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					The Scottish
Patient Safety
Programme



        Learning Session 5
     Title of the session & name of
          NHS Lanarkshire
                  faculty
          Core Team Members
Work stream      Executive Sponsor                  Team Leader
Medicines        Paul Wilson, Director of           Christine Gilmour, Head of
management       Nursing, Midwifery and AHP         Pharmacy Services

Critical Care    Rosemary Lyness, Director of       Rory MacKenzie, Consultant
                 Acute Services                     Anaesthetist


Leadership       Alison Graham, Medical Director Alison Graham, Medical Director


Peri operative   Rosemary Lyness, Director of       Jane Burns, Associate Medical
Care             Acute Services                     Director

                                                    Joan James, Divisional Nurse
General Wards    Paul Wilson, Director of Nursing   Director, Acute Services
    Your Aims and Programme Goals                       (Place a
    check mark next to any goals you have already achieved)


   Mortality: 15% reduction
   Adverse Events: 30% reduction
   Ventilator Associated Pneumonia: 0 or 300 days
    between
   Central Line Bloodstream Infection: 0 or 300 days
    between
   Blood Sugars w/in Range (ITU/HDU): 80% or > w/in
    range
   Staph Aureus Bacteraemias: 30% reduction
   Crash Calls: 30% reduction
   Harm from Anti-coagulation: 50% reduction in ADEs
   Surgical Site Infections: 50% reduction (clean)
   All process measures will be reliable at the 10-2 level
    (defects in the parts per 100) (???)
Critical care

           monitoring , ease of use – all
           bundles and monitoring on one
           sheet



               Hand hygiene, PVC and Central
               line – numerous initiatives and
               staff ownership
       Critical Care – achieving results
                                     Hairmyres Central line insertion   Hairmyres central line Infections


Working together
•Leadership – focus on shifting
in the right direction
•Communication has been vital –
excellent use of teleconferencing
for all three units
•Surveillance Nursing staff in        Wishaw MDT Rounds + other
place for education, surveillance     contributory bundle factors        Wishaw ICU / HDU ALOS
and using data for improvement
•Regular team review of data
•Integrated working with HAI
teams, SPSP and frontline staff –
integrate wherever possible and
target resources
•Infections treated as adverse
incidents                            Monklands PVC Compliance           Monklands SABs
•Education and training for all
HCW
                                    Wishaw ICU / HDU ALOS
•Identification of champions
•Spreading to other areas using
Critical Care Champions
Critical Care – reducing
infection


           Reducing Infection
           Attention to Detail
           Implementation of bundles
           Using data for
           improvement
           Team buy in
           Multi Disciplinary input
           Integration with other
           priorities


           Treat every infection as an
           adverse event
                               This is key
                 Critical Care – the tools of the trade!



                                        Feedback &
                                                     Info out
                 All on one checklist
                                        education
Data coming in




                                                                Info out
                                        Info out




                                                     Info out
General Ward

                             Compliance, education
                             monitoring, pre requisite
                             for Emergency care Team



                              Team approach,
                              integration key, absolute
                              buy in and ownership,
                              loads of initiatives, high
                              profile




                   Strength of teams
                    has been vital, especially noted
                   in relation to safety brief and HAI




    Data management and review, SBAR,
    incident reporting, DATIX, verifiers, full
    risk management guidance, succession
    planning.
            General wards – achieving high
            level aims

                            A range of measures
                            •No single approach – has to be achieved by
                            combining relevant processes

Safety Briefs:              •Strategic and operational priority
 an excellent               •Using safety briefs to get the message across and
 opportunity
 to reinforce               ownership
patient safety
 aims within                •Integrated working with HAI teams, SPSP and
general wards               frontline staff – integrate wherever possible and
                            target resources
                            •Education and training for all HCW
                            •Identification of champions
                            •Systematic spread, underpinned by continual
                            testing and monitoring
                            Single biggest success factor
                            Staff themselves – ownership at all levels in the
                            organisation from strategic leadership by executive
                            team right through to frontline clinical staff
General Wards-Reducing SABs
SABs per 1,000 bed days Monklands Hospital (inc ITU, HDU & renal)


Process Measures                           Outcome Measure



               Not being sustained,
               begin sequence of
               improvement again                                 PVC bundle testing
                                                                 reinstated
                   Refocus




                                      Monklands Hospital Aggregated Data
                                                                     Sustaining
                                      PVC compliance not sustained, it was improvement to
                                                                            necessary
                                      review and begin sequence of improvement again
                                      Challenge:
                                      Do not lose momentum, but use data and evidence to
                                      refocus and energise
                                      Lesson learned:
                                      Do not be afraid to stop, reflect, take stock and begin
                                      again
Changes to Prescribing
CDAD Bundle
NHS Lanarkshire
Clostridium difficile associated disease (CDAD) Bundle
Cross-transmission minimisation bundle
Guidance Notes:
      Bundle should be commenced for all confirmed CDAD patients within 24 hours of referral from Infection Control Team or prior to this if already known
      If patient still symptomatic after 7 days, this data should be recorded again on next week’s form
      One form should be completed for each patient
      All 5 components MUST be answered (Yes or No) to produce accurate compliance rates
      If Yes to all 5 questions - optimal management care of CDAD has been achieved
      The week will run from Monday to Sunday
      Reports should be submitted electronically to gillian.airns@lanarkshire.scot.nhs.uk at Clinical Effectiveness each Monday before 12noon with any data recorded the
       previous week
Hospital
Acute: ---                Community:       ---         Ward: ---        Other:                  Date bundle carried out:

       Isolating CDAD patients in a                                       Checking all HCWs remove PPE
                                        Reviewing antibiotic regimens                                          Checking that the patient's    Ensuring HCWs perform hand
     single room with either en suite                                      (gloves and aprons) after each
                                           and stop inappropriate                                           immediate environment has been     hygiene with liquid soap and
         facilities, or an allocated                                       CDAD patient care activity and
                                                 antibiotics                                                  cleaned today with a chlorine    water when leaving a CDAD
     commode, until they are at least                                       before leaving patient’s room
                                                                                                                     based solution                   patient's room
          48 hours symptom free

          Yes          No                        Yes        No                   Yes         No                  Yes           No                  Yes          No



   Reasons / factors that influenced any non-compliance:
   Non-availability of:
        Single room
                                           Drs to review drugs               PPE (gloves and aprons)            Cleaning products                Hand hygiene products
        Commode
   Other:
       Staff knowledge                            Staffing resources:        Nursing      Domestic

Specify any other reasons:

Were patient/relative information leaflets given?
Suggestions for improvements in practice to achieve optimal care:




Completed by:
             Clostridium Difficile




Achieved by:-
•Strategic leadership
•Ongoing review of data
•Identification of all processes
•Education
•Antibiotic prescribing practice
•Integrate with other priorities and initiatives
•Hand hygiene compliance
•Ownership and determination
Team working – everyone's business                 This is key
                                                                                                                      Team effort

                        General Ward
                       tools (we’ve remained busy!)


                                                                 PVC
                                                                   Other initiatives –
                                                                   visitors ‘meet and
                                                                       greet’, visual                     SBAR REPORTING
                                                                       reminders –
                                                                    ‘cardboard staff’    SBAR       ATTENTION ALL TEAM MEMBERS
                                                                   bearing messages,                WDGH General Ward Workstream
                                                                      flashing signs
                                                                                                    SITUATION
                                                                                                    This is……………………………………………………….
                                                                                                S   Calling from………………………………
                                                                                                    Regarding patient………………………………Do you know this patient?
                                                                                                    Admitted with……………………….On……/………/………
                                                              Hand hygiene                          I am concerned regarding this patient
                                                                                                    because………………………………........................................................

                Safety brief                                                                    B   BACKGROUND
                                                                                                    This is a new / old concern
                                                                                                    Patients MEWS score is……………………….
                                                                                                    Changes/Concerns with their observations are
                  PATIENT SAFETY BRIEF                                                              …………………………………………………………………………………
                      W/E – 16/11/08
                                                                                                    Comments regarding:
MONDAY                                                                                              Pain      Cyanosis     O2 requirement    Change in mental status
Fire lectures today
Nurse on night duty moved to ward 15                                                                   IV Access
Cleaning- All staff responsibility not just CSW                                                     Any relevant PMH……………………………………………………………
Bear hugger missing again – Amina to action
TUESDAY
                                                                                                    I have done…………………………………………………………………………
Pts notes found in sub waiting area by another pt
Jennifer at ward 8 2100 -2230                                                                   A   ASSESSMENT
Stacy at ECU 0530-0630
Ventilators unplugged – please be vigilant
                                                                                                    I think the problem is………………………………………..
GC – suggested a screen at minors waiting area – GC to
action
Remember pain score and MEWS on care plan                                                           I feel the patient is at risk of deteriorating further and requires
Lorazepam remains an issue – Datix completed                                                        review
Bear Hugger at manufacture for repair.
WEDNESDAY
Eclamsia box in resus- top of dda cupboard                                                      R   RECOMMENDATION
Fire service out for burnt toast during night. FINAL WARNIN                                         I need this patient to be reviewed
THURSDAY
Adam at ward 4 730-1130                                                                             by…………………………………..Immediately / within the next 30 minutes
DR at meeting – no pts details to be left lying around.                                             / as soon as you are able.
FRIDAY
Equipment – OK
                                                                                                    Do you need me to do anything further in the interim period?
Medicines Management


         MDT approach, very valuable
         information and resultant
         ownership – patient focus. Now
         testing process with other high
         risk areas


                Triangulation the key to
                success
                Discussion with patient
                Use of Emergency Care
                Summary
                Patients’ own drugs
                Integration with other
                initiatives such as LEAN
               Anticoagulants
                                   Information transfer
                                   Has the patient been
Risk Assessment                    educated?
   Risk assessment tool                                             Results
          Repeat RPN by          Has the patient’s yellow book    •Completion of inpatient
           46% in year 2           been fully completed?             documentation
   Dispensing – pan NHSL                                            •Patient Education
   Prescribing / Administration   Does the patient know the        •Information transfer at discharge
    – site specific                dose of Warfarin to take until
                                   their next blood test?            •Anticoagulant book completion
   Multidisciplinary Group
                                                                     •Follow up
                                    Does patient know date and         Hairmyres % INRs > 6
                                   time of next INR check?
Education                                                               (All three hospitals displaying excellent INR
Three different structures                                                  results for all categories)
                                      Stickers – empower patients
   Education Checklist
                                       Patients view
Patients identified in clinical
areas                                  ‘Having someone go over
                                       this book with me in person
Dispensaries check if educated        has really cleared up the
when dc Rx arrives                     questions I had from
                                       reading the book earlier.”
          Medicines reconciliation

Three way process:
                                An ongoing challenge
   Discussion with             Continued focus required
    patient
   Use of Emergency            Tendency to be seen as a
    Care Summary                pharmacy driven and
   Patients’ own drugs         owned initiative
                                Huge effort made
Documentation and
   planning:                    Starting to improve
                                ownership
   Recording the
    whole audit trail
   Initial focus               Next steps
   Spread                      Link with other quality
   Everyone's                  initiates such as LEAN –
    responsibility              early results looking
                                promising
             Medicines management tool example
Medicines Reconciliation
             Medicines Reconciliation
             Page
             Includes plan: -


             • continue
             • withhold
             • discontinue
Peri - operative

                             Simple measures –
                             remove razors,
                             education and pre
                             assessment education




           Surgical pause buy in from all,
           success breeds success, education,
           champions, used to collect other
           necessary information, DVD formed
      Communication - a wide range of
      initiatives
Theatre and Day Surgery Progress Board




                                Ownership
                                of data
             DVT Prophylaxis
                                                     PDSA Cycle – not climbing a mountain – instead rapid
                                                     change!
Ongoing Work – understanding data                      Change 8: refine questions to ensure capturing
through PDSA                                           data
                                                      Change 7: Protocol being spread out to all other
                                                      theatres with new format
                                                       Change 6: Local Interim Protocols
                             Now getting
                                                       established for theatres 1,2,3 and 4
                             an accurate
                             picture?                  Change 5: Tests of change

                             Refining the              Change 4: Training sessions
                             question
                                                       Change 3: Local group within MK
                                                       set up to agree protocol for TED’s
                         Asking the wrong question
                                                      Change 2: Recommendations
                                                      not filled out by medical staff
                                                      e.g. Prescription for TED’s
                                                      Change 1: Determine how many
                                                      surgical patients in theatre 2
                                                      received DVT Prophylaxis
              Surgical Pause and Brief


 Surgical Pause a Great Success            Surgical brief a slower start!

 Surgical Pause




                         WHO Cares!
                            WE do.
                                                      Identification of
Excellent Compliance and in ALL theatres              Champions
Normothermia
               Visual reminder (designed by staff
               member Diane Ritchie)

                           Normothermia




                   X               X


                            Normothermia
                             throughout
                       the Perioperative Period
Leadership

       Data base development for run charts and
       compliance as well as walk rounds




             Excellent executive and senior clinical
             ownership to drive programme forward and
             embed in organisational culture
    Major Challenges and Barriers

   Programme resources for managing spread, data
    management and analysis

   Ensuring integration with national and operational
    priorities
Help Needed Please!
Critical Care:

General ward:

Medicine Management: How do others manage
  multidisciplinary buy in?

Peri – operative:

Leadership:
And Lastly
   During the day 1 afternoon breakouts
    there will be a storyboard learning
    event. Please nominate someone from
    each of your workstreams and ask that
    they be prepared to present their work
    on your board’s storyboard and share
    their tools.

				
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posted:12/5/2011
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