Stakeholders

ACE Clinical Lead: Dr Mathew Mathai oversees 4 work streams – i) clinical governance, ii) service configuration, development and implementation, iii) pathway development, iv) training and competence.

ACE Project manager: Denise Stewart manages the ACE implementation programme.

Trust Management: Prof Clive Kay, Chief Executive; John Holden, Director of Strategy; Cindy Fedell Director of Informatics; Dr Janet Wright Directorate Lead, and Dr Helen Jepps and Dr Shaun Gorman, Service leads.

Clinical Commissioning Group lead for Acute and Urgent Care: Dr David Tatham keeps the CCG Urgent Care Board informed of project development.

Lead commissioner for Urgent Care: Louise Atherton.

Primary care: Dr David Tatham is the CCG lead for Acute and Urgent Care in Bradford. He is also a GP. He leads on the development of the primary care section of each clinical pathway. He also leads on promoting the service and pathways in primary care.

GP Surgeries and Primary Care Advanced Nurse Practitioners: The service is open to referrals from all surgeries across Bradford.

Inpatient ward staff at BTHFT: This includes ED and the Paediatric Clinical Decision Area and includes doctors, nurses and the administrative team. The team are updated on each pathway. Hospital doctors and Advanced Nurse Practitioners (ANP) can also refer into the service. Consultant Paediatricians take full clinical responsibility for all CYP referred into the service. Together with the ED ACE leads (Drs Liz Jones and Georgina Hudson) they have been involved in developing governance processes and input into the development of all pathways. They are involved in training ACE nurses and assessing their clinical competence.

Head of Children’s Nursing at BTHFT and lead for ACE clinical governance: Kay Rushforth.

Children’s Matron at BTHFT for community service: Emma Wilkinson manages the ACE nursing team.

ACE nursing team: Each ACE nurse inputs into a clinical pathway and helps to develop it. Each ACE nurse is also linked to individual GP surgeries, to Consultants and to specific clinical areas (i.e. primary care, ED and Paediatrics) for service promotion and networking.

Children and Family: We engage with CYP and families through specific sessions including focus groups and also through paper and online questionnaires.

Team administrator: Attia Gilani produces real time reports on all aspects of the service including Key Performance Indicators. These are fed back to Commissioners on a monthly basis.

Clinical educators and training development: Dawn Hare (ANP), Tamlin Walker, Laura Deery and Clair-Marie Clarke have developed a training package for ACE nurses.

ACE nurse supervisors: Dr Liz Jones, Vicki O’Keefe (ANP), Sharon Popple (ANP), Gill Falloon (ANP), Dawn Hare (ANP), Dr Anne Pinches, and Dr Mathew Mathai.

Pharmacist: Manrita Khatker leads on medicine governance for each pathway.

Pathway lead developers: Dr Anne Pinches, Dr Uma Jegathasan, Dr Helen Berry, Dr Anil Shenoy, Dr Sumera Farooq, Dr David Tatham and Dr Mathew Mathai.

Web development: Dan Webber has developed our webpage and keeps it up to date. He is also involved in analysing our on line patient experience surveys. IT support: Steve Pearson and John Greenaway.

Bradford Institute of Health Research and Improvement Academy collaboration: Prof John Wright and Beverley Slater. York University are undertaking an external service evaluation sponsored by Connected Health Cities Yorkshire and Humber.

Health Education England: Funded a Clinical Leadership Fellow to develop a local network CYP Ambulatory care across West Yorkshire in 2019-20.

The King’s Fund: Dr Mathew Mathai has a blog on their website promoting the ‘virtual hospital model’.

New partnerships are being sought with Yorkshire Ambulance Service, clinical prescribers and NHS 111. Initial scoping meetings have taken place or are currently being planned.

PDSA Cycles / Solution(s) Tested

With reference to the specific aims above:

1. The Ambulatory Care Experience (ACE) model is the result of system wide collaboration between GPs, the local CCG and the Bradford Royal Infirmary (BRI). The service which is the first of its kind in the UK, provides specialist nursing care at home for unwell CYP who would ordinarily have been referred, seen and potentially admitted to hospital. Referrals into the service are taken from primary care, ED and the CYP Clinical Decision Area (CDA) at the BRI. ACE is delivered in the community setting and is staffed by children’s community nurses (band 6) working between 09.00 – 21.00, 7 days a week.
2. Once a CYP has been accepted into the service full clinical responsibility lies with the Consultant Paediatrician on call at the BRI. CYP have 24-hour ‘open access’ to the CDA while under the ACE service. If a CYP meets the pathway referral criteria they are accepted into ACE. Referrals are made by phone and electronically via primary and secondary care electronic patient systems.  The ACE nurse then makes telephone contact with the family within 2 hours and arranges a home visit usually within 4 hours of referral. At this visit a focussed history and assessment is undertaken. Further home visits or telephone reviews are then arranged.
3. CYP remain in the service for up to 3 days. In addition to acute management the team also deliver a ‘care bundle’ e.g. for asthma/wheeze this includes support with inhaler delivery, monitoring effectiveness of treatment, education in managing future episodes, identifying deterioration and smoking cessation advice. Nurses discuss each CYP under their care with the paediatric consultant. Clinical discussions occur between the ACE nurse and consultant at least 3 times a day.
4. Individual clinical pathways have been developed with GPs, nurse practitioners, nurses, pharmacists and paediatricians and are based on best available evidence, national guidance and local clinical agreement.  To date we have implemented the asthma/ wheezy child pathway, the gastroenteritis pathway and the croup pathway. The bronchiolitis pathway and neonatal jaundice pathway will be introduced by the end of December 2018.
5. Pathways have been developed with a multidisciplinary team and according to a tightly managed implementation process. Each pathway has been audited against ‘current state’ (before launch) to ensure safety and then re-audited after ‘go live’ to make sure parameters are appropriate and there are no quality issues.
6. The model and pathways are based on a simple design with components that can be found in all acute trusts around the country. Governance processes have been developed and tested and in the first 9 months there have been no adverse events.

The model and pathways have all been implemented to a time frame.

Data results

Main outcomes in the first 9 months of the service

100 per cent of those responding to the service user satisfaction survey said they were very happy with the service.

Some responses:

There have been no adverse events since service launch.

In the first 9 months of the service 87 per cent of appropriately referred CYP referred during service hours had all their care delivered at home.

Service model and Key Performance Indicators (KPI):

KPI1 – Achieve a minimum of 6 contacts each day.

• This was achieved on 17 per cent of days. As a new service we were keen to develop safely. Therefore we implemented one pathway initially and tested all our governance processes around it. We then launched the second pathway six months later. We have developed an engagement strategy to address this KPI.

KPI2 – Accept 100 per cent of appropriate referrals.

• 95.5 per cent of appropriate referrals were accepted. The cases not accepted were due to service capacity and referral times. The team followed the escalation protocol successfully.

KPI3 – Make contact with 100 per cent of families within 2 hours of referral.

• This was achieved  98.5 per cent of the time. The only family that we were unable to contact did not have a working mobile. They were seen within 4 hours of referral. The team followed the governance protocol successfully.

KPI4 – 100 per cent access to consultant/step up huddles.

• This was achieved 100 per cent of the time.

KPI5 – 100 per cent of patients have a face to face review in the home.

• This was achieved 98 per cent of the time. The 2 per cent of CYP who were not seen at home were managed by phone and after discussion with the consultant.

Referral times into the service:

Frequency of ACE mode of contact:

58 per cent of referrals have come from primary care:

34 different GP surgeries have referred into the service (out of a total of 95 surgeries), and we have saved 228 bed days in the first 9 months: