patient safety priorities
TRANSCRIPT
Patient Safety Priorities
Helen Blanchard, Director of Nursing and Midwifery
Dr Lesley Jordan, Consultant Anaesthetist and Trust Patient Safety Lead
10 Patient Safety Priorities 2017 / 2018
5 Executive sponsored projects
NatSSIPS
Movement of pts
Pressure Ulcers
Emergency Department safety
Insulin Safety
5 Patient Safety
Priorities
Sepsis inc AMR
AKI
EWS
Falls
C.Difficile
Falls
Falls in moderate harm
Actions
Developing a whole ward improvement plan with a number of
interventions including bay watch, use of safety magnets
Falls resulting in a serious injury are subject to an investigation
with the learning informing the Falls workplan
Themes and key messages from Falls Steering Group widely
disseminated
Review of the Falls risk assessment tool and associated care plan
Development of a Falls Trust wide training package
Pressure ulcers
Avoidable pressure ulcers - ward accumulation 2016/17
0
1
2
3
4
5
6
Category 2
Category 3
Category 4
exc. wards
with 0
Actions
Nursing Intensive Support into key areas
Targeted intensive training for high risk wards
Senior Sisters are being held to account where lapses in care have been
identified
Themes and key messages from Tissue Viability Steering Group widely
disseminated
Purchased visual training aids and are providing monthly ward based bulletins
on key themes and messages
Addressed the accessibility of equipment and are in the process of
centralising/ standardising the pathway.
Clostridium difficile performance April 2016 - January 2017
Background
The RUH target for ‘Trust apportioned’ Clostridium difficile in 2016/17 is 22 cases. Clostridium difficile toxin positive
stool samples taken 3 or more days after admission are ‘Trust apportioned’.
Current Performance
Month Actual number of
cases
Number of
successful appeals
Number awaiting
appeal response
Number of
outstanding RCAs
April 2016 2 1 0 0
May 2016 1 0 0 0
June 2016 7 3 0 0
July 2016 3 1 0 0
August 2016 4 1 0 0
September 2016 4 0 1 0
October 2016 3 1 0 0
November 2016 3 0 1 0
December 2016 4 2 0 0
January 2017 4 0 1 0
February 2017 4 0 1 1
Clostridium difficile actions
C diff Collaborative (September 16) - 6 wards. Teams identified
improvement strategies and will feedback on their projects in April 2017
C diff workbook implemented: compliance reported to IPCT, shared with
Heads of Nursing
Actions and learning from RCAs reviewed through the divisional
governance meetings. RCAs reviewed at the C diff Working Group
Disinfectant and sporicidal wipes launched (October 16)
Introduction of ‘C diff passport planned for Spring 2017
Actions
NHSi visit took place in February 2017.Headlines included:
Prescribing of antibiotics is a key challenge for the Trust: need to
increase antimicrobial pharmacist hours to improve antimicrobial
stewardship
Increased presence of Microbiology Team in clinical areas which
will also help with antimicrobial stewardship
‘Nursing’ equipment cleaning needs to be standardised
National Early Warning Score ( NEWS)
Embedded across whole organisation since 2014
WEAHSN Patient safety work stream – NEWS across all
sectors
Included in SWAST electronic patient record
RUH Champions in every ward
Focused on training - accurate recording
Trust wide 98% observations - NEWS recorded
88% NEWS recorded accurately
Current steps
New observation chart : Decrease common errors with NEWS
Improve escalation process
Include sepsis screening
Implementation electronic observations – investigating systems Significantly improve accuracy
Improve escalation
Sepsis screening simple and automatically recorded
Easily available information for all patients to support improvement work.
Sepsis
Feb 2016 New definition : ‘Organ dysfunction resulting from infection’
July 2016 – New NICE guidelines – early detection and timely treatment (RUH
launched second 60 day campaign)
National Campaign NHS England & DOH – improve sepsis education and management
Recommendation to use NEWS to screen those at risk
2016 - HEE report on education in sepsis – RUH acknowledged as area of good
practice
Educational campaign – 60 days for Sepsis 6 Finalist for National Patient Safety Care
Awards in 2016
National public awareness campaign for Sepsis in children December 2016
CQUIN since 2015 and joint Sepsis and AMR CQUIN for next 2 years
Progress at RUH
Training
Over 1000 staff received new training since July 2016
New senior sepsis nurse November 2016
Sepsis Screening:
Directly admitted patient since 2015
Average 85% at risk adult patients screened 2016 (Nationally 78%)
2016 included :
Paediatric patients admitted
75% Jan 2017 ( NICE guidelines very unspecific)
Inpatients at risk of sepsis
Improvement from baseline of 29% to current Q4 performance of 78%
Timely Antibiotics
Patients admitted with sepsis:
2016 average 76% patients with sepsis received antibiotics in an
hour (Nationally 62% in 2016)
Inpatients who develop sepsis
Improvement from baseline 19% to 78% patients receiving
antibiotics in 90 mins by end 2016
Patients with Sepsis as inpatient
Acute Kidney Injury
‘Sudden reduction in kidney function due to an acute
incident, such as sepsis, dehydration, haemorrhage, or
due to medications ‘
National Think Kidneys campaign since 2015
AKI National Renal Register
CQUIN 2015/16 and Quality Indictor for 2016
RUH incidence :
250 patient / month with AKI ( 5% all patients)
60% were admitted with an AKI
RUH Progress
July 2015 - electronic alert on blood test of kidney function
Educational campaign, Urine Trouble November 2015: raised awareness and
introduced simple bundle of care for patients with AKI
Over 1000 staff trained – core skills
Improvement of 20% in AKI bundle compliance trust wide with 90% having
timely senior review
Improved information in discharge summary for GPs by 30%, with 90%
information on medication review and follow up in December 2016
Mandatory questions on discharge summary from April 2017
AKI- Current Focus
Decrease inpatient acquired AKI
Further improve our fluid balance monitoring and recording of urine
output
Raising awareness of patients have had contrast
Outcomes: Decrease Inpatient Acquired AKI and Length of stay
Next steps – Sepsis, AKI and NEWS 2017
Electronic vital signs recording and sepsis screening
Develop ‘Deteriorating Patient’ training combining NEWS, Sepsis and AKI for all staff
Teaching session
Simple ‘Simulation’ – scenario based training
Simple assessment