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Safer Patients Storyboard Template Kick off LS - PowerPoint 6

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					Learning Session 7
Critical Care Breakout 1: Person-centred care
K Rooney, T Clemmer, A Hunter, K McKinlay
           Person centred care
• Agenda
  –   Wendy Kelleher (University of Glasgow)
  –   Louise Boyle (NHS Forth Valley)
  –   Norma Beveridge (NHS Fife)
  –   Alison Hunter (NHS National Waiting Times
      Centre)
ICU Patient Experience Survey
  Royal Alexandra Hospital, Paisley



   Wendy Kelleher (4th yr Medicine)
   Supervisors: Professor K. Rooney Doctor
   R. Price
       Background to the Survey

• Commenced 14th September 2010 – 24th October 2010
• Undertaken following 2010 Scottish Inpatient Experience
  Survey results from August 2010
• Results from August 2010 show that approximately 6% of
  8834 respondents spent time in ICU during their stay
• Identified areas for improvement including
  communication with patient and patient surroundings
                 Survey Design
• Anonymous survey
• Completed outside of ICU with patients discharged to
  RAH wards
• Sixteen questions covering six areas:
                          - Overall
                          - Nursing
                          - Doctors
                          - All Staff
                        - Cleanliness
                       - Clinical Care
• Five options for rating each answer
• Comments optional at the end of each section
                 Survey Response

•   Fifteen patients surveyed
•   Two surveys uncompleted
•   Capture rate: 48%
•   Patients not captured by survey:
         - Discharged from ICU to other hospitals
         - Self discharge
         - Death
         - Admission/discharge outside of survey hours
Overall
         Overall Comments

“Sometimes it was a little impersonal and it
     didn’t feel like you were involved”
“Would have liked to be able to look out the
                    window”
Nursing
           Nursing Comments
“ Nurses are overworked and get called away when
              they are attending to you”
       “ Couldn’t fault the nurses, excellent”
 “Nurses had to deal with more important matters
                 prior to my requests”
 “Hard to comment without thinking of one or two
                nurses. Not as a group”
“The nurses, if in twos, tend to laugh and pass over
                          you”
Doctors
          Doctors Comments

 “Doctors explained things to the best of their
                     ability”
          “ Doctors were excellent”
       “Felt family were well involved”
“My confusion was not well appreciated, it was
                    ignored”
All Staff
          All Staff Comments

“They did stop to explain things, but it seemed
   impersonal. Some staff were better than
                    others”
Cleanliness
Clinical Care
       Clinical Care Comments

“ Doctors and nurses had meetings and decided
               on my medications”
   “Once they managed to get my pain under
       control, they kept it under control”
   “You had to sit and wait for pain care, and
       sometimes you just went to sleep”
    Ratings Above Average (4.53/5)
• Overall quality of care and services while in the ICU
• Caring and concern shown by ICU nurses
• How well was privacy respected by ICU staff
• Would you say friend and family visits were allowed for a
  reasonable amount of time
• Cleanliness of the ward
• How well were your symptoms controlled while in the
  ICU
• How well was pain controlled while in the ICU
         Areas for Improvement

• How well the ICU nurses explained things
• How well staff prepared you to leave ICU
• How well the ICU nurses followed through when asked to
  do something
• How well doctors explained things
• How well ICU staff worked together to co-ordinate your
  care
                       General
• Patients were very happy to complete the form
• The questions with the most skipped responses
  included:
- Efforts of ICU staff to involve you in your care
- Would you say friend and family visits were allowed for a
  reasonable amount of time
- How well was pain controlled when in ICU
               Future Directions

• Review/rewrite questions that patients had difficulty
  understanding
• Make staff in the unit aware of results
• Discuss results with staff
• Take measures to improve lower rated areas
Questions?
Overall
Nursing
Doctors
All Staff
Cleanliness
Clinical Care
Bringing patients and their
families into the ICU team
       Background – policy
     The Six Dimensions of Quality Care

1.   Safe
2.   Effective
3.   Patient Centred
4.   Efficient
5.   Timely
6.   Equitable
                 (IOM 1999 – Crossing the Quality Chasm)
               Background – policy
 NHS Scotland Healthcare Quality Strategy (May
                                 2010)

1.   Caring & compassionate staff
2.   Good communication (inc. listening)
3.   Collaboration (between provider & recipient)
4.   Clean hospitals
5.   Continuity of care
6.   Clinical excellence
            Background – impact?
• Orthopaedics – LOS effic. outcomes
  – DiGioia et al (2009) (USA)

• Neonatal / Paed. ICU – safety LOS
  – Ortenstrand et al (2010) (Swedish)

• Cancer Care - safety Quality
  – Ponte & Peterson (2008) (USA)

• GI Service Redesign- Waiting Adm
  LOS
  – Rejler et al (2007) (Swedish)
                     What about adult ICU?
            Background - literature
Critical Care Family Needs Inventory (CCFNI) (Molter &
  Leske 1983)
   1. Proximity & Access
   2. Information                Review of 57 Belgian ICU’s –
   3. Assurance                 ALL reported using
   4. Comfort & support         restrictive visiting policies.
                                Vandijck et al; Heart & Lung;
                                March 2010
Families of pts in ICU suffer
from significant levels of
anxiety, depression, PTSD
Jones et al; Int. Care Med
2004
Pochard et al; Crit Care Med
2001
    Background – our experience
• Sept 2006: Families experience of ICU
  – 23 families
  – Found it difficult to retain information
  – Found environment bewildering
  – Written communication would be helpful
  – Information about functioning of an ICU would be
    helpful
  – Would like visiting to be more flexible
       Proposed Improvements
• Invite families to participate in setting daily
  goals

• Abolish restrictive visiting in favour of flexible
  visiting
             Implementation
• Daily Goals Tool
  – Lots of small tests over a 4 wk period Mar/Apr
    2010
  – 1pt 1 nurse, then 2, then 3, and all
  – Opportunity to iron out flaws & make tool fit for
    purpose
  – Raised awareness amongst staff, gave opportunity
    to get used to tool, ask questions, etc.
                 Implementation
• Flexible Visiting
   – Evoked strong emotions!
   – Not amenable to small tests of change!
   – Informal coffee-room focus groups (Mar – July 2010)
   – Formal focus groups at tutorial time (Mar – July 2010)
   – 1-2-1 interviews with key personnel (Mar – Apr 2010)
   – Formation of guidance document & circulated for
     comment
   – August 2010 - implementation
   – Teething problems
             Implementation
• Focus Group Questions

1.What impact do you think a liberalised visiting
  policy would have on your job?

2.What type of access would you like if a
  member of your family was critically ill in ICU?
       Family Able to Describe Two or More Daily Goals OR know to refer to
100%                            Family Info Folder

90%


80%


70%


60%


50%


40%


30%


20%
       12%                                 14%
10%
                             No data


 0%
                          0%
          Jan-10             Feb-10              Mar-10                Apr-10               May-10

          % Families Describe 2 Goals   % Patients with info sheet present at bedside & completed
               Family Describe the Plan?



100%
                                                                 86%                                       94%
         Mar 15th
         1st PDSA
                       Mar 25th 2nd       Apr 27th 3rd
                                           PDSA with
                                                           Apr 28th 4th
                                                            PDSA with
                                                                               89%                89%               90%
90%
        with family
        daily goals
                        PDSA with
                        family daily      family daily      family daily                 83%
                        goals sheet       goals sheet     goals sheet (7
80%        sheet       (2 pts). Make        (3 pts).        pts). Some
       (1pt) change       relatives        Rephrase       families taking
        main box to      comments            family        sheet home
70%      "Today's       area bigger        comments
           Plan"
60%                     Apr 27th        April 28th 3rd    May 11th      June 14th
        March 25th                                        4th PDSA
                       2nd PDSA         PDSA family                     5th PDSA
         1st PDSA                                           family
50%                    rephrased            survey                        ranked
       family survey                                        survey
                       involveme          postcard                      questionair
         postcard -
                           nt            rephrased                           e
        post box in
40%         unit
                        question        visiting times
                                          question

30%
                                                         39%
20%
       12%                         14%
10%                        No
                       0%
 0%
        Jan-10         Feb-10          Mar-10        Apr-10       May-10        Jun-10   Jul-10   Aug-10   Sep-10   Oct-10

                                                         % Families Describe 2 Goals
               FamilyGoals Sheets Completed?



100%
         Mar 15th
         1st PDSA
                       Mar 25th 2nd       Apr 27th 3rd
                                           PDSA with
                                                          Apr 28th 4th
                                                           PDSA with
                                                                           94%                                             93%
90%                     PDSA with
                                                                                               89%      89%
        with family
        daily goals
                        family daily      family daily     family daily
                                                                                     86%                         88%
                        goals sheet       goals sheet    goals sheet (7
80%        sheet       (2 pts). Make        (3 pts).       pts). Some
       (1pt) change       relatives        Rephrase      families taking
        main box to      comments            family       sheet home
70%      "Today's       area bigger        comments
           Plan"
60%                     Apr 27th        April 28th 3rd   May 11th      June 14th
        March 25th                                       4th PDSA
                       2nd PDSA         PDSA family                    5th PDSA
         1st PDSA                                          family
50%                    rephrased            survey                       ranked
       family survey                                       survey
                       involveme          postcard                     questionair
         postcard -
                           nt            rephrased                          e
        post box in
40%         unit
                        question        visiting times
                                          question

30%

20%

10%                        No
 0%
        Jan-10         Feb-10          Mar-10        Apr-10      May-10        Jun-10      Jul-10   Aug-10   Sep-10   Oct-10

             % Families Describe 2 Goals                       % Patients with info sheet present at bedside & completed
Learning Session 7
Critical Care NHS Fife
A Patient’s Story
This is Colin’s story.


• Colin was diagnosed with Guillain- Barre Syndrome
  (GBS) in early 2008. He was then 62 years old
• Colin is a retired ,self employed computer programmer
• Colin’s family = 2 sisters and 2 dogs
• Colin spent a total of 761 days in ICU in NHS Fife
  between February 2008 and July 2010.
• What we know about patient centred care we learned
  from Colin.
• During the first admission – patient centred care ICU
  style including:
   ICU clean shaven look
   ICU hairstyle combed back , short neat and tidy!
   Restricted visiting
   ICU staff choice of music etc.
   medically focussed care plan
• All delivered in a very caring manner and of a high
  standard
However

• After a few weeks Colin’s condition improved
• once he could communicate our lessons in
  patient centred care began!
• Colin's list version 1 was developed in
  negotiation with the nursing team.
Colin’s List V 1

•   Daily Routine
•   Daily Bath no earlier than 10am – later at weekends if possible
•   Do not shave my beard or moustache without consent
•   Do not cut my hair

• Likes and Dislikes
• Colin enjoys peace and quiet – no music please
• Colin may appear to be sleeping at times but is often relaxing and
  can therefore hear everything that is being said
• Colin likes to see photos of his dogs
• Colin does enjoy a good banter!!
Patient centred medical care

• Weaning plan during admission 2 QMH was a
  challenge
• Atypical presentation of GB following
  reactivation of the disease
• Conventional weaning did not fit
• Colin very unhappy at frequent changes in
  weaning plans and variation in opinion.
• Became quite non compliant!
Prompted a number of actions:


• Daily goals set
• Multidisciplinary team / family conferences
• Multidisciplinary management plan developed with
  review dates
• Open discussion about quality of life issues and
  treatment limitations
• Identified a Consultant Intensivist to lead and coordinate
  Colin’s case
• Discharge planning
• Colin’s list V2
Colin’s List V 2

Daily Routine                                  Weaning
•   Daily bath no earlier than 10am – later    •   Always consult Colin regarding his
    on weekends if possible                        weaning plan
•   Do not shave beard or moustache            •   When on a T piece Colin does not
    without consent                                tolerate a peep valve (rise in C02 and
•   Do not cut my hair                             agitation)
Physiotherapy                                  Likes and Dislikes
•   Chest physio in the morning                •   Colin enjoys peace and quite – no
•   Passive limb movements in the                  music please
    afternoon                                  •   Colin may appear to be sleeping at
•   Not too many interventions in the one          times but is often relaxing and can
    day , alternate getting up in the chair.       therefore hear everything that is being
    tilt table and sitting on edge of bed          said
•   One day of rest per week - usually         •   Colin likes to see photographs of his
    Saturdays                                      dogs
                                               •   Colin likes a good banter !!
And……….

•   Visiting times relaxed
•   Trips outside the unit- well at last to the car park
•   Visits from his dog Razzle!
•   Family involvement -
    Biggest catalyst in his recovery was the visits by
    a beagle rather than a sibling
Challenges


•   Staffing pressures – continuity of care
•   H1N1
•   Personality issues
•   Negotiation techniques - usually drafted SCN
    Paton
Colin was discharged from ICU on
13thJuly2010.He is currently doing well in
Cameron Hospital , rehabilitation Unit.

He celebrated his 65th birthday this week.
Patient centred care should not be special but
    should be the norm.
It is more easy to demonstrate on a longer term
    patient .
It can be a challenge in times of high activity and
    high patient dependency .
Its difficult to measure.
Thank you for listening and to Colin for his
     expertise as a human being who
     happened to be a patient in ICU.
Golden Jubilee National Hospital



       Person Centred Care in
            Critical Care
Designing Rounds around Patients
 COLOUR          ORDER ON ROUND          PATIENT STATUS




              Seen 1st unless RED     Needs seen for
 BLUE          patients are urgent    discharge



             Seen 2nd unless urgent   Unstable – needs
  RED                                 review



                   Seen last          Stable - can wait
 GREEN
             PATIENT A

A post discharge interview conducted with a

   young patient admitted with a sudden &

     life-threatening illness which ran a

             complicated course
                QUOTES
• MOTHER
 – ‘I’ve seen it on the telly; I know what you get
   told in these rooms.’ ‘he put his arm round me
   and told me it would be OK’.
 – ‘I felt comfortable asking the doctors any
   question.’
 – ‘they’re arguing’ - ‘they would say something
   from the top of their head but we don’t know it
   was from the top of their head’

                                                 67
                  QUOTES
• PATIENT
  – ‘I don’t wake up at 7.30 and it would be – wait
    a minute, who are you?’
  – ‘They might have seen this thousands of times
    but they haven’t seen me thousands of times’.
    ‘I’m quite prudish.’
  – ‘They have a great understanding of one
    another, camaraderie .... They understand the
    patient’
                  ACTIONS
• Wherever possible, ensure continuity of nursing
  care on a shift by shift basis.
• On days of major treatment interventions, ensure
  the patient has a nurse who is familiar with them
• Ensure debate about condition and treatment
  options takes place away from the patient and
  family.
• Ensure privacy and dignity is maintained during
  medical or nursing procedures.
       LETTER of COMPLAINT
                       September 2010
• I experienced unpleasantness from a particular (nurse)........I turned
  and saw her sneer at me. Something maybe a child would do. From
  that day forward I thought it better to observe and not complain as I
  could not be with xxx at all times. I dreaded leaving him behind.

• Not all staff behave in this manner and it is a great pity that these
  upsetting memories are the foremost memories I have.

• Everything in life has consequences, the things we do and the things
  we say. There are also consequences for things we do nothing about.
               Feedback to Staff
• Buzzers must be available to all patients who could use
  them.
• Where no commode is available, a bed pan should be
  offered.
• Curtains between rooms should be open unless for
  protection of privacy and dignity.
• Disposable tissues, and the means to discard used ones,
  should be available to all patients who could use them
• MOST IMPORTANTLY, we should all be mindful of our
  actions and attitudes and their effect on patients and their
  families.

				
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