|The first evidence-gathering for phase 1 (discharge to care homes during the Covid-19 pandemic) of the Scrutiny Review of Hospital Discharge took place during this Committee meeting, and involved contributions from representatives of North Tees and Hartlepool NHS Foundation Trust (NTHFT), and a written submission from South Tees Hospitals NHS Foundation Trust (STHFT). Members were also provided with several relevant links to background papers prior to this session.|
North Tees and Hartlepool NHS Foundation Trust (NTHFT)
Senior representatives from NTHFT gave a presentation to the Committee which focused on the following key elements:
Local care home data
Key milestones and national guidance
Integrated Single Point of Access (Covid-19 support)
Role of Infection Prevention and Control (IPC) Team and Community Matrons during the pandemic
Care home protection work
Enhancement of digital capabilities
Enhanced Health in Care Homes model
What have we learnt? Are we prepared for a second surge?
Facilitated through a strategic approach with oversight from senior management, the Trust had provided a very localised response to the Covid-19 pandemic since its escalation in March 2020. As such, there was a strong desire to build on the already established relationships to best support care homes across the Borough during this exceptionally challenging time. To this end, a multi-agency forum was established with care home providers on the 18th March 2020 to ensure appropriate support was availed to care homes in addition to answering any questions or concerns that were raised.
The key role of the Clinical Decisions group (led by the Trust Medical Director), which dealt with all information (including Government guidance) coming into the Trust and then disseminated this both internally and to wider partners where required, was highlighted, and the Committee was also informed that the Trust was already operating the guidance issued on the 19th March 2020 (Hospital discharge requirements) prior to the pandemic through its work with partners and care homes to facilitate safe discharge. In addition, attention was drawn to the start of the weekly multi-agency care home protection meetings on the 23rd March 2020, which allowed key partners to come together, address concerns and put measures in place.
Whilst the national guidance regarding testing changed on the 15th April 2020 (requiring the testing of all patients prior to discharge from hospital), the Trust had robust measures in place before this date in relation to discharge and infection control / isolating in accordance with the guidance at the time. The Trusts IPC team provided training and specific support to care home providers to ensure guidance was shared and understood in care homes, along with practical guidance relating to isolating and cohorting of residents. It was also noted that, in terms of more general discharge requirements, it is not good for people to stay in hospital if they no longer need acute-based care.
The importance of the Integrated Single Point of Access (ISPA) during the pandemic was emphasised to Members, a key element of which involves support to care homes. The role of the Community Matrons, who were pivotal in providing responsive care on a daily basis and continued to recognise underlying non-Covid-19 issues with residents during this time, was also highlighted. A short video showing examples of the infection control work provided by the Trust both internally and to care homes was subsequently shown to the Committee.
Members learned about the increased use of the Whzan system (providing live data for clinical interpretation regarding basic health checks), a tool which had been vital in identifying resident deterioration and prompting care homes to seek support. The Enhanced Health in Care Homes (EHCH) model, involving virtual meetings (first one held on the 20th July 2020), had strengthened communications with care homes and primary care colleagues, with all discharges to homes discussed with GPs and Community Matrons - it had also enabled any required actions to be given to the most appropriate teams in a more timely manner. Whilst the EHCH concept had always been intended, the pandemic had accelerated the implementation of the model. The Committee was informed that these digital advancements complemented face-to-face contacts within care homes to ensure timely and appropriate care was provided at all times.
In terms of learning from the initial outbreak, the Trust felt confident that the strong collaborative approach amongst local partners, enhanced through some of the measures outlined within the presentation, would enable it and others to manage an escalation of the current Covid-19 situation. In addition, there is a desire to evolve the multidisciplinary EHCH meetings regarding what they do and can potentially achieve.
The main issues discussed were as follows:
Members began by praising the efforts of the Boroughs care homes, who were doing an amazing job in the face of an incredibly difficult situation. However, concerns were expressed regarding the back-up they were receiving from organisations, specifically the dependence on virtual meetings in place of face-to-face involvement, and the scheduling of the first multi-agency care home protection meeting which did not take place until several days after a number of care homes had already closed. The Trust confirmed that face-to-face contact continued throughout the pandemic (and that this had never stopped), and clarified that the virtual / digital component was in addition to what was already provided. In terms of support, the Trust were able to clarify to the Committee, that the care homes were supported with training, IPC advice and guidance, provision of PPE, testing of workers where indicated, fit testing with FFP3 masks, and regular communication and support from senior colleagues from the Trust in addition to support with care for residents within the care homes.
The Committee asked for clarity around the testing process that had been in place, particularly what was meant by rapid response testing. The Trust provided assurance that testing had been in line with national guidance throughout, with the requirements evolving over time. Since the 15th April 2020, the Trust had been testing patients upon admission, after seven days (if still within the hospital), and prior to discharge to a care home, with results obtained before people are moved. It was also highlighted that testing was only one element in protecting care home residents, but was a vital indicator in establishing whether a person needed to be isolated within the care home - as such, the testing of care home residents had been prioritised when considering laboratory capacity. Regarding rapid testing, it was noted that swabs can be taken in the community, with results ascertained very quickly.
Reflecting on testing capacity, Members queried if there were any local concerns similar to those that had been reported in other areas of the UK. The Trust commended the work of their very responsive Laboratory Team, and were actively working to increase capacity (as was the case elsewhere).
The issue of discharging without testing during the initial stages of the pandemic was raised, and the Committee was keen to know whether this was ever questioned by hospital staff. In response, the Trust advised that all clinical guidance was considered initially by the Clinical Decisions group, and this was then disseminated via robust systems. Clarity was sought when needed and challenge to ensure appropriate implementation of guidance would occur. Some queries did arise from individual care homes who were supported on an individual basis, and the Trust had been involved in webinars with other Trusts where approach was debated and lessons learned were shared.
Noting the benefits of the Whzan system, Members were pleased to see an increase in the number of care homes using this tool. The Trust advised that it would continue to promote its value and monitor its use on a weekly basis. Whzan will be utilised in conjunction with the Is my resident unwell communication tool, a further resource which assists care home staff in recognising signs and recording a set of observations of residents.
Concerns were expressed in relation to the current state of care home residents mental health, particularly around the impact of visiting restrictions upon both families / carers and professionals. The Trust noted that the Whzan system was only an aid to clinical work, not a substitute.
The strong partnership-working evidenced in the presentation was commended, and the Trust confirmed that other care home residents who are on different (non-Covid) pathways should benefit from the relationships that have been built between partners during the pandemic.
Challenges for all partner organisations in relation to interpreting the national guidance was discussed, particularly since it was often issued at short notice, and could be viewed as incomplete and / or contradictory. What was clear in the initial stages of the pandemic escalation was that the Government did not state that testing prior to discharge to care homes was required (with the focus at the time on creating space on hospital wards for an anticipated influx of Covid-19 patients), and that this would likely form part of a future national inquiry.
South Tees Hospitals NHS Foundation Trust (STHFT)
STHFT representatives were unable to attend this meeting as planned, but had submitted a written submission to the Committee in response to the questions put to them regarding the reviews key lines of enquiry.
The Committee expressed disappointment in the information provided and frustration that representatives could not be in attendance to answer any questions that Members wanted to ask. The submission itself required far more detail, therefore it was proposed that the Trust was asked to attend a future meeting to present an enhanced response to the Committees key lines of enquiry. The presence of the Lead Director (who co-ordinated and ensured discharge processes were followed) was also requested.