ed safety checklist masterclass presentation

ED Safety Checklist Masterclass

Monday 25th April 2016

Welcome & IntroductionDeborah Evans, Managing Director,

West of England AHSN

The West of England Academic Health Science NetworkWe are delivering positive healthcare outcomes by • driving the development and adoption of

innovation• supporting the adoption and spread of

evidence-informed practice• and making a meaningful contribution to the

economy.

The West of England Academic Health Science Network

Academic Health Science Networks

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The ED Safety ChecklistThe Why!

Dr Emma Redfern, ED ConsultantUniversity Hospitals Bristol

The Problem

Patient safety in the urgent care environment, particularly at handover and during crowdingDelays in recognition and treatment of severe illness and deteriorationA staffing crisis and reliance on agency staff.Human factors in urgent care

Where’s Wally?

Safer Transfers of Care

There’s Wally!

The ED Safety ChecklistThe What!

Alex Hastie & Caroline ClarkED Safety Checklist Project Nurses

University Hospitals Bristol

PDSA Cycles

The PDSA cycle is shorthand for testing a change by developing a plan to test the change (Plan), carrying out the test (Do), observing and learning from the consequences (Study), and determining what modifications should be made to the test (Act).

• A comprehensive list of essential components of care, prioritised according to required completion time

• Incorporating elements to improve not only safety but patient experience through their ED journey.

• A multidisciplinary tool to provide safe, timely emergency care

What is the ED Safety Checklist?

• Feedback from ED Team

• Review of Clinical Incidents

• Review of complaints

• Inclusion of information from nursing indicators

How was it conceived?

• Focused on hourly themesVital signs, NEWS, pain scoring

• Frontloading of investigations• Promotion of care pathways• Early identification of required referrals onto

specialist teams

What does it comprise of?

• Checklist pilot trial• Checklist roll out• Reformation of ED Safety Checklist Team• Collection of multi-sourced feedback

How was it implemented?

• Fluctuating enthusiasm from a large team• Timing• Correlation between checklist uptake and

department acuity• Varying attitudes from different staff groups• Data collection

What problems did we face?

• Length of Stay• Outliers• ED Targets – 4 hour breaches, nurse indicators • Mortality• Clinical Incidents• Patient Experience

How did we measure our success?

• Introduction of CQuin• Staff group specific, multi source feedback• Shop floor champions• Senior support• SWAS involvement• Continued indicator audit• Shift from monthly to daily uptake auditing

How did we maintain our results?

Within the DepartmentBusiness as normalContinued auditingShop floor champion

Outside the DepartmentCollaboration between other trustsNational dissemination

What next for the project?

• Structured introduction• Designated team• Specific staff group engagement• Multidisciplinary involvement• Shopfloor champions• Daily and monthly auditing• Set targets

What have we learnt?

The ED Safety ChecklistThe How!

Ellie Wetz, Patient Safety Improvement LeadWest of England AHSN

The ED Safety Checklist Toolkit

• Developed to support the implementation of the ED Safety Checklist at adopting trusts.

• Guidance not mandate!


Toolkit Structure:1. About the ED Safety Checklist2. Form your team3. Organise your ED4. Agree your measuresAppendixes


1. About the ED Safety Checklist• Local Fields

• Baseline Data• Comprehensive review of ED clinical incidents

• ‘Best Practice’ Fields• Vital signs taken and NEWScore calculated regularly• Front loading of investigations i.e. imaging, bloods


• PDSA• Helps teams plan• Test on small scale• Review• What works? What

doesn’t?• QI Toolkithttp://www.weahsn.net/ what-we-do/skills-knowledge-development/improvement-resources-and-tools/the-improvement-journey/


Project Logic Model• Inputs• Activities• Outputs• Outcomes• Impact


2. Form your team• Local Implementation Team (LIT)

• Existing ED Staff• Lead Nurse• Lead Consultant• Audit Coordination Nurse/Data Analyst• Other key stakeholders


• LIT fortnightly meetings• Agenda

• Project documentation• Risk & Issue Log


3. Organise your ED• How will you print, store and restock the ED Safety

Checklist?• ED Safety Checklist Training• Real-time feedback• NEWS Training


4. Agree your measures• How do we know a patient safety intervention has a

positive impact? We measure it!• Baselining• KPI’s & Dashboards• Life System Platform• Evaluation


Appendixes• ED Safety Checklist

http://www.weahsn.net/what-we-do/enhancing-patient-safety/• SHINE 2014 Final Report• QI Resources

http://www.weashn.net/what-we-do/skills-knowledge-development/improvement-resources-and-tools/the-improvement-journey/

• Research Papers

http://www.weahsn.net/what-we-do/enhancing-patient-safety/



Q & AGeneral Discussion

Chaired by Deborah Evans, Managing Director,West of England AHSN

Refreshments & Networking

The Interface with the Ambulance Trust

Phil Cowburn Acute Care Medical Director

South Western Ambulance Service NHS Foundation TrustConsultant in Emergency Medicine

University Hospital Bristol

Emergency Department

• Increased demand• “Winter Pressures”• Lack of discharges• Poor flow

• Exit block• Crowding

Effects on Ambulance Service

• Crews tied up• Hours lost• Poor performance• Delayed response

times• Undifferentiated risk

in community

Who’s Caring for Patients in the Queue?

Care of Queue

ED at Bristol Royal Infirmary– University Hospitals Bristol NHS Foundation Trust– Adult only ED

2012 Retrospective review of ED notes and PCF100 consecutive queuing patients over 2 week period

Care of Queue

Patient care responsibility of ambulance TrustClinical SOP requiring minimum 15 minute observationsIncreased frequency if clinically indicated

Care of Queue

Care of QueueNumber of Sets of Observations Compared to Time Queuing

0

5

10

15

20

25

30

<30 30-59 60-89 90-119 >=120Time in Queue (minutes)

Num

ber P

atie

nts

0 1 2 3 >=4

What was really happening in the Queue

Queue Events

6 CVE– Average age 76– All queued > 75 minutes– No CT < 60 minutes

4 # NoF– Average age 87– All queued > 90 minutes– No X-Ray < 60 minutes

Queue Events4 Serious Incidents

Missed MI– Deteriorated in queue, moved to resus, arrest, RIP

OD self discharged– No capacity assessment or mental health matrix

# dislocation ankle with critical skin– Queued 3 hours, reduction >6 hours post injury– Plastics referral

Who Owns this Risk?

Late Night ChatAcute Gold

• We’re full• We’re not performing• Stop bringing patients• I need nurses and beds• We’re unsafe• We want a divert• We’re un-safer than you• We might closeJust shut the doors and don’t

let ‘em in

Ambulance Gold• Everyone is full• We’re not performing• Start taking the patients• I need crews• We’re unsafe• No-one will take a divert• We’re un-safer than you• You can’t close

Push ‘em through the doors and go

Risk ReductionImprove quality care

Get basics right Work together

Grassroots

ED & Queue

Which patients are sick?Which patients are deteriorating? Which patients have time critical conditions ?

Birth of The ED Safety Checklist

Better NEWS

How NEWS might help?

Potential for ambulance service to – Prioritise HCPC calls – Assist on decision making to discharge– Define & communicate pre-alerts

Transforming Urgent and Emergency Care Service in

England Safer, Faster, Better: Good Practice in delivering urgent

and emergency care NHS England August 2015

“All adult patients should have a NEWS established at

time of admission.”“Where patients experience

long waits, their NEWS should be recorded, pain

assessed and managed and essential care given.”

Ambulance ServiceElectronic Care System & ePCR

WEAHSN supported Roll out & incorporation of NEWS into ePCR

Auto calculatesED can see all information

Including NEWSPart of executive summary

Aim to incorporate SHINE Checklist

Working Together

Adoption and spread-safer transfers of care

Measuring the Impact of the ED Safety Checklist

Kevin Hunter, Patient Safety Programme Manager, West of England AHSN

Baseline Data

• Understanding your current standards of care• Case note review

• Suggested 20 notes per month• 1 year of data• Performance against Key Performance Indicators• Data input sheet provided in Toolkit

• Serious Incident Review• Common themes Inform local checklist & PDSA

Key Performance Indicators


• Suggested 5% ED Safety Checklist audited per month (at UHB: 200 per month)

• <50% complete – not valid• Basic clinical care• Pathways• Patient experience• Local KPIs to reflect local checklists


1. Red: <49%2. Amber: 50% -

79%3. Green: >80%

Nov-13

Jan-14

Mar-14

May-14

Jul-14

Sep-14

Nov-14

Jan-15

Mar-15

May-15

40.00%

50.00%

60.00%

70.00%

80.00%

90.00%

100.00%

Pain scoring at triage and analgesia given Nov 13 - May 15

Pain - Pain score & triage Pain - Analgesia

Intro

duct

ion

of E

D S

afet

y

Che

cklis

t

What is the ‘Life’ System?• A web based platform designed to assist front line staff running

Quality and Safety improvement projects

• It has been developed as part of the PSC in partnership by SeeData and South West AHSN

• Regional subscription model – Free for our members to use

• Supports team working and collaboration – an open and transparent culture

• Ability to view projects on the system from across the country

• Able to seek assistance and support from other users

• Gives a regional overview of improvement activity

The PrinciplesLife has been build by SeeData and South West AHSN on a set of principles that are designed to support continuous improvement:

• All users agree that the information they add to the system can be viewed (with limitations able to be set)

• The system is not designed to collect detailed information on users, organisations or patients

• The system will make minimal use of mandatory fields to encourage flexible use

• The information collected is only to support improvement and is never to be used for performance management

Login Page

Front Page – My Projects

My Organisations Projects

All Projects

Project General Info Tab

Project Driver Diagram Tab

Project Measures Tab

Project Change Ideas Tab

Project PDSA Tab

Project SPC Chart Tab

Project Documents Tab

Connect Module - Discussions

Resources Module

Organisations List

Users List

Aggregate Chart Development

Participating AHSN’s in ‘Life’:• West of England• South West• Wessex• Kent, Surrey and Sussex• UCLPartners• Oxford• West Midlands• East Midlands• Eastern• North West Coast.

Any questions then please see Kevin Hunter throughout the day or email [email protected]

To sign up for a user account:https://life.seedata.co.uk/login/

Further Information

mailto:[email protected]

The West of England ED Collaborative

Dr Emma Redfern, ED ConsultantUniversity Hospitals Bristol

Participating Trusts

• Weston Area Health Trust• North Bristol NHS Trust• Gloucestershire Hospitals NHS Foundation Trust• Great Western Hospital NHS Foundation Trust• Royal United Hospitals Bath NHS Foundation Trust• University Hospitals Bristol NHS Foundation Trust• South Western Ambulance Service NHS Foundation

Trust

West of England AHSN Support

• Implementation Toolkit• Financial Award

• Band 7 Lead Nurse• 2 days per week for 6 months• 1 day per week for 12 months

• Band 4 Data Manager• 1 day per week for 18 months

• Conditional on:• Attendance at ED Collaborative Meetings• Submission of KPI Data

Lesson’s Learnt

• Cultural ‘Buy In’• Executive Teams• ED Medical & Nursing Leads

• Local ‘ownership’ of the ED Safety Checklist is important

• EDs are structured and staffed in different ways • Success is more likely if adopting Trusts plan

their own implementation model

Interactive SessionChaired by Deborah Evans, Managing Director,


Discussion:

• Barriers

• Challenges

• The role of Patient Safety Collaboratives

• What other support is needed?

Next StepsDr Emma Redfern, ED Consultant

University Hospitals Bristol

• Pledges• Can we form a nation-wide collaborative?• How shall we structure ourselves?• The role of Patient Safety Collaboratives• KPI Data• Life System

Summary & CloseDeborah Evans, Managing Director,


@weahsn

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