Appendix 2.pdf

Appendix 2
RELEASED UNDER THE OFFICIAL
INFORMATION
ACT (1982)

In Confidence
Attendees
•
Dr Jeff Brown, District Director
•
Lyn Horgan, Operations Executive, Te Uru Arotau (Acute and
Elective Specialist Services)
•
Dr Hagay Weinberg, Clinical Executive, Unplanned Care, General
Medicine Physician
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•
Dr David Prisk, Emergency Physician and Medical Lead, ED
•
Carrie Naylor-Wil iams, Operations Lead, ED and Integrated
Operations Centre
•
Kellie Stickney, Associate Director of Nursing, Te Uru Arotau
•
Dr Jason Prior, Medical Lead, System Flow, General Medicine
Physician
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•
Debbie Perry, Charge Nurse, Medical Assessment and Planning
Unit (MAPU)

Media
Media are not expected.  A member of the MidCentral communications
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team will take photos during the tour.

OFFICIAL
The following departments/agencies have been consulted:
Acute Demand, Hospital and Health Services
Communities, Localities and Commissioning Directorate
THINK Hauora (primary health organisation)
INFORMATION

Attachments
Appendix One
‘Safe and Calm Hospital 2022/23’ Plan
Appendix Two
Directions to Hospital Administration Building

ACT

(1982)
Dr Jeff Brown
District Director
Te Pae Hauora o Ruahine o Tararua | MidCentral
Te Whatu Ora - Health New Zealand

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AM HNZ00011598 Minister Verrall Visit MidCentral – 24 February 2023

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Minister Verrall’s visit to Palmerston North Regional Hospital ED
Purpose
1.  Minister Verrall requested the opportunity to visit and discuss how things are tracking in
Palmerston North Regional Hospital’s Emergency Department, including a run down of
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progress since the last Covid-19 surge, and the ability to meet with the leadership and
frontline kaimahi.
Recommendations
2.  Te Whatu Ora recommends that you:
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a)  Note the work completed, underway and planned to improve
Noted
system flow across the hospital.
b)  Note the medium and longer term strategies completed and
underway to improve capacity, and the development of a Clinical
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Services Plan.
c)  Note the approaches being taken to support staff, including health
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and wellness activities, recruitment and targeted new roles.
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Executive Summary
3.  Palmerston North Regional Hospital’s Emergency Department (ED) continues to
experience high levels of demand, and the complexity and acuity of these presentations
INFORMATION
is increasing.  Over recent times (post Covid-19) the department is also seeing a rise in
the rate of trauma presentations.  Staff are fatigued and high levels of nursing sick leave
across the hospital are being experienced.
4.  Treatment and clinical management of ED admissions is exacerbated by both hospital
systems flow issues and the small size and configuration of the physical facility (ED and
the hospital).
5.  Under the leadership of a Systems Flow Medical Lead, initiatives continue to be
implemented to improve the flow of patients through the hospital and back into the
community. This work, and proposed new initiatives, were discussed with the national
ACT
system flow team when it visited Palmerston North Regional Hospital on 17 February
2023.  The key issue is the system outflow back into the community.  Challenges in this
area are impacting on all areas of the hospital.
(1982)
6.  A medium-term coping strategy in terms of physical capacity was completed in January
2023 and was officially opened by the MP for Palmerston North on 17 February 2023.
This is a facility for the Medical Assessment and Planning Unit (MAPU) and the
Emergency Department Observation Area (EDOA).  MAPU has relocated from an acute
inpatient ward in the hospital to the new facility, and now has increased bed numbers.

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AM HNZ00011598 Minister Verrall Visit MidCentral – 24 February 2023

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Background / context
7.  MidCentral provides a range of secondary and tertiary services to the central region,
including Wairarapa, Whanganui and Hawke’s Bay.  It also provides cancer services for
Taranaki.  The Palmerston North Regional Hospital is a teaching hospital with 365 beds.
8.  The local population is 191,000 and this is expected to increase to 219,000 over the next
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15 years (source: Infometrics, Feb 22).  The wider area served (central region north of
Kāpiti) has a population of 501,000 (forecast to be 570,000 by 2037), of which 31% are
Māori.
9.  Over the past 15 years, MidCentral has invested heavily in primary care, establishing
integrated family health centres across the district.  These include key enablers such as
specialist primary care nursing and collaborative clinical pathways.  The integrated
health centre approach plays a significant role in improving equity and the delivery of
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services closer to home.
10. MidCentral has also invested heavily in community mental health services, community
child health services, older persons services and cancer services.  The cancer
screening, treatment and support service has an outreach model.
THE
11. Investment in acute mental health services has completed the design phase and is now
undertaking construction enabling works on site with the foundation work to commence
in April 2023.   This will be a 28-bed unit with two de-escalation beds and potential for
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future expansion (eight beds). The unit is based on a contemporary model of care and is
inspired by the concepts of Tiaho Mai. It is also part of a wider strategy which includes
community-based step-down services to support discharge of patients from acute care.
12. People presenting to hospital have higher levels of acuity and complexity than was the
case historically. This is resulting in longer inpatient stays, and challenges with
INFORMATION
discharge.  General practice is busy and currently only four of the 30 practices under
THINK Hauora have open books. There are 14 iwi/Māori providers within the district.
13. The current main hospital building was established in 1970 and significantly constrains
the level and range of care which can be provided.  Clinical care capacity falls well short
of what is required.  It is severely stretched and facilities have been augmented over time
to accommodate more beds and services – often at the expense of clinical support
space.  Facilities are now significantly undersized, evidence by national benchmarking
via the National Asset Management Programme (NAMP).  MidCentral rates in the bottom
four nationally for ED, ICU and inpatient wards floor area per bed.  In short, the facilities
ACT
cannot safely accommodate further capacity.
Discussion
(1982)
14. Further improvements in both the hospital’s system flow and facilities are critical to
enable ED and other services to cope with growing demand and complexity.
15. Workforce fatigue, staff shortage and sickness present significant challenges and a
broad approach is being taken to address these, including health and wellness
strategies, recruitment and new roles to support system flow.
16. A clinical services plan is under development to support planning for a new acute care
facility and the re-lifing of the current clinical service block.

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AM HNZ00011598 Minister Verrall Visit MidCentral – 24 February 2023

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System Flow
17. The hospital's Integrated Operations Centre manages system flow across the hospital,
utilising MIYA information systems.  MIYA patient flow boards are throughout the hospital
to support this process and enable a hospital-wide systems approach.
18. A general medicine senior medical officer, Dr Jason Prior, has been appointed Medical
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Lead, System Flow to advance work in improving systems flow.
19. A ‘Safe and Calm Hospital 2022/23’ plan has been developed and this focuses on the
hospital’s:
- ways of working
- hospital flow
- home warding (reducing medical outliers in surgical beds)
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- high demand response
- workforce
- collaboration.
A pictorial view of this plan is attached.
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20. Significant work has been done in the ‘ways of working’ area, including the establishment
of telehealth in Horowhenua and Dannevirke community health centres to support
outpatient consultations, funded by the Planned Care Funding initiative, as was a
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community infusion service.  The infusion service operates from three major community
health centres – Kauri HealthCare, The Palms and Tararua Health Group (Dannevirke).
Discussions are underway with community health centres in Feilding and Horowhenua to
commence the service at those localities.
21. An Older People’s Assessment and Liaison Community Service (OPAL CS) commenced
in 2022. This service focuses on reducing avoidable displacement of older people from
INFORMATION
their home.  It shifts more care from the hospital setting closer to people’s homes,
incorporating Kaupapa Māori approaches.  A specialist multidisciplinary team of allied
health and nursing with medical support works with general practice teams and other
community-based and Iwi providers to proactively manage frailty, supporting kaumatua
to live well for longer in their communities.  OPAL CS also interfaces with ED and
inpatient wards, including our OPAL Unit (acute ward for older people with frailty) to
facilitate supported transfers of care back out into the community.  The service operates
from three locations – Horowhenua, Manawatū and Palmerston North, with a planned
extension into Tararua mid-year.
ACT
22. The possibility of piloting an extended Hospital in the Home Service is being explored.
23. We are exploring initiatives to address issues with ‘system flow’ and ‘surge response’ (1982)
with support from the national system flow team.
Capacity
24. The ED is too small as noted above.  It was built in early 2000 based on 17,000
presentations per year with moderate growth.  In 2023 we are forecasting presentations
to be around 55,000. The department does not meet standards, e.g., resuscitation room
areas, whānau/family and privacy requirements, central workstation and computers.

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AM HNZ00011598 Minister Verrall Visit MidCentral – 24 February 2023

In Confidence
25. Temporary changes have been made – both physical and in terms of work practices – to
manage within the area, particularly the management of airborne disease, such as
Covid-19.  These changes now need to be permanent. These includes air management
systems and negative pressure rooms.
26. A 30 bed MAPU and EDOA facility opened this year, located alongside ED.  Previously,
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MAPU was accommodated within part of an acute inpatient in the hospital tower block.
Relocating next to ED, and increasing from 13 to 20 beds, will enable it to take more
patients direct from ED.  It is planned that MAPU will accept direct referrals from general
practice.
27. The current EDOA is a six-bedded area within the ED.  It will move out into the new
EDOA facility in April which will provide a further four beds.  With the use of Trust funds,
a paediatric area will be developed within ED utilising the space previously occupied by
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EDOA.
28. The hospital’s clinical treatment areas were severely chal enged by Covid-19 as they did
not have the air management systems required.  Further, high pressure oxygen was
lacking.  Solutions have been, and continue to be, put in place.  Progress is restricted by
the availability of skilled contractors.  A Covid treatment ward was established, and work
THE
is underway to bring a further ward up to this standard, with ventilation and oxygen
systems being addressed.  While this work is underway, we have temporarily closed a
32-bed acute medical inpatient ward and the new EDOA area is being used for inpatient
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care.
29. The Critical Care funding initiative supported the establishment of an additional two
critical care beds and these will be operational in late 2023.
30. A further interim solution, yet to be implemented, is the expansion of ICU capacity.
Alternative office space has been found for the anaesthetic department which will enable
INFORMATION
the ICU area to be reconfigured.  A concept design is under development, focused on
addressing key issues, increasing the number of beds from six to eight, improving lines
of sight for clinical staff, and improving storage areas.  The beds will be flexible, able to
be used as ICU and HDU as required.  Requirements for managing airborne disease,
such as Covid-19, will also be taken into account.
Workforce
31. Like other hospitals, Palmerston North Regional Hospital is experiencing staff shortages,
staff fatigue and illness.
ACT
32. High sick leave is currently being experienced within the nursing workforce.  We are
implementing the Bradford scoring tool, health and wellness conversations, and health
(1982)
and wellness strategies to support staff.
33. Recruitment efforts continue. A cohort of enrolled nurses is due to graduate this year.
We also plan to develop the non-clinical workforce so that these staff members can take
on duties such as phlebotomy, ECGs, basic plasters, particularly within ED.
34. The establishment of a Clinical Nurse Specialist – Equity for ED is being progressed
given high Māori ‘did not wait’ rates.

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AM HNZ00011598 Minister Verrall Visit MidCentral – 24 February 2023

In Confidence
35. To support the timely discharge of acute adult inpatients, two Complex Discharge Nurse
roles are in place.
36. Using the Critical Care funding, a Patients-At-Risk nursing service has been established,
to operate 24/7 365 days of the year. The service will be further augmented following
current recruitment efforts.
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Next steps
37. Implementation of the ‘Safe and Calm Hospital 2022/23’ will continue.  A very useful
discussion was held with the national systems flow team on 17 February and the
opportunity of support for new initiatives and pilots will be progressed.
38. Alongside this, work will continue to support staff, including health and wellness
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strategies, as well as the establishment of positions to support improvements in the
system flow, thus reducing pressure on all teams.

THE
OFFICIAL
INFORMATION
ACT
(1982)

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AM HNZ00011598 Minister Verrall Visit MidCentral – 24 February 2023

In Confidence
Appendix One – Safe and Calm Hospital 2022/23

RELEASED

UNDER
THE
OFFICIAL
INFORMATION
ACT
(1982)

AM HNZ00011598 Minister Verrall Visit MidCentral – 24 February 2023

In Confidence
Appendix Two – Directions to Hospital Admin Building

Come through Gate 2 on Heretaunga Street (entrance almost opposite the
Hospital Store).
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Go through the ticketing machine.

The Administration Building is directly in front of you (red brick building
with the pillars in front).  There are some visitor carparks in front of the
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building.  If they are full, there are more visitor carparks just inside Gate
2 (on the left as you drive in).

THE
Entry to the Administration Building is via swipe card access.  On arrival,
phone or text Margaret Bell (EA to District Director) who will let you in.
Parking exit cards will be provided.
OFFICIAL

INFORMATION
ACT
(1982)

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AM HNZ00011598 Minister Verrall Visit MidCentral – 24 February 2023