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Delivering a rapid response service in the community

Nadeem Moiden
RN, Charge Nurse
Rapid Response Acute Care Service,
Luton Community Services, Bedfordshire

Althea Salau
RN, Senior Sister
Rapid Response Acute Care Service
Luton Community Services, Bedfordshire

The Rapid Response Acute Care Services team in Luton, Bedfordshire, facilitates early discharges of clinically stable patients and plays a vital role in preventing unnecessary and inappropriate hospital admissions

With recent developments in the country's financial status and pressure to save, cost efficiency has never been more central to the NHS. The Rapid Response Acute Care Team (RRACS) in Luton was established 10 years ago to help frontline staff in assisting in unnecessary and inappropriate hospital admissions and accelerating early discharges, thus saving and redirecting funds in developing more services.

A hospital stay is usually the most expensive episode in the experience of healthcare delivery but it may not be the right place to receive certain services.1 The current position in many health and social care systems is a 'vicious circle of care', where failure to invest in preventive and intermediate measures has increased pressure on hospital care and long-term bed-based social care.2 The Department of Health (DH) wants to move towards a 'virtuous circle', which keeps people at home and promotes independence with planned service provision.2

The NHS framework also emphasises the provision of the 'right care to people in the right place at the right time'.3 A barrier to the feasibility of this approach is inadequate or insufficient provision of a range of services; a lack of inter-organisational communication to plan and provide services; inflexible and inappropriate referral to services or a combination of these factors. Therefore, the DH emphasises that hospital services must link with other agencies and organisations to meet the needs of service users.4 This is not about minimising use of hospitals but designing and structuring services around the needs of service users. This may avoid hospital admission where there is a suitable and available alternative in place, thus rendering an admission as 'inappropriate'.

There are other services already established that need to be consistent and standardised, but the services provided by the RRACS in Luton are unique.

RRACS is a joint venture between Luton Community Services and the hospital. The team consists of experienced nurses able to work across primary and secondary care to provide acute medical and nursing care in patients' own homes, residential or intermediate care settings. The service aims to provide timely, evidence-based acute care interventions for a period of planned care to patients and work closely with consultants and GPs to support the care of patients in the community.

The service
Rapid response is designed for patients with acute illness with potential for rapid recovery. It is not suitable for medically unstable or critical conditions. The service offers both hospital care and support at home allowing patients to regain their independence until treatment is completed and/or extended as required.

Following an initial assessment, patients follow planned care pathways according to the diagnosis and treatment plans made by the patient's GP or consultant. The team has developed and put in place robust, evidence-based protocols, maintaining patient safety at an enhanced level of care. Once the planned episode of care is complete patients are referred onto supporting local services as required.

The team, supported by administrative and clerical staff, consists of highly skilled nurses who are trained to undertake full assessment of patients, deliver acute interventions and monitor and support patients during acute episodes of illness. A holistic approach is adopted using a multidisciplinary team of healthcare professionals working across primary and secondary care to deliver the service, collaborating with other services such as the community assessment and rehabilitation team, and social services.

Sources of referral
Referrals are received from:

  • A&E.
  • Medical assessment units.
  • GPs.
  • Outpatient clinics.
  • Community matrons.
  • District nursing service.
  • Consultant post-domiciliary visits.
  • Social workers.
  • Ward consultants.
  • Respiratory teams.
  • Single Point of Access (referral from Luton Borough Council for integrated crisis management).
  • First Point of Contact (nurse practitioners based in Luton Community Services who manages crisis in care homes).
  • Out of area hospitals that have patients registered with a Luton GP.

Criteria for referral

  • Patient lives within the Luton area.
  • Adult aged 18 years or older, whose care is managed by a hospital consultant or GP.
  • Patient must be clinically stable before transfer.
  • Treatment plan has been agreed by GP/consultant.
  • Clinician in charge accepts medical responsibility.
  • Patient has a telephone (that can be used for emergency).
  • It is only for patients who would otherwise require hospital admission/extended hospital stay.
  • Patient/carer/family consent to transfer of care to RRACS and have signed the consent form, and the patient/carer/family agree to ongoing referral to statutory service, if necessary, following discharge.

Exclusion criteria

  • Any patient who is not registered with a Luton GP.
  • For IV treatment initiated at home, patients who do not have a responsible adult available at the time of the first two visits may be excluded to maintain patient safety (in case of anaphylactic shock).
  • However, if the team has capacity for two nurses for joint visit then the patient is taken on board.

Response time and prioritisation
All referrals are seen within an agreed time. Patients are assessed both in hospital and at home. The diagnosis and treatment plan is explained, a service profile and leaflets on acute and long-term conditions being treated are given to each patient. All patients have care plans and are asked to give signed consent before commencement of care. Also, carers/families are educated around acute and long-term conditions, and group education sessions are provided to residential care staff.

In circumstances where an individual's needs cannot be met by the RRACS team and hospital admission is unnecessary, a stay within a nursing home environment is considered and arranged by RRACS accordingly. However, to meet the criteria the individual must require nursing care for an acute illness or infection that can be treated within a care home environment until the acute episode is resolved. The GP must continue to provide medical cover and support during that episode.

Discharge planning
Following completion of medical treatment and acute nursing care, RRACS decides whether the patient is ready for discharge. The discharge planning process begins on the first day of treatment in order to ensure smooth transition of care for those patients who require ongoing support. RRACS refers patients to those identified services in appropriate timescales to avoid delays. RRACS completes a discharge summary at the end of treatment detailing the intervention with any onward referrals and sends a copy to the GP and the patient.

The way forward
RRACS intervention, although acute, has a social perspective, which presents challenges within health and social care; in particular, the manner in which information is given and how services are commissioned and risk managed. However, highly skilled nurses managing and delivering the care bring together trust and understanding from the patient. All of these, and the medical and nursing models of care are combined to the benefit of the patient.

Interventions provided by the team not only keep the patient at home but also provide hospital care, reduce length of stay, and avoid unnecessary admissions. Care is delivered by the right person, at the right place and the right time, avoiding hospital-acquired infections.2,5,6

The team has the capacity to carry out a range of nursing interventions and may be able to assist in postoperative intervention if needed. This is an area that could be developed with the surgical teams at the hospital.

There are also financial implications. Some staff members are independent prescribers and undertake full physical assessments of patients. Funding needs to be secured for key training and updates on key skills, such as acute assessment, vascular access, phlebotomy and administration of IV therapy. Secured funding can also increase the levels of intensive homecare interventions.

RRACS monitors its activity, and regular audits are carried out to evaluate service users' and healthcare professionals' experiences. For the Rapid Response Acute Care Service Annual Patient Experience Survey 2009, 46 questionnaires were sent out between June and August 2009. Of this total there were 27 (58%) responses. This sample size may seem small; however, it reflects the average number of referrals received per month, which is about 20-25.

The questionnaire consisted of nine questions pertaining to information (4), patient satisfaction (2), service improvement (2) and receiving care at home (1). Of this, 92% felt adequately informed of the service provision and the planned treatment, 93% were very satisfied with the care received and 100% were happy to receive hospital care at home. It was identified that communication could be improved in terms of the awareness other healthcare professionals have of the RRACS. This would facilitate a more seamless transition for the patient and ultimately improve the whole patient experience.

Of the average 25 patients each month with an average length of care of seven days this equals a saving of £472,500 each year in bed days saved (based on £225 per day). However, as the service actually treats some patients at home for periods of four to six weeks, the cost savings in reality are higher.

Additional cost savings are made by prevention of admission to hospital, which currently averages at 10 patients per month, producing a current saving of £180,000. This saving is anticipated to grow with the increased involvement and awareness of the local GPs as to how the RRACS can be used more by them to increase avoidable admissions to hospital.
The findings from this survey were fed back to the service user involvement group and partners at the Luton and Dunstable NHS Foundation Trust. It was also discussed within the RRACS from which action plans were made towards improvement.

The RRACS information booklet has been updated and redistributed to key services; the patient information leaflet is included in all service packs and explained to the patient and family at each assessment.

In September 2010, a lunchtime display board was set up at the hospital to promote and raise awareness of RRACS. A GP survey has been undertaken this year, the results of which are currently being analysed. This data will be made available once collated, via the NHS Luton Community Services.

The next stage of the project is to arrange visits to each hospital ward, and hospital doctors meetings within the Luton and Dunstable Hospital NHS Foundation Trust, as well as the GP surgeries within Luton to promote the RRACS.
In future, the team could also contribute to providing home assessment of frequent users of services and offering increased monitoring and rapid intervention. This could be done by using information available regarding those who are 'revolving door' users of services through the hospital's administration system/commissioners.

The service can also be expanded to the wider community, not only to patients registered with Luton GP but to all Luton and Dunstable hospital patients. The commissioners of services may have to work out a system to cover a wider geographical area so that patients will have equal services indiscriminately and not be liable to the 'postcode lottery'.

The out-of-hours nursing team's support is crucial to the success of the RRACS. Therefore, having those staff competent in IV administration and acute assessment skills is central to promoting and maintaining the service.

Nursing homes are already funded to provide nursing care. Commissioners of older adult care services could consider introducing IV therapy (antibiotics and fluids for hydration), supervised by RRACS if needed. Nursing homes need to evolve and train their staff to provide these services as there will be increasing numbers likely to require them. As the population ages and patients with long-term conditions live longer, nursing homes can contribute to achieving the Department of Health's Quality, Innovation, Productivity and Prevention (QIPP) agenda, a programme set up to improve NHS quality and productivity.

Conclusion
The RRACS cannot function without the commitment and support of hospitals and community teams, and admission avoidance can be more successful with joint planning. It is about shared aims and objectives, intelligent multi-agency working, all linked together to make it happen. Failure to provide a carefully planned service will result in an increase in unscheduled hospital admissions and a decrease in early discharges resulting in unnecessary stays. Therefore, it is recommended that all NHS employees are aware of the service and that RRACS is established, monitored and evaluated all over the UK to work towards one shared aim.

References
1.    Graves N, Weinfold D, Tong E, Birrell F, Doidge S, Ramritu P, Halton K, Lairson D, Whitby M. Effect of healthcare-acquired infection on length of hospital stay and cost. Infection Control and Hospital Epidemiology 2007;28(3):280-92.
2.    Department of Health (DH). Avoiding and diverting admissions to hospitals: a good practice guide. London: DH; 2004.
3.    Department of Health (DH). The Operating Framework for the NHS in England 2009/10. High Quality Care for All. London: DH; 2008.
4.    Martin F, Sturdy D. Half way home? Update guidance from the DH on Intermediate Care in England. London: DH; 2010.
5.    Plowman, RP, Graves N, Roberts JA. Hospital Acquired Infection. Office of Health Economics. London; 1997.
6.    Plowman RP, Graves N, Griffin MAS, Roberts JA, Swan RV, Cookson B, Taylor L. The rate and cost of hospital-acquired infections occurring in patients admitted to selected specialties of a district general hospital in England and the national burden imposed. Journal of Hospital Infection 2001;47(3):198-209.