Wards
The SWLEOC Ward nursing team is an integrated team of Registered Nurses, Registered Nursing Associates, Associate Practitioners and Health care assistants. The ward teams work in collaboration with the intensivist, pharmacist, discharge and the physiotherapy teams. The service delivers a modernised approach to elective orthopaedic recovery which is evidence based and focussed on individualised patient care.
The SWLEOC Ward nursing Team provides specialist input in the pre-operative and post -operative phase of the patient journey.
The patient completes a lifestyle questionnaire on the electronic pre-operative assessment tool (LifeBox), which provides information about their home environment, their support structures, how they are coping at home and if they have any concerns about their discharge. This is triaged by the pre-operative assessment nurse and the discharge team. This pre-admission assessment provides the basis for discharge planning, enabling:
- early action;
- optimisation;
- equipment provision;
- highlights the potential need for post discharge social care input;
- multidisciplinary problem solving to minimise any potential barrier or delay in discharge.
Vulnerable adults are identified through this process, such as those living with: disability; learning needs; Parkinson’s disease or dementia. A Best Interest meeting will be scheduled involving a member of staff from relevant SWLEOC departments to discuss provision the patient may require for their SWLEOC journey.
High risk patients with complex respiratory, cardiac or haematological history will be identified in pre-assessment and may need to be admitted pre-operatively to the inpatient ward to be optimised.
Preparing for surgery classes are now provided in the form of an AI supported video that SWLEOC developed in collaboration with our digital partners ‘Lifebox’. The video contain information to the patient in relation to preparing themselves as well as the home environment prior to the surgery. It also provides them an overview of what to expect through their journey in SLWEOC.
Patients are sent the specific video link (links below) by the Lifebox support team, as they set up an account for the patient and reminds them to watch the video. The Pre-operative assessment team confirms with the patient that the video information was received, that they watched the video and clarify any questions that they may have. Any patients who have not received the video link will be sent the link as an Envoy text message or email link by one of the discharge nursing team/admin staff.
Non-digital patients are identified at the pre-operative assessment point and are offered face to face sessions as required.
Please see links below:
Unicompartmental Knee Replacement
This helps to alleviate anxiety and improve their confidence. Patients are provided with patient information booklets, containing information about:
- preparing for their surgery;
- their hospital stay;
- their recovery.
Patients are also signposted to view this information in the form of videos. They are encouraged to complete the pre-surgery exercise programme to maximise their strength and function following surgery.
Enhanced recovery and fast track pathways are followed, the nursing teams work closely with the physiotherapy teams. The patient’s post-operative rehabilitation starts on the day of their surgery, aiming for mobilisation between 2- and 4-hours post-surgery.
We aim for all patients to recover in their home environment as soon as possible following surgery once all discharge criteria have been met. Patients undergoing primary joint replacement surgery can go home from day 0 onwards.
Nursing Discharge criteria includes:
- Stable Vital signs;
- oriented to time and place;
- no nausea, vomiting or dizziness;
- able to tolerate food and drink;
- pass urine;
- minimal wound ooze;
- pain is controlled;
- discharged by the physiotherapist;
- has a responsible adult to collect and stay with patient overnight for the first 24 hours following surgery;
- post operative X-ray reviewed as satisfactory by the consultant or one of their team.
The SWLEOC Nursing team aims to ensure that the patient has the best possible recovery journey, priority is to ensure pain and post-operative nausea and vomiting is well managed. Patients are empowered to be independent by engaging in the post-operative exercises and referring to their comprehensive patient information booklets.
The Discharge Team, work in conjunction with the nursing team and clarify social support at home and organise Packages of Care based on the needs of the patient.
The SWLEOC Nursing Team complete a robust and comprehensive discharge; each patient is given a Nursing Discharge Summary containing the following information:
- any complications and their medical and nursing management;
- information about their wound closure and instructions on post-operative management either by the district nurse, attendance to SWLEOC post-operative clinic or practice nurse;
- information about their DVT prophylaxis, medication prescribed, dose and duration of course;
- Waterlow score;
- latest biochemistry and haemoglobin levels;
- details of GP follow-up bloods or investigations requested by the intensivist;
- contact numbers and email address for the SWLEOC team if patients have any concerns following discharge regarding their wound, recovery, and physiotherapy.
Discharge Advice line:
All patients on discharge are given the telephone number of the ward in addition to the email address of the Discharge team. Patients are able to contact the discharge advice line to discuss concerns regarding any aspect of their recovery such as; their wound, analgesia, swelling and bruising. Telephone enquiries are managed by both the nursing and discharge team. Emails are addressed by the discharge team.
Patients who are concerned over their surgical wounds are asked to submit a photo to the email address. Based on the image, they may be asked to attend a face-to-face consultation with the surgical surveillance nurse or discharge nurse, or be referred to the surgeon for advice and management.
Patients with suspected DVT are also managed by the discharge team as outlined in the SOP to reduce 30-day patient readmission rates after discharge from SWLEOC following elective surgery.
Our post-operative discharge advice line offers a robust safety net and oversight of the acute part of the patient’s recovery, and follow-up is delivered by the familiar SWLEOC team. This provides consistency, ring-fenced review and prompt escalation to the most appropriate clinician, improving patient confidence and reducing anxiety. In addition, it reduces GP and A&E visits.
The above applies to surgical post-operative concerns and complications, and excludes medical emergency.
The wards were set up when the Centre opened in 2004, there were two inpatient wards, Oaks and Derby, funded for 20 beds each. The shift patterns hours were 7:30am – 20:00pm (day shift) and 1930pm – 0800am (Night Shift).
In June 2020 following the first wave of COVID 19, as part of the recovery of services and ensuring patients are supported by the surgical team following their discharge, together with an individualised post-operative recovery journey, changes to the wards were made. Oaks ward now focuses on day case procedures and day case joint arthroplasties. Derby ward focuses on patients with complex medical and rehabilitation needs and those awaiting packages of care and places at rehabilitation facilities.
The Service has evolved: Oaks ward primarily functions as a Daycase unit and closes at night. Patients who are not fit for discharge are transferred to Derby ward in the evening. Since November 2021, Oaks ward closes 5-6 nights per week depending on the caseload of patients scheduled for surgery. Closure of the ward provides the flexibility to reallocate staff scheduled to work the night shift later in the week and fill gaps from sickness and staff vacancies.
The surgical wound service has evolved, and a consultation room has been built in the main reception to accommodate patients requiring a face-to-face review. The development of this service and the building of the safe space adds to patient experience, as the review by a SWLEOC team member reduces patient anxiety and avoids visits to A & E and GP Surgeries.
The nursing establishment has evolved; when the centre opened it consisted of registered nurses supported by health care assistants. The hosting Trust and SWLEOC have invested in health care assistants to complete their Registered Nursing Associate and Associate Practitioner training, and the successful staff have been integrated into the nursing teams on both Oaks and Derby Ward. The Nursing Associates play an active role on both wards alongside the registered nursing and physiotherapy teams, they manage a group of patients and discharge patients with the support of the Registered Nurse.
Nursing Handovers have also evolved; they have moved away from nursing only to include multi-professional team members, specifically, the Discharge and Physiotherapy teams. This enables a joint multidisciplinary handover in the morning, afternoon and evening and maximises the ability to discharge patients who are ready to go home.
The Ward Nursing teams interact with the whole multidisciplinary team in the inpatient and outpatient environment. In the inpatient unit, the integrated team meets in “safety huddles” 3 times per day and there are many informal opportunities to meet with the relevant intensivist throughout the day. In the Wound review setting, the Registered Nurse can quickly escalate post discharge concerns to the intensivist, senior nurse or Surgical Clinician depending on the patient’s presentation. This includes the Surgical Consultant, Intensivist or Senior Nurse Practitioners, Pharmacist, Radiologists as well as having access to the Trust Radiology and Doppler scans.
The team also interacts with administrative staff aligned to different parts of the patient journey, including; triage, outpatients and physiotherapy administration. This includes appointment bookings, transport bookings and sending of community referrals.
The team undertakes work on the wards and the wound review clinic, a purpose-built clinic room in the reception area of SWLEOC.
- Bluespier;
- Clinical Manager;
- Patient Manager;
- PACS;
- LifeBox
- it is important from the outset to build strong relationships across the multi-professional team to ensure integrated and collaborative working with one team ethos;
- have structured, standardised pathways for all patients to ensure care delivery is streamlined and organised;
- have strong communication links and robust pathways with not only community MSK services but with social care by Borough to ensure the post discharge pathway is streamlined, the post discharge services are in place, and that there is not any unnecessary delay to discharge. If offering mutual aid to patients from other regions, it is imperative that this is in place prior to admitting the first patient.
Inpatient unit:
- When a patient’s motor power and sensation has not sufficiently returned to enable safe mobility and same day discharge;
- When patients are waiting for social services input and discharge is delayed due to system capacity (package of care, rehabilitation bed, equipment).
Inpatient unit:
- Ongoing audit and monitoring to feedback to anaesthetists about the average time for motor power or sensation to return following primary joint arthroplasty. Data collected to evaluate trends: Anaesthetist, start time of spinal anaesthetic, type, concentration and volume of anaesthetic drug used, any additional nerve block given, duration of surgery.
- Close working with discharge nurses. Strong relationships with social services in the different Boroughs. Robust documentation and pathway information, based on each Borough, that is regularly updated to ensure that it is current.
- Not having discharge nurses integrated with the nursing team;
- having separate handover for nurses, physiotherapists and discharge nurses;
- not having all the MDT attend all the safety huddles;
- not having an upskill program in place for integrated working between the nurses and therapy team.
- Staff turnover leading to inconsistent staffing levels and recruitment of staff;
- fixed staffing patterns reducing flexibility in the rota;
- as a hub based elective orthopaedic service requires constant innovation, change is inevitable and regular. Change fatigue and staff resilience during change can be challenging;
- although integrated working fundamental, and generally classified as a strength in SWLEOC, it can occasionally be a challenge due to differing opinions and approaches.
- Integrated working: To successfully implement enhanced recovery pathways, it is imperative to harness the wealth of expertise in the individual professions within the Centre and ensure one builds a multi-skilled and sustainable workforce who can overlap in areas of care provision. This collaboration is successful in improving patient outcomes, satisfaction and confidence, improves staff morale, and reduces length of stay and variation in care delivery.
- Consistent Communication: It is essential that all team members that the patient encounters along their journey repeat the same message. This manages patient expectations, reduces anxiety and improves the confidence the patient has in the team looking after them.
- Patient Information: Comprehensive and clear patient information should be provided in written (paper and online) and video format as well as in different languages and in brail so that patients can adequately prepare for their surgery and know what to expect.
- Multidisciplinary handover and safety huddles (3 x daily): This eliminates the necessity for multiple handovers, enables streamlined and MDT discharge planning, accurate sharing of information, and MDT problem solving. A dynamic and visible combined nursing and physiotherapy allocation board improves communication and daily caseload management.
- Consultant Communication links: Being a surgical hub with consultants from multiple Trusts, it is essential to have access to consultants to be able to promptly escalate concerns and to implement the most appropriate management plan, quickly.
- SWLEOC X-ray service: This enables fast track and ring-fenced X-ray for any post-operative concerns of increased pain, difficulty weight bearing or change to mobility. This eliminates the necessity of attending A&E.
- Extended Physiotherapy service: A shift pattern aligned with nursing staff 7.30am to 8pm, 7 days per week, enables MDT handover, integrated working, enhanced recovery and day case discharge pathways. The level and quality of service provision is the same 7 days per week.
- Higher skill mix: Due to the high volume and fast paced nature of the orthopaedic unit, together with allowing for treatment of more complex patients, the staffing model encompasses a higher skill mix of more experienced and specialist staff. Senior nurses are Nurse Prescribers, trained to undertake male catheterisation, IRMER trained to order X-rays and bloods.
- Intensivist on site 24 hours a day;
- Post Discharge Advice line;
- Dynamic Discharge Team;
- Non-medical prescriber on each shift;
- Implementation Day Case Joint Arthroplasty Pathway;
- Dedicated Daycase ward;
- Building of the Consultation Room in reception safe space for the review of patients post discharge;
- Implementation of SWLEOC SOP: To reduce 30-day patient re-admission rates after discharge from South West London Elective Orthopaedic Centre (SWLEOC) following elective surgery.
- Implementation Day Case Joint Arthroplasty Pathway –unexpected problem – delay in receiving controlled Drugs as TTOs for patients.
- having an Intensivist on site to manage complex medical patients and complications;
- having a Surgeons review rota for inpatient assessment of wounds and X-rays;
- service level agreements to be established for services outside of the Centre;
- pharmacy on site for the dispensing of Controlled Drugs TTOs;
- robust Clinical Governance board.
Staff
Staff Member: Ward Matron (Band 8a x 1 WTE)
Role:
- Leadership and Management: 30 hours per week;
- Rota Management: 3.5 hours per week;
- Patient care: 4 hours per week.
- Matron is responsible for the ward based inpatient service.
Role:
- Nurse in Charge: To organise and manage own time and the time of others, allocating and delegating tasks appropriately, to ensure effective performance (3.5 hours per week);
- to act as the Bleep holder for the Centre, ensuring cohesive working between POA, PACU and both Wards. (2 hours per week);
- lead MDT ward rounds and complex discharge planning (7 hours per week);
- medication review and prescribing (2 hours per week);
- complex nursing management of inpatient caseload (6.5 hours per week);
- specialist orthopaedic advice– Reviewing patients in consultation clinic and offering post discharge advice over the telephone (2 hours per week);
- IRMER trained and able to request imaging and bloods (1 hours per week);
- preparing for surgery class (1 hour per week);
- managing pre and post registration students (4 hours per week);
- HR management (2 hours per week);
- rota management (3.5 hours per week);
- audits (1 hour per week);
- deputising for Matron (2 hours per week).
Staff Member: Junior Staff Nurse (Band 6 x 7 WTE)
Role:
- Nurse in Charge: To organise and manage own time and the time of others, allocating and delegating tasks appropriately, to ensure effective performance (7.5 hours per week);
- to act as the Bleep holder for the unit, ensuring cohesive working between POA, PACU and both Wards (1 hour per week);
- lead MDT ward rounds and complex discharge planning (7 hours per week);
- medication review (1 hour per week);
- complex nursing management of inpatient caseload (8.5 hours per week);
- specialist orthopaedic advice– Reviewing patients in consultation clinic and offering post discharge advice over the telephone (4 hours per week);
- IRMER trained and able to request imaging and bloods (1 hour per week);
- preparing for surgery class (1 hour per week);
- managing pre and post registration students (4 hours per week);
- rota management (1 hour per week);
- deputising for Matron (2 hours per week).
Staff Member: Discharge Coordinator (Band 6 x 4 WTE)
Role:
- Co-ordinate the discharge planning for the EOC patients, from the pre-assessment stage all the way through the patient’s journey through the EOC in conjunction with the physiotherapy team (complex discharge planning, complex equipment provision and collaboration with social services in all Boroughs) (12 hours per week);
- offer telephone advice/ support to both patients and relatives in the Primary setting (6 hours per week);
- to review and manage surgical wounds post discharge in conjunction with the surgical surveillance nurse and the patient’s surgeon (7.5 hours per week);
- co-ordinate services for Doppler scan for inpatients or patients suspected for DVT post discharge with the radiology department (2 hours per week);
- to be an effective interface between the EOC and the community teams (3 hours per week);
- identifying patients suitable for day case joint arthroplasties (1 hours per week);
- preparing for surgery class (1 hour per week);
- being aware of the pathway and issues surrounding vulnerable adults and making the appropriate referrals, if required. (1.5 hour per week);
- supervise and support any junior members of staff (3 hours per week);
- audits (2 hours per week).
Staff Member: Registered Nurse (Band 5 x 13 WTE)
Role:
- Management of inpatient caseload offering specialist orthopaedic nursing in conjunction with nurse in charge and timely discharge (22.5 hours per week);
- orthopaedic advice offering post discharge advice over the telephone (4 hours per week);
- IRMER trained and able to request imaging and bloods (1 hour per week);
- medication rounds (3 hours per week);
- assist with physiotherapy and supervise patients when mobilising (2 hours per week);
- record patient’s vital signs, both pre and post operatively reporting any changes to the nurse in charge (2 hours per week);
- managing pre-registration students (3 hours per week).
Staff Member: Registered Nursing Associate (Band 4 x 4 WTE)
Role:
- Management of inpatient caseload and timely discharge of inpatients supported by Nurse in charge (20.5 hours per week);
- offering post discharge advice over the telephone (4 hours per week);
- oral medication rounds (2 hours per week);
- record patient’s vital signs, both pre and post operatively reporting any changes to the nurse in charge (2 hours per week);
- caring for patient’s personal clothing and other property (1 hour per week);
- cleaning and preparing a bed space on discharge. (2 hours per week);
- assist with physiotherapy and supervise patients when mobilising (2 hours per week);
- escort patients to X-ray and other departments as requested by the nurse in charge. (1 hour per week);
- take routine bloods as requested (1 hours per week);
- assisting the nursing staff to keep the ward tidy, including storage cupboards, sluice, equipment and treatment rooms (1 hours per week);
- assist with all clerical and administrative duties (1 hours per week).
Staff Member’s Title: Associate Practitioner (Band 4 x 3.61 WTE)
Role:
- Management of inpatient caseload and timely discharge of inpatients supported by Nurse in charge (18.5 hours per week);
- offering post discharge advice over the telephone (2 hours per week);
- to give direct care to patients as instructed by nursing staff, including bathing, bed making and helping with meals as necessary (3 hours per week);
- assist with the planning of patient’s care (1 hours per week);
- record patient’s vital signs, both pre and post operatively reporting any changes to the nurse in charge (2 hours per week);
- caring for patient’s personal clothing and other property (1 hours per week);
- cleaning and preparing a bed space on discharge. (2 hours per week);
- assist with physiotherapy and supervise patients when mobilising (2 hours per week);
- escort patients to X-ray and other departments as requested by the nurse in charge. (2 hours per week);
- take routine bloods as requested (1 hours per week);
- assisting the nursing staff to keep the ward tidy, including storage cupboards, sluice, equipment and treatment rooms (1 hours per week);
- assist with all clerical and administrative duties (2 hours per week).
Staff Member’s Title: Health Care Assistant (Band 2 x 9.34 WTE)
Role:
- To give direct care to patients as instructed by nursing staff, including bathing, bed making and helping with meals as necessary (14.5 hours per week);
- assist with the planning of patient’s care (1 hours per week);
- record patient’s vital signs, both pre and post operatively reporting any changes to the nurse in charge (6 hours per week);
- caring for patient’s personal clothing and other property (1 hours per week);
- cleaning and preparing a bed space on discharge (6 hours per week);
- assist with physiotherapy and supervise patients when mobilising (2 hours per week);
- escort patients to X-ray and other departments as requested by the nurse in charge. (2 hours per week);
- take routine bloods as requested (2 hours per week);
- assisting the nursing staff to keep the ward tidy, including storage cupboards, sluice, equipment and treatment rooms (1 hours per week);
- assist with all clerical and administrative duties (2 hours per week).
Daily Staffing Model
On Oaks ward the minimum staffing every day will contain 4 Registered Nurses (1 Registered Nursing Associate) and 2 unregistered (HCA and Associate Practitioner). Staffing skill mix may be adjusted according to activity to be received from theatre (day cases and day case arthroplasties). If Oaks ward is to remain open overnight the minimum staffing will be 2 Registered Nurses and 1 unregistered staff member.