York Hospital, York

General Services Information

Hospital Questions

• How many single rooms are available to NHS patients at this hospital: 151

• Of these how many have an ensuite toilet: 43

• Of these how many have an ensuite toilet and shower or bath: 16

• Does this hospital operate an accident and emergency unit:

• How many specialist palliative care beds are available at this hospital: 0 The Palliative Care Team assesses patients on the wards. There are 3 palliative care outpatient clinics per week (2 in York and 1 in Selby)

• Does this hospital have a named private unit/service:

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: DATIX Trust has an Adverse Incident Reporting policy and procedure, incidents are logged on DATIX. Any occurrences would be investigated as a Serious Untoward Incident

• 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: DATIX Trust has an Adverse Incident Reporting policy and procedure, incidents are logged on DATIX

• 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: DATIX Trust has an Adverse Incident Reporting policy and procedure, incidents are logged on DATIX. This would be reported as a Never Event and investigated

• During the period 01 April 2010 - 31 March 2011, how many operations resulted in a foreign body being left post surgery: 0

• 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: 0

• How many incident investigations using a full Root Cause Analysis did were carried out in 2010/11: 126 RCA for Healthcare Associated Infections = MRSA 4, C.difficile 96 ( 53 post 72 hour cases, the rest pre 72 hour cases), 15 SUIs, 10 falls and 1 pressure sore

• 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: 61-90% Excludes children

• What percentage of patients are risk assessed for venous thromboembolism on admission: 91-99% As per CQUIN return

• 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). :

• Does the Trust have a policy for providing educational programmes on using and interpreting clinical indicators: The Trust has an overarching training and education policy but does not have a specific policy for clinical indicators. Training is in place via the Clinical Director's Development Programme and the new Consultant's programmes. The Information Team provide assistance in interpreting data reported on the local web-based performance system. The Medical Director and Chief Nurse have educated the Board of Directors and Executive Board on clinical indicators over the last 6 months and clnical indicator data is presented monthly to both groups.

• Does the Trust have a designated member of staff who supports teams in locating and analysing safety and quality data? (support): Improvement Analyst and IT Information Team

• Is safety and quality data available on a central platform and actively disseminated to users: The Trust has a web-based performance system and information is also centrally available on a shared drive

Infection Control

Trust Questions

• Does the Trust employ an antibiotic pharmacist: 1 x wte consultant pharmacist (8c), 0.5 wte specialist pharmacist (8a) and 1 x wte senior technician (band 5)

• 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: Screened for MRSA. Results returned in advance if the patient's TCI date allows otherwise patients are given MRSA suppression therapy to take away if they are high risk

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

• Are all oncology patients screened at the pre-op assessment clinic: YES

• Are all chemotherapy patients screened at the pre-op assessment clinic: YES

• Are all elective neurosurgery patients screened at the pre-op assessment clinic: YES

• 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: Yes, only if high risk emergency admissions

• 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:

• Protocol for isolating patients with infections: All patients with HCAI are prioritised for single rooms as per Isolation, MRSA and C.difficile policies. Infection Prevention and Control and Bed Managers have a clearly defined list of those patients who need to be in side rooms. All side room allocation is captured electronically. Aderse Incident Reports are completed on the rare occasions this fails All patients with HCAI are prioritised for single rooms as per Isolation, MRSA and C.difficile policies. Infection Prevention and Control and Bed Managers have a clearly defined list of those patients who need to be in side rooms. All side room allocation is captured electronically. Adverse Incident Reports are completed on the rare occasions this fails

• 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 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: Other York Hopsital has a 19 bed rehabilitation unit and a separate 19 bed acute unit, 4 of which are designated as hyperacute

• Number of beds in the unit: 38 19 bed rehabilitation unit and 19 bed acute unit

Trust Questions

• Does the Trust have a specialist stroke unit or units: York Hospital has 2 separate units on the same site

• Is the Trust part of a stroke care network:

• Details: North and East Yorkshire and Northern Lincolnshire Stroke and Cardiac Network (NEYNL)

• 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): 723

• Of these, what was the number of patients given a Computerised Tomography (CT) scan within 24 hrs of admission: 532

• Is thrombolysis for stroke patients provided 24 hours per day and 7 days a week : We have a dedicated and funded service from 8am to 5pm Monday to Friday, a business case is being developed to provide a 24 hour 7 day per week service, which will be dependant on the provision of PCT funding

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

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): We have a Trauma list 6 days per week, Monday to Saturday

• 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: Weekly MDT meetings led by the Elderly Medicine Consultant are also attended by Orthopaedic medical staff, nurses and therapists. We have a fracture neck of femur ward which is run by Elderly Medicine consultants with orthopaedic liaison. We also have a trauma and elective ward.

• 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 Following the launch of the Joint School, this estimate is based on the number of DNAs as all patients are invited. The joint school is an MDT-led education programme which covers the whole care pathway, from improving fitness for surgery to post-operative recovery. The is also medical input from anaesthetists and orthopaedic surgeons.

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

• Estimated percentage compliance to this protocol: 95 This is currently under review and we have no recent audit data. We estimate that at least 95% of patients receive a standard anaesthetic procedure

• Estimated percentage of the Trusts total knee replacement (TKR) and total hip replacement (THR) patients walk within 24 hours of surgery: 95

• 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 We have not identified any patients whose discharge has been delayed due to a lack of physiotherpy services at weekends

• Are patients for total knee replacement (TKR) and total hip replacement (THR) admitted prior to the day of surgery: When we very occasionally admit patients prior to surgery this is for medical reasons, usually due to poor mobility or the necessity of further pre-operative anaesthetic review

• 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: Not at present, but this is planned for our new TKR pathway which is in the process of being launched

• Is criteria-based discharge used:

• Are patients routinely phoned in the first 48 hours after discharge to check on their progress: The Community Physiotherapist contacts patients 24-48 hours after discharge. This does not apply to "out of area" patients, who are referred back to their local primary care services.

Paediatrics

Hospital Questions

• Does the hospital have a paediatrics 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: Elective paediatric surgery is carried out by specific trained surgeons. Children admitted acutely may be operated on by the on call consultant surgeon. We have seperate Vascular, Urology and General Surgery rotas.

• Do the Trust's anaesthetists with responsibility for paediatric anaesthesia participate in at least one paediatric list per week: the Trust has designated paediatric anaesthetists who share the available paediatric experience which would equate to under 1 list per week per anaesthetist

• 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

• Does the hospital's specialist palliative team includes: A consultant in palliative medicine,A palliative care nurse,Other (please specify) 0.55 WTE Consultant, a specialist registrar in palliative medicine and 3 clinical nurse specialists (1WTE Band 7 and 1.45 WTE Band 6)

• Is the Trust's specialist palliative care team available 24 hrs a day seven days a week: The team is avalable Monday to Friday from 8am to 4pm for face to face contact. Palliative Medicine telephone advice to doctors is avialable 24 hours 7 days a week in the locality.

• Are facilities provided to support relatives and carers who wish to stay with a patient in hospital: There is accomodation (1 bedroom) available on the medical floor, ICU also has a relatives room. Wards do not have relatives room but relatives are provided with a blanket and a chair.

• 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: As part of the cancer peer review measures the Palliative Care Team will be surveying patients and carers known to the service. Beareavement Services are also planning a survey for the forthcoming year.

Maternity Care

Maternity Sites

• York Hospital - Consultant Led

• How many women gave birth in the unit during the year? (not including home births): 3264

• How many babies were born in the unit during the year? (not including home births): 3355

• How many women were booked for a home birth: 41

• How many women had a home birth? (not including births at home by accident): 41

• Number of antenatal rooms: 8

• Total antenatal beds: 12

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

• Total assessment area beds: 3 3 trolleys

• Number of delivery rooms: 10

• Total delivery beds: 10 9 beds and 1 birthing pool

• Number of postnatal rooms: 10

• Total postnatal beds: 20

• 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): 0

• 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): 85

• Does the maternity unit have a neonatal intensive care unit: 2 cots

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

• Does the maternity unit have a special care baby unit: 10 cots

• 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: Not available

• Pain relief available - Aromatherapy: Not available

• Pain relief available - TENS: Provided by unit

• Pain relief available - Epidural: Provided by unit

• 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: 101 Actual number is 101.1, form will not accept this number

• Total number of WTE midwives at the unit as staff in post, including agency and bank staff: 138

• Does the unit have midwives available to provide one-to-one care available 24 hours a day, 7 days a week: On site we are not able to provide 1 to 1 care 24 hours per day

• 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 site

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

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

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

Trust Questions

• Do all women have a choice about where they receive their antenatal appointments (i.e. at hospital or local health centre):

• 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:

• Also available for: Teenagers

• Are all women routinely offered ultrasound scans:

• Scan 1 available between: 12-14 weeks

• Scan 2 available between: 20 weeks

Trust Statistics

Trust Questions

• You can view various measures relating to the Trust's performance by clicking the following link: York Hospitals NHS Foundation Trust