University Hospital Lewisham, London

General Services Information

Hospital Questions

• How many single rooms are available to NHS patients at this hospital: 94

• Of these how many have an ensuite toilet: 94

• Of these how many have an ensuite toilet and shower or bath: 94

• Does this hospital operate an accident and emergency unit:

• How many specialist palliative care beds are available at this hospital: 0 Palliative Care Team provide care to any patient requiring palliative care throughout the whole Trust. Access to specialist palliative care beds is by referral to local voluntary sector hospice

• Does this hospital have a named private unit/service: Very small amount of private ultrasound and physiotherapy undertaken.

Trust Questions

• Does the Trust treat private patients:

Patient Safety

Trust Questions

• Is there a system for recording operations that resulted in a foreign body being left post surgery:

• What is the reporting system for a foreign body being left post surgery: Safeguard online incident reporting system. Cross-referenced to coding and misadventure list received from coding department.

• Is there a system for recording operations that were cancelled due to missing notes:

• What is the reporting system for operations that were cancelled due to missing notes: Safeguard online incident reporting system. Cross-referenced to coding and misadventure list received from coding department.

• Is there a system for recording operations that resulted in wrong site surgery taking place:

• What is the reporting system for operations that resulted in wrong site surgery taking place: Safeguard online incident reporting system. Cross-referenced to coding and misadventure list received from coding department.

• During the period 01 April 2010 - 31 March 2011, how many operations resulted in a foreign body being left post surgery: 1

• During the period 01 April 2010 - 31 March 2011, how many operations were cancelled due to missing notes: 0

• During the period 01 April 2010 - 31 March 2011, how many operations resulted in wrong site surgery taking place: 1

• How many incident investigations using a full Root Cause Analysis did were carried out in 2010/11: 85

• What percentage of patient safety incidents resulting in severe harm or death had a full RCA initiated/completed: 100%

• What percentage of acute inpatients have a track and trigger warning system in place for the duration of the admission: 100% The Trust used the patient at risk trigger score system until 31st January 2011. The Trust then changed over to the Modified Early Warning Score system from 1st February 2011.

• What percentage of patients are risk assessed for venous thromboembolism on admission: 91-99% (0% for April-May 2010; 31%-60% for June - August 2010; 61%-90% September to December 2010. and greater than ;90% from January 2011).

• Compliant with all relevant NPSA safety alerts issues in 2010/11 (you can find a full list of alerts issued at http://www.nrls.npsa.nhs.uk/resources/?p=3). : We are completely up to date with all those that reached their deadlines. We are fully compliant with all the alerts where the deadlines have passed. The following NPSA Alerts issued in 2010/11 have not yet reached their deadlines: NPSA / 2010 / RRR018. Preventing fatalities from medication loading doses NPSA / 2010 / RRR019. Safer ambulatory syringe drivers NPSA / 2011 / PSA001. Safer spinal (intrathecal) epidural and regional devices. Part A update NPSA / 2011 / PSA002 reducing the harm caused by misplaced nasogastric feeding tubes in adults, children and infants. NPSA / 2011 / PSA003 the adult patient passport to safer use of insulin.

• Does the Trust have a policy for providing educational programmes on using and interpreting clinical indicators: There is no specific policy but training and clinical indicators are detailed in specific policies such as Slips, Trips and Falls, Venous Thromboembolism and Resuscitation. We also use Symbiotix for each ward area to record various clinical outcomes eg wound infections, hand hygiene audits and pressure ulcers.

• Does the Trust have a designated member of staff who supports teams in locating and analysing safety and quality data? (support): The Risk and Clinical Effectiveness teams provide support to Directorates and the Trust in locating quality and safety data. Analysis is undertaken by different specialists eg Maternity issues - Maternity Manager, VTE - a Lead Consultant, Infection Control - Consultant Nurse for IPC, Falls - Falls Specialist Nurse, Medical Devices Issues - Trust Risk Manager. The Information department also provides support for analysis on request.

• Is safety and quality data available on a central platform and actively disseminated to users: The Clinical Effectiveness Team has developed outcomes and dashboards for all Directorates and relevant committees. The Risk Team provides quality risk reports to each Directorate. Quarterly extractions are provided to each ward / department manager. Safety and quality data is monitored by all relevant committees including the Trust Board.

Infection Control

Trust Questions

• Does the Trust employ an antibiotic pharmacist:

• Does the Trust operate a pre-admission assessment clinic or equivalent system where patients are screened and results returned in advance of the day of admission:

• Elective patient groups screened at the pre-op assessment clinic: All elective surgical

• Are all oncology patients screened at the pre-op assessment clinic: Not Applicable Screened on admission

• Are all chemotherapy patients screened at the pre-op assessment clinic: Not Applicable Screened on admission

• Are all elective neurosurgery patients screened at the pre-op assessment clinic: Not Applicable

• Are all patients with past history of MRSA screened at the pre-op assessment clinic:

• What method of MRSA screening is used when screening at admission: Culture based in 24-48hrs

• On admission, does topical suppression take place immediately: As soon as positive result available.

• Does the Trust have at least one accident and emergency unit:

• Are all patients admitted through A&E screened:

• Is screening done according to individual risk assessment:

• Does the Trust have a dedicated isolation ward:

• How many beds does it contain: 94 Single rooms available throughout wards for isolation.

• Does the Trust have an isolation policy:

• Where medically appropriate, are patients with C Diff isolated in single rooms as a matter of priority:

• Does the Trust prescribe probiotics to any patient groups as a prophylactic measure to reduce C.difficile infections:

• Does the Trust have a policy to guide the use of metronidazole and vancomycin for C.difficile infected patients:

• Does the Trust routinely isolate all patients with diarrhoea:

Stroke Medicine

Hospital Questions

• Does the hsopital have a specialist stroke unit:

• What type of stroke unit does the hospital have: combined acute and rehabilitation stroke unit

• Number of beds in the unit: 22

Trust Questions

• Does the Trust have a specialist stroke unit or units:

• Is the Trust part of a stroke care network:

• Details: South East London Cardiac and Stroke Network

• How many emergency admissions with a primary diagnosis of stroke (ICD10 codes I60 - I64) did the Trust receive in the financial year (period 01 April 2010 - 31 March 2011): 304

• Of these, what was the number of patients given a Computerised Tomography (CT) scan within 24 hrs of admission: 304

• Is thrombolysis for stroke patients provided 24 hours per day and 7 days a week : Thrombolysis provided at another hospital as part of the stroke network.

• Are there any formal arrangements with neighbouring hospitals for the emergency transfer of stroke patients who would benefit from thrombolytic treatment:

• These arrangements are with: King's College Hospital

Trauma & Orthopaedics

Trust Questions

• Does the Trust offer a trauma service:

• Does the Trust have a dedicated trauma list available 24 hours a day for the duration of the week, (Sunday to Sunday):

• Does the Trust offer an orthopaedics service:

• Do all the Trust's orthopaedic ward/team have a linked geriatric team with whom they have regular meetings at least once a week:

• Does the Trust run a pre-operative patient education session/class for patients to attend prior to Total Knee Replacement (TKR) and Total Hip Replacement (THR)? :

• What is the estimated percentage of all patients that attend the class prior to surgery: 90

• Does the Trust have a standardised anaesthetic protocol for Total Knee Replacement (TKR) and Total Hip Replacement (THR) patients: In development.

• Estimated percentage of the Trusts total knee replacement (TKR) and total hip replacement (THR) patients walk within 24 hours of surgery: 90

• Does the Trust have a specialist orthopaedic physiotherapy service which is available 7 days a week:

• How many patients' discharge's delayed due to lack of physiotherapy services at weekends - estimated figure: 0

• Are patients for total knee replacement (TKR) and total hip replacement (THR) admitted prior to the day of surgery:

• Are patient records routinely recorded using a specific multi-disciplinary team THR/TKR pathway document:

• Is this data used to monitor compliance with the agreed pathway:

• Is criteria-based discharge used:

• Are patients routinely phoned in the first 48 hours after discharge to check on their progress:

Paediatrics

Hospital Questions

• Does the hospital have a paediatrics service: We also provide community paediatric services as part of an integrated service.

Trust Questions

• Is the Trust's elective paediatric surgery carried out only by designated surgeons with at least six months training in a specialist unit:

• Do the Trust's anaesthetists with responsibility for paediatric anaesthesia participate in at least one paediatric list per week:

• Is a paediatrician on site (SpR or higher) 24 hours per day, 7 days per week:

• Are at least two registered children's nurses on duty 24hours per day in each children's ward:

• Is there a designated facility on site for parents or guardians to stay overnight:

Palliative Care

Trust Questions

• Does the Trust provide a palliative care service:

• How is specialist palliative care delivered at the hospital: A multi-disciplinary specialist palliative care team Also, access to inpatient specialist palliative care beds by referral to local voluntary sector unit.

• Does the hospital's specialist palliative team includes: A consultant in palliative medicine,A palliative care nurse,Counsellor(s),Other (please specify) Chaplain, Occupational Therapist and Dietitian.

• Is the Trust's specialist palliative care team available 24 hrs a day seven days a week:

• Are facilities provided to support relatives and carers who wish to stay with a patient in hospital: Relatives can stay overnight, chairs available, no sleeping facilities.

• Does the Trust routinely survey and evaluate the views of patients and bereaved relatives and carers regarding the delivery of care on the end of life programme:

Maternity Care

Maternity Sites

• University Hospital Lewisham - Midwife Led

• How many women gave birth in the unit during the year? (not including home births): 659

• How many babies were born in the unit during the year? (not including home births): 659

• How many women were booked for a home birth: 0 Statistics unavailable

• How many women had a home birth? (not including births at home by accident): 36

• Number of antenatal rooms: 0

• Total antenatal beds: 0

• Number of assessment area rooms (for monitoring and / or induction): 1

• Total assessment area beds: 1

• Number of delivery rooms: 5

• Total delivery beds: 5

• Number of postnatal rooms: 0

• Total postnatal beds: 0

• Number of rooms in obstetric high dependency unit: 0

• Total obstetric high dependency beds: 0

• Number of single rooms used for both delivery and postnatal care (labour, delivery, recovery and postnatal, or LDRP, rooms): 5

• Amenity rooms; Are women able to book a single room in advance of their birth:

• If women can pay for a single room what is the average cost per night (GBP): 0

• Does the maternity unit have a neonatal intensive care unit: MLU is co-located with the consultant led unit - babies requiring the services of the NICU will be admitted to the unit

• Does the maternity unit have a neonatal high dependency unit:

• Does the maternity unit have a special care baby unit: MLU is co-located to the on site with the consultant led unit - babies born in the MLU requiring the services of special care will be admitted to NICU

• Security measures - ankle bands for the baby:

• Security measures - cot alarms:

• Security measures - CCTV:

• Security measures - restricted access:

• Pain relief available - bath or shower: Provided by unit

• Pain relief available - birthing pool: Provided by unit

• Pain relief available - birth ball: Provided by unit

• Pain relief available - Massage: Provided by unit

• Pain relief available - Aromatherapy: Provided by unit

• Pain relief available - TENS: Provided by unit

• Pain relief available - Epidural: Not available

• Pain relief available - Mobile epidural: Not available

• Pain relief available - Entonox (gas and air): Provided by unit

• Pain relief available - Intramuscular injection: Provided by unit

• Total number of WTE midwives at the unit in your funded establishment, including vacant posts: 14.00

• Total number of WTE midwives at the unit as staff in post, including agency and bank staff: 13.83

• Does the unit have midwives available to provide one-to-one care available 24 hours a day, 7 days a week: On site

• Does the unit have midwives available for home births available 24 hours a day, 7 days a week: On call

• Does the unit have midwives trained and experienced in water birth available 24 hours a day, 7 days a week: On site

• Does the unit have a paediatrician available 24 hours a day, 7 days a week: On call Neonatologists attend emergencies in the MLU

• Does the unit have an obstetrician available 24 hours a day, 7 days a week: On call Obstetricians attend emergencies only

• Does the unit have an anaesthetist available 24 hours a day, 7 days a week: On call Attend emergencies only

• Does the unit have a dedicated obstetric anaesthetist available 24 hours a day, 7 days a week: On call Attend emergencies only

• University Hospital Lewisham - Consultant Led

• How many women gave birth in the unit during the year? (not including home births): 2175

• How many babies were born in the unit during the year? (not including home births): 2990

• How many women were booked for a home birth: 0 Statistics unavailable

• How many women had a home birth? (not including births at home by accident): 0

• Number of antenatal rooms: 4

• Total antenatal beds: 12

• Number of assessment area rooms (for monitoring and / or induction): 1

• Total assessment area beds: 3

• Number of delivery rooms: 10

• Total delivery beds: 10

• Number of postnatal rooms: 7

• Total postnatal beds: 31

• Number of rooms in obstetric high dependency unit: 1

• Total obstetric high dependency beds: 1

• Number of single rooms used for both delivery and postnatal care (labour, delivery, recovery and postnatal, or LDRP, rooms): 1

• Amenity rooms; Are women able to book a single room in advance of their birth: Women are able to book a room once they have given birth

• If women can pay for a single room what is the average cost per night (GBP): 35

• Does the maternity unit have a neonatal intensive care unit: MLU is co-located with consultant led unit - babies requiring the service will be admitted to the unit

• Does the maternity unit have a neonatal high dependency unit:

• Does the maternity unit have a special care baby unit:

• Security measures - ankle bands for the baby:

• Security measures - cot alarms:

• Security measures - CCTV:

• Security measures - restricted access:

• Pain relief available - bath or shower: Provided by unit

• Pain relief available - birthing pool: Provided by unit

• Pain relief available - birth ball: Provided by unit

• Pain relief available - Massage: Provided by women

• Pain relief available - Aromatherapy: Provided by women

• Pain relief available - TENS: Provided by unit

• Pain relief available - Epidural: Provided by unit

• Pain relief available - Mobile epidural: Provided by unit

• Pain relief available - Entonox (gas and air): Provided by unit

• Pain relief available - Intramuscular injection: Provided by unit

• Total number of WTE midwives at the unit in your funded establishment, including vacant posts: 112.42

• Total number of WTE midwives at the unit as staff in post, including agency and bank staff: 107.6

• Does the unit have midwives available to provide one-to-one care available 24 hours a day, 7 days a week: On site

• Does the unit have midwives available for home births available 24 hours a day, 7 days a week: On call

• Does the unit have midwives trained and experienced in water birth available 24 hours a day, 7 days a week: On site

• Does the unit have a paediatrician available 24 hours a day, 7 days a week: On call Neonatologists are based onsite but oncall for births in the labour ward

• Does the unit have an obstetrician available 24 hours a day, 7 days a week: On site Consultant presence in the labour ward from 09.00 - 20.00 hours. Oncall at nights and weekends. Junior doctors present in labour ward 24/7

• Does the unit have an anaesthetist available 24 hours a day, 7 days a week: On site

• Does the unit have a dedicated obstetric anaesthetist available 24 hours a day, 7 days a week: On site

Trust Questions

• Do all women have a choice about where they receive their antenatal appointments (i.e. at hospital or local health centre): Women who live out of the Lewisham area will not have the choice of seeing their midwife at their local GP

• Are NHS antenatal classes available (e.g. Parentcraft):

• Available during the daytime (until 5pm):

• Available in the evenings (after 5pm):

• Available at weekends (Saturday and/or Sunday):

• Available for women only groups:

• Available for other groups: There is a class for pregnant young women and their partners, there is a class for women having twins.

• Also available for: Pregnant young women and their partmers, women having twins

• Are all women routinely offered ultrasound scans:

• Scan 1 available between: 11-13 weeks dating scan (combine screening)

• Scan 2 available between: 20-23 weeks Anonamly scan

Trust Statistics

Trust Questions

• You can view various measures relating to the Trust's performance by clicking the following link: The Lewisham Hospital NHS Trust