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Restructuring trauma wards to reduce patient stay

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Heart of England NHS Foundation Trust has implemented an initiative to improve trauma and orthopaedic care. The changes have allowed staff to focus on patients’ specific needs according to their dependency level.

  • This article has been double-blind peer reviewed
  • Figures and tables can be seen in the attached print-friendly PDF file of the complete article found under “related files”

Ann-Marie Riley, RGN
, is matron for trauma and orthopaedics; Jane Teall, RGN, is trauma unit senior sister; Barbara Quinn, RGN, is trauma unit senior sister; Jane Wallace, RGN, is assistant matron; Alison Doyle, RGN, is trauma clinical nurse specialist; all at Heart of England NHS Foundation Trust, Birmingham.

Riley, A.M. et al (2008) Restructuring trauma wards to reduce patient stay. Nursing Times; 104: 10, 29.A team of nurses led an initiative to reconfigure trauma wards and to improve patient care through the use of a dependency-based model

Heart of England NHS Foundation Trust has implemented an initiative to improve trauma and orthopaedic care. The changes have allowed staff to focus on patients’ specific needs according to
their dependency level. It has brought about a range of improvements to patient care, including a reduced length of stay, prompt admission and discharge and rapid access to treatment for patients with a hip fracture.

The project

This project involved a nurse-led reconfiguration of two trauma wards. The hospital now uses a dependency-based model. This consists of a 25-bed acute zone that takes all admissions and cares for patients for up to 48 hours post-operatively, and a 25-bed non-acute zone, where the focus is on rehabilitation and discharge.

This restructuring has enabled us to implement the following changes to improve patient care:

  • The skill mix has been adapted to reflect patients’ level of dependency;

  • Patient notes, trolleys and essential equipment are now situated in patient bays to allow staff to spend more time with patients;

  • The introduction of the trauma coordinator role to ensure patients are admitted and discharged promptly;

  • New admission, discharge and operational standards;

  • The introduction of fractured neck of femur key performance indicators;

  • The application of LEAN principles.

Implementing guidance

Government guidance from the NHS Institute for Innovation and Improvement (Delivering Quality and Value) relating to fractured neck of femur highlights areas of good practice. Before the reconfiguration, our compliance with these recommendations was not consistent.

We began process mapping the patient pathway in January 2006. The team met regularly to rewrite admission and discharge standards, work out the skill mix required and liaise with disciplines such as physiotherapy, the domestic team and occupational therapy. We were unable to move the wards until this year because of an ongoing research project.


The objectives of this project were to:

  • Introduce a more systematic approach that allowed staff to focus on the specific care needs of a group of patients;

  • Minimise duplication of work;

  • Ensure that all acutely ill patients are admitted to the trauma unit instead of general surgery and medicine;

  • Ensure patients are cared for by staff with knowledge and skills relevant to their needs;

  • Allow the nursing team to drive forward the change in practice;

  • Introduce fractured neck of femur key performance indicators to enable us to analyse performance critically.

Benefits for patients

This project’s implementation has resulted in a reduction in patients’ length of stay. In addition, the number of patients nursed within general surgery and medicine instead of the trauma unit has decreased.

We have also introduced local key performance indicators relating to patients with fractured neck of femur, which exceed guidance. The work also prompted the surgical board to introduce board-level key performance indicators on length of stay for trauma patients.

There is a fast-track system for patients with fractured neck of femur, to ensure they enter the ward within one hour of admission to A&E.

We have also implemented bespoke flexible cleaning schedules to ensure high standards of cleanliness for each zone. We have designed new monitoring sheets so that patients, relatives and staff can tell at a glance which areas of the wards have been cleaned and by whom.

Future aims

The nursing team presented the project to the trust management teams and the chief executive considered the work to be inspirational. We have had a new website designed so all areas of the trust can access our operational standards. They can also see our training information and general information on developments taking place within our directorate.

The project’s success has meant operational managers are investigating the possibility of using the model in other areas of the trust. We are also working with A&E to expand the fast-track system to other categories of patients, so that all stable patients can be fast-tracked into an appropriate bed.


This work highlighted areas in practice that did not add value to the patient journey and that could be eliminated. It also focused the team on specific points in the patient journey that needed improvement.

This work is a continuous process and meetings take place to review progress and strive for continual improvement.

Find out more

If you would like to have additional information on this project, contact Ann-Marie Riley at:

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