Nursing and Midwifery Report

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					                                                                                                                 Agenda item: 9.2.1
                                                                                                                Paper No: TB(09)73


                                                Nursing and Midwifery Report



1.0 Infection Control

1.1 MRSA


                 Number of MRSA bacteraemias per month (> 48 hour and < 48 hours after admission) since
                                                  December 2006



                      20
                             GICU cohorting stopped
                             Jan 07
                      18
                                     DH visit
                                     Feb 2007
                      16
                                      New RCA
                                      system March 2007
                      14
                                            MRSA decolonisation
                                                                                                                   Non-trajectory
                      12                    for all patients May 2007
                                                                                                                   < 48 hours
                                                  Strict antibiotic guidelines
                                                  introduced Trustwide June 2007                                   > 48 hours
  number of infections 10
                                                                                                                   trajectory
                                                      Rapid PCR test
                         8                            introduced for ITUs July 2007
                                                                            Rapid PCR for all emergency
                         6                                                  admissions Nov 2007 to April 2008


                         4


                         2


                         0
                      Ju -07




                      Ju -08




                      Ju -09
                      Fe -07




                       Ju 07

                      Se -07
                      O -07




                      Fe -08




                       Ju 08

                      Se -08
                      O -08




                      Fe -09




                       Ju 09
                      Ja -06




                      M r-07
                      M -07
                      Ap -07




                      D -07
                      Ja -07


                      M -08
                      Ap -08
                      M r-08




                      D -08
                      Ja -08



                      Ap -09
                      M r-09
                      Au l-07




                      Au l-08




                      M -09




                              9
                      N -07




                      N -08




                          l-0
                         n-




                         n-




                         n-
                        ay




                        ay




                        ay
                         n




                         g
                         p




                         n




                         g
                         p




                         n
                       ec




                       ov
                       ec




                       ov
                       ec
                         b




                         b




                         b
                        ar




                        ar




                        ar
                        ct




                        ct
                     D




                                                                               month




Cases of MRSA bacteraemia remain within the trajectory set. Each case is
reviewed using root cause analysis. Of the cases identified in the last six months,
many were patients with long standing chronic illness or wounds and/or long
standing colonisation with MRSA. However, with the recent emphasis on
screening and decolonisation, in future the number of patients with long term
colonisation will be fewer and consequently there will be fewer of these cases of
bacteraemia.




                                                                                      1
                                                                                                                                                            Agenda item: 9.2.1
                                                                                                                                                           Paper No: TB(09)73

1.2 Clostridium Difficile

                    Monthly number of attributable cases of Clostridium difficile infection at St George's Hospital 2009-10 with monthly
                                 mandatory and aspirational targets and monthly totals from 2008-09 at 30th June 2009


 25




 20




 15
                                                                                                                                                            2009-10
               12
                                                                                                                                                            2008-09

 10                                                                                                                                                         mandatory target
                                                 8                                       8                                           8                      09-10
                                                                                                      7                                       7             aspirational target
                                     6                                                                                                                      09-10
                     5 5                                                                                                    5
 5                              4                                           4                                      4
           3                                                   3



                                             0             0            0            0            0            0        0        0        0
 0
          Apr-09    May-09     Jun-09        Jul-09       Aug-09    Sep-09       Oct-09       Nov-09          Dec-09   Jan-10   Feb-10   Mar-10




                    Cumulative number of attributable cases of Clostridium difficile infection at St George's Hospital shown with cumulative
                                               mandatory and aspirational targets for 2009-10 at 30th June 2009


 250




 200




 150

                                                                                                                                                                       mandatory target
                                                                                                                                                                       aspirational target
                                                                                                                                                                       2009-10
 100




  50




      0
           Apr-09     May-09        Jun-09       Jul-09        Aug-09       Sep-09       Oct-09       Nov-09       Dec-09   Jan-10   Feb-10       Mar-10




Cases of Clostridium Difficile also remain within both the mandatory and
aspirational targets, with fewer cases than the corresponding months last year.




                                                                                                          2
                                                                  Agenda item: 9.2.1
                                                                 Paper No: TB(09)73


1.3 Deaths

Information regarding cause of death is organised on the death certificate as
follows:

Part 1a – the condition that killed the patient
Part 1b – what caused the patient to get the condition that actually killed them
Part 1c – what led to the condition that caused the death

Part 2 – other conditions that were present, that might have contributed to the
death, but did not kill the patient

   MRSA             1a           1b            1c            2                Total
 April 2008          0            0             0            0                 0
    May              0            0             0            0                 0
    June             0            0             0            0                 0
    July             1            0             0            0                 1
   August            0            0             0            0                 0
 September           0            0             0            0                 0
  October            0            0             0            0                 0
 November            0            0             0            0                 0
 December            0            0             0            0                 0
  January            0            0             0            0                 0
  February           1            0             0            0                 1
   March             0            0             0            0                 0
    April            0            0             0            0                 0
    May              0            0             0            0                 0
    June             1            0             0            0                 1
                (community
                 acquired)


    C diff         1a             1b                1c             2            Total
 April 2008         0              0                 0             1             1
    May             0              0                 0             3             3
    June            0              0                 0             1             1
    July            0              0                 0             0             0
   August           0              0                 0             0             0
 September          0              0                 0             0             0
  October           0              1                 0             0             1
 November           0              0                 0             1             1
 December           0              0                 0             0             0
  January           0              0                 0             0             0
  February          0              0                 0             0             0
   March            0              0                 0             0             0
    April           0              0                 0             0             0
    May             0              0                 0             0             0
    June            0              0                 0             1             1
                                                           (later found to
                                                              be a false
                                                           positive result)



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                                                                              Agenda item: 9.2.1
                                                                             Paper No: TB(09)73

There have been two reported deaths involving MRSA and/or C diff in the last
month. In one case, a patient died who had been admitted already having MRSA
bacteraemia. In another case, a patient who died of other causes was believed to
also have Clostridium Difficile, but after the completion of the death certificate, a
confirmatory test was shown to be negative. The patient therefore did not have C
diffcile but the certifying Doctor would not have been aware of this when the
certificate was written.


1.4 Swine Flu
The Trust has a robust plan in place to deal with cases of swine flu. This is being
reported in more detail elsewhere. To date there have been 8 patients with
swine flu who required admission, there has been no transmission of swine flu to
other patients in the Trust, and there have been no deaths as a result of swine
flu. The need to isolate patients with suspected swine flu, plus the ongoing need
to try and isolate patients with other infections, is challenging given the relatively
low proportion of single rooms in the hospital.


2.0 Pressure Sores

Figure 1 Number of pressure ulcers
(all grades; 2009 data extrapolated)


          700
          600
          500
          400
          300
          200
          100
           0
                1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009


Red = hospital acquired
Blue = admitted with




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                                                                   Agenda item: 9.2.1
                                                                  Paper No: TB(09)73


Figure 2 Incidence as a percentage of all admissions (all grades)

       2.5

         2

       1.5

         1

       0.5

         0
             1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008



Incidence of pressure ulcers is seen as an indicator of the quality of nursing care.
The system of pressure ulcer prevention at St Georges is managed by Dr
Krzysztof Gebhardt, Clinical Nurse Specialist, who has a national reputation in
pressure ulcer prevention. Figure 1 indicates that over the years the number of
hospital acquired pressure ulcers has reduced, but the number of patients
admitted with pressure ulcers is increasing. Figure 2 shows the incidence of
pressure sores as a percentage of all admissions. Figure 3 shows the number of
serious, deep pressure ulcers, which also indicates an increase in the number of
patients being admitted with deep pressure ulcers. Figure 3 also shows that in
2008 there was a small increase in deep pressure ulcers acquired in the Trust,
after several years of showing a steady reduction. This was investigated and was
believed to be due to a change in the system of mattress delivery following a
change in personnel, and higher incidence of patients moving between wards as
a result of emergency bed pressures, resulting in mattresses not being provided
quickly enough, particularly out of hours. These problems have been resolved
and pressure ulcers in 2009 (figure 4) appear to be back to the levels of the
previous year. Pressure ulcer numbers on individual wards are closely
scrutinised at the Nursing Board, and each patient with a hospital acquired deep
pressure ulcer is individually reviewed by the clinical nurse specialist and lessons
fed back to ward teams.

Good assessment by nursing staff is essential, but at the corporate level,
ensuring that there are sufficient low pressure mattresses and that there are
good processes for maintenance, cleaning and rapid delivery to ward areas are
important factors in an efficient organisational system of managing pressure
ulcers.




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                                                                                    Agenda item: 9.2.1
                                                                                   Paper No: TB(09)73


Figure 2 Numbers of deep pressure ulcers


  120
  100
    80
    60
    40
    20
     0
       95

              96

                     97

                            98

                                   99

                                          00

                                                 01

                                                        02

                                                               03

                                                                      04

                                                                             05

                                                                                    06

                                                                                           07

                                                                                                  08
     19

            19

                   19

                          19

                                 19

                                        20

                                               20

                                                      20

                                                             20

                                                                    20

                                                                           20

                                                                                  20

                                                                                         20

                                                                                                20
                                                                                                       R
Red = hospital acquired
Blue = admitted with

Figure 4 Number of deep pressure sores per quarter




3.0 Patient Satisfaction

Patient experience, and indicators of patient satisfaction are reviewed at the
Patient Issues Committee. Following the receipt of results of the 2008 patient
survey (reported in detail at the May Board meeting), the Patient Issues
Committee identified a number of specific areas for improvement, based on
those areas where the Trust scored in the bottom 20% of Trusts, and those
where the Trusts scores were in the middle 60%, but felt that there was room for



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                                                              Agenda item: 9.2.1
                                                             Paper No: TB(09)73

improvement. The questions prioritised for improvement are shown in the Table
below, and these have also been chosen as the priorities within the patient
satisfaction “CQUIN” measure. The next stage will be for the leads in each area
to develop action plans and indicative measures of progress for each question.

Table One

Question/Area                  2008 Score      Executive Lead     Operational
                                                                  Lead
Did you ever use the same      61%             Director of        Divisional
bathroom or shower area                        Nursing            Directors of
as patients of the opposite                                       Nursing within
sex?                                                              each divison
How clean were the toilets     76%             Director of        Jenni Doman
and bathrooms that you                         Estates
used in hospital?
Did you feel threatened        95%             Chief Operating    Mary Sheerin
during your stay in hospital                   Officer
by other patients or
visitors?
When you had important         77%             Director of        Zoe Packman
questions to ask a nurse,                      Nursing
did you get answers you
could understand?
Did you have confidence        83%             Director of        Zoe Packman
and Trust in the nurses                        Nursing
treating you?
Did the nurses talk in front   83%             Director of        Zoe Packman
of you as if you were not                      Nursing
there?
Did you feel that you were     66%             Director of        Adrian McCourt
involved in decisions about                    Transformation
your discharge from
hospital?
Were given written             64%             Director of        Adrian McCourt
information about what you                     Transformation
should do after discharge?
Did hospital staff explain     83%             Medical Director   Chris Evans
the purpose of the
medicines you were to take
home?
Did a member of staff tell     46%             Medical Director   Chris Evans
you about medication side
effects to watch for?
Were you told how to take      85%             Medical Director   Chris Evans
your medication in a way


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                                                                  Agenda item: 9.2.1
                                                                 Paper No: TB(09)73

you could understand?
Were you given clear           76%                Medical Director    Chris Evans
written information about
your medicines?



4.0 Maternity Services Improvements

The attached summary shows the current position against the indicators within
the maternity services improvement project. There are currently 2 areas of
concern:

Indicator Nine: The percentage of women booked by 12 weeks + 6 days has
increased since we implemented a new approach and additional weekend clinics,
however we are still not at the target level of 80%. We are continuing to increase
appointment capacity and are working in conjunction with the PCT, to encourage
women to refer themselves earlier. We expect to see further improvement in the
coming months.

Indicator Ten: We have made improvements to provide continuity of care for
women throughout their pregnancy, but this needs to be re-audited to measure
current performance. The national standard is based on women receiving
antenatal care by one midwife throughout their pregnancy. There has been a
reduction in the number of midwives that a woman sees during her pregnancy,
but for most women shared care involving the GP and Midwife is provided. This
is a model that some GP‟s and women prefer.

The rest of the actions will be fully completed by December 2009. There are no
targets at „red‟ currently. We feel it is important to retain amber status for those
indicators where significant action has already been taken, but where the target
has not been fully achieved, in order to keep a tight focus on the issue.

Significant investments in staffing have been made and progress is being made
towards achieving the 1:30 midwife/women ratio by December, and increase
Consultant presence on Labour Ward.

The PCT have supported us in delivering the action plan and we continue to work
together to deliver further improvements in care.




                                          8