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									The Scottish Patient Safety
Programme




     Learning Session 5
        NHS Highland
          Our Implementation Sites
                                 Caithness General
                                 Hospital, Wick




                                Raigmore (Acute)
Belford (General)
                                Hospital,
Hospital, Fort
                                Inverness
William




 Lorn and Islands
 (General) Hospital,
 Oban
Core Team Members

   A Senior Leadership Team oversees the implementation of the
    programme in NHS Highland

   A central team, based in the Clinical Governance Department,
    provides Highland-wide support for the programme

   Each hospitals ha developed their own infrastructure and has a
    core team to support the work streams

   Hospital based core teams consist of nursing and medical staff,
    theatre staff, AHPs, Pharmacists and Hospital Management
    Your Aims and Programme Goals                       (Place a
    check mark next to any goals you have already achieved)


   Mortality: 15% reduction
   Adverse Events: 30% reduction
   Ventilator Associated Pneumonia: 0 or 300 days
    between
   Central Line Bloodstream Infection: 0 or 300 days
    between
   Blood Sugars w/in Range (ITU/HDU): 80% or > w/in
    range
   Staph Aureus Bacteraemias: 30% reduction
   Crash Calls: 30% reduction
   Harm from Anti-coagulation: Reduction in INRs > 6
   Surgical Site Infections: 50% reduction in population of
    choice
   All process measures will be > 95% reliable
Critical Care…Our journey so Far
   Work currently being undertaken in ICU in Raigmore
   All process measures apart from one are showing
    signs of improvement and/or triggering run chart
    rules
   Improvement in outcomes can be seen in ALOS
    (CCB1), Central Line Blood Stream Infection Rates
    (CCO2) and Blood Sugars in Range (CCO6)
   The team are now looking at how to involve patients
    in care, starting with communication with relatives.
    A feedback survey has just been completed to
    identify areas for improvement
Scottish Patient Safety Programme Critical Care Current Work: Drivers
and Changes (Note only Raigmore is working on this work stream at the moment)

Outcomes               Primary Drivers           Secondary Drivers                 Improvements
                                               Reduce complications from ventilators       All process
                       Provide reliable,                                               measures showing
                                               Reduce complications from central
                       timely, care using                                                improvement
                                               venous catheters
                       evidence-based
                       therapies               Optimal glucose control                  300 days with no
                                                                                          CL infections
                                               Prevent HAIs                              reached for 2nd
                                                                                              time!


   Improved
                         Integrate patient                                              Relative feedback
    Patient                                   Promote open communication
                          and family into                                              survey introduced.
   Outcomes                                   among team and family
                               care                                                      Results used to
 (Reduced Mortality,                                                                    inform next tests
 Infections, & Other
  Adverse Events)       Develop
                        infrastructure that    Improve ICU throughput                  ICU ALOS showing
                        promotes                                                        downwards shift
                        quality care

                                                                                        Daily Goal Sheet
                       Create a               Reliable care planning,                  now implemented
                       collaborative team     communication and collaboration           across unit and
                       and safety culture     of a multi disciplinary team                  showing
                                                                                         improvement
      Multiple Cycles of PDSAs for Central Line
                       Insertion
                                                                 Improved care
Aim: Reduce the incidence of                                       Unit policy
catheter related bloodstream
infection                                      A P
                                               S D         Cycle 5: All central lines

                                                     Cycle 4: Ramp up to next 5
                                                     Central Line placement

                                         Cycle 3: Sticker changed re test 1,3
                     A P                          central line placement
                     S D            Cycle 2: Ramp up to next 3
 Standardise each
    central line                                central line placements
placement with use
   of a checklist          Cycle 1: Test sticker with one doctor, one nurse
                           one central line placement.
Keys to Success – Central Line
Insertion
   Change 1 - Protocol
      Team developed departmental protocols




   Change 2 - Checklist
      Insertion checklist tested and agreed

      Sticker developed and tested




   Change 3 - Insertion pack
      Insertion pack sourced and tested
                             Test
                             insertion
                             packs

Testing
protocols
and stickers

               Investigate
               insertion
               packs
300 days target reached twice!
                                                              Number of Days Between CVC Infections in ITU
                                                                   Surveillance commenced 01/01/08


                            400                                                                                   358
                                                                                                                  days
                            350                                                                                                                                                                       300 days
  days between infections




                            300
                                                                                  244days
                            250

                            200                               182 days

                            150

                            100

                            50

                             0
                                                                                                     Nov
                                  Jan




                                                                    June




                                                                                                                                                                                    Jul-09
                                                                                                                              Jan-09




                                                                                                                                                                           Jun-09
                                                                           July
                                        Feb




                                                                                  Aug
                                              March




                                                                                                                                       Feb-09
                                                                                                                   Dec 23rd




                                                                                                                                                Mar-09

                                                                                                                                                         Apr-09




                                                                                                                                                                                             Aug-09

                                                                                                                                                                                                       Sep-09
                                                                                                                                                                  May-09




                                                                                                                                                                                                                oct 19/09
                                                      April




                                                                                        Sept

                                                                                               Oct




                                                                                                            Dec
                                                              May




                                                                                                           Date
General Ward…Our journey so
Far
   Each hospital is working on the General Ward
    measures
   Improvement is seen in SEWS, PVC, SBAR
    and Safety Brief
   Changes implemented include a revised
    SEWS chart (Raigmore), PVC implementation
    checklists (all Rural hospitals) and revised
    admission documentation following the SBAR
    structure (Caithness General)
   Scottish Patient Safety Programme General Ward Current Work across all hospitals:
   Drivers and Changes
   Outcomes          Primary Drivers    Secondary Drivers      Process Changes
                                                                       SEWS – Education improved
                                             Early identification of   scoring and RR recording.
                                             patient deterioration     Revised chart to assist in
                        Provide reliable,    (EWS)                     highlighting need for
                        timely, care using                             interventions. Space for
                        evidence-based       Prevent healthcare        recording name and actions
                        therapies            associated infections

                                                                       PVC - Reliability achieved
Improved general                                                       through introduction of
ward outcomes                                                          insertion checklist / sticker
(Reduced infections,
crash calls,                                                           SBAR – testing in all
pressure                                                               hospitals on handover.
ulcers, AE in CHF and                                                  Caithness incorporated
AMI patients)                                                          methodology to admission
                                                                       documentation to improve
                         Create a             Reliable planning,       written communication.
                         collaborative        communication and
                         team                 collaboration of multi
                         and safety           disciplinary team
                                                                       Safety briefings – Multi-
                         culture
                                                                       disciplinary at all sites.
Driver: Institute Safety Briefings




                       A P            Share learning with spread wards
                       S D      Cycle 1D: Review process
                                after reliability dips

                        Cycle 1C: Test who to involve

  AP             Cycle 1B: Test incorporating brief into existing ward
  S D            round set up
          Cycle 1A: Test existing content from borrowed templates
Keys to Success – Safety Brief
   Change 1 – Who to involve
      Teams kept testing which staff groups to involve
      Domestic staff joined to highlight infection control issues
      Brief summary kept so additional staff groups can be made aware
       of issues (Security visit AMAU later in day and read notes)

   Change 2 - Timing
      Time of briefing adapted to local site
      Some sites introduce safety brief at staff handovers at start and
       end of day
      One day revised format of ward round to incorporate safety brief
                  Problems with
                  weekend –
                  review of process

Ongoing testing
of format and
participants
Medicines Management…Our
journey so far
   The Raigmore team have made significant
    progress in this work stream
   Medicines Reconciliation on Admission has
    reached target, and further work is underway
    to maintain reliability when FY1 rotas change
   Parallel testing on Medicines Reconciliation on
    Admission has started in Surgical Directorate
    and Surgical Pre-Admission Clinics
   Anti-coagulation prescription charts are also
    being tested
   Scottish Patient Safety Programme Medicines Management Current Work:
   Drivers and Changes
   Outcomes        Primary Drivers         Secondary Drivers             Process Changes
                                                                    FMEA - Raigmore. Developed first RPN score
                                        Identify high risk areas    for warfarin and identified warfarin
                                        using FMEAs                 management at discharge is the highest risk
                                                                    process.
                                                                    Tests of change to prevent this. Copy of
                   Reliable medicines   Use standardised
                                                                    current warfarin chart sent to GP and letter
                   management           protocols and algorithms    from pharmacy to GP attached to prescription
                   processes            for high risk medicines


                                        Identify patients at risk
Provide safe and                        with high alert             Anti-coagulation protocol - Raigmore. New
                                        medications                 protocol developed through tests of change.
effective
medicines                                                           Anti-coagulation prescription form tested and
                                                                    ready for implementation
management


                                                                    Medicines Reconciliation. Standardised form
                                                                    has been developed in all 4 hospitals.
                                                                    Implementing in pilot ward in Raigmore.
                                                                    Ongoing education and star charts improved
                     Coordination of    Accuracy of medicines
                                                                    compliance. Reliability impacted by change of
                     care               at the interface
                                                                    FY1s
                                                                    Form being tested by surgeon and surgical
                                                                    pre-admission clinics.
                                                                    Revising discharge letters to include more
                                                                    detail about medication on discharge
Secondary Driver:
Improve accuracy of the medicines at the interface


                                      Cycle 1D: Emailing all
                                      receiving physicians to tell
                       A P            them how well their team had
                       S D            performed relative to other
                                      teams
                          Cycle 1C: Introduction of star chart
                          for junior doctors
   AP            Cycle 1B: Changing form to highlight areas that are
   S D           often not completed.
         Cycle 1A: Education of junior doctors on ward round


Process Change: Medical staff should complete
medicines reconciliation form at admission
Keys to Success – Medicines
Reconciliation on Admission
   Change 1 – Test form
      Repeated testing so that only essential information contained in
       form

   Change 2 - Education
      Training of staff on new form
      Feedback to individuals and their consultants on performance
      Case studies shared on what happens when meds rec not correctly
       performed

   Change 3 – Encourage competition
      Introduction of star chart and certificates
Introduce star
chart




                               Examples
                               of poor
                               meds rec

                                          Rotas changed
                                          and new
                 Posters and              FY1/2s!!
                 education
Peri-operative…Our journey so
Far
   All hospitals are working on the peri-operative
    bundles
   Surgical pause has been successfully implemented at
    all sites and work has begun on surgical briefs at all
    sites
   Improvement is seen with normothermia in all sites
    and with antibiotic administration in Caithness
   Beta blockade and glucose control is proving difficult
    due to small patient numbers
   Raigmore have introduced SPSP champions to
    encourage greater participation from staff
   Scottish Patient Safety Programme Peri-Operative Care Current Work: Drivers
   and Changes
   Outcomes     Primary Drivers           Secondary Drivers              Process Changes
                                        Proper prescribing and
                  Provide appropriate   administration of prophylactic    Antibiotics. Local protocols being
                  care to prevent       antibiotics                       reviewed
                  surgical site
                                        Hair removal by clippers
                  infections                                              Clippers. All razors removed from
                                        Maintain normal blood             theatres
                                        glucose level
                                                                          Normothermia. Local processes
                                        Maintain normal body              reviewed
                                        temperature
Improve peri-
operative
                                                                          Surgical pause. Introduced into all
outcomes                                                                  sites and consistently reliable
                  Create a team         Use briefings
                  culture attuned to
                                                                          Surgical briefing. Being tested in
                  detecting and         Use standard intra-
                                                                          all sites with enthusiasts
                  rectifying intra-     operative procedures to
                  operative errors      prevent AEs


                                        Identify patients at risk         DVT. Testing ongoing in all sites
                  Provide appropriate
                  care to prevent       DVT prophylaxis
                  peri-operative                                          Beta Blockers. Testing ongoing in
                  cardiovascular        Continuation of beta              all sites
                  events                blockers
Keys to Success – Surgical
Pause
   Change 1 – Identify test team
      Enthusiasts targeted to test concept

   Change 2 – Agree content
      Multiple tests undertaken in each site to agree what should be
       included in the pause

   Change 3 – Integrate pause into ‘the way we do things’
      Laminated boards set up in most theatres
      Pause checklist created in some sites


   Change 4 – Patient involvement
      In Raigmore patients asked if they want the pause to take place
       whilst they are conscious
Major Challenges and Barriers
   Cross professional ownership and
    integrated working towards SPSP
    objectives
   Data! Setting up an infrastructure to
    support data collection in spread phase
    but working smarter to streamline data
    collection demands on front line staff
Help Needed Please!
Critical Care
   Multi-disciplinary ward rounds
General Ward
   Actions from SEWS
Medicines Management
   How have other boards succeeded with medicines reconciliation
    in a rural setting?
   FMEAs
Peri-operative
   How to engage surgeons to be more involved with SPSP
   Blood Glucose Control
And Lastly

   We are integrating our SPSP work with
    Leading Better Care / SCN Review
   Our greatest challenge is sharing data
    across programmes to save duplication
    of data entry (e.g. hand hygiene
    figures)

								
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