summary report 1.16.19 (6) trust board...aspiration pneumonitis; food/vomitus 120 35.31 34 17.60%...

SUMMARY REPORT 1.16.19 (6)

TRUST BOARD 25th February 2016

Subject Mortality Report

Prepared by Frances Keane, Deputy Medical Director

Approved by Dr Rob Parry, Medical Director

Presented by Dr Rob Parry, Medical Director

Purpose

To update the Board concerning current mortality statistics and provide an overview of the actions presently being undertaken in response to Trust wide position. This paper updates the Board on: Mortality statistics The Trust Mortality Committee work plan and improvement

agenda The Sepsis Steering Group work plan and improvement

agenda The work plan relating to Deteriorating Patient agenda

Receive ●

Approve

Trust Objectives

Quality People Partnership Resources

● ●

Executive Summary

Our mortality indicator continues to be a major concern for the Trust (HMSR 114.71, baseline 100) and we continue to address this as a priority. The latest 12 month rolling HSMR is: 114.71 (December 2014 – November 2015). The excess deaths are mainly in medicine apart from Fractured Neck of Femur. The alerts for the period December 2014 – November 2015 were 6 alerting diagnosis groups:-

Acute cerebrovascular disease Chronic renal failure Fluid and electrolyte disorders Fracture neck of femur (hip) Septicaemia Urinary tract infections

Key Mortality improvement actions. Mortality improvement actions:

Mortality 1. Review of Mortality action plan- to define key areas of improvement

of 2

2. On-going review of weekend nurse cover ( in line with junior doctor and Consultant cover)

3. Mortality awareness shared conversation sessions (x3 ) led by Deputy MD Sepsis

4. Weekly ED Sepsis grand round attended by ED Consultant, Chair Sepsis Steering Group, Deputy MD, Consultant Nurse-ED, ANP, Associate Director Clinical Governance, Ward Sister

5. Purchase of 3 Sepsis trollies for ED & MAU 6. Daily sepsis audits in ED/MAU

Paediatric Sepsis

7. New observation charts incorporating PEW scores and actions to assess against PEW>2 introduced end 2015

8. Sepsis stickers to guide sepsis six with audit tool for completed stickers. 9. New paediatric patient flow management system implementation date Feb 2016 with

automated request for review if PEW >2 (electronic whiteboard). Education

10. Review of sepsis half day training programme- to a shorter 2 hour session that all ED & MAU staff must attend ( must do)

11. Online sepsis education programme for all staff ( must do) 12. Deteriorating patient education change programme for all staff ( must do) with an aim

to roll out the change package following the same ward list programme as the E-obs scheduling but over 30, 60, 90 day timescale.

13. Launch event for the Ward Sisters and Matrons at the start of each phase of the deteriorating patient education so that they are familiar with the change package.

14. Engage specialist/non ward based nurses in helping with the roll out of the deteriorating patient change education plan

Key Recommendations

For the Trust Board to note and receive the current report.

Assurance Framework

The report provides information on the key risks and current level of assurance in meeting the Trust’s objectives.

Next Steps

The Trust Board to receive regular reports to meeting and be kept informed by exception reporting outside of the meeting cycle as required.

Corporate Impact Assessment

CQC Regulations Covers all CQC regulations

Financial Implications None.

Legal Implications None.

Equality & Diversity None.

Workforce and Staffing

Performance Management None.

Communication None.

Acronyms / Terms used in Report

DFU Dr Foster Unit

CUSUM Cumulative sum chart

CIU Chemotherapy Intelligence Unit

1

Royal Cornwall Hospitals NHS Trust – Mortality Data

1. DECEMBER 2014 – NOVEMBER 2015 (Information downloaded from HED on 8 February 2016) 1.1 Mortality Update Mortality is a key indicator of the trusts safety and effectiveness; this can be expressed in 2 ways, HSMR and SHMI. HSMR is a metric that looks at 56 key diagnoses for in hospital deaths, these 56 diagnoses make 80-90% of the Trusts deaths. SHMI looks at all deaths in hospital regardless of diagnosis, plus all deaths for patients who died in the 30 days following discharge from hospital, this does not adjust for patients who were discharged from hospital with palliative care support in their own home or a hospice, nor is there a requirement for the patient’s death to be related to their previous hospital admission. HSMR and SHMI are both measures of quality of care that use patient records to determine a patients mortality risk based on a number of factors including age, gender, diagnosis, comorbidities and background and lifestyle factors. Outcomes are then compared to this risk and when expressed for the entire Trust are expressed as a number; 100 is considered to be average with anything below 100 showing more patients who would have been expected to die survived (i.e. excellent care) whilst above 100 shows some patients died that may have been expected to survive (potential improvements in care required). 1.2 Trust position- December 2014 – November 2015 HSMR = 114.71 (December 2014 – November 2015) / 114.98 (November 2015)

Flagging for the year as lower confidence interval (LCI) is more than 100, currently at 109.21

Not flagging for November 2015 as LCI is 96.91 Total number of deaths = 1626 (12 months) / 143 (November 2015)

2

Table 1: HSMR Funnel Plot: December 2014 – November 2015

Non-elective non-weekend admissions have alerted for the 12 months ending November 2015:

HSMR = 111.77 LCI = 105.53

Non-elective weekend admissions have alerted for the 12 months ending November 2015:

HSMR = 123.78 LCI = 112.36

3

Table 2: Rolling 12 Month HSMR: December 2014 – November 2015

4

1.3 6 diagnostic groups alerting (lower confidence interval >100):

Acute cerebrovascular disease Chronic renal failure

HSMR = 121.73 HSMR = 114.71

Fluid & electrolyte disorders HSMR = 187.24 Fracture neck of femur (hip) HSMR = 143.4 Septicaemia Urinary tract infections

HSMR = 128.75 HSMR = 146.65

Table 3: HED HSMR Diagnostic Group Dashboard: December 2014 – November 2015

CCS Diagnostic Group

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Abdominal pain 2231 4.29 7 14.30% 163.14 65.36 336.14 167.39 6 1.9 0.31% Acute and unspecified renal failure 367 51.37 63 17.50% 122.64 94.23 156.91 122.79 24 14.88 17.17% Acute bronchitis 821 10.66 11 0.00% 103.2 51.45 184.67 105.35 8 2.73 1.34% Acute cerebrovascular disease 791 128.16 156 16.00% 121.73 103.37 142.4 113.53 17 10.48 19.72% Acute myocardial infarction 712 64.32 56 10.70% 87.06 65.76 113.06 89.75 12 9.16 7.87% Aortic; peripheral; and visceral artery aneurysms 128 16.99 18 11.10% 105.95 62.76 167.45 111.66 4 6.2 14.06% Aspiration pneumonitis; food/vomitus 120 35.31 34 17.60% 96.29 66.67 134.56 94.68 11 11.39 28.33% Biliary tract disease 1244 13.32 21 4.80% 157.64 97.54 240.98 150.23 7 2.96 1.69% Cancer of bladder 1136 4.96 7 14.30% 141.12 56.54 290.77 118.91 6 3.89 0.62% Cancer of breast 2181 6.48 6 16.70% 92.54 33.79 201.43 104.57 11 9.24 0.28% Cancer of bronchus; lung 1050 33.24 33 21.20% 99.29 68.34 139.45 104.79 53 10.77 3.14% Cancer of colon 968 12.73 15 26.70% 117.82 65.9 194.34 119.28 17 12.04 1.55% Cancer of esophagus 357 9.69 8 12.50% 82.58 35.56 162.73 87.54 16 7.95 2.24% Cancer of ovary 504 6.42 6 0.00% 93.49 34.14 203.5 125.99 16 11.34 1.19%

5

Cancer of pancreas 272 11.4 16 6.30% 140.39 80.19 228 146.67 24 11.44 5.88% Cancer of prostate 818 8.24 6 0.00% 72.77 26.57 158.4 78.77 14 8.86 0.73% Cancer of rectum and anus 588 6.19 5 0.00% 80.8 26.04 188.57 76.6 9 10.02 0.85% Cancer of stomach 167 2.55 2 0.00% 78.48 8.81 283.34 79.3 4 13.64 1.20% Cardiac arrest and ventricular fibrillation 63 35.71 39 0.00% 109.22 77.66 149.31 110.89 5 11.79 61.90% Cardiac dysrhythmias 1270 13.96 15 13.30% 107.42 60.08 177.19 116.87 6 6.52 1.18% Chronic obstructive pulmonary disease and bronchie 868 37.47 49 10.20% 130.77 96.74 172.89 121.57 13 6.24 5.65% Chronic renal failure 665 3.32 8 50.00% 240.85 103.7 474.59 267.83 5 1.63 1.20% Chronic ulcer of skin 98 5.98 11 36.40% 184.01 91.73 329.26 207.87 3 10.54 11.22% Complication of device; implant or graft 1163 8.6 11 27.30% 127.94 63.78 228.93 118.38 6 4.6 0.95% Congestive heart failure; nonhypertensive 660 70.06 87 12.60% 124.19 99.47 153.19 119.24 19 8.8 13.18% Coronary atherosclerosis and other heart disease 1894 12.67 12 8.30% 94.72 48.89 165.47 92.86 2 6.89 0.63% Deficiency and other anaemia 1800 3.78 8 12.50% 211.82 91.21 417.39 198.16 4 6.22 0.44% Fluid and electrolyte disorders 227 10.68 20 25.00% 187.24 114.32 289.19 189.58 8 10.27 8.81% Fracture of neck of femur (hip) 677 50.91 73 28.80% 143.4 112.4 180.31 140.39 11 10.32 10.78% Gastrointestinal haemorrhage 1031 38.11 47 10.60% 123.34 90.61 164.01 115.64 13 5.63 4.56% Intestinal obstruction without hernia 257 13.61 15 0.00% 110.22 61.64 181.8 104.9 8 4.35 5.84% Intracranial injury 169 21.05 27 7.40% 128.28 84.51 186.64 124.25 5 5.76 15.98% Leukaemia 1692 5.95 6 16.70% 100.85 36.83 219.51 96.94 12 1.57 0.35% Liver disease; alcohol-related 274 16.56 13 0.00% 78.52 41.77 134.28 75.57 3 6.26 4.74% Malignant neoplasm without specification of site 217 7.92 7 0.00% 88.43 35.43 182.2 77.88 9 13.32 3.23% Non-Hodgkin`s lymphoma 935 5.67 8 25.00% 141.04 60.73 277.92 163.89 8 2.13 0.86% Non-infectious gastroenteritis 497 1.2 1 0.00% 83.55 1.09 464.87 131.83 4 1.84 0.20% Other circulatory disease 398 4.2 2 0.00% 47.57 5.34 171.74 49.68 3 6.14 0.50% Other fractures 386 13.4 13 69.20% 97.01 51.6 165.9 98.02 5 5.83 3.37% Other gastrointestinal disorders 1989 13.19 15 6.70% 113.74 63.61 187.6 121.21 12 2.21 0.75% Other liver diseases 292 11.53 13 30.80% 112.72 59.96 192.76 127.16 8 10.51 4.45% Other lower respiratory disease 237 8.59 9 11.10% 104.72 47.79 198.81 107.58 5 4.59 3.80% Other perinatal conditions 929 14.09 14 0.00% 99.36 54.27 166.71 98.98 0 0 1.51% Other upper respiratory disease 839 4.75 6 66.70% 126.4 46.16 275.13 115.71 1 4.03 0.72% Peripheral and visceral atherosclerosis 206 25.93 22 9.10% 84.83 53.14 128.44 85.34 9 7.87 10.68% Peritonitis and intestinal abscess 35 6.94 7 28.60% 100.91 40.43 207.93 105.8 4 10.51 20.00% Pleurisy; pneumothorax; pulmonary collapse 295 10.53 14 14.30% 132.99 72.65 223.16 131.2 10 6.36 4.75% Pneumonia (except that caused by tuberculosis 2046 313.16 324 8.60% 103.46 92.5 115.37 99.33 74 10.43 15.84%

6

or s Pulmonary heart disease 236 14.28 17 29.40% 119.02 69.29 190.58 125.52 14 7.5 7.20% Respiratory failure; insufficiency; arrest (adult) 72 18.06 20 0.00% 110.77 67.63 171.08 103.87 2 12.61 27.78% Secondary malignancies 2339 26.34 26 34.60% 98.72 64.47 144.66 107.94 76 9.5 1.11% Senility and organic mental disorders 243 15.61 20 20.00% 128.16 78.25 197.95 123.46 7 11.68 8.23% Septicaemia (except in labor) 317 58.25 75 2.70% 128.75 101.26 161.39 126.44 22 12.5 23.66% Skin and subcutaneous tissue infections 853 11.23 15 6.70% 133.59 74.72 220.36 127.96 4 4.45 1.76% Syncope 632 4.67 9 33.30% 192.58 87.88 365.6 224.31 3 6.62 1.42% Urinary tract infections 1572 53.19 78 28.20% 146.65 115.92 183.03 150.2 30 7.5 4.96% Grand total 42828 1417.4 1626 14.30% 114.71 109.21 120.43 113 692 6.53 3.80%

7

1.4 Summary Hospital-level Mortality Indicator (SHMI) The data below shows the current quarterly SHMI for the period April 2014 – March 2015 SHMI = 107.13; LCI = 102.8 Table 4: Funnel Plot – RCHT benchmarked against all other Trusts

Table 5: Line Graph – RCHT

8

1.5 Trust Crude Mortality Rate

Crude Mortality Rate (per 1,000) based on all inpatient activity & deaths occurring in RCHT in a 12 month period (Includes elective & non-elective admissions; does not include ED admissions or ED deaths) (Compiled by Information Services 11 January 2016) Table 6: Trust Crude Mortality Rate: December 2014 – December 2015

Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15

9

1.6 Alerts This Month

For the period December 2014 – November 2015 there were 6 alerting diagnosis groups (flagging at a lower confidence interval (LCI) at >100):

Acute cerebrovascular disease Chronic renal failure Fluid and electrolyte disorders Fracture neck of femur (hip) Septicaemia Urinary tract infections

1.7 Standard & High Risk Tracking (HSMR & Alerts) The diagnosis groups below represent those as on-going high risk/high volume. The data highlighted in red captures those diagnoses with a lower confidence interval (LCI) at >100 (as captured in the HED diagnostic extracts) across the 12 month period. Table 7: Standard & High Risk Tracking (HSMR & Alerts)

*Already subject of previous in-depth review by CQC and TDA (#NoF as part of procedure group, Reduction of Bone)

1.8 Key Mortality improvement actions.

December 2014 – November 2015

November 2015

Diagnosis HSMR LCI No. of Deaths

Expected Deaths

HSMR LCI No. of Deaths

Expected Deaths

Pneumonia 103.46 92.5 324 313.16 98.53 63.11 24 24.36

Stroke 121.73 103.37 156 128.16 131.91 73.77 15 11.37

Congestive Heart Failure

124.19 99.47 87 70.06 111.82 48.15 8 7.15

Acute MI 87.06 65.76 56 64.32 128.11 46.78 6 4.68

Fracture NoF 143.4 112.4 73 50.91 152.42 49.12 5 3.28

Syncope 192.58 87.88 9 4.67 362.25 4.73 1 0.28

Chronic Renal Failure

240.85 103.7 8 3.32 607.02 7.93 1 0.16

Septicaemia 128.75 101.26 75 58.25 114.06 41.65 6 5.26

Weekend 123.78 112.36 430 347.39 141.97 104.67 48 33.81

Non-Weekend 111.77 105.53 1196 1070.04 104.90 84.87 95 90.56

A summary of the latest mortality data for the 12 month period December 2014 – November 2015, including: a snapshot of hospital activity during November 2015, monitoring of weekend/weekday mortality & previously

alerting and high risk diagnosis groups. (Healthcare Evaluation Data (HED) replaces Dr Foster from 1 July 2015)

10

The Mortality Improvement Plan has been reviewed for impact, with three areas identified for current focus as likely to have the greatest impact on morality reduction: sepsis recognition and management; the deteriorating patient; treatment escalation plans.

1.8.1 Sepsis recognition and management

Daily sepsis audits are being undertaken in the Emergency Department/Medical Admission Unit with feedback to staff. A weekly audit report is generated from the data collected by the Lead Nurse for Sepsis. The Lead Nurse for Sepsis follows this review with feedback to all ED staff on a weekly basis. No data comes from the MAU as all the patients have been originally admitted via the ED. The reason the hospital’s RADAR surveillance notes these patients in MAU is because they continue to NEWS at Red/Amber status once admitted.

A sepsis ‘Grand Round’ has been introduced in the Emergency Department. The ‘Grand Round’ is a weekly review meeting that includes the Emergency Department Consultant, Chair Sepsis Steering Group, Deputy Medical Director, Consultant Nurse Emergency Department, Advanced Nurse Practitioner Emergency Department, Associate Director Clinical Governance and the Lead Sepsis Nurse.

Three ‘sepsis’ trolleys are being purchased for the Emergency Department; the effective use of these will be audited for consideration of roll out to other areas.

Medical and Nursing staff in the Emergency Department are receiving a 15 minute highlight session each morning on being sepsis aware. All staff for the day shift assembles for handover in the ED staffroom. It is via this forum that the Lead Nurse for Sepsis joins them every morning to deliver a Sepsis safety briefing and remind all staff to screen for sepsis, and promptly report it to a Dr where they do identify sepsis. The Lead Nurse for Sepsis also provides verbal feedback based on the previous 24 hours’ worth of medical notes that she has checked for sepsis screening. There have been 5 briefing since this commenced on Thursday 11th February.

The Emergency Department Consultant has ensured that Junior Doctors are conversant with the plan for Sepsis hour to hour screening and prescribing.

The sepsis half day training programme has been reviewed with all Emergency Department and Medical Admission Unit staff to undertake the training over the next 90-120 days.

An online sepsis awareness video has been identified for use and is currently being made available to staff via the intranet.

Sepsis stickers have been introduced in paediatrics with an audit tool for completed stickers.

1.8.2 Recognising the deteriorating patient

A new observation chart for children has been introduced. This incorporates a paediatric early warning score and associated actions.

A new paediatric patient flow management system being implemented in 2016 has an automated request for review where the early warning score flags.

11

Electronic observation system has been successfully introduced on Grenville Ward. The roll out programme will implement in four additional wards weekly with full introduction due to complete October 2016

A deteriorating patient educational change package has been designed by the clinical training team. This will be rolled out alongside the electronic observation system using a 30, 60, 90 day phased programme. The change package will be introduced through a launch event at the start of each phase, with support for implementation being sourced from specialist nursing teams.

The critical care outreach team has been extended to cover 24 hours over the weekend for a one month evaluation period.

1.8.3 Treatment Escalation Plans

Medical Admission Unit has been identified as the focus area for improving use of Treatment Escalation Plans (TEPs).

An improvement programme, supported by the Palliative Care Specialist Nurses, is being finalised, with implementation to commence by end of February 2016.

Three open staff sessions have been scheduled during February 2016 to raise awareness amongst medical and nursing staff of the key mortality actions and to listen to staff’s views on what other actions are needed within the mortality plan for greatest impact.

An analysis of Trust and community deaths is being undertaken with the support of the Academic Health Science Network. This is due by the 26th February 2016.

2. Recommendation

The Trust Board are asked to note and receive the current report.

Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Mar-16

1.1 106.49 108.9 109.53 109.77 109.96 109.91 110.87 112.55 112.69 111.98 113.17 <100

1.2 Weekday 106.04 108.21 109.44 109.86 108.8 108.79 109.08 110.32 110.36 109.21 110.61 <1001.3 107.85 110.98 109.8 109.47 113.58 113.41 116.48 119.39 119.88 120.61 121.13 <100

2.1 9 Not available 13 14 Not available 7 3 6 7 8 5

2.2.1 Sepsisno flag Not available no flag no flag Not available no flag no flag no flag no flag 131.25 132.85 <100

2.2.2Redutction of fracture of bone (upper/lower limb) 170.13 Not available 194.25 142.98 Not available no flag

128.94(#NoF) 228.23 no flag

134.79 (#NoF)

140.19(#NoF) <100

SIs related to the deteriorating patient 3 4 4 3 1 0 0 1 0 0 1 0 0 1612 9 8 15 10 16 7 12 10 11 10 13 17 year total 120

Peri Arrests 11 15 18 5 8 7 7 9 8 10 4 13 8

5 Antibiotics within 1 hour for severe sepsis 61.5% (16/26)* Not available Not available 58% (15/26) 60% (28/47) 73% 37% 90%

121.14

175.52

140.19

132.85

152.95

HSMR alerts: October 2015

Fluid and electrolyte disorders

Fracture neck of femur (hip)

Septicaemia

Acute cerebrovavascular disease

Urinary tract infections

1

34

2

High Level KPIs Supporting the Mortality Improvement Plan

Version 1 - 17 March 2015, updated January 2016

Overall

WeekendHSMR

Cardiac Arrest Calls

Number of Mortality Alerts

Cardiac Arrests

Mortality Alerts:Observed / Expected

number of deaths2.2 CQC

Ser No

1

2

3

Key Performance Indicators and performance trajectory

Current 3 months 6 months 9 months

1 Quality 114.71 <100

2 Quality 111.77 <100

3 Quality 123.78 <100

4 Quality 5 25% reduction



7 Quality 62.0% 60.0%

8 Quality 44.0% 45.0% 51.0% 57.0% 64.0%

9 Quality 2 0 0 0 0

Key Issues/Risks to Delivery

Risk ID Likelihood Consequence Risk score Residual LikelihoodResidual

Consequence

Residual Risk

ScoreOwner Open/ Closed

5230

4 5 20 3 5 15Medical

DirectorOpen

Deliverables and Milestones

Ser No Key Area Target Date Accountable Action StatusDate

Completed

1 Infrastructure

31/01/2016‐

achieved

February 2016

Frazer

UnderwoodGreen

01/02/2016‐

Complete

2 Infrastructure 14‐Mar‐16

Frazer

Underwood/Jona

than Paddle

Amber 21‐Mar‐16

3 Infrastructure 29‐Feb‐16

Sheena

Wallace/Jonatha

n Paddle

Amber 17/02/2016


Duncan

Bliss/Jonathan

Paddle

Amber 17‐Feb‐16

Additional coders appointed to review co‐morbidity coding in 6 frailty conditions Review of co‐morbidities in 6 fraility conditions to commence

Level 1 beds are required for patients needing a greater level of nursing care and monitoring support than that

provided through normal ward care. MAU

MORTALITY IMPROVEMENT PLAN ‐ MONTHLY STATUS REPORTPLAN STATUS

AMBER

Board/Executive Committee Trust Management Committee Plan updated by

Executive Lead Rob Parry Version 10

Local Monitoring Group/CommitteeMortality Review Committee/ Emergency

Care BoardDate Updated 11‐Feb‐16

Plan Objectives % Competition

Reduction in HSMR to <100 within 12 months (weekend and weekday)

25% reduction in serious incidents relating to suboptimal management of the deteriorating patient

Level 1 beds are required for patients needing a greater level of nursing care and monitoring support than that

provided through normal ward . Surgery ‐

Following an internal review by the Associate

Medical Director‐ ITU the Trust require an

agreement at the emergency care board (ECB)

of the need for additional level 1 beds on both

medicine and surgery. Options still being

discussed but no formal proposal in place‐

require a full and detailed update as to the

position of the increase in resources‐ to be

discussed at the February Emergency Care Board

Reduced cancellations of elective patients

requiring HDU post operatively following start

date.

Following an internal review by the Associate

Medical Director‐ ITU the Trust require an

agreement at the emergency care board (ECB)

of the need for additional level 1 beds on both

medicine and surgery. Options still being

discussed but no formal proposal in place‐

require a full and detailed update as to the

position of the increase in resources‐ to be

discussed at the February Emergency Care Board

Patients cared for in a safe environment by

appropriately skilled staff which should result in a

reduction in SI's

Review of HED flaggers ‐AKI, decubitus ulcers and weekend mortality due 31/01/16

Nerve‐centre (e‐Obs) phased roll out ude to commence Grenville ward 26/01/16 Revised mortality review process to commence

Description

Revised mortality review process discussed at MRC 20/01/16

National Hospital Standardised Mortality Ratio (HSMR)

data

indicates that the Trust has higher than average mortality,

particularly at weekends, leading to;

� Concerns about the quality and safety of clinical care.

� Trust reputation.

� Increased likelihood of regulatory intervention.

Mitigation

Awaiting meetingThe Trust is able to implement best practice from

a centre with established e‐obs use

10% reduction in cardiac arrest calls

HSMR Weekend rolling 12 month Trajectory and target for review 1 Feb 16

Physio cover for Trauma patietns delayed to Apr 16

Commentary

HSMR Overall rolling 12 month Trajectory and target for review 1 Feb 16

Sepsis 6 pathway compliance

Ser No

SIs related to the deteriorating patient ‐ 21 in 14/15

CQC open alerts Green 0, Amber 1‐2, Red 3 and above

MetricIncremental improvement trajectoryCurrent

PerformanceData Source

HSMR Weekday rolling 12 month Trajectory and target for review 1 Feb 16

Cardiac arrest calls ‐ Peri Arrests ‐ 108 in 14/15 Trajectory and target for review 1 Feb 16

Cardiac arrest calls ‐ cardiac arrest ‐ 133 in 14/15 Trajectory and target for review 1 Feb 16

Antibiotics within 1 hour for severe sepsis Trajectory and target for review 1 Feb 16

Trajectory and target for review 1 Feb 16

Revised care bundle stickers for COP pneumonia and chest pain launched Relaunch of cardiology care bundles‐ chest pain and heart failure

Teaching sessions for F1/F2 doctors delivered re respiratory care bundles Teaching sessions for F1/F2 doctors to support above

Tasks delayed in month (with revised completion) Decisions / Support required

orthogeriatrician not likey to be in place by Apr 16

Activities completed in month

Junior medical staff on Trauma will not be in place until August rotation Senior medical team support for coding review ‐finance identified,

business plan for level 1 beds in surgery Business cases/proposals from Medicine and Surgery for level 1 bed long‐term resourcing and respiratory consultant resource

Actions planned for next month

business plan for additional respiratory consultant resource Funding of Critical care outreach to include 24/7 at weekends as an initial step

business plan for level 1 beds in medicine

Action Progress / update Evidence /Outcome

E‐alerts : Assessment of eObservations functionality and

initial roll‐out to improve the recording, awareness and real‐

time reporting of the deteriorating patient

Infrastructure and messaging testing underway.

Adult NEWS specification signed off and with

nervecentre for system build. User acceptance

testing to commence second week of January

2016 with an anticipated go‐live date on launch

ward ‐Grenville. Launch date set for Grenville

February 16 .

Reduction of Sis expected relating to the

deteriorating patient. Impact expected after start

date

Visit planned to Nottingham to learn from thier introduction

of Nerve Centre and supporting Recognition and Rescue

initiatives 14/03/16

5a Infrastructure 31‐May‐16 Frances Keane Green 14/05/2016


Paul

Johnson/Steve

Creely/Steve

Dickinson

Green 29/02/2016

7 Staffing 31‐Mar‐16 Sheena Wallace Amber 29‐Feb‐16

8

Staffing

31‐Mar‐16

Jonathan

Paddle/Duncan

Bliss

Amber

9Pathways and

protocols30‐Jun‐16 Michael Spivey Amber 30/06/2016

10Pathways and

protocols30‐Jun‐16

David Ashton‐

ClearlyGreen 31/07/2016

11Pathways and

protocols31‐Mar‐16

David Ashton‐

ClearlyGreen 31/03/2016

12Pathways and

protocols29‐Feb‐16 Jay Over Amber 30/06/2016

13Pathways and

protocols29‐Feb‐16

Kenna Duston/

Steve IlesGreen

Audit programme to be established to evidence

conformance

Increase in Senior Medical Cover: Increase endocrine/neuro and respiratory substantive capacity to

ensure consistent medical cover at weekends for enhanced

patient review

Review of co‐morbility coding of six frailty conditions

Additional coders have been appointed and

Senior Medical staff identified to assist with

verification and sign‐off ‐ completed. Work to

commenced 01 Feb 16‐ in hand.

Enhanced co‐morbility codings in six fraility

conditions

Data quality : Review of conditions flagging as outliers

on HED mortality data to ensure a standardised systematic approach to outliers and establish failures in

care requiring improvement

Review of weekend deaths (ie patients who are

admitted at the weekend and subsequently die)

and Acute Kidney Injury completed. Review of

decubitus ulcers underway

Reduction in deaths in conditions flagging as

outliers

Improved Consultant to consultant referral for in‐

patients. Implement an electronic referral system for in‐

patients only to enable more timely consultant to

consultant referrals.

62 specialties are now live with Maxims, 7

specialities still to go live.

Project handed over to IT support as Business as

Usual.

Internal Referral module modified to support the

Add to Waiting List and Pre‐operative

Assessment (POA) workflow, reducing the

waiting time for POA appointment by up to 4

weeks.

Internal Referral module modified to support

clinical test and procedure requests.

Audit on delayed reviews to enable urgent

patients to be seen on the day of referral ‐ report

due on 7 Jan 16 ‐ KD will then inform Service Leads

and Clinical Leads and supports it's use. Audit

report data items agreed with Information

Services. Under development, and will be

available on Radar in a couple of weeks for users.

KD to send comms as soon as it is available.

Some improvement in recognition of sepsis

noted (NEWS completion 73% 01/16 c/t 36%

09/15) and deliverly of iv antibiotics 62% 01/16

c/t 50% 09/15) observed but needs

strengthening. Revised training programme,

including on‐line resource and shorter simulation

planned, weekly ED sepsis round introduced with

input from sepsis lead and key ED staff, Sepsis

trolley being trialled in ED, daily sepsis high‐

lighting to all staff, Paediatric screening tool

(PEWS) introduced.

Re‐launch of Key Care Bundles : phase 2: Chest pain

and heart failure

Programmes for training of F1/2 doctors in chest

pain and LVF in place for Dec 2015 & Jan 2016.

Revised chest pain care bundle sticker has gone

to print. Re‐assess options for clinical secondee

for a potential revised roll‐out plan across re‐

launched care bundles

SEPSIS nurse in place focussed on educating in ED

and MAU.

SEPSIS embedded in mandatory training.

Audits in place of all severe sepsis and septic

shock.

Weekly compliance reports in place and trajectory

improvement plan.

Sepsis 6: Embed sepsis 6 pathway to >90% compliance to

improve outcomes to patients with severe sepsis

The endocrine and neurology consultant posts‐

are out to advert‐ awaiting update . The

substantive business case for additional

respiratory consultant resource is due in Jan 16

(RF) ‐ not complete‐ DMD to review with

Divisional Manager/Directors of Medicine before

end February 2016

Critical Care outreach Service. Review tangible benefits of further expansion‐ the present plan‐ weekdays 12 hours‐

weekends 24/7 For review March ECB

A stepped approach has been agreed ‐the CCOS

will provide a costed plan to provide 24/7 cover

at the weekend initially and the benefit of further

expansion will then be reviewed. Will be

reviewed at March ECB.

Timely 24/7 review of deteriorating patients

Embed appropriate use of Treatment Escalation Plan

(TEP). The Adult TEP is now in place to document

treatment and CPR decisions. Community‐ wide

adoption of TEP is underway with PCH and KCCG.

First Audit of TEP form use completed. In general

documentation/form completion was good apart

from Mental Capacity assessments.

Safeguarding/MCA nurse involved. Paediatric

TEP introduced Jan 16‐ however evidence from

case review suggests that this is not fully

embedded and further work is required.

Consideration needed regarding resource‐ to be

discussed Feb ECB

Expected reduction in cardiac arrest calls

Weekend audit data evidencing patient review has

commenced.

Audit key Care bundles: phase 1 Respiratory

(Pneumonia/COPD)

Audit of Care Bundle pathway ‐ reported to July

ECB

Audit programme to be established to evidence

conformance

14Training/Culture/

Audit31‐Jan‐16

Amanda

Thompson

Roger Langford

Green

15Training/Culture/

Audit31‐Jan‐16 Sally Shipley Green

16 Fractured NoF 31‐Jan‐16 Duncan Bliss Red

17 Fractured NoF 30‐Apr‐16 Claire Rotman Amber 30/04/2016

18 Fractured NoFSue Ingram/

Kathy SmithAmber

19 Fractured NoF 30‐Apr‐16Simon McIntosh/

Helen WilliamsAmber

20 Fractured NoF 30‐Apr‐16 Duncan Bliss Green

21 Fractured NoF 31‐Dec‐15Simon McIntosh/

Ben WarrickRed

22 Fractured NoF 31‐Dec‐15

Sean Dixon/

Laura Wesson/

Helen Williams

Amber

23 Fractured NoF 31‐Dec‐15Helen Williams /

Kevin WrightRed

24 Fractured NoF 29‐Feb‐16 David Smith Green

25 Fractured NoF 31‐Dec‐15 Duncan Bliss Red

26Congestive Cardiac

Failure31‐Jan‐16

Jo Davies, HF

Specialist Nurse

Roberta Fuller,

Interim

Cardiology

Service Lead

Green Complete.

Pathways and

protocols31‐Mar‐16 Barney Scrace Amber

Pathways and

protocols31‐Mar‐16 Frances Keane Amber

Pathways and

protocols31‐Mar‐16 Steve Dickinson Amber

Consider provision of on‐going care for NOF patients to be

within designated orthogeriatric rehabilitation units in the

community. This is not an action!

Aim to roll out the change package following

the same ward list programme as the E‐obs

scheduling but over 30, 60, 90 day timescale.

launch event for the Ward Sisters and Matrons at

the start of each phase so that they are familiar

with the change package.

Engagement of some specialist/non ward based

nurses in helping with the roll out at clinical level.

Improve awareness and management of the

deteriorating patient ‐ Junior Medical staff ‐

Establish/Review Training ‐ ward based simulation. Nursing ‐

proposal required

Reduction of Sis relating to the deteriorating

patient

Data quality and data review ‐ Identification of patients at

risk of deterioration most likely to deteriorate after

admission or on the wards.

2 members of the ECB tasked to review existing

tools for patients being admitted through ED and

MAU. Proposed scoring system agreed and to be

trialled in ED. Sepsis nurse reviewing patients

with NEWS of 5 or more who deteriorate on the

wards

Develop a systematic process to identify the risk

of deterioration / sick patients admitted through

medical take

Redesign the pathway to ensure that patients who require

post‐ operative surgical review are seen by the orthopaedic

consultant.

In place. Any patient escalated have review.

Approved with orthopaedic deep dives with

Medical Director. Job plans being revised

Monitored through PALS/complaints

Encourage and facilitate referral to the heart failure nurse

service:

To existing service by

a) advertising service to other areas, particularly eldercare

and MAU

b) Appointment to 2nd heart failure nurse post

Second HF Nurse taking up post in mid January

2016 . Promotion of the service to other

specialties is underway and will improve with

second HF nurse in post.

Increase in patient referrals to the HF Nurse‐

review.

Review opportunity for a standardised anaesthetic

approach for frail elderly hip fracture patients.

In brief: on‐going consultations re standardizing

anaesthesia for NOF but anaesthetists feel a

good idea ‐ presented an anaesthetic governance

meeting. Under review by anaesthetics

Consistent junior medical ward staff on the Trauma Unit.‐

what does this mean?

Deanery approval for F2s to be under the

Orthogeriatric supervision looking after only

factured hips from Aug 16

Monitored through denary feedback

Improve checking and cross‐referencing of HES data and

NHFD.

Improve documentation of fluid balance and nutrition on

the Trauma Unit.

Documentation reviewed by pre CQC team on

Trauma 17 12 15. Feedback was that there was

no issue with the current documentation and

completion on trauma for their visit. new food

and fluid charts currently being trialled on

Trauma unit and driven by ward managers/senior

nursing staff to good effect. Physicians feel this

has been an improvement

Audit of documentation

Increase orthogeriatric time on Trauma Unit to 15 PAs per

week.

Fascia iliaca nerve blocks to be implemented as standard

part of NOF pathway – to be progressed as part of Listening

into Action review.

NoF Pathway implemented 3 Dec 15

where patients receive clerking and block where

appropriate in ED following x‐ray on arrival

Pathway in place ‐ reviews on‐going

Increase physiotherapy cover for trauma patients to seven

days a week and increase number of patients mobilised on

Day 1.

Additonal physios expected in post April 16

including provision for 7/7 working Reduced length of stay

.

The JD etc for extra orthogeriatrician is being

finalised by Helen Williams. A short term plan is

agreed for the short/immediate term for

orthogeriatric staff grade which is very doable

with good potential candidates and is being

sorted by Laura Wesson/Helen . This would just

be for NOFs and will hopefully be up and running

early next year. Job plan in progress. Full time

Staff grade in orthogeriatrics starting end of

January 16

Increased PAs

Update from Helen Williams

Clerical support for 30 day follow‐up.

Built in to job description for ring and remind

administration team currently being recruited to

the task of 30 day follow‐up. Staff in place by

end Feb 16

NoF best practice pathway measure being met

Re‐launch phase 3 pathway for AKI to improve consistency

and systematic care and improve outcomes Introduced at grand round Dec 15. Further

embedding required Audit programme to be established

Explore potential for the use of advance care pathways and

opportunities for use of the SPICT tool. Assess benefit of

system wide projectEstablish working group with key clinicians Feb

16

New development activity

Triangulate learning from SIs and complaints relating to

mortality

Themes from Sis and mortality review

disseminated through Divisions. Medical

Director has established a clinical quality board

to enable cross division/trust wide learning. First

meeting ‐23 February 2016

Ensure learning achieved and shared across

organisation ‐ Identify and implement any

process change needed

Pathways and

protocols29‐Feb‐16

Duncan Browne/

Kim O Keefe Amber

Identification of in‐patients with diabetes who are at risk of

hyopgylcaemic episodes. Review data for inpatient

diabetics to understand the scope of required actions and

identify leads and timeframes

Report to be submitted to Feb 16 Emergency

care board

Identification of patients at risk of hypoglycaemic

episodes and appropriate action taken

summary report 1.16.19 (6) trust board...aspiration pneumonitis; food/vomitus 120 35.31 34 17.60%...

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