ULHT Patient Panel

Will the day case unit at Louth be for planned or unplanned surgery?

Our proposal for change (which reflects the pilot arrangements) is to establish a dedicated day case centre for planned orthopaedic surgery at County Hospital Louth.

What is the situation if I break a bone in the Louth area, where will I go?

EMAS would take you to your nearest Emergency Department and you would be recommended to head to the nearest department which will depend on your exact location

How long did the pilot run? And was it impacted by the COVID pandemic?

The Trauma and Orthopaedics Pilot began in August 2018 and continues to run.

Due to the impact of the COVID-19 pandemic on capacity and implementing social distancing restrictions the Key Performance Indicators were unable to be measured during March 2020 to present date. During the pandemic the trust continued to run the Emergency trauma service for urgent/emergency patients which enabled the faster treatment of non-elective outpatients.

If the orthopaedic centre of excellence is at Grantham, are there suitable staff left to treat emergency/unplanned orthopaedic surgery at Lincoln and Boston?

Yes. The pilot workforce model successfully removed the need for temporary staff to cover vacancies, and the service is more attractive to junior doctors which supports long term service sustainability.

You gave one example of a heart attack, what other ambulance cases would not go to Grantham now and be transferred to Peterborough or Nottingham?

Across the NHS, including our colleagues in the ambulance service, one of our key objectives is getting patients to the best possible care as soon as possible. The clinical criteria for conveyance to Grantham by East Midlands Ambulance Service have been reviewed against the planned clinical acuity for the Grantham Hospital site. Ambulance crews fully understand the scope of service available at Grantham. They will assess the patient and will decide, or in some cases seek advice from specialist units, as to where best to take that patient to ensure they receive the right treatment as soon as possible.

In Lincolnshire, paramedics are able to take advice by phone, talking with clinicians either in the county’s successful Clinical Assessment Service or a consultant in an A&E, to assist in making this decision. This happens now.

One of the options for care will be taking low acuity patients to Grantham Hospital at night and directly admitting the patient (with prior agreement with night teams). Treating patients locally and within the Grantham community is important, as is keeping people out of hospital whenever that is possible.

The following patients would not be taken to Grantham and District Hospital Urgent Treatment Centre

• News ≥ 7 WITH frailty score of < 5
• A patient requiring immediate airway management and/ or resuscitation
• Status epilepticus
• Fast Positive Stroke / high risk TIA
• STEMI
• Acute coronary syndrome- Ongoing ischaemic chest pain with 1mm ST depression in more than one limb lead or in two or more consecutive chest leads
• CONFIRMED NSTEMI- Once diagnosis made In UTC or Ambulatory Care- transfer to LCH
• Post cardiac arrest
• Significant bradycardia < 40bpm, 2nd or 3rd degree AV block, Ventricular tachycardia
• Suspected acute heart failure WITH frailty score < 5
• Reduced conscious level (not alert) – Glasgow Coma Score < 5
• Acute respiratory distress with an oxygen saturation < 91% on room air WITH frailty score < 5 “unless” the patient has known significant chronic lung disease
• Gastro-intestinal haemorrhage (fresh blood or melaena).
• Severe abdominal pain and acute abdomen (refer patient directly to Lincoln County.)
• A female of childbearing age with lower abdominal pain
• A male with testicular pain
• A patient with suspected AAA or ischaemic limb needs admission to the on-call vascular unit (Pilgrim Hospital)
• All Obstetric and Gynaecological patients
• Neutropenic sepsis
• Patients requiring dialysis
• Patients with renal transplants
•  Ophthalmological emergencies e.g. acute glaucoma, trauma
• All Major trauma is excluded from this site in line with the East Midlands Trauma Network Triage Tool, including all suspected femoral fractures.
• Fractures/ dislocations with evidence of distal neurovascular compromise.
• Open lower limb fractures of femur, tibia/fibula, ankle or forefoot

Note: Patients who are house bound OR from a nursing/care home OR where RESPECT form has limitations of care in place that would make escalation of care inappropriate should normally continue to be brought to Grantham for assessment for medical conditions

 As far as the UTC is concerned, will ambulances go there ever? Is there any reason why an ambulance would ever go to Grantham?

Yes, EMAS will be able to take all patients to Grantham that are not identified in the exclusion criteria outlined above.​​​​

I understand that this proposal is talking about Grantham, but across the county is there a proposal to increase the number of acute medical beds available?

The below doesn’t answer the question, which I think is:

The number of beds in the NHS fluctuate for many reason but no, there are no current plans to increase acute medical beds across Lincolnshire.

As those people using these acute medical beds are those who often end up blocking beds in the system for those with other medical requirements. Is there a strategy to work across the county with other agencies to provide money and assets for these beds as a countywide stream across the area covered by the CCG?

Yes we are working closely with the Local Authority to fully implement the discharge to assess best practice care models as outlined by NHS England. This will help patients get discharged safety from hospital quicker than they currently are.

Would it be fair to say that what is proposed for Grantham & District Hospital is the modern-day version of a cottage hospital?

No. The proposals for Grantham, added to the services there outside of the consultation process, include a mix of acute and non-acute services.

Clearly this is reliant on primary care being slightly more involved, but primary care are screaming at the moment about all the pressures that GPs are under.

Has the consultation gone to the GPs involved and received good feedback from them? Do they see the benefits, and do they have the time to be involved in this, for the combined approach to primary and secondary care?

The models of care being proposed on were developed by clinicians across Lincolnshire including GP’s. As well as a focus on redesigning the acute care sector to drive improvements in the outcomes, quality and sustainability of those services, it is recognised that the out-of-hospital sector (referred to as integrated community care (ICC)) also requires a bold redesign. Lincolnshire system partners have an opportunity to deliver an ambitious and radical integrated care model and have the potential to act as an exemplar to the rest of the country. The clinical leads involved in the service review process included GPs.

What we lost a number of years ago were the convalescence homes- low dependency, had physios, for people who don’t necessarily need doctors but do need support before they are ready to home. If that is more the role that is intended for areas at Grantham hospital, is there going to be sufficient space? Are there adequate facilities at Grantham to cope with the numbers?

The capacity modelling for the future requirement of acute medicine beds on the Grantham Hospital site under the preferred ASR option for these services identified a requirement for 69 beds. This can comfortably be delivered within the current footprint and bed capacity of 79 beds currently being used to provide Acute Medicine (EAU Ward, Ward 1 and Ward 6).

There was no estates or capital requirement in the original ASR PCBC and for this proposed service change as the view has always been held that it can be done within existing resources.

There is the potential to improve the flow of acute medicine patients in Grantham Hospital by acute medicine using one of the wards currently used by orthopaedics and vice a versa. However, implementation of the preferred option is not dependent on it happening and is something that will be explored further in the context of the totality of service provision on the Grantham Hospital site.

I live in the Boston area. Are there any stroke facilities still at Boston, or have they already gone over to Lincoln? If I had a stroke would I go to Boston, or would I rely on an ambulance?

Temporary changes due to COVID mean that the hyper-acute pathway is currently centralised at Lincoln however acute stroke wards are still in place at Boston. This temporary change was made to ensure that the workforce numbers available in the county could safely provide the service for all patients in the county.

In the event that a patient presented at Boston Pilgrim Hospital having experienced a stroke, the team would have the clinical expertise and equipment to resuscitate, intubate and stabilise a patient until transfer, if required, to an alternative site where the correct, specialist care can be provided to best support the patient.

In the case of a suspected stroke, the advice is to request an ambulance rather than self-presenting at your nearest hospital. Treatment commences once the trained EMAS paramedics arrive and continues throughout the ambulance journey until they reach the hospital. The stroke team currently communicate closely with the ambulance crew throughout this journey time, and use it to order investigations, review past medical history and many other necessary actions that then save time when the patient arrives at the hospital.

On the journey to hsopital, the paramedics call ahead to alert emergency department doctors and stroke team that a stroke patient will be arriving soon. They conduct a physical exam, run tests for blood sugar and blood pressure levels, and start an IV to save valuable minutes in the emergency room.

What about if you don’t live in Boston, you live in Skegness or an outlying area- how would you get to Lincoln in the Golden hour, which is so important?

The golden hour is a term commonly used as the benchmark for intervention following trauma or injury and is seen as a critical timeframe in which any such patients should be seen. It is also loosely used as a broader term for timings in which a patient with a particular presenting condition must be seen, for example, stroke.

For patients who have experienced a stroke, the formal clinical target is related to treatments such as thrombolysis, which should be given within the first 4.5 hours following a stroke.  In this scenario the "golden hour" would relate to the 4.5-hour window to treatment time, though it is always best to be given as soon as possible. Thrombolysis is an appropriate treatment for approximately 20% of people who suffer a stroke.

It is important to remember that, as most patients who have suffered a suspected stroke are attended by an ambulance, treatment commences once the trained paramedics arrive, and continues throughout the ambulance journey until they reach the hospital. The stroke team currently communicate closely with the ambulance crew throughout this journey time, and use it to order investigations, review past medical history and many other necessary actions that then save time when the patient arrives at the hospital.

It is also important to consider the other aspects of patient care for stroke. Rehabilitation is an extremely important aspect, and our consultants stress what a difference getting this care right can make to people’s quality of life after suffering a stroke. We believe this proposal will mean patients across the county will benefit as a result of improvements to the care package as a whole.

What level of stroke service can those of us in the South of the county expect to get?

The preferred proposal for change to stroke services would:

• Establish a ‘centre of excellence’ in Lincolnshire for hyper-acute and acute stroke services at Lincoln County Hospital. This would mean hyper-acute and acute stroke services would no longer be provided from Pilgrim Hospital, Boston. It is anticipated the change would affect, on average, 1 to 2 patients a day. These patients would receive hyper- acute and acute stroke services at an alternative hospital.
• This would be supported by enhancement of the community stroke rehabilitation service across the county, so it can support stroke patients with more complex needs​​​​​.
• The Transient ischaemic attack (TIA) or ‘mini stroke’ clinic would be unaffected at Pilgrim Hospital, Boston. This clinic is for patients whose symptoms have resolved but are still thought to be ‘high risk’. These patients will be seen the next day by a stroke consultant and have appropriate investigation and results for the patient all in the same day.
• Patients in the south of the county already access stroke services at Peterborough Hospital (prior to any change at Boston) and some patients would still be transferred to the stroke unit there as it will be closer than Lincoln County

Had two recent cases where we’ve waited for 2-2.5 hours for an ambulance to get to a patient. It’s going to take an ambulance possibly an hour to get to Lincoln instead of Boston from Skegness. What are you putting in place to improve the ambulance service?

We are working closely with EMAS regarding this aspect of the service. As well as prioritising patients with suspected stroke, as they fall into the highest category for the ambulance service, we have localized arrangements to ensure best care. These include dialogue between the crew and the stroke service as soon as the crew receive the patient and direct access to the stroke ward (as opposed to waiting and going through A&E) upon arrival at the hospital.​​​​​