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					Learning Session 6
NHS LOTHIAN
STORYBOARD
                            NHS Lothian
                            Adverse Event Rate
                                                                                                                    How good is our care and how do we compare?
NHS Lothian
                                                                                                                    The rate for harmful events per 1000 patient days for NHS Lothian is currently 48. According to IHI and
                                             Rate of Adverse Events per 1000 patient days
                                                                                                                    international rates the adverse event (AE) rate should be between 80 and 90 per 1000 patient days.
RIE, WGH & SJH
                         100.0
                                                                                                                    Achieving a reliable baseline is important as the AE rate is an outcome measure for the Patient Safety
                                                                                                                    Program against which we have to achieve a 30% reduction by 2011. The Lothian baseline is currently
                          90.0
                                                                                                                    considerably lower than the standard and therefore the
                          80.0                                                                                      adverse event rate is probably not accurate. IHI undertook a Quality Assurance review in Lothian and
                          70.0                                                                                      Tayside in February and the table shows the Scottish AE rate compared to the US rate. Out of a random
 per 1000 patient Days




                                                                                                                    sample of 110, 85 case notes were found and reviewed with an improved rate of 64/1000 patient days.
                          60.0
                                                                                                   48
                          50.0
                                                                                                                    Is our care getting better?
                          40.0                                                                                      Until we have a robust baseline we are unable to establish whether there has been an improvement or
                          30.0                                                                                      not. A significant improvement is only likely to occur when the SPSP has spread further and a larger
                          20.0                                                       29                             proportion of the clinical areas have implemented the SPSP interventions reliably.
                                                                                                                    The IHI reviewers reported that the standard of multidisciplinary care recorded was good; filing and
                          10.0
                                                                                                                    discharge letters were also of a good standard. Lothian reviewers have noticed an improvement in record
                           0.0                                                                                      keeping and completeness of the SEWS charts and the presence of SPSP activity such as recording of
                                                                                                                    bundle compliance and the use of SBAR.
                           De 7




                           De 8
                                 07




                           Fe 8




                                 08




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                                 09
                           M 8
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                           M 9
                                   9
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                                 07




                           Se 8

                           O 8




                                 08




                           Se 9
                                 09
                           M 8




                           M 9
                                  8




                                  9
                           No 7




                           No 8
                                 0




                                 0
                                -0




                                 0




                                 0
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                                                               Month of Discharge
                                                                                                                    Interpretation
                                                                                                                     If the adverse event rate is not between 80 and 90 per 1000 patient days it is an indication of a problem
                                                                                                                    with:
                                    No Case % case notes Events/ 1000 Events/100 Average                                       • the sample not being random
                                                                                                                               • the reviewers not being appropriately trained about the process
                                     Notes with events     pt days    admissions  LOS                                          • reviewers not being consistent over time,
                         US                        32                       91                45          4.8                  • an experienced medical reviewer reviewing all cases undertaken by first reviewers
                         Sites        795                                                                           Over the last 2 years the monthly random samples were increased to compensate for notes not being
                                                (28-35)                (79-90)              (37-49)     (4.7-5.1)   available which means that the sample was one of convenience. When IHI visited we went to great
                                                                                                                    lengths to obtain all the notes of inpatients in the sample and this made a significant difference to the
                         Scottish                  34                       59                34          5.8       rate.
                         Sites        194
                                                (28-35)                (56-65)              (28-41)     (4.2-7.3)
                                                                                                                    Next steps
                         NHS                                                                                        NHS Lothian is therefore reviewing all the cases missed in the baseline sample to ensure that the
                         Lothian      85           34                     64.3                40          7.3       sample is random and bias has been eliminated. This means that the rate may change and early
                                                                                                                    indications are that it may increase. The monthly sample size is now a maximum of 22 and missing
                                                                                                                    cases are followed up until they are available.
                                                                                                                    Although the IHI review team consider the calibre of the reviewers to be very good, ensuring a consistent
                                                                                                                    review team over time is difficult due to leave and workload pressures. Ensuring that an experienced
                                                                                                                    medical lead is the second reviewer for all cases and that all staff have good training is imperative and is
                                                                                                                    being put in place. The intention is to make AE reviews count towards doctors PSA time
                     NHS Lothian
                     Surgical Safety Checklist
NHS Lothian
                                                Surgical Safety Checklist Compliance & Number of Procedures                                                                                                                                                                                                                   Are we improving?
                                                                                                                                                                                                                                                                                                                              At board level, there has been an improvement in compliance with the surgical pause but it is not yet
                    100                                                                                                                                                                                                                                                                1400
                                                                                                                                                                                                                                                                                                                              reliable. This could partly be due to the rapid increase in new clinical areas participating in the
                     90                                                                                                                                                                                                                                                                                                       programme. This increase is shown in the first run chart between Aug-Sept 09 with a corresponding drop
                                                                                                                                                                                                                                                                                       1200
                     80                                                                                                                                                                                                                                                                                                       in % compliance with the surgical pause.




                                                                                                                                                                                                                                                                                                  Number of Procedures
                                                                                                                                                                                                                                                                                       1000
                     70
                                                                                                                                                                                                                                                                                                                              Is the process reliable?
% compliance




                     60                                                                                                                                                                                                                                                                                                       There has also been a significant improvement at theatre level such as Theatre 10 in chart 2 but this
                                                                                                                                                                                                                                                                                       800

                     50                                                                                                                                                                                                                                                                                                       improvement is not yet at 95% (reliable).
                                                                                                                                                                                                                                                                                       600
                     40

                     30
                                                                                                                                                                                                                                                                                                                              Where has it spread to?
                                                                                                                                                                                                                                                                                       400
                                                                                                                                                                                                                                                                                                                              All the theatres in RIE, WGH and Sick Children’s are testing and improving compliance. St John’s
                     20
                                                                                                                                                                                                                                                                                       200
                                                                                                                                                                                                                                                                                                                              Hospital are testing in 6 theatres. The spread is to three quarters of theatres in the board.
                     10                                                                                                                                                                                                                                                                                                       The Surgical Safety Checklist has now spread out with the theatre environment to Radiology, Endoscopy
                      0                                                                                                                                                                                                                                                                0                                      and Cath labs to name a few.
                              May-08




                                                                                                                                                                  May-09
                                                                                                                                                Mar-09
                                           Jun-08




                                                                                                        Nov-08


                                                                                                                             Jan-09




                                                                                                                                                                           Jun-09




                                                                                                                                                                                                                                     Nov-09


                                                                                                                                                                                                                                                             Jan-10
                                                        Jul-08




                                                                                                                                                                                     Jul-09
                                                                  Aug-08




                                                                                                                                                                                                Aug-09
                                                                                            Oct-08




                                                                                                                                                         Apr-09




                                                                                                                                                                                                                        Oct-09
                                                                               Sep-08




                                                                                                                   Dec-08


                                                                                                                                       Feb-09




                                                                                                                                                                                                            Sep-09




                                                                                                                                                                                                                                               Dec-09


                                                                                                                                                                                                                                                                          Feb-10
                                                                                                                                                                                                                                                                                                                              What are the benefits?
                                                                                                                                                                                                                                                                                                                              As we have no reliable outcome measures such as SSI rates for all areas, we have been using the
       Run chart displaying % compliance with presence of a safety checklist and total                                                                                                                                                                                                                                        feedback information as a form of
       number of procedures from up to 18 theatres/areas within NHS Lothian                                                                                                                                                                                                                                                   outcome measure:                             At patient
                                                                                                                                                                                                                                                                                                                                                                       confirmation, right
                                                                                                                                                                                                                                                                                                                                                                                       wrist band stated
                                                                                                                                                                                                                                                                                                                                                                                       incorrect patient
                                                                 Theatre 10 RIE: Surgical Safety Checklist Compliance                                                                                                                                                                                                                                                                      surname           Essential imaging
                                                                                                                                                                                                                                                                                                                                                                                                             not displayed on
                                                                                                                                                                                                                                                                                                                                                                                                                  PACS
                     100
                                                                                                                                                                                                                                                                                                                                                        Patient name
                      90                                                                                                                                                                                                                                                                                                                                    on list
                                                                                                                                                                                                                                                                                                                                                          incorrect
                      80                                                                                                                                                   74

                      70
     % compliance




                      60
                                                                                                                  48
                      50
                                                                                                                                                                                                                                                                                                                                                                                                                 Case notes still
                      40               38                                                                                                                                                                                                                                                                                                                                                                           on ward;
                                                                                                                                                                                                                                                                                                                                                                                                                 requested and
                      30                                                                                                                                                                                                                                                                                                                                                                                         received after
                                                                                                                                                                                                                                                                                                                                                       Patient booked                                                pause
                                                                                                                                                          5 points above new median, hope to make                                                                                                                                                        for different
                      20
                                                                                                                                                              6 to show significant improvement                                                                                                                                                        procedure as to
                      10                                                                                                                                                                                                                                                                                                                                consent form

                          0
                                  May-08




                                                                                                                                                                            May-09
                                                                                                                 Nov-08




                                                                                                                                                                                                                                                        Nov-09
                                               Jun-08




                                                                                                                                      Jan-09


                                                                                                                                                         Mar-09




                                                                                                                                                                                       Jun-09




                                                                                                                                                                                                                                                                                   Jan-10


                                                                                                                                                                                                                                                                                                                     Mar-10
                                                             Jul-08




                                                                                                                                                                                                   Jul-09
                                                                           Aug-08




                                                                                                                                                                                                               Aug-09
                                                                                                     Oct-08




                                                                                                                                                                                                                                          Oct-09
                                                                                                                            Dec-08


                                                                                                                                                Feb-09
                                                                                        Sep-08




                                                                                                                                                                  Apr-09




                                                                                                                                                                                                                                                                      Dec-09


                                                                                                                                                                                                                                                                                             Feb-10
                                                                                                                                                                                                                            Sep-09




                                                                                                                                                                                                                                                                                                                                                                                                           Patient consented
                                                                                                                                                                                                                                                                                                                                                                                                              for right stent
                                                                                                                                                                                                                                                                                                                                                                                                           removal, surgeons
                                                                                                                                                                                                                                                                                                                                                                                                           wanted to remove
                                                                                                                                                             Month                                                                                                                                                                                                Patient listed for                       stent from left side
                                                                                                                                                                                                                                                                                                                                                                 left eye operation
                                                                                                                                                                                                                                                                                                                                                                  when it was right
                                                                                                                                                                                                                                                                                                                                                                eye being operated
         Run chart displaying significant improvement with presence of a safety checklist                                                                                                                                                                                                                                                                                on
                                       from Theatre 10 RIE
                                                                                                                                                                                                                                                                                                                                                   Issues identified and documented on the WHO Surgical Safety Checklist
                                                                                                                                                                                                                                                                                                                                                                              from NHS Lothian
                                                       NHS Lothian
                                                       Medicines Management
CAA
                                                                                                                                                                                                                                                                                                                              Are we improving?
RIE
                                      Medicines Reconciliation Element Compliance                                                                                                                                                                   Med Rec Compliance by Consultant Group                                    There has been an improvement in medicines reconciliation compliance and a
                                        100
                                                                                                                                                                                                List of meds
                                                                                                                                                                                                                                                                                                                              reduction in the RPN for the insulin process.
                                                                                                                                                                                                                   35
                                            90

                                            80
                                                                                                                                                                                                                   30                                                                                                         How did we achieve this?
                                                                                                                                                                                                                   25
                Percent compliance




                                            70                                                                                                                                                  Two sources        20
                                                                                                                                                                                                                                                                                                                              1. Pharmacy and junior medical staff put the foundations in place by testing and
                                            60
                                                                                                                                                                                                                   15
                                                                                                                                                                                                                                                                                                                              raising awareness
                                            50
                                                                                                                                                                                                                   10                                                                                                         2. Effective front line consultant leadership to engage medical staff
                                            40
                                                                                                                                                                                                Hold/Stop
                                                                                                                                                                                                                    5
                                                                                                                                                                                                comments
                                            30                                                                                                                                                  documented          0
                                                                                                                                                                                                                                                                                                                              3. Senior management support to reinforce & performance manage the process
                                                                                                                                                                                                                                               Group A         Group B                    Group C                 Group D

                                            20
                                                                                                                                                                                                List and                                                                                                                      3. Twice daily review & feedback of med rec compliance by Consultants on call
                                            10                                                                                                                                                  comments
                                                                                                                                                                                                match Kardex                                                                                                                  4. Incorporated into induction and education
                                                0
                                                                                                                                                                                                                                                     Medicines Reconciliation                                                 5. Compliance feedback by consultant led team (Thank you NHS Highland)
                                            28 /09

                                            04 /09

                                            11 /10

                                            18 /10

                                            25 /10

                                            01 /10

                                            08 /10

                                            15 /10

                                            22 /10

                                            01 /10

                                            08 /10

                                            15 /10

                                            22 /10

                                            29 /10

                                            05 /10

                                            12 /10

                                            19 /10
                                                   10
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                                                 2

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                                     21




                                                                                                 Week Beginning                                                                                                                                                                  At least 2 sources                           6. Insulin RPN reduction is due to Medical leadership & MDT working
                                                                                                                                                                                                                                                                                 Signed & dated
                                                                                                                                                                                                                                                                                                                              Outcome
                                                                                                                                                                                                                                                                                Names, dose frequency
                                                                                                                                                                                                                                                                                                                              Testing on one site for med rec and small areas for insulin so no improvement in
                                                                                                                                                                                                                                                                                Any changes made i.e.                         the adverse drug event rate as yet, greater spread and reliability would be
                                                                                                                                                                                                                                                                                drugs stopped on                              required to bring about significant improvement
CAA
RIE                                     Overall Medicines Reconciliation Compliance                                                                                                                                                                                             admission
                                      100
                                                                                                                                                                                                                                                                                                                                            RIE
                                       90                                                                                                                                                                                                                                                                                                                                         Total RPN for the Insulin Process
                                       80
                                                                                                                                                                                                                   RIE, WGH & SJH                                                                                                                                  4000
  Percent compliance




                                                                                                                                                                                                                                                                            Adverse Drug Event Rate
                                       70




                                                                                                                                                                                                                                                                                                                                       Total RPN for the Insulin
                                                                                                                                                                                                                   NHS Lothian
                                                                                                                                                                                                                                                                                                                                                                   3500
                                                                                                                                                                                                                                             80.0
                                       60
                                                                                                                                                                                                                                             70.0          All Adverse Events
                                                                                                                                                                                                                                                                                                                                                                   3000                                           5 or more
                                       50                                                                                                                                                                                                                  ADE Rate
                                                                                                                                                                                                                                                                                                                                                                                                                 consecutive




                                                                                                                                                                                                                                                                                                                                               Process
                                                                                                                                                                                                                                                                                                                                                                   2500
                                                                                                                                                                                                                    Rate per 1000 bed Days




                                                                                                                                                                                                                                             60.0
                                       40                                                                                                                                                                                                                                                                                                                          2000                                             points
                                                                                                                                                                                                                                             50.0
                                                                                                                                                                                                                                                                                                                                                                   1500                                           constantly
                                       30                                                                                                                                                                                                    40.0
                                                                                                                                                                                                                                                                                                                                                                   1000                                         decreasing = a
                                       20                                                                                                                                                                                                    30.0
                                                                                                                                                                                                                                                                                                                                                                   500
                                                                                                                                                                                                                                                                                                                                                                                                                    trend
                                                                                                                                                                                                                                             20.0
                                       10
                                                                                                                                                                                                                                                                                                                                                                     0
                                                                                                                                                                                                                                             10.0
                                            0




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                                                                                                                                                                                                                                                                                                                                                                                                     Month
                                                                                                                    Week Beginning                                                                                                                                                              Month
NHS Lothian
Management of Central Lines
ITU                                                                                                                                                                             Spread                                     ITU
                                                                                      Days between CRBSI                                                                                                                                                                Compliance with CVC Insertion Bundle
WGH                                                                                                                                                                                                                        WGH
                                                                               Current Number of days since last CRBSI = 246
                                                                                                                                                                                The central line bundles are in use in
                                       180                                                                                                                                      all ITUs in Lothian as well as some                        100
    Number of days since last CRBSI




                                       160                                                                                                                                      HDUs, theatres, radiology and                               90

                                       140
                                                                                                                                                                                surgical wards. These four charts                           80
                                                                                                                                                                                refer to pilot ITU to show relationship                     70




                                                                                                                                                                                                                            % compliance
                                       120
                                                                                                                                                                                between process & outcome.                                  60
                                       100
                                                                                                                                                                                Are we improving?                                           50                                                                                              Including lines
                                        80                                                                                                                                                                                                                                                                                                    inserted in
                                                                                                                                                                                                                                            40
                                                                                                                                                                                Days between outcome measure saw
                                        60
                                                                                                                                                                                a significant improvement from                              30                                                                                                  theatre
                                        40                                                                                                                                      Feb’08, but this was not sustained                          20

                                        20                                                                                                                                      due to 2 infections in Jan’09, but from                     10
                                                                                                                                                                                Feb’08 we have shown a change in                             0
                                          0
                                                                                                                                                                                median from 10 to 47. With current




                                                                                                                                                                                                                                                                   8




                                                                                                                                                                                                                                                                                                                      9
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                                                                                                                                                                                                                                                                                                                                                                   0
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                                                                                                                                                                                                                                                                                                                                                  9
                                                                                                                                                                                                                                               08




                                                                                                                                                                                                                                                                                           09




                                                                                                                                                                                                                                                                                                                                                          10
                                                                                                                                                                                                                                                                             8




                                                                                                                                                                                                                                                                                                                                9
                                                                                                                                                                                                                                                                            08




                                                                                                                                                                                                                                                                                                                               09
                                          07




                                                                                                     08




                                                                                                                                                                  09




                                                                                                                                                                                                                                                                -0




                                                                                                                                                                                                                                                                                                                   -0
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                                                   07




                                                                                                              08




                                                                                                                                                                           09




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                                                                                                                            8




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                                                                                                                                              09
                                                                         7




                                                                                                                                      8




                                                                                                                                                                                days since last infection at an all time




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                                                                                                                                                                                high, you can’t help but see the
                                                                  D




                                                                                                                                D




                                                                                                   Date of CRBSI                                                                                                                                                                                      Month
                                                                                                                                                                                improvement. This is shown (below
                                                                                                                                                                                left) as a rate of zero for 7              ITU
ITU                                                                                                                                                                                                                                                                    Compliance with CVC Maintenance Bundle
                                                                                            CRBSI Rate                                                                          consecutive months.                        WGH
WGH
                                        17                                                                                                                                                                                                 100
                                                                                                                                                                                The insertion bundle has been
                                                                                                                                                                                                                                            90
                                        15                                                                                                                                      reliable from early on due to existing
                                                                                                                                                                                practice. The maintenance bundle                            80
 Rate per 1000 bed Days




                                        13
                                                                                                                                                                                wasn’t great to start but improved                          70




                                                                                                                                                                                                                            % compliance
                                        11                                                                                                                                      significantly, was sustained and is                         60                                                                                          Monthly
                                                                                                                                                                                now reliable.
                                         8                                                                                                                                                                                                  50                                                                                         Monitoring
                                                                                                                                                                                                                                            40
                                         6                                                                                                                                      Both process measures changed to
                                                                                                                                                                                monthly monitoring once reliability                         30
                                         4
                                                                                                                                                                                was achieved to allow focus on other                        20
                                         2                                                                                                                                      areas, this has seen measured                               10

                                         0
                                                                                                                                                                                compliance more variable but has not                         0
                                                                                                                                                                                deviated significantly from the



                                                                                                                                                                                                                                                        08




                                                                                                                                                                                                                                                                                                                   09
                                                                                                                                                                                                                                                                 08




                                                                                                                                                                                                                                                                                                                              09
                                                                                                                                                                                                                                                8




                                                                                                                                                                                                                                                                              8




                                                                                                                                                                                                                                                                                                          9




                                                                                                                                                                                                                                                                                                                                        9
                                                                                                                                                                                                                                                                                                09




                                                                                                                                                                                                                                                                                                                                                            10
                                                                                                                                                                                                                                                                                        8




                                                                                                                                                                                                                                                                                                                                                    9
                                                               8




                                                                                                                         9
                                                    8




                                                                                                              9




                                                                                                                                                                          0
                                                                                             8




                                                                                                                                                         9
                                           08




                                                                                                     09




                                                                                                                                                                 10
                                                                         8




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                                                                                      N




                                                                                                                                               N




                                                                                                                                                                                moved for insertion bundle as well                                                                                    Month
                                                                                                          Month
                                                                                                                                                                                which now includes data from lines
                                                                                                                                                                                inserted in theatre
                 NHS Lothian
                 Hand Hygiene
General Ward Areas                                                                                                                                                                                                           RIE, WGH & SJH
                                            Hand Hygiene Compliance Vs Number Observed                                                                                                                                                                            SAB per 1000 days
NHS Lothian
                                                                                                                                                                                    Are we improving?                        NHS Lothian
                100                                                                                                                                       2000
                                                                                                                                                                                                                                                           0.80
                 90                                                                                                                                       1800
                                                                                                                                                                                    At time of writing in NHS Lothian we
                                                                                                                                                                                    have recorded 88,530 Hand Hygiene                                      0.70
                 80




                                                                                                                                                                                                                              Rate per 1000 bed days
                                                                                                                                                          1600
                                                                                                                                                                                    observations. The data for General                                     0.60




                                                                                                                                                                 Number Inspected
                 70                                                                                                                                       1400                      Ward areas on the three acute sites is
% compliance




                                                                                                                                                                                                                                                           0.50
                 60                                                                                                                                       1200                      shown on the left. This has shown a
                 50                                                                                                                                       1000
                                                                                                                                                                                    significant and sustained improvement                                  0.40
                                                                                                                                                                                    in compliance since Oct 07. This has
                 40                                                                                                                                       800                                                                                              0.30
                                                                                                                                                                                    been alongside a significant increase
                 30                                                                                                                                       600
                                                                                                                                                                                    in the number of observations carried                                  0.20

                 20                                                                                                                                       400                       out, where we might expect this to                                     0.10
                 10                                                                                                                                       200
                                                                                                                                                                                    have had a negative impact on overall
                                                                                                                                                                                    results.                                                               0.00
                     0                                                                                                                                    0




                                                                                                                                                                                                                                                                   7




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                                                                                                                                                                                                                                                                 0
                                                                                                                                                                                    Compliance by staff group, shows




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                O 8




                O 9
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                Au 9
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                      08




                      09




                      10
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                D 8




                D 9
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                      0
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                     -0




                     -0
                    -0




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                                                                                                                                                                                    medical staff as the lowest compliance
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                                                                                                                                                                                                                                                                             Month
                O




                                                                                                                                                                                    however the gap has narrowed
                                                                                                                                                                                    considerably and they started at a       RIE, WGH & SJH
                                           Overall Compliance by Staff Group                                                                                                        much lower point so have made the                                                 Cdiff rate
                                                                                                                                                                                                                             General Ward Areas
               100                                                                                                                                                                  greatest improvement of all
                                                                                                                                                                                                                                                           2.50
                95                                                                                                                                                                  While the improvement in compliance
                90                                                                                                                                                                  is a great achievement in itself, it




                                                                                                                                                                                                                                  Rate per 1000 bed Days
                                                                                                                                                                                                                                                           2.00
                85                                                                                                                                                                  would be even better to have a visible
% compliance




                80                                                                                                                                                                  improvement in outcomes.
                                                                                                                                                                                                                                                           1.50
                75                                                                                                                                       AHP                        The only marker we have for
                70                                                                                                                                       Medical                    outcomes are SABs and C.Diff, both                                     1.00
                65                                                                                                                                       Nursing
                                                                                                                                                                                    of which have show significant
                60                                                                                                                                                                  improvements within general ward
                                                                                                                                                         Other Staff                                                                                       0.50
                55                                                                                                                                                                  areas as well as across Lothian.
                                                                                                                                                         Overall Score
                                                                                                                                                                                    Theses reduction are undoubtedly
                50
                                                                                                                                                                                    due to many factors, but Hand                                          0.00
                                                             Jun-08




                                                                                                                   Jun-09
                                                                      Aug-08




                                                                                                                            Aug-09
                         Oct-07


                                           Feb-08
                                                    Apr-08




                                                                               Oct-08




                                                                                                          Apr-09




                                                                                                                                     Oct-09
                                  Dec-07




                                                                                        Dec-08
                                                                                                 Feb-09




                                                                                                                                              Dec-09
                                                                                                                                                       Feb-10




                                                                                                                                                                                    Hygiene does play an important role




                                                                                                                                                                                                                                                                   7




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                                                                                                                                                                                                                                                           M 8




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                                                                                                                                                                                                                                                           M 0
                                                                                                                                                                                                                                                           Se 7




                                                                                                                                                                                                                                                           Se 8




                                                                                                                                                                                                                                                           Se 9
                                                                                                                                                                                                                                                           N 7




                                                                                                                                                                                                                                                           N 8




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                                                                                                                                                                                                                                                                -0




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                                                                                                                                                                                                                                                            Ju




                                                                                                                                                                                                                                                            Ju
                                                                                                                                                                                    in the reduction of infection.                                         Ja
                                                                                                                                                                                                                                                                             Month
                                                                                        Month
                     NHS Lothian
                     Deteriorating Patients
NHS Lothian                                                                                                                                                                         RIE, WGH & SJH
                                         SEWS compliance & number inspected                                                                Are we improving?                                                                                                 SEWS Intervention Compliance
                                                                                                                                                                                    NHS Lothian
                 100                                                                                             7000                      Compliance with completion of
                                                                                                                                                                                                                           100
                     90
                                                                                                                                           accurate SEWS scores has been
                                                                                                                                                                                                                            90
                                                                                                                 6000                      monitored for some time now, but at
                     80                                                                                                                                                                                                     80
                                                                                                                                           board level we have not seen




                                                                                                                        Number Inspected
                                                                                                                 5000
                     70                                                                                                                    statistically significant improvement,                                           70




                                                                                                                                                                                     % compliance
% compliance




                     60                                                                                                                    this is in part due to the increasing                                            60
                                                                                                                 4000

                     50
                                                                                                                                           number of areas involved in the                                                  50
                                                                                                                 3000
                                                                                                                                           monitoring of SEWS so improvement                                                40
                     40
                                                                                                                                           made by pilot areas is masked by                                                 30
                     30                                                                                          2000                      new areas coming on board.
                                                                                                                                                                                                                            20
                     20
                                                                                                                 1000
                                                                                                                                           An external audit repeating an audit                                             10
                     10                                                                                                                    of SEWS 2 years ago has confirmed                                                 0
                      0                                                                                          0                         improved compliance with SEWS.




                                                                                                                                                                                                                                             9




                                                                                                                                                                                                                                                                                                                                               0
                                                                                                                                                                                                                                                                                                      9
                                                                                                                                                                                                                                                     09




                                                                                                                                                                                                                                                                                                                            10
                                                                                                                                                                                                                                                                        09
                                                                                                                                                                                                                                                                9
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                                                                                                                                                                                                                                                                                            9




                                                                                                                                                                                                                                                                                                                                     10
                                                                                                                                                                                                                                                                                 09




                                                                                                                                                                                                                                                                                                                    9
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                                                                                                                                                                                                                                                                                                                 -0
                           Aug-08




                           Aug-09




                                                                                                                                                                                                                                                   n-




                                                                                                                                                                                                                                                                                                                          n-
                            Apr-08

                           Jun-08
                            Jul-08




                            Apr-09

                           Jun-09
                            Jul-09




                                                                                                                                                                                                                                                                      g-
                           May-08




                           Sep-08

                           Nov-08




                           Mar-09




                           Mar-10
                           Jan-09
                           Feb-09



                           May-09




                           Sep-09

                           Nov-09

                           Jan-10
                           Feb-10




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                           Oct-08

                           Dec-08




                           Oct-09

                           Dec-09




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                                                                                                                                                                                                                                                                                                                                 Fe
                                                                                                                                           Local examples of sustained




                                                                                                                                                                                                                                                                             Se


                                                                                                                                                                                                                                                                                      O




                                                                                                                                                                                                                                                                                                                                          M
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                                                                                                                                                                                                                                                                                                N


                                                                                                                                                                                                                                                                                                          D
                                                                                                                                           reliability are available such as in                                                                                                       Month
                                                                                                                                           Ward 108, below left.
108                                                                                                                                                                                 24
                                                 SEWS Compliance                                                                           Although 40 wards are improving                                                                                Deteriorating patients admitted to CCU
RIE                                                                                                                                                                                 SJH
                                                                                                                                           reliability it is too early for
                      100                                                                                                                                                                                                 18.00
                                                                                                                                           improvements at ward level to lead




                                                                                                                                                                                        Count of deteriorating patients
                          90                                                                                                                                                                                              16.00
                                                                                                                                           to improvement in a high level
                          80                                                                                                               outcome measure such as board                                                  14.00
                          70                                                                                                               wide crash call rate, however
      % compliance




                                                                                                                                                                                                                          12.00
                          60                                                                                                               increased compliance with SEWS
                                                                       10 points over baseline                                                                                                                            10.00
                          50                                             median = sustained                                                has led to better management of
                                                                            improvement                                                    deteriorating patients at St John’s                                             8.00
                          40
                                                                                                                                           Hospital Ward 24 where there are                                                6.00
                          30
                                                                                                                                           lower numbers of patients being
                                                                                                                                                                                                                           4.00
                          20                                                                                                               admitted with high SEWS suggesting
                                                                                                                                                                                                                           2.00
                          10                                                                                                               they are being detected earlier and
                           0                                                                                                               better managed downstream.                                                      0.00




                                                                                                                                                                                                                                                                                        9




                                                                                                                                                                                                                                                                                                                            10
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                                           9
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                                                                                                                        0
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                                                                       9




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                                                                                                                                                                                                                                                                                     -0
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                                                                                                                                           Next steps




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                                                            Month                                                                          A working group of key stakeholders                                                                                                        Month
                                                                                                                                           is being set up to improve the
                                                                                                                                           reliability of escalation and response
                                                                                                                                           to deteriorating patients using TOC
                                                                                                                                           and MDT simulation training.

				
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