructive surgery undertaken in NALHN

will continue to be provided. More complex surgery will be referred to CALHN as LMH does not

provide this. Refer to Attachment 2 for the emergency pathway for surgical patients presenting to

ModH.


Gynaecology

As part of the one service multi site model the Women and Children’s Division will establish rapid

access appointments at ModH to facilitate discharge from ED for non-urgent gynaecological patients

and ensure timely review. The Division will also consolidate the existing early pregnancy service at

LMH to a dedicated unit, with all threatened miscarriage patients referred to this unit for follow up

and continuity of care.

6.3 NALHN Medical Services

The NALHN medical services operate under the governance of the Medical Sub Specialties Division.

This Division provides inpatient and outpatient services in a number of sub-specialties. All specialties

and Obstetric Medicine are multi-site. Nurse-led clinics form an important part of service delivery.

The Chronic Disease Management Unit provides management of chronic disease with a focus on

hospital avoidance and frequent-utiliser strategies.

Medical Sub Specialties

General Medicine (including Short Stay General Medicine Unit)

General Medicine will move away from the traditional take system under the current 5 medical units

at LMH to 3 medical units. The consolidation of services will allow the Division to move toward a 7

day service and reallocate resources, specifically junior medical staff to sub-specialties where junior

medical staff has traditionally been scant. This approach will include daily ward morning rounds by

consultant and criteria led discharge. This approach will contribute significantly to equitable

dispersion of activity, earlier senior decision-making and hospital avoidance. The General Medicine

pathway is outlined in Attachment 8. Ward reconfiguration and movements are outlined under

Section 5.

Allied Health including dietetics, occupational therapy, physiotherapy, speech pathology, social

work, and orthotics and podiatry service will be provided to the 3 general medicine units at LMH.

Resources will be relocated to the LMH from the ModH to support the intra NALHN moves with staff

rotating across sites.

Deteriorating patient:

It is proposed that pathways for deteriorating patients at ModH will be either to the 4 higher

intensity nursing beds, termed Medical Assessment Beds, or transferred to LMH (refer to

Attachment 9 for draft flow chart). LMH processes for deteriorating patients will continue.

Outpatients:


General Medicine outpatient clinics will continue to be available at ModH and LMH. To facilitate

early morning ward rounds it is proposed that the outpatient clinics at both sites be scheduled for

the afternoon.

Short Stay General Medicine Unit (SSGMU) at ModH The model for this unit will be consistent with the LMH acute medical unit (AMU) model, providing

care for up to 48 hours. Patients who have higher acuity needs or require greater than 48 hours care

will be transferred to LMH. Evidence from the LMH AMU model demonstrates more appropriate and

timely care, with more rapid assessment, earlier diagnosis and treatment due to early review by

senior medical officer (consultant physician and/or senior medial registrar); reduction in

unnecessary admission and investigations; and reduced LOS. Allied Health will work across the

SSGMU and the EDSSU.

The key components of the ModH SSGMU include:

Management responsibility lies with Division of Medical Sub Specialities

18 short stay medical beds

General medicine patients will be assessed and admitted in the SSGMU

After patients are assessed in the SSGMU, their estimated LOS will be determined and those

with an estimated LOS <48 hours will remain in the unit. For patients deemed to require >48

hours of inpatient care, will be transferred to LMH general medicine units (24 hours 7 days a

week) to the appropriate inpatient ward

Seven day, 24 hours service with features at least once daily consultant led ward rounds

Multiple decision making points over 24 hour period

Focus on multidisciplinary early assessment, proactive planning and intervention

Nursing staff rostered as per business rules and allied health team with sufficient numbers of

experienced non-rotational staff dedicated to the unit

Clerical support for extended hours

Patients can remain in the unit for a maximum of 48 hours with the aim to make a decision

about discharge or transfer to inpatient medical units at LMH as soon as possible

Exclusion Criteria:

Where existing patient admission pathways exist they will continue (i.e. chest pain, ICU, stroke,

gastroenterology, etc).

Acute general medical patients whose clinical condition would be best managed in a General

Medicine inpatient bed at LMH or palliative care at ModH. These are patients who have:


An anticipated LOS>48 hours with a diagnosis and comprehensive treatment plan in place

(prolonged admission)

Patients requiring palliative care measures in the terminal phase of the illness

Psychiatric illness but no psychiatric package in place to facilitate leaving the SSGMU within

48 hours

Patients who do not have a disposition destination on discharge

Patients requiring non-invasive ventilation or HDU/ICU interventions

Patients present with acute surgical or orthopaedic conditions

Patients who are best managed under subspecialty units

Deteriorating patient:

It is proposed that pathways for deteriorating patients will be either to the Medical Assessment Beds

at ModH or transferred to LMH.

Cardiology

Chest pain is a common presentation to LMH and ModH ED’s and is a NALHN priority area for

productivity improvement to ensure efficiencies and flow through the ED’s and improved inpatient

length of stay. A NALHN Chest Pain Pathway has been developed (refer to Attachments 10 and 11

for detail). High risk chest pain patients will go to LMH. ModH will continue to provide a 24 hour

walk-in service for low risk chest pain with pathway to LMH if assessed as requiring higher care and

intervention. Rapid Assessment clinics for early stress tests and review will be established. Ward

reconfiguration and movements are outlined under Section 5.

To support the chest pain pathway LMH will provide a central Chest Pain Unit (CPU) service. The aim

of the CPU is to provide a cost effective efficient service to manage patients presenting with chest

pain with the goal to transfer patients out of ED within 120 minutes of presentation and to reduce

length of stay by timely diagnostics (eg High Sensitive Troponin) and management intervention.

The CPU will be located in the LMH AMU. Initially the CPU will be a stand-alone unit with minimal

supports from the AMU nursing staff, however over time this service will become a more integrated

service. Clinical and operational governance of the CPU resides with the Division of Medical Sub-

Specialties and at an operational level the Medical Head of Unit for Cardiology and the Cardiology

Clinical Service Co-ordinator (CSC).

Scope of the Chest Pain Unit - in scope:

Low risk chest pain - if index pain began >6hrs from triage is now resolved


Low risk chest pain - if index pain began <6hrs from triage (ALOS 8-12 hrs)

Medium risk chest pain - discriminate degree at assessment

Out of scope:

Chest pain resulting from a diagnosed non-cardiac cause; eg mechanical injury/ pneumonia/

pulmonary embolism

Out-of-Hospital Cardiac Arrest (OOHCA)

Cardiogenic Shock and haemodynamic instability

Acute Pulmonary Oedema (APO) and other forms of decompensated heart failure

Anterior ST-Elevation Myocardial Infarction (STEMI)

Non-STEMI

Unstable Angina

Moderate to high risk Acute Coronary Syndrome (ACS)

Physically dependent patient

Cardiovascular Intervention Suite (CVIS) LMH:

To support the transfer of activity from CALHN to NALHN a second CVIS at LMH will be

commissioned. The procedures that would be in scope for the second CVIS are still being confirmed,

however may include procedures relating to vascular, electrophysiological cardiac services and

STEMI to support vascular, stroke and cardiology.

Respiratory Medicine

Respiratory (in particular COPD) is a NALHN priority area for productivity improvement to ensure

efficiencies and flow through the ED’s and improved inpatient length of stay. The COPD group are

over represented in the patients who frequently utilise ED and medical beds. Pathways for the acute

exacerbation of COPD have been developed (refer to draft in Attachment 12). This will contribute to

more appropriate admission criteria and hospital avoidance and the Respiratory service’s

engagement with the Chronic Disease Management Unit (CDMU) and ED.

Respiratory patients will be able to access the SSGMU at ModH if their care needs are assessed as

meeting the criteria for this unit. It is anticipated that all sub-specialties will rotate to Modbury

Hospital with daily Consultant ward rounds 7 days per week. The 24 bed Ward 2D at LMH will be a

mixed ward for the sub-specialties of respiratory, gastroenterology, endocrine and renal.


Respiratory Quick Access Clinics (QACs) are planned, in addition to close engagement with the

CDMU. Modbury Hospital requires additional input. The home oxygen service will be transferred to

LMH. Pathways to pulmonary rehabilitation are outlined in the acute exacerbation to COPD

pathway to ensure optimal access. Non Invasive Ventilation (NIV) is the next evolution of the

inpatient service. With the infrastructure and equipment now in place at LMH; the next step is the

process of developing an education plan to support nursing and junior medical staff. It is anticipated

CN time will be utilised to resource this program for 12 months.

Gastroenterology service

The service model for the NALHN Gastroenterology service is based on the principle of one NALHN

Gastroenterology Service provided across the two sites of LMH and ModH with a wait list at ModH

and a wait list at LMH. Gastroenterology outpatient services and elective endoscopies will be

provided at ModH. The service will remain at the same location in the Gastroenterology suite at

ModH continuing to utilise the gastroenterology theatre and recovery area. Inpatient activity for the

SRG Gastroenterology will not be transferred as part of the CALHN to NALHN activity transfer.

In 2016 improving administrative processes and utilising consultant FTE adequately will be

progressed and consolidated, in particular:

Redistribution of nurse sedationist vs High Risk Anaesthetics lists to allow for more High

Risk lists to be undertaken

Target of 80% list utilisation

Active management of Colonoscopy wait list

Increased consult lists for referrals

Referral pathways and referral criteria to General Practitioners

Inpatient and outpatient consultation service at Modbury Hospital

Limited nurse sedationist lists at Modbury Hospital

NALHN self-sufficiency in the provision of Gastroenterology services

Model for scope cleaning - currently reviewing the model, exploring the use of Technicians

to provide this function.

Diabetes and Endocrinology

The service model for the NALHN diabetes services aims to emulate progressive models on the

eastern seaboard, with clinics managed by specialist diabetes teams. Multiple clinics occur at the

same time including walk-in clinics and rapid access clinics with senior medical input throughout the


day. This model facilitates reduced waiting times for new patient appointments, improved access for

patients who require rapid care for urgent cases and avoidable hospital admissions. Clinics are

located at LMH and GP Plus Superclinic Modbury.

Further diabetes inpatient activity will be transferred as part of the CALHN to NALHN activity

transfer. This activity will be absorbed into Ward 2D at LMH which will be a mixed ward for the sub-

specialties of respiratory, gastroenterology, endocrine and renal.

Neurology and Stroke Services

Stroke is a NALHN priority area for productivity improvement to ensure efficiencies and flow through

the ED’s, improved inpatient length of stay and earlier initiation of rehabilitation whilst awaiting

transfer to sub acute rehabilitation. A NALHN Stroke Pathway has been developed (refer to

Attachment 13). Stroke inpatient activity will be transferred as part of the CALHN to NALHN activity

transfer. This activity will be absorbed into Ward 1E at LMH which will be a mixed ward for the sub-

specialties of general medicine and neurology. In addition, the hours of stroke thrombolysis will

extend from the current 0800-1600, to 2000.

The following areas and actions have been identified to improve the efficiency of the NALHN Stroke

Service:

Areas Actions

1. Service approach Principles, vision, goals:

Engagement of staff in the development of common vision,

goals and principles to guide the service.

Service name:

Engagement of staff in the development and promotion of a

service name.

2. Multidisciplinary review Trial of an additional formal weekly MDT meeting at LMH.

Explore appropriate: membership of MDT; meeting time;

agenda format; method of recording meeting outcomes.

Explore opportunities for video-conferencing between NALHN

sites.

Continuation of informal daily stroke team brief.

3. Percutaneous endoscopic

gastrostomy (PEG) pathway

for patients admitted with

Development and implementation of enhanced PEG pathways

including timeframe for PEG.

A PEG pathway (refer to Attachment 14). has been developed

for patients admitted with stroke and is outlined on the


stroke NALHN PPG OWI02147 Percutaneous endoscopic gastrostomy

(PEG) pathway for patients admitted with stroke.

4. Referral on admission Inclusion of prompt for referral on admission in Admission

Checklist.

Promotion of referral on admission (within 24 hours.)

5. Pathway to rehabilitation Exploration of slow and fast stream pathways-

Mild-moderate (2-3 days); Severe (7 days)

Changes to MDT frequency, format, etc may assist movement

through pathway.

6.TIA Minor stroke pathway Clarify opportunities for implementation of proposed pathway.

A TIA nurse has been appointed and nurse-led clinics are being

established.

Renal Services

Renal Medicine is a specialty providing management of chronic renal failure and dialysis, as well as

inpatient care for acute renal failure, acute glomerular disease and nephrotic syndrome. Renal

failure complicates many conditions, especially Diabetes, Vascular Disease and Hypertension.

Renal inpatient activity will be transferred as part of the CALHN to NALHN activity transfer. NALHN

currently is unable to provide inpatient dialysis. This activity will be absorbed into Ward 2D at LMH

which will be a mixed ward for the sub-specialties of Respiratory, Gastroenterology, Endocrine and

Renal. This will enable:

Existing LMH patients that require expert Renal care, or inpatient dialysis to be managed by the

Renal Team, thus improving the quality of care delivered and reducing the associated morbidity

and mortality currently identified within the division.

The ability to manage the care of patients who are currently managed within CALHN. This

includes patients admitted for non-complex renal diagnoses (as the tertiary renal service for

CNARTS, RAH will continue to manage complex and unwell renal patients) as well as patients

admitted to CALHN for non-renal diagnoses (e.g., respiratory conditions) who require dialysis

during their inpatient stay.

No direct admission from ED to a Renal bed card will be allowed.

The service to also support patients with renal conditions who require surgery to have their

procedures performed at LMH rather than RAH.


Haematology and Medical Oncology

The transfer of haematology and medical oncology inpatient activity as part of the CALHN to NALHN

activity transfer will enable NALHN patients to be managed within the network, however is not

enough to maintain a stand-alone Haematology bed card. This activity will be absorbed into Ward 1D

at LMH which will be a mixed ward with General Medicine and Oncology disciplines, and will enable:

an increase in current cancer treatments being undertaken

inpatient chemo to be undertaken

4 additional oncology chairs will be introduced to support this

the following activity to move back to NALHN:

o RBC disorders as described in DRG transfers

o Increase in activity currently done in NALHN

o Low grade lymphomas and myelomas.

Chronic Disease Management Unit

The priorities within this unit are hospital avoidance, case identification, case management and

coordinated care of all chronic disease programs (refer to Attachment 15 for an overview of the

unit). By the end of the 2015/2016 financial year, it is planned that this unit will be fully established

and have a profile within the organisation with chronic disease being managed in a structured

manner. The clinical leads in Allied Health, Nursing and Medicine are facilitating:

Entry and exit criteria for the chronic disease programs

Creating single referral point for all chronic disease management

Developing screening tools for high risk individuals

Meeting with General Practitioners and start developing Shared Care Models

Strengthening Hospital Avoidance strategies

Incorporating End of Life Project


7. Interdependencies- clinical support summary

NALHN Service Associated with intra NALHN

Level of required clinical capability Source - SA Health Clinical Capability Services Framework (2015)

Critical Care Services

Interdependency LMH ED (based on Level 5)

ModH ED (based on Level 3 -4)

Anaesthetic on site Level 5 on site Level 3 - 4

Children’s anaesthetic on site Level 4 on site Level 4

Cardiac care unit on site Level 5 accessible Level 4

Cardiac diagnostic & interventional on site Level 5 accessible Level 4

Cardiac medicine on site Level 5

Intensive care on site level 5 accessible Level 4

Children’s intensive care accessible Level 4

Medical on site Level 5 accessible Level 3; on site Level 4

Children’s medical accessible Level 4 accessible Level 4

Medical imaging on site Level 5 on site Level 1-4

Mental Health on site Level 5 accessible Level 4

Mental Health (child & youth) accessible Level 4 accessible Level 4

Nuclear medicine on site Level 4

Children’s nuclear medicine accessible Level 4

Pathology on site Level 4 accessible 3-4

Perioperative on site Level 5 accessible Level 3; on site Level 4

Pharmacy on site Level 5 on site Level 3-4

Surgical on site Level 5 accessible Level 3; on site Level 4

Children’s surgical accessible Level 4 accessible Level 4

Interdependency LMH ICU Anaesthetic on site Level 5

Cardiac medicine accessible Level 5

Medical on site Level 5

Medical imaging on site Level 4

Mental health accessible Level 5

Pathology accessible Level 4



Level of required clinical capability Source - SA Health Clinical Capability Services Framework (2015)

Perioperative on site Level 5

Pharmacy on site Level 5

Renal accessible Level 5

Surgical on site Level 5


Surgical Services

Interdependency LMH impact

ModH impact

Anaesthetic Emergency; multi day;

preadmission

Same day; 23 hour;

preadmission

Theatres Sterilising Unit

Post Anaesthetic Recovery Unit

Sterilising Unit

Post Anaesthetic

Recovery Unit

ED Bypass or transfer process Bypass or transfer

process

Intensive care Increased activity Change of service

profile

Medical imaging Imaging intensifier increase;

Ultrasound increase

CT scans increase

Interventional radiology for

emergency activity

Greater access to

ultrasound,

mammograms, CT

Pathology Histology;

Phlebotomist

Histology access for

one stop breast care

clinic

Perioperative Increased activity

Pharmacy Increased activity;

Increased volume primarily for

high volume, low cost

prophylactic antibiotics;

Clinical pharmacy requirements

to support the additional

Clinical pharmacy

requirements



surgical multi day activity at

LMH

Allied Health Comprehensive Allied Health services including dietetics, occupational therapy, orthotics, physiotherapy, speech pathology, podiatry and social work to provide ward based services.

Outpatient clinics Clinic types Clinic types


Medical Services

Interdependency LMH & ModH impact

ED Bypass or transfer process

Intensive care Site profile changes

Medical imaging Patient identifier / documentation across sites

Pathology Phlebotomy rounds to match proposed future ward

configuration;

Access to High Sensitivity Troponin

Pharmacy Clinical pharmacy requirements to support the move

from ModH (3East) to LMH (1B).

Allied Health Comprehensive Allied Health services including dietetics, occupational therapy, orthotics, physiotherapy, speech pathology, podiatry and social work to provide ward based services.

Outpatient clinics Clinic types and timing

8. Interdependencies- non clinical support summary

Intra NALHN

Hotel Services ICT Transfers

Cleaning

Imprest

Linen requirements

Orderly support

Waste removal

A process has been established with

ICT to identify ICT requirements and

timing / lead in times. This will be

ongoing to encompass the CALHN

NALHN transition.

Medical records

transfers between sites;

PAS – UR numbers SAAS transfers


9. Infrastructure - summary

NALHN Service Associated with intra NALHN [Space / minor /major works / Equipment]

Critical Care Services (note: equipment to be moved from 1 West as appropriate)

Purpose built short stay unit at ModH – proposed end 2016

H@H space at ModH

Four fully equipped MET trollies either located centrally at RRT

home base or strategically located around the hospital.

- One trolley will be suited to responding to external MET

calls. This trolley will have a Propaq Defibrillator which is

lighter

Communication devices (pagers and mobile phones)

The following equipment will be available (most likely in ED):

Transport ventilator oxylog (2 in hospital)

Non-invasive ventilators (2) in hospital)

Telemedicine technology functionality would be highly valuable to

enable consultations between LMH ICU and ModH.

Surgical Services Infrastructure available/required at each site to support changes to

service location, roles and model of care.

2nd II available at LMH to support theatres although staffing for

second is required. Future service changes will require third II.

Breast Endocrine – gamma probes and nerve monitor already

available.

Consider future growth for interventional radiology.

Consider outpatient audiology booth requirements for ENT.

Equipment – broad requirements have been identified. Detailed

analysis is currently being undertaken.

Patient mobility aids and ADL equipment at both sites.

Office space – to be confirmed

Medical Services Location of stress test at ModH and space for admin officer

Minor works associated with establishment of chest pain unit at

LMH

Minor works required to enable the location of a Stress Test Lab to

service the chest pain unit at LMH


NALHN Service Associated with intra NALHN [Space / minor /major works / Equipment]

Equipment for Stress Test at LMH: already purchased.

Utilise existing bed side monitors

Cardiac AED

All other equipment to be utilised from AMU

10. Staff education / training required for implementation

The three principles that underpin staff education and training in readiness for implementation

include:

People work safely in their workplace

Patient safety is not compromised

The work environment is safe

To facilitate this the following will occur:

Operational procedures and work instructions will be updated so they are suitable for the

new environment

All staff to complete their work unit induction and any other specialised training required

Communication and providing access to online tools

Allocate super user/s who will deliver train the trainer unit orientation across both sites


11. Workforce – FTE summary by service

The following only includes FTE associated with this NALHN consolidated service plan.

INTRA NALHN TRANSFERS 2015-16 labour budget (in scope cost centres only) Current Staffing -

Total Total Future State

(Intra NALHN)

Northern Adelaide LHN - in scope cost centres 1,163.16 1,126.70

Lyell McEwin Hospital 778.05 863.60

Critical Care - LMH 325.99 330.99

LMH EMERGENCY SERVICE 212.60 212.60

ENDP 30.50 30.50

MD02 18.40 18.40

MDP1 6.00 6.00

MDP2 47.60 47.60

MDX1 1.53 1.53

RN01 85.43 85.43

RN2A 8.46 8.46

RN2C 7.11 7.11

RN3A 1.17 1.17

RN4A 6.40 6.40

LMH ICU/HDU 102.25 102.25

ASO3 1 1

MD02 8.22 8.22

MDP2 14.50 14.50

RN01 63.26 63.26

RN2A 5.19 5.19

RN2C 8.91 8.91

RN3A 1.17 1.17

LMH HOME HOSPITAL 11.14 16.14

AS02 0.60 0.84

ENDP 0.77 0.77

RN2A 1.03 2.06

RN2C 7.57 10.13

RN3A 1.17 1.17

RN4A 0 1.17

Medical Administration - LMH 21.64 23.64

Medical Sub-Specialties - LMH 139.16 183.44

LMH CHEST PAIN ASSESSMENT - -

ASO2 0 -

MDP2 0 -

RN3A 0 -

LMH CARDIOLOGY 14.80 15.80


AHP1 0.20 0.20

AHP2 1.00 1.00

ASO2 2.4 2.40

CAMD 0 -

MD02 4.20 4.20

MDP1 1.00 1.00

MDP2 6.00 7.00

Lmh Chest Pain Unit - 1.00

RN4A 0 0

RN3A 0 0

RN01 0 0

ENDP 0 0

MDP2 0 1

LMH GASTROENTEROLOGY 24.90 25.90

ASO2 3.00 3.00

ENDP 4.10 4.10

MD02 4.40 4.40

MDP2 4.00

5.00

RN01 6.21 6.21

RN2A 0.91 0.91

RN2C 1.14 1.14

RN3A 1.14 1.14

LMH GENERAL MEDICINE 74.83 76.83

ASO2 2.00 2.00

ASO3 2.00 2.00

MD02 8.50 8.50

MDP1 11.00 11.00

MDP2 51.00 53.00

MOV3 0.33 0.33

LMH Ward - Ward 1B - 36.28

ASO2 0 1.00

ENDP 0 11.67

RN01 0 16.28

RN2A 0 2.57

RN2C 0 3.59

RN4A 0 1.17

Lmh Infectious Diseases 2.10 3.10

MD02 2.10 2.10

MDP2 0 1.00

LMH NEUROLOGY 4.30 4.30

MD02 3.00 3.00

TGO1 1.30 1.30

LMH ONCOLOGY 13.66 14.66

ASO2 1.00 1.00


ASO3 1.00 1.00

MD02 2.20 2.20

MDP2 2.00 3.00

RN01 3.17 3.17

RN2A 0.58 0.58

RN2C 3.13 3.13

RN3A 0.58 0.58

LMH THORACIC MEDICINE 4.57 5.57

MD02 1.80 1.80

MES2 0.80 0.80

MES4 0.80 0.80

RN2A 1.17 1.17

MDP2 0 1

Surgical Specialties & Anaesthetics - LMH 292.37 321.54

LMH ANAESTHESIA 57.70 60.22

ASO3 1.00 1.00

ENDP 5.66 5.72

MD02 16.98 16.98

MDP2 16.67 16.67

MDP3 1.00 1.00

MDP4 0.50 0.50

RN01 10.91 13.64

RN2A 1.26 1.27

RN2C 2.58 2.29

RN3A 1.14 1.15

LMH Acute Pain Service 1.63 1.65

RN2C 0.46 0.47

RN3A 1.17 1.18

Lmh Surgical & Acute Admin 10.15 11.39

ASO2 1.80 2.00

ASO3 2.20 2.20

MD02 0.80 0.80

RN2C08 0 1.04

RN3A 2.32 2.32

RN5A 3.03 3.03

LMH CSSD 13.62 13.62

AS04 1.00 1.00

WHA5 10.94 11.94

WHA6 1.68 1.68

LMH RECOVERY 18.87 22.13

RN01 12.07 14.75

RN2A 1.26 1.78

RN2C 4.40 4.45

RN3A 1.14 1.15


WHA4 0 0

LMH OPERATING THEATRE 58.70 65.22

ASO2 6.68 7.79

ASO3 1.00 1.00

EN01 1.26 1.27

ENDP 5.66 5.96

RN01 31.43 36.48

RN2A 5.53 5.59

RN3A 1.14 1.14

WHA4 1.00 1.00

WHA5 5.00 5.00

LMH PRE ADMISSION CLINICS 6.06 8.56

RN01 3.67 6.17

RN2A 1.22 1.22

RN3A 1.17 1.17

LMH BREAST ENDOCRINE 6.70 6.70

MD02 2.00 2.00

MDP1 1.00 1.00

MDP2 2.00 2.00

MDP3 1.00 1.00

RN3A 0.70 0.70

LMH COLORECTAL 8.90 7.90

MD02 2.90 2.90

MDP1 2.00 1.00

MDP2 3.00 3.00

MDP3 1.00 1.00

LMH WARD 2F-SAME DAY UNIT 10.30 8.44

ENDP 2.41 1.46

RN01 5.28 3.88

RN2A 0.84 0.74

RN2C 1.20 1.21

RN3A 0.57 1.15

LMH WARD 2FX (PERMANENT WARD) 12.13 16.59

ENDP04 0 1.81

RN01 10.90 12.82

RN2A 0.77 0.78

RN3A 0.46 1.18

LMH STOMAL THERAPY 1.17 2.35

RN3A 1.17 2.35

LMH WARD 2B 38.88 45.17

EN01 8.78 9.52

ENDP 5.19 5.89

RN01 18.59 23.38

RN2A 5.14 5.20


RN3A 1.18 1.18

LMH WARD 2E 31.67 35.63

ENDP 8.13 8.22

RN01 16.79 20.60

RN2A 5.58 5.64

RN3A 1.17 1.17

LMH ORTHOPAEDIC SURGERY 9.59 9.69

MD02 2.00 3.10

MDP1 2.00 2.00

MDP2 3.35 3.35

MDP4 2.00 1.00

MOV3 0.24 0.24

LMH UPPER GI 6.30 6.30

MD02 1.90 2.30

MDP1 2.00 2.00

MDP2 2.00 2.00

MOV3 0.40 0.00

Modbury Hospital 384.00 267.09

Critical Care - Mod 151.45 116.22

Mod Emergency Department 110.36 110.36

ASO2 1.00 1.00

ENDP 9.42 9.42

MD02 12.50 12.5

MDP1 5.00 5.00

MDP2 17.26 17.26

MDP4 9.24 9.24

RN01 44.85 44.85

RN2A 2.75 2.75

RN2C 4.88 4.88

RN3A 1.17 1.17

RN4A 2.29 2.29

MOD WARD - CRITICAL CARE UNIT 36.33 -

ASO2 1.00 0

ENDP 1.03 0

RN01 14.61 0

RN2A 2.12 0

RN2C 11.4 0

RN3A 1.17 0

MD02 0.00 0

MDP2 5.00 0

MOD OUTREACH & H@H 4.76 -

RN2A 1.03 0

RN2C 2.56 0

RN4A 1.17 0


RAPID RESPONSE TEAM - 5.86

RN01 0 3.41

RN2C 0 2.45

Medical Sub-Specialties - Mod 98.25 46.61

MOD GENERAL MEDICINE - CLIN SERV 22.40 12.40

MD02 1.80 1.80

MDP1 9.00 3.00

MDP2 11.00 7.00

MOV3 0.60 0.60

Mod Ward - Medical 3E 37.78 -

ASO2 2.50 0.00

ENDP 11.67 0.00

RN01 16.28 0.00

RN2A 2.57 0.00

RN2C 3.59 0.00

RN4A 1.17 0.00

Mod Ward - Short Stay Unit - 34.21

ASO2 0 2.40

ENDP 0 7.89

RN01 0 20.93

RN3A 0 1.81

RN4A 0 1.18

MOD WARD - MEDICAL 3W 38.07 -

ASO2 1.00 0.00

ENDP 11.67 0.00

RN01 16.28 0.00

RN2A 2.57 0.00

RN2C 3.59 0.00

RN3A 1.79 0.00

RN4A 1.17 0.00

Surgical Specialties & Anaesthetics - Mod 134.30 103.26

MOD STOMAL THERAPY 1.17 -

RN3A 1.17 0.00

Mod Anaesthetics - Nursing 8.76 4.48

RN01 5.87 2.33

RN2A 1.28 0.78

RN2C 1.03 0.78

RN3A 0.58 0.59

MOD ANAESTHESIOLOGY - CLIN SERV 14.08 14.08

MD02 5.55 5.55

MDP2 7.40 7.40

MOV3 1.13 1.13

MOD OPERATING THEATRE 27.49 23.58

ASO2 4.78 4.78


ENDP 0.51 1.29

RN01 9.48 8.30

RN2A 2.57 0.00

RN2C 8.98 8.04

RN3A 1.17 1.17

MOD ACUTE PAIN SERVICE 1.22 -

RN3A 1.22 0.00

Mod Pre Admission Clinic - Nursing 2.44 -

RN01 1.22 0.00

RN2C 1.22 0.00

MOD WARD - DAY PROCEDURE UNIT 7.33 12.32

ENDP 1.22 2.48

RN01 3.42 7.15

RN2A 0.49 0.49

RN2C 0.98 0.98

RN3A 1.22 1.22

MOD GENERAL SURGERY - CLIN SERV 21.62 20.88

MDP1 4.00 3.00

MDP2 13.00 13.00

MDP3 1.00 1.76

MDO2 1.62 1.62

MOV2 0.50 0.00

MOV3 1.50 1.50

Mod Recovery - Nursing 9.97 9.54

RN01 7.14 6.71

RN2A 1.22 1.22

RN2C 1.03 1.03

RN3A 0.58 0.58

MOD WARD - SURGICAL 21.06 0.80

ASO2 1.00 0.80

ENDP 5.19 0.00

RN01 9.35 0.00

RN2A 1.61 0.00

RN2C 2.69 0.00

RN3A 1.22 0.00

MOD WARD - 23 HOUR 12.96 11.38

ASO2 1.80 1.80

ENDP 2.57 2.33

RN01 6.73 6.16

RN2A 0.77 0.25

RN2C 1.09 0.84

MOD ORTHOPAEDIC SURGERY - CLIN SERV 6.20 6.20

MDP2 5.00 5.00

MOV3 1.2 1.20


PALLIATIVE CARE 0 1.00

MDP1 0.00 1.00

An Expression of Interest process will be finalised for all on-going non-Medical staff directly affected

by the service change. Any on-going employee who may become unattached will be placed into an

on-going position in accordance with the relevant industrial instrument.

There will be no surplus on-going employeeat the conclusion of all the intra-NALHN moves.

12. Activity – summary by service

The following tables outline the current activity and indicative future state based on the medicine

and surgical models of care outlined in previous sections. Activity is based on NALHN 2014/15

inpatient data set (ISAAC).

Division Medical Sub Specialties

Overall summary

Table 1: Summary NALHN 2014/15 activity for Division Medical Sub Specialties at LMH and ModH

2014/15 Actuals seps per site

LMH ModH Total

<48 hours 5,688 2,052 7,740

>48 hours 6,754 2,719 9,473

Grand Total 12,442 4,771 17,213

Table 2: Summary future state NALHN Division Medical Sub Specialties at LMH and ModH

Future state seps per site based on model of care

LMH ModH Total

<48 hours 5,839 4,416 10,255

>48 hours 9,471 0 9,471

Grand Total 15,310 4,416 19,726


Current state

Table 3: Current Activity for the LMH by Division Medical Sub Specialties


Seps Bed Days ALOS Seps Bed Days ALOS

01 - CARDIOLOGY 1,235 1,459 1.18 867 4,552 5.25

02 - INTERVENTIONAL CARDIOLOGY 444 558 1.26 584 2,577 4.41

03 - CARDIOTHORACIC SURGERY 7 9 1.29 16 142 8.88

04 - RESPIRATORY MEDICINE 709 965 1.36 1,551 8,713 5.62

05 - GASTROENTEROLOGY 298 359 1.20 337 1,850 5.49

06 - GIT ENDOSCOPY 79 109 1.38 183 1,445 7.90

07 - NEUROLOGY 504 603 1.20 813 6,597 8.11

08 - NEUROSURGERY 20 24 1.20 49 463 9.45

09 - ENDOCRINOLOGY 249 308 1.24 242 1,431 5.91

10 - RENAL FAILURE 62 73 1.18 106 818 7.72

12 - HAEMATOLOGY 231 252 1.09 135 739 5.47

13 - ENT 6 6 1.00 8 35 4.38

14 - OPHTHALMOLOGY 9 10 1.11 9 41 4.56

15 - MEDICAL ONCOLOGY 51 64 1.25 185 1,607 8.69

17 - RHEUMATOLOGY 46 37 0.80 58 354 6.10

18 - DERMATOLOGY 17 19 1.12 18 64 3.56

19 - HEAD & NECK SURGERY 1 1 1.00 1 12 12.00

20 - DENTISTRY 5 4 0.80 11 66 6.00

21 - UPPER GIT SURGERY 0 0 2 19 9.50

22 - COLORECTAL SURGERY 0 0 3 25 8.33

23 - ORTHOPAEDICS 81 94 1.16 180 1,397 7.76

24 - UROLOGY 20 23 1.15 23 175 7.61

25 - VASCULAR SURGERY 32 27 0.84 48 377 7.85

26 - GENERAL MEDICINE 1,122 1,221 1.09 1,086 8,124 7.48

27 - GENERAL SURGERY 103 126 1.22 146 901 6.17

28 - BREAST SURGERY 0 0 0 0

29 - PLASTIC & RECONSTRUCTIVE SURGERY 1 0 0.00 3 31 10.33

30 - GYNAECOLOGY 1 2 2.00 3 26 8.67

31 - OBSTETRICS 285 289 1.01 12 53 4.42

34 - TRACHEOSTOMY 2 2 1.00 26 369 14.19

35 - DRUG & ALCOHOL 39 48 1.23 18 93 5.17

36 - BURNS 1 1 1.00 0 0

37 - PSYCHIATRY 28 33 1.18 23 118 5.13

38 - ACUTE REHABILITATION 0 0 0 0

39 - UNGROUPABLE 0 0 8 101 12.63

Grand Total 5,688 6,726 1.18 6,754 43,315 6.41

<48H

Division of MSS - 2014/15 Actual Activity (LMH)

>48H


Table 4: Current Activity for the ModH by Division Medical Sub Specialties


01 - CARDIOLOGY 720 835 1.16 381 2,055 5.39

02 - INTERVENTIONAL CARDIOLOGY

03 - CARDIOTHORACIC SURGERY 3 24 8.00

04 - RESPIRATORY MEDICINE 283 374 1.32 718 4,219 5.88

05 - GASTROENTEROLOGY 86 109 1.27 142 995 7.01

06 - GIT ENDOSCOPY 6 83 13.83

07 - NEUROLOGY 215 260 1.21 314 2,339 7.45

08 - NEUROSURGERY 14 18 1.29 29 164 5.66

09 - ENDOCRINOLOGY 55 77 1.40 98 513 5.23

10 - RENAL FAILURE 26 33 1.27 24 141 5.88

12 - HAEMATOLOGY 136 149 1.10 70 401 5.73

13 - ENT 3 4 1.33 7 40 5.71

14 - OPHTHALMOLOGY 2 3 1.50 3 10 3.33

15 - MEDICAL ONCOLOGY 18 22 1.22 64 545 8.52

17 - RHEUMATOLOGY 10 13 1.30 26 158 6.08

18 - DERMATOLOGY 3 3 1.00 5 30 6.00

19 - HEAD & NECK SURGERY

20 - DENTISTRY 1 2 2.00 2 11 5.50

21 - UPPER GIT SURGERY 1 3 3.00

22 - COLORECTAL SURGERY

23 - ORTHOPAEDICS 44 56 1.27 135 1,092 8.09

24 - UROLOGY 8 9 1.13 19 86 4.53


26 - GENERAL MEDICINE 348 390 1.12 544 4,703 8.65

27 - GENERAL SURGERY 49 62 1.27 83 660 7.95

28 - BREAST SURGERY 1 12

29 - PLASTIC & RECONSTRUCTIVE SURGERY 2 21 10.50

30 - GYNAECOLOGY

31 - OBSTETRICS 1 1 1.00

34 - TRACHEOSTOMY

35 - DRUG & ALCOHOL 16 23 1.44 10 40 4.00

36 - BURNS

37 - PSYCHIATRY 9 13 1.44 15 76 5.07

38 - ACUTE REHABILITATION 1 4

39 - UNGROUPABLE 2 36 18.00

Grand Total 2,052 2,461 1.20 2,719 18,587 6.84

<48H >48H

Division of MSS - 2014/15 Actual Activity (ModH)


Future state

Table 5: Future state for the LMH by Division Medical Sub Specialties


01 - CARDIOLOGY 1,245 1,468 1.18 1,248 6,055 4.85

02 - INTERVENTIONAL CARDIOLOGY 444 558 1.26 584 2,577 4.41

03 - CARDIOTHORACIC SURGERY 7 9 1.29 19 162 8.50

04 - RESPIRATORY MEDICINE 715 969 1.36 2,269 11,890 5.24

05 - GASTROENTEROLOGY 298 359 1.20 479 2,637 5.50

06 - GIT ENDOSCOPY 79 109 1.38 189 1,519 8.04

07 - NEUROLOGY 527 626 1.19 1,127 8,491 7.53

08 - NEUROSURGERY 20 24 1.20 78 585 7.50

09 - ENDOCRINOLOGY 250 310 1.24 340 1,806 5.31

10 - RENAL FAILURE 62 73 1.18 130 923 7.10

12 - HAEMATOLOGY 310 332 1.07 205 1,035 5.05

13 - ENT 6 6 1.00 15 65 4.30

14 - OPHTHALMOLOGY 9 10 1.11 12 47 3.88

15 - MEDICAL ONCOLOGY 56 69 1.23 249 2,062 8.28

17 - RHEUMATOLOGY 47 38 0.81 84 479 5.70

18 - DERMATOLOGY 18 20 1.11 23 87 3.76

19 - HEAD & NECK SURGERY 1 1 1.00 1 12 12.00

20 - DENTISTRY 5 4 0.80 13 74 5.69

21 - UPPER GIT SURGERY 0 0 3 22 7.33

22 - COLORECTAL SURGERY 0 0 3 25 8.33

23 - ORTHOPAEDICS 84 96 1.14 315 2,288 7.26

24 - UROLOGY 22 23 1.05 42 233 5.54


26 - GENERAL MEDICINE 1,141 1,241 1.09 1,630 12,197 7.48

27 - GENERAL SURGERY 103 126 1.22 229 1,441 6.29

28 - BREAST SURGERY 0 0 1 11 10.50


30 - GYNAECOLOGY 1 2 2.00 3 26 8.67

31 - OBSTETRICS 285 289 1.01 12 53 4.42

34 - TRACHEOSTOMY 2 2 1.00 26 369 14.19

35 - DRUG & ALCOHOL 39 48 1.23 28 118 4.21

36 - BURNS 1 1 1.00 0 0

37 - PSYCHIATRY 29 34 1.17 38 172 4.51

38 - ACUTE REHABILITATION 0 0 1 4 4.00

39 - UNGROUPABLE 0 0 8 101 12.63

Grand Total 5,839 6,874 1.18 9,471 58,094 6.13

<48H >48H

Division of MSS - Future State (LMH)


Table 6: Future state for the ModH by Division Medical Sub Specialties

Division of MSS - Future State (ModH)

<48H >48H


01 - CARDIOLOGY 1,078 1,378 1.28 0 0 0.00

02 - INTERVENTIONAL CARDIOLOGY 03 - CARDIOTHORACIC SURGERY 3 5 1.50 0 0 0.00

04 - RESPIRATORY MEDICINE 972 1,413 1.45 0 0 0.00

05 - GASTROENTEROLOGY 225 318 1.41 0 0 0.00

06 - GIT ENDOSCOPY 6 9 1.50 0 0 0.00

07 - NEUROLOGY 489 683 1.40 0 0 0.00

08 - NEUROSURGERY 42 60 1.43 0 0 0.00

09 - ENDOCRINOLOGY 146 213 1.46 0 0 0.00

10 - RENAL FAILURE 50 69 1.38 0 0 0.00

12 - HAEMATOLOGY 127 174 1.37 0 0 0.00

13 - ENT 10 15 1.45 0 0 0.00

14 - OPHTHALMOLOGY 5 8 1.50 0 0 0.00

15 - MEDICAL ONCOLOGY 73 107 1.47 0 0 0.00

17 - RHEUMATOLOGY 31 45 1.45 0 0 0.00

18 - DERMATOLOGY 7 10 1.36 0 0 0.00

19 - HEAD & NECK SURGERY 20 - DENTISTRY 3 5 1.67 0 0 0.00

21 - UPPER GIT SURGERY 22 - COLORECTAL SURGERY 23 - ORTHOPAEDICS 175 255 1.46 0 0 0.00

24 - UROLOGY 25 38 1.50 0 0 0.00


26 - GENERAL MEDICINE 749 1,000 1.34 0 0 0.00

27 - GENERAL SURGERY 129 182 1.41 0 0 0.00

28 - BREAST SURGERY 1 2 1.50 0 0 0.00


30 - GYNAECOLOGY 31 - OBSTETRICS 1 1 1.00 0 0 0.00

34 - TRACHEOSTOMY 35 - DRUG & ALCOHOL 26 38 1.46 0 0 0.00

36 - BURNS 37 - PSYCHIATRY 23 35 1.50 0 0 0.00

38 - ACUTE REHABILITATION 39 - UNGROUPABLE

Grand Total 4,416 6,086 1.38 0 0 0.00


Table 7: ModH Activity for Division Medical Sub Specialties flowing to LMH

Modbury >48HR Activity flowing to LMH

>48 Hours

Row Labels Seps Bed Days ALOS

01 - CARDIOLOGY 368 1,411 3.83

02 - INTERVENTIONAL CARDIOLOGY


04 - RESPIRATORY MEDICINE 695 3,035 4.37

05 - GASTROENTEROLOGY 139 761 5.47

06 - GIT ENDOSCOPY 6 74 12.33

07 - NEUROLOGY 297 1,686 5.68

08 - NEUROSURGERY 28 117 4.18

09 - ENDOCRINOLOGY 92 347 3.77

10 - RENAL FAILURE 24 105 4.38

12 - HAEMATOLOGY 70 296 4.23

13 - ENT 7 30 4.21

14 - OPHTHALMOLOGY 3 6 1.83

15 - MEDICAL ONCOLOGY 60 401 6.68

17 - RHEUMATOLOGY 22 101 4.59

18 - DERMATOLOGY 5 23 4.50

19 - HEAD & NECK SURGERY

20 - DENTISTRY 2 8 4.00

21 - UPPER GIT SURGERY

22 - COLORECTAL SURGERY

23 - ORTHOPAEDICS 134 884 6.60

24 - UROLOGY 19 58 3.03

25 - VASCULAR SURGERY 14 105 7.50

26 - GENERAL MEDICINE 420 2,189 5.21

27 - GENERAL SURGERY 80 516 6.45

28 - BREAST SURGERY 1 11 10.50

29 - PLASTIC & RECONSTRUCTIVE SURGERY 1 8 7.50

30 - GYNAECOLOGY

31 - OBSTETRICS

34 - TRACHEOSTOMY

35 - DRUG & ALCOHOL 10 25 2.50

36 - BURNS

37 - PSYCHIATRY 15 54 3.57

38 - ACUTE REHABILITATION

39 - UNGROUPABLE

Grand Total 2,515 12,266 4.88


Surgical Activity

Overall summary:

Table 8: Summary NALHN Surgical Activity for 2014/15 at LMH and ModH by care type and length of stay category

14/15 Actuals Seps per site based on care type and LOS category

LMH ModH Total

Elective Emergency Elective Emergency

Multiday sub total 771 2,917 425 1,427 5,540

23HR sub total 724 715 683 474 2,596

Same day sub total 2,007 319 1,095 143 3,564

Grand total 3502 3951 2203 2044 11700

Table 9: Summary future state NALHN Surgical activity at LMH and ModH, by care type and length of stay category (intra NALHN)

Future state Seps per site based on care type and LOS category

LMH ModH Total

Elective Emergency Elective Emergency

Multiday sub total 1,178 3,718 N/A N/A 4,896

23HR sub total 358 1,109 1,043 N/A 2,510

Same day sub total 908 462 1,961 N/A 3,331

Grand total 2,444 5,289 3,004 N/A 10,737 Note: 2014/15 Gastro and GIT endoscopy total separations for the LMH of 644 multi-day, 233 for same-day and 86 for 23 hour has been removed in future state as this activity is now under the governance of the Division of Medicine. Activity undertaken at ModH for Gastro and GIT Endoscopy is included as this is undertaken by General Surgery.

Current state

Table 10: Current Multi-day Activity for the LMH by Division of Surgery 2014/15

LMH Multi-day Surgical Activity 2014/15 Elective Emergency

SRGs Separations Bed Days ALOS Separations Bed Days ALOS

01 - CARDIOLOGY

6 25 4.2 02 - INTERVENTIONAL CARDIOLOGY 1 12 12.0 3 18 6.1 03 - CARDIOTHORACIC SURGERY

04 - RESPIRATORY MEDICINE

22 137 6.2 05 - GASTROENTEROLOGY 6 10 1.6 505 1926 3.8 06 - GIT ENDOSCOPY 12 17 1.4 121 777 6.4 07 - NEUROLOGY

2 7 3.3 08 - NEUROSURGERY 2 2 0.9 10 35 3.5 09 - ENDOCRINOLOGY

6 20 3.3 10 - RENAL FAILURE

43 212 4.9 12 - HAEMATOLOGY 6 20 3.4 15 57 3.8 13 - ENT 6 9 1.6

15 - MEDICAL ONCOLOGY 2 9 4.5 21 106 5.0 17 - RHEUMATOLOGY

21 95 4.5 18 - DERMATOLOGY

8 18 2.2


Table 11: Current Multi-day Activity for ModH by the Division of Surgery 2014/15

Multi-day Surgical Activity 2014/15 ModH

Elective Emergency

SRG Separations Bed Days ALOS Separations

Bed Days ALOS

01 - CARDIOLOGY 2 6 3.1 02 - INTERVENTIONAL CARDIOLOGY


04 - RESPIRATORY MEDICINE 1 2 1.7 9 35 3.9 05 - GASTROENTEROLOGY 2 5 2.4 292 1005 3.4 06 - GIT ENDOSCOPY 10 33 3.3 28 126 4.5 07 - NEUROLOGY 1 5 5.0 2 9 4.6 08 - NEUROSURGERY 2 11 5.4 3 12 4.0 09 - ENDOCRINOLOGY 1 4 4.1 4 16 3.9 10 - RENAL FAILURE 1 1 1.3 1 6 5.5 12 - HAEMATOLOGY 3 7 2.4 10 44 4.4 13 - ENT 39 73 1.9 38 115 3.0 15 - MEDICAL ONCOLOGY 8 28 3.4 17 - RHEUMATOLOGY 1 2 2.0 16 61 3.8 18 - DERMATOLOGY 2 1 0.7 1 2 2.2 19 - HEAD & NECK SURGERY 10 24 2.4 1 2 2.1 20 - DENTISTRY 3 5 1.7 21 - UPPER GIT SURGERY 24 62 2.6 59 254 4.3 22 - COLORECTAL SURGERY 35 272 7.8 39 384 9.9 23 - ORTHOPAEDICS 175 875 5.0 356 2771 7.8 24 - UROLOGY 40 106 2.7 9 39 4.4 25 - VASCULAR SURGERY 4 21 5.3 17 130 7.7 26 - GENERAL MEDICINE 7 37 5.3 113 391 3.5 27 - GENERAL SURGERY 38 119 3.1 399 1406 3.5 28 - BREAST SURGERY 14 40 2.9 1 2 1.7 29 - PLASTIC & RECONSTRUCTIVE SURGERY 13 36 2.7 8 47 5.9 30 - GYNAECOLOGY 6 13 2.2 31 - OBSTETRICS 1 3 2.8 34 - TRACHEOSTOMY

36 - BURNS 1 1 1.4

39 - UNGROUPABLE 1 17 16.7

Grand Total 425 1740 4.1 1427 6929 4.9

19 - HEAD & NECK SURGERY 15 39 2.6 20 - DENTISTRY

21 - UPPER GIT SURGERY 71 204 2.9 257 1189 4.6 22 - COLORECTAL SURGERY 170 1442 8.5 130 1611 12.4 23 - ORTHOPAEDICS 253 1071 4.2 330 2544 7.7 24 - UROLOGY 105 264 2.5 280 876 3.1 25 - VASCULAR SURGERY

8 180 22.5 26 - GENERAL MEDICINE 4 15 3.7 168 711 4.2 27 - GENERAL SURGERY 70 279 4.0 884 3487 3.9 28 - BREAST SURGERY 32 78 2.4 18 52 2.9 29 - PLASTIC & RECONSTRUCTIVE SURGERY 11 25 2.3 16 53 3.3 30 - GYNAECOLOGY 3 4 1.2 21 52 2.5 31 - OBSTETRICS

9 28 3.1 34 - TRACHEOSTOMY

5 146 29.2 36 - BURNS

39 - UNGROUPABLE 2 6 3.1 8 98 12.2

Grand Total 771 3506 4.5 2917 14461 5.0


Table 12: Current 23 hour Activity for the LMH for the Division of Surgery 2014/15

Table 13: Current 23 hour Activity for ModH for the Division of Surgery 2014/15

ModH 23 hour Emergency and Elective 2014/15 Elective Emergency

SRGs Separations Bed Days ALOS Separations

Bed Days ALOS

01 - CARDIOLOGY

1 1 0.9 03 - CARDIOTHORACIC SURGERY 3 3 1.1




10 - RENAL FAILURE 12 - HAEMATOLOGY 2 2 1.1 2 2 1.1

13 - ENT 323 348 1.1 24 23 1.0 14 - OPHTHALMOLOGY 1 1 1.0


6 5 0.9 18 - DERMATOLOGY

3 3 1.1 19 - HEAD & NECK SURGERY 10 11 1.1

20 - DENTISTRY 3 3 1.1 1 1 1.0

LMH 23 hour Emergency and Elective 2014/15 Elective Emergency

SRGs Separations Bed Days ALOS Separations Bed Days ALOS

01 - CARDIOLOGY

2 2 0.8 03 - CARDIOTHORACIC SURGERY 4 5 1.1 1 1 1.0 04 - RESPIRATORY MEDICINE



1 1 0.9 10 - RENAL FAILURE 2 2 1.0 15 15 1.0 12 - HAEMATOLOGY 6 7 1.1 2 1 0.6 13 - ENT 56 60 1.1 3 3 1.0 14 - OPHTHALMOLOGY


7 7 0.9 18 - DERMATOLOGY 2 2 1.2 7 6 0.9 19 - HEAD & NECK SURGERY 49 54 1.1

20 - DENTISTRY 21 - UPPER GIT SURGERY 124 132 1.1 16 16 1.0

22 - COLORECTAL SURGERY 35 39 1.1 33 31 0.9 23 - ORTHOPAEDICS 176 196 1.1 90 91 1.0 24 - UROLOGY 82 91 1.1 124 111 0.9 25 - VASCULAR SURGERY

2 1 0.6 26 - GENERAL MEDICINE 3 3 1.0 108 98 0.9 27 - GENERAL SURGERY 59 64 1.1 196 174 0.9 28 - BREAST SURGERY 106 114 1.1 5 4 0.9 29 - PLASTIC & RECONSTRUCTIVE SURGERY 4 4 1.1 8 7 0.8 30 - GYNAECOLOGY 2 2 1.1 4 4 0.9 31 - OBSTETRICS 1 1 0.9 2 2 0.8 37 - PSYCHIATRY

39 - UNGROUPABLE 1 1 1.1 Grand Total 724 789 1.1 715 656 0.9


21 - UPPER GIT SURGERY 40 44 1.1 4 5 1.2 22 - COLORECTAL SURGERY 14 15 1.0 21 20 0.9 23 - ORTHOPAEDICS 140 158 1.1 79 77 1.0 24 - UROLOGY 19 21 1.1 7 7 1.0 25 - VASCULAR SURGERY 1 1 1.0 3 3 0.9 26 - GENERAL MEDICINE 7 7 1.0 90 84 0.9 27 - GENERAL SURGERY 83 88 1.1 141 134 1.0 28 - BREAST SURGERY 7 7 1.1

29 - PLASTIC & RECONSTRUCTIVE SURGERY 14 14 1.0 3 3 1.0 30 - GYNAECOLOGY

3 3 1.0 31 - OBSTETRICS

1 1 0.8 37 - PSYCHIATRY 1 1 0.9

39 - UNGROUPABLE Grand Total 683 740 1.1 474 451 1.0

Note: 23 hour defined as those patients whose LOS is 29hours or under and where the admission and discharge date are different.

Table 14: Current Same-day Activity at the LMH and ModH by Division of Surgery 2014/15

ModH LMH Same-day Separations by Site 2014/15 Elective Emergency Elective Emergency

SRGs Seps ALOS Seps ALOS Seps ALOS Seps ALOS

01 - CARDIOLOGY

1 0.5 1 0.1 2 0.2


3 0.2

05 - GASTROENTEROLOGY 16 0.3 31 0.4 51 0.3 21 0.4

06 - GIT ENDOSCOPY 43 0.2 182 0.1

07 - NEUROLOGY 3 0.2

1 0.2 1 0.4

08 - NEUROSURGERY 4 0.3 1 0.6 11 0.3 1 0.6

09 - ENDOCRINOLOGY

1 0.3

10 - RENAL FAILURE 7 0.2

6 0.2 9 0.4

12 - HAEMATOLOGY 3 0.3 2 0.3 11 0.3 2 0.4

13 - ENT 121 0.3 3 0.3 26 0.3 14 - OPHTHALMOLOGY 1 0.2

409 0.2 1 0.6

15 - MEDICAL ONCOLOGY 5 0.2 4 0.4 40 0.2 18 - DERMATOLOGY 23 0.2 5 0.4 17 0.3 4 0.4

19 - HEAD & NECK SURGERY 11 0.2

4 0.3 20 - DENTISTRY 7 0.3

1 0.4 21 - UPPER GIT SURGERY 36 0.4

83 0.5 1 0.6

22 - COLORECTAL SURGERY 30 0.3 6 0.5 89 0.3 23 0.4

23 - ORTHOPAEDICS 311 0.3 23 0.3 324 0.3 53 0.4

24 - UROLOGY 230 0.2 7 0.3 384 0.2 38 0.4

25 - VASCULAR SURGERY 4 0.4 2 0.1 2 0.3 26 - GENERAL MEDICINE 8 0.3 14 0.3 88 0.3 74 0.4

27 - GENERAL SURGERY 87 0.4 35 0.3 139 0.4 67 0.4

28 - BREAST SURGERY 16 0.3 1 0.4 64 0.3 8 0.3

29 - PLASTIC & RECONSTRUCTIVE SURGERY 127 0.3 3 0.2 72 0.3 13 0.4

30 - GYNAECOLOGY 1 0.3 1 0.3 2 0.0 35 - DRUG & ALCOHOL

1 0.7

37 - PSYCHIATRY 1 0.4

Grand Total 1095 0.3 143 0.4 2007 0.3 319 0.4


Future state

Table 15: 23 Hour Elective Activity at ModH based on intra NALHN transfers

23 Hr Elective Activity at ModH (intra NALHN transfers)

SRGs Seps ALOS Bed Days

13 – ENT 263 1.1 283

00 – ORTHOPAEDICS 200 1.1 225

21 - UPPER GIT SURGERY 131 1.1 140

27 - GENERAL SURGERY 114 1.1 122

28 - BREAST SURGERY 90 1.1 96

24 – UROLOGY 81 1.1 90

19 - HEAD & NECK SURGERY 47 1.1 51

22 - COLORECTAL SURGERY 39 1.1 43

29 - PLASTIC & RECONSTRUCTIVE SURGERY 14 1.1 15

26 - GENERAL MEDICINE 8 1.0 8

12 – HAEMATOLOGY 6 1.2 7

03 - CARDIOTHORACIC SURGERY 6 1.0 6

08 – NEUROSURGERY 5 1.0 5

05 – GASTROENTEROLOGY 5 1.0 5

15 - MEDICAL ONCOLOGY 5 1.0 5

06 - GIT ENDOSCOPY 4 1.0 4

20 – DENTISTRY 2 1.1 3

18 – DERMATOLOGY 2 1.2 2

10 - RENAL FAILURE 2 1.0 2

30 – GYNAECOLOGY 134 1.1 143

39 – UNGROUPABLE 1 1.1 1

14 – OPHTHALMOLOGY 1 1.0 1

25 - VASCULAR SURGERY 1 1.0 1

31 – OBSTETRICS 1 0.9 1

37 – PSYCHIATRY 1 0.9 1

Total 1175 1.1 1259

Table 16: Same day Elective Surgical Separations ModH

MPH Same- Day Elective Activity

SRG Separations

05 – GASTROENTEROLOGY 13 06 - GIT ENDOSCOPY 34 13 – ENT 118 19 - HEAD & NECK SURGERY 12 21 - UPPER GIT SURGERY 95 22 - COLORECTAL SURGERY 95 23 – ORTHOPAEDICS 508 24 – UROLOGY 491 27 - GENERAL SURGERY 181 28 - BREAST SURGERY 64 29 - PLASTIC & RECONSTRUCTIVE SURGERY 159 26 - GENERAL MEDICINE 77 25 - VASCULAR SURGERY 5


12 – HAEMATOLOGY 11 08 – NEUROSURGERY 12 01 – CARDIOLOGY 1 04 - RESPIRATORY MEDICINE 0 07 – NEUROLOGY 3 09 – ENDOCRINOLOGY 0 10 - RENAL FAILURE 10 14 – OPHTHALMOLOGY 0 15 - MEDICAL ONCOLOGY 36 18 – DERMATOLOGY 32 20 – DENTISTRY 0 30 – GYNAECOLOGY 613 35 - DRUG & ALCOHOL 0 37 – PSYCHIATRY 1

Grand Total 2571

Note: includes Women’s and Children’s Division activity under gynaecology

Table 17: ModH Multi-day Elective Activity Flowing to LMH

ModH Multi-day Activity to transfer to LMH Elec (intra NALHN transfers)

Elective

SRGs Separations ALOS Bed Days Minus ICU


04 - RESPIRATORY MEDICINE 1 1.7 2

05 - GASTROENTEROLOGY 2 2.4 5


07 - NEUROLOGY 1 5.0 5

08 - NEUROSURGERY 2 5.4 11

09 - ENDOCRINOLOGY 1 4.1 4


12 - HAEMATOLOGY 3 2.4 7

13 - ENT 39 1.9 73

17 - RHEUMATOLOGY 1 2.0 2

18 - DERMATOLOGY 2 0.7 1




23 - ORTHOPAEDICS 175 5.0 875

24 - UROLOGY 40 2.7 106






36 - BURNS 1 1.4 1

Grand Total 425 4.1 1740


Table 18: ModH Multi-day Emergency Activity Flowing to LMH

Table 19: Multi-day Emergency Activity at LMH (excluding flows from ModH)

ModH Multi-day Activity to transfer to LMH

SRG

Emergency

Seps ALOS Bed Days Minus ICU

01 - CARDIOLOGY 2 3.1 6 03 - CARDIOTHORACIC SURGERY

04 - RESPIRATORY MEDICINE 9 3.9 35 05 - GASTROENTEROLOGY 292 3.4 1005 06 - GIT ENDOSCOPY 28 4.5 126 07 - NEUROLOGY 2 4.6 9 08 - NEUROSURGERY 3 4.0 12 09 - ENDOCRINOLOGY 4 3.9 16 10 - RENAL FAILURE 1 5.5 6 12 - HAEMATOLOGY 10 4.4 44 13 - ENT 38 3.0 115 15 - MEDICAL ONCOLOGY 8 3.4 28 17 - RHEUMATOLOGY 16 3.8 61 18 - DERMATOLOGY 1 2.2 2 19 - HEAD & NECK SURGERY 1 2.1 2 20 - DENTISTRY 3 1.7 5 21 - UPPER GIT SURGERY 59 4.3 254 22 - COLORECTAL SURGERY 39 9.9 384 23 - ORTHOPAEDICS 356 7.8 2771 24 - UROLOGY 9 4.4 39 25 - VASCULAR SURGERY 17 7.7 130 26 - GENERAL MEDICINE 113 3.5 391 27 - GENERAL SURGERY 399 3.5 1406 28 - BREAST SURGERY 1 1.7 2 29 - PLASTIC & RECONSTRUCTIVE SURGERY 8 5.9 47 30 - GYNAECOLOGY 6 2.2 13 31 - OBSTETRICS 1 2.8 3 36 - BURNS

39 - UNGROUPABLE 1 16.7 17


LMH Multi-day Activity (not including ModH Flows)

Emergency

SRG Separations ALOS Bed Days Minus ICU

01 - CARDIOLOGY 6 4.2 25

02 - INTERVENTIONAL CARDIOLOGY 3 6.1 18







13 - ENT


Table 20: Multi-day Elective Activity at LMH (excluding flows from ModH)

LMH Multi-day Activity (not including ModH Flows)

Elective

SRG Separations ALOS Bed Days Minus ICU

01 - CARDIOLOGY 02 - INTERVENTIONAL CARDIOLOGY 1 12.0 12

04 - RESPIRATORY MEDICINE 07 - NEUROLOGY 08 - NEUROSURGERY 2 0.9 2

09 - ENDOCRINOLOGY 10 - RENAL FAILURE 12 - HAEMATOLOGY 6 3.4 19

13 - ENT 6 1.6 9

15 - MEDICAL ONCOLOGY 2 4.5 9 17 - RHEUMATOLOGY

18 - DERMATOLOGY 19 - HEAD & NECK SURGERY 15 2.6 31

21 - UPPER GIT SURGERY 71 2.9 198 22 - COLORECTAL SURGERY 170 8.5 1377


24 - UROLOGY 105 2.5 255 25 - VASCULAR SURGERY



28 - BREAST SURGERY 32 2.4 77 29 - PLASTIC & RECONSTRUCTIVE SURGERY 11 2.3 25

30 - GYNAECOLOGY 3 1.2 4

31 - OBSTETRICS 34 - TRACHEOSTOMY 39 - UNGROUPABLE 2 3.1 6





19 - HEAD & NECK SURGERY 21 - UPPER GIT SURGERY 257 4.6 1138



24 - UROLOGY 280 3.1 871







31 - OBSTETRICS 9 3.1 28

34 - TRACHEOSTOMY 5 29.2 55

39 - UNGROUPABLE 8 12.2 91

Grand Total 2291 5.1 11373


Table 21: Total 23 hour elective activity at LMH based on intra NALHN transfers

23 Hr Elective Activity at LMH (intra NALHN transfers)

SRGS Seps ALOS Bed Days




13 - ENT 115 1.1 123


20 - DENTISTRY 1 1.1 1


24 - UROLOGY 17 1.1 19






Total 358 1.1 393

Table 22: Total 23 hour emergency activity at LMH based on intra NALHN transfers

23 hour Emergency Activity at LMH (intra NALHN transfers)

SRGs

Emergency

Seps ALOS Bed Days minus ICU

01 - CARDIOLOGY 3 0.9 3



05 - GASTROENTEROLOGY 75 0.9 71







13 - ENT 27 1.0 26





20 - DENTISTRY 1 1.0 1




24 - UROLOGY 131 0.9 118







31 - OBSTETRICS 3 0.8 2


Table 23: Total Same-day Separations at LMH based on intra NALHN transfers

Same-day Elective and Emergency Separations at LMH (intra NALHN transfers)

Elective Emergency

SRGs Seps Seps 13 - ENT 29 3 19 - HEAD & NECK SURGERY 3 0 21 - UPPER GIT SURGERY 24 1 22 - COLORECTAL SURGERY 24 29 23 - ORTHOPAEDICS 127 76 24 - UROLOGY 123 45 27 - GENERAL SURGERY 45 102 28 - BREAST SURGERY 16 9 29 - PLASTIC & RECONSTRUCTIVE SURGERY 40 16 26 - GENERAL MEDICINE 19 88 25 - VASCULAR SURGERY 1 2 12 - HAEMATOLOGY 3 4 08 - NEUROSURGERY 3 2 01 - CARDIOLOGY 0 3 04 - RESPIRATORY MEDICINE 0 3 07 - NEUROLOGY 1 1 10 - RENAL FAILURE 3 9 14 - OPHTHALMOLOGY 410 1 15 - MEDICAL ONCOLOGY 9 4 18 - DERMATOLOGY 8 9 20 - DENTISTRY 8 0 35 - DRUG & ALCOHOL 0 1 37 - PSYCHIATRY 0 0 30 - GYNAECOLOGY 758 175 31 - OBSTETRICS 1 0 05 - GASTROENTEROLOGY 3 31 06 - GIT ENDOSCOPY 8 0

Grand Total 1666 615 Notes: includes Women’s and Children’s Division activity under gynaecology, including the Family Advisory Clinic.

13. Risk management

A full risk register has been established for the NALHN Transforming Health program. The risk

register sets out risks under the following broad categories:

Workforce

Public Perceptions

Program Delivery

Benefits Realisation

Clinical Commissioning

Governance and Compliance



ICT

Procurement

Assets and Infrastructure

The risk register outlines two risks of significant concern to NALHN:

the ability to transfer and SA Ambulance Service’s capacity due to the numbers of transfers

NALHN’s ICT capacity.

NALHN is currently working with SAAS and SA Health’s ICT to assist in mitigating and minimising

these risks.


ATTACHMENT 1

MET TL to discuss with duty ICU or MET consultant

TRANSFER TO MH ED (PENDING TRANSFER TO LMH) TRANSFER TO MH Short-Stay STAND DOWN

MT TL to documentNew treatment planFrequency of observationEscalation pathwayInvestigationsReview time frameAssess response to treatment and liaise with HT consultant. If deteriorates while in Short Stay, recall MET (and duty MET consultant).

MET nurses to Assist with stabilisation. Assist ward staff with ongoing

management Handover to short stay ward and review as

required

MET TL to

Stabilise for transfer to LMH

Lead clinical management

Refer to receiving team at LMH

Arrange transfer with MedSTAR or SAAS

MET nurses to Assist with stabilisation Assist transfer to ED Support and manage patient in ED (remain with

patient) Prepare patient for transfer to LMH

TRANSFERRED TO LMH ICU or CCU or other ward (as appropriate)

Does the patient still meet RDR Red or Purple Zone Criteria or have unresolved clinical

concern about the patient?

End of MET call assessment

Does the patient needintervention or are organ supports not

available at MH?

Does the patient needintervention or are organ supports not

available at MH?

CONSIDERATIONS

Suitability for escalation Comorbidities/7 step pathway

Suitability to remain in MH Current clinical requirements/Potential for further deterioration

MET TL to discuss with Home Team / Covering consultant

YES

YES NO

YES NO

NO

RAPID RESPONSE TEAM


ATTACHMENT 2


ATTACHMENT 3


ATTACHMENT 4a


ATTACHMENT 4b


ATTACHMENT 4c


ATTACHMENT 5


ATTACHMENT 6


ATTACHMENT 7


ATTACHMENT 8


ATTACHMENT 9

General Medicine


ATTACHMENT 10


ATTACHMENT 11


ATTACHMENT 12



ATTACHMENT 13

Potential Stroke Pathway - NALHN

Patient presents to ED with stroke symptomsReferral to Allied Health through Oacis on admission

CODE Stroke 8.00am-8.00pm

Walk-in to ED after 8.00pm

Rapid transfer to RAH for

thrombolysis

Patient Admitted to Stroke Service Assessment and Care

AH Assessment – Nursing – malnutrition screen (MUST) 24hrs SP – 24 hours: PH/OT – 24 hours;

Dietician – MUST ≥ 2/Enteral Nutrition/poor oral intake ; SW – 48 hours as requested

Medical Assessment - Identify risk factors for secondary prevention. (investigations -Blood/ telemetry/ MRI/ CT/echo)

Monitoring - ongoing improvement deficitsRehabilitation, secondary prevention

and palliationMultidisciplinary (MDT) rehabilitation assessment ( twice weekly)

Rehabilitation service notifiedRehabilitation review

Initiate post acute management and discharge planning on presentation

Consultation with patient, family and GP

AH (SP) swallow screen and assessment Treatment if needed

Minor stroke- TIA

After hours- Admitted to stroke service

TIA nurseNotify Stroke Service

Patient Admitted to

Ward

If medically stable

discharged to home

TIA Clinic for follow-up after

24 hours

End of life management Medically stable

Facilitate discharge planning and follow-up Assessment as required: (ACAT/ Rehabilitation/ TCP

Patient remains in stroke unit as long as required

Mild to Moderate stroke severity - 2-3 days

Suitable for RITH or day

rehabilitation

Unsuitable for RITH or day

rehabilitation

Severe stroke - 7 days

Long term palliation

- Hospice or community

Inpatient rehabilitation or TCP

Patient NET (see PEG pathway)

YES

Ongoing assessment (including MDT), therapy and care

NOInpatient/

Interhospital transfer

Medically un-stable

Note:Blue

indicates potential pathway

categories

Patient admitted to AMU. (If no inpatient stroke beds or

if telemetry required) YES


ATTACHMENT 14


ATTACHMENT 15

Documents

Northern Adelaide Local Health Network (NALHN) Adelaide Local Health Network (NALHN) ... Michael Francese Executive Sponsor, ... and Northern Adelaide Local Health Network