Peer Review Report Severe Respiratory Failure (ECMO) Service

Transcription

1 Peer Review Report Severe Respiratory Failure (ECMO) Service Date of visit: 27 th June 2016 Report date: 5 th July 2016 This report has been prepared by a review team (listed below) to provide a record of findings from a peer on-site review visit to Aberdeen Royal Infirmary, performed on behalf of NHS England. It is intended to summarise the organisation s performance against the standards assessed during the review. The recommendations contained in this report are designed to guide local and national quality improvement discussions. The review team Name Trudi Scott Julie Bracken Chris Harvey Aimee Hurst Kath Daly Nicola Symes Theresa Fenech Position Physiotherapist Royal Brompton and Harefield NHS Foundation trust Critical Care Service Manager, Papworth NHS Foundation Trust Consultant University Hospitals Leicester NHS Foundation Trust Perfusionist University Hospitals South Manchester NHS Foundation Trust Nurse Consultant Guy s and St Thomas NHS Foundation Trust Commissioning Manager Highly Specialised Commissioning, NHS England Director of Nursing, Specialised Commissioning, NHS England Page 1

2 Mel Miller Programme Manager, NSD, NHS National Services Scotland Local team Name Iain Scott Stephen Friar Iain McLeod Gillian Park Position Consultant Consultant Consultant ECMO Co-ordinator Page 2

3 Introduction This report covers a peer review of the ECMO service at Aberdeen Royal Infirmary by the multidisciplinary team listed above on 27 th June The review was conducted on behalf of NHS England in accordance with the guidance on peer review of nationally designated ECMO centres. It is of note however, that Aberdeen Royal Infirmary is not an NHS England designated ECMO Centre, but provides additional non-commissioned surge capacity in Scotland when required. ECMO activity for NHS Scotland is commissioned as part of a portfolio of services commissioned on their behalf by NHS England, with Glenfield Hospital, Leicester, being the designated centre for referrals from Scotland. At times of surge, Glenfield Hospital maintains co-ordination of referrals from Scotland and liaises with Aberdeen Royal Infirmary accordingly. It is therefore acknowledged that as a non-commissioned ECMO centre, some processes differ from the five designated centres in England. It is also of note that some areas of regulation in NHS Scotland differ to NHS England, and where appropriate in relation to the specified standards these are highlighted in the text of the report. Site visit The site visit included the following agenda items: Review of documentation demonstrating compliance with standards 1 10 Review of clinical facilities and meet clinical staff Review of case selection, mortality and contributing factors. We were able to view clinical areas including the intensive care unit, family waiting areas, perfusion equipment as well as training and simulation facilities. Documents reviewed The following documents were reviewed: Detailed files of appropriate documentation were presented and available for the reviewers. Copies of individual documents are available upon request. Page 3

4 Areas of good practice: No immediate risk or concern was noted by the reviewing team. The service was considered by the reviewing team to be remarkable as it is operates as a non-commissioned surge centre. The following areas were particularly highlighted: Due to the nature of the service as a surge centre there was significant dedication by the team to maintain skills through simulation and training. The nature of the surge arrangements also required specialist staff to be flexible in their approach at times of high national demand which was demonstrated. The new accommodation for relatives and waiting areas (including the garden area) were noted by the reviewing team as positive for the environment and support to families. The getting to know me documentation (originating from dementia services) was discussed as providing an opportunity for relatives to contribute and provide some valuable information to the clinical team, and supported rehabilitation by identifying key motivational factors for the individual. Areas with potential for improvement: Review process with regard to retrieval to explore ways of reducing average time from acceptance to dispatch. It was acknowledged that this would require wider discussion with transport services. Additional perfusion staff would be valuable in supporting the current clinical team. It was recognised that there is a UK shortage of perfusion staff and this is exacerbated by differing grading / T&C between England and Scotland. This makes recruitment to Scottish vacancies very challenging. for change: It was noted that commissioning discussion is ongoing with regard to the current noncommissioned, surge status of the current service. Any significant change to the service will be dependent upon future commissioning arrangements. Page 4

5 Standard 1 Trust Assigned Rating Assigned Rating Patient Centred Care 1.1 Met. Information reviewed, ECMO and general hospital information available, as well as NICE guidelines. Information included age appropriate literature for children & young people (Medikidz publication). 1.2 Met. Extracts from patients notes reviewed. 1.3 Met. Range of information available for patients and carers, including citizen advice, waiting facilities with access to on site chaplaincy, social work, spiritual care and end of life support. 1.4 Partly Met. As a non-commissioned centre there is not a 24/7 rota at all times. Support is available as the need arises in line with activity and patient need. Evidence of flexible staffing in place at times of surge. 1.5 Met. Getting to know me documentation and questionnaire outcomes reviewed. Evidence of feedback resulting in changes to waiting areas. 1.6 Met. 1.7 Met. No Breaking Bad News policy in place, however training with regard to managing bereavement and palliative care in place. 1.8 Met. Surge centre with referral via Leicester. Service is part of Critical Care delivery group within Scotland. Standard 2 Trust Assigned Rating Assigned Rating MDT Team Page 5

6 2.1 Met. Service operates with an MDT. Meeting frequency varies in accordance with activity. Regular meetings occur during surge periods. 2.2 Met. Staff rota reviewed. It was noted that specialist nursing cover is flexible to respond to surge periods. Evidence of wide range of specialities are available to provide support 24/7. Noted perfusion support is available 24/7 to build circuit but not available for retrievals however this was mitigated as other members of the team are trained to deal with emergencies. 2.3 Met. 2.4 Met. 2.5 Met. Evidence of access to services out of hours in patient notes. 2.6 Met 2.7 Met. ECMO co-ordinator in place, however, it was noted that 24/7 availability of specialist staff is in place as required during periods of surge, but not necessarily at all other non-surge times. 2.8 Met 2.9 Met 2.10 Met. It was noted that there are not weekly meeting when there are no patients. Frequency will vary according to service need. This was considered to be proportionate Met. Clear range of guidelines in place Met Met The flexibility of the MDT to respond to periods of surge was noted. Standard 3 Trust Assigned Rating Assigned Rating Physical Facilities Page 6

7 3.1 Met. 3.2 Met. Appropriate equipment was observed as being available. It was noted that when patient numbers exceeded 2, additional equipment was sourced through rental agreements with suppliers. 3.3 Met. 3.4 Met. Standard 4 Trust Assigned Rating Assigned Rating ECMO Care Pathway. 4.1 Met. Due to current commissioning arrangements all referrals are triaged through Leicester, prior to discussion with Aberdeen. 4.2 Met. Evidence of staff training in place. Most staff trained via Leicester. 4.3 Met. The service is part of the Scottish critical care delivery group and Scottish Intensive Care Society. 4.4 Met. 4.5 Met. Referrals are managed via Leicester with onward referral as required during periods of surge. 4.6 Met. Engagement with wider network in England to manage surge periods. Service also demonstrated ability to increase capacity from 2 patients to 4 when required to manage significant surge in Scotland. 4.7 Met. In discussion with Leicester. 4.8 Met. Page 7

8 Standard 5 Trust Assigned Rating Assigned Rating Retrieval of Patients 5.1 Met. Pathway in place. 5.2 Met. It was noted that the retrieval team does not include perfusion staff due to staff capacity, however this is mitigated through enhanced skills in other team members. 5.3 Met. Good links in place with Scottish Ambulance Service. Arrangements for retrieval by air are being reviewed. 5.4 Met. It was noted that the law in Scotland is different: the Adult Incapacity Act (Scotland 2000) is applied, which does not include a process for assent of the family. 5.5 Met. Clear documentation templates in place. 5.6 Met. As above, there is no perfusionist within the retrival team. Team usually includes 2 consultants and 2 specialist nurses. Average time from acceptance to departure is 3 hrs, with average travel time to referring hospital (Glasgow, Edinburgh, Inverness) 2-3 hours by road. 5.7 Met. 5.8 Met 5.9 n/a no air capacity at present. Review processes to identify opportunities to reduce the time from acceptance to departure. Standard 6 Trust Assigned Rating Assigned Rating Education and Training 6.1 Met. Via Leicester and in-house training. 6.2 Met. 6.3 Met. Via Leicester and Brompton. 6.4 Met. Sign-off via Leicester. 6.5 Met. Including 4 ECMO updates annually, and regular Page 8

9 availability of wet labs. A 2-day ECMO uncovered nursing programme is available. Standard 7 Trust Assigned Rating Assigned Rating Research and Development 7.1 No specific ECMO research strategy in place however, has active engagement in and supports other national research. Active engagement in Audit, ELSO, Scottish Intensive Care society audit group. 7.2 Met. Supported through NHS Grampian. 7.3 Met. Including participation and presentation at Euro-ELSO. 7.4 Met 7.5 Met Standard 8 Trust Assigned Rating Assigned Rating Wider Networks 8.1 Met. via Leicester. 8.2 Met. 8.3 Met. There are 23 ITU facilities in Scotland which the service links with, however, as a non-commissioned centre, there are limitations of its ECMO role within the network. 8.4 Met. Page 9

10 Standard 9 Trust Assigned Rating Assigned Rating Management and Organisation It is noted that Aberdeen is a surge centre, not a nationally designated ECMO centre. 9.1 Met 9.2 Met. As a surge centre, the service currently treats aprox. 12 patients per year under surge conditions. The service noted that it does have capacity to increase activity if commissioned / required. 9.3 Met 9.4 Met. The service has a named Clinical Director. 9.5 Met. Datix reports presented and discussed. 9.6 Met 9.7 Met 9.8 Met 9.9 Met 9.10 Met 9.11 Met. Dedicated audit nurse in post. Standard 10 Trust Assigned Rating Assigned Rating Audit Page 10

11 10.1 Met. ELSO data submitted pending IG query Met Met 10.4 Met. Via Scottish Intensive Care Society (rather than ICNARC) 10.5 Met. Case selection Trust Assigned Rating Assigned Rating Not discussed - cases are selected via Leicester. Mortality contributors Trust Assigned Rating Assigned Rating Presentation available on request. Learning from the cases presented including poor clinical outcomes for those with long periods of ventilation prior to ECMO. Learning around the decision to move to end of life care, support for the team and managing family expectations. ICH consider CT on admission as at St. Thomas, service to consider a policy change with regard to this practice. The service felt that team debrief had been successful to discuss individual case learning. Page 11

12 Conflicts of interest: None of the peer reviewers have any financial, intellectual or personal conflict of interest relating to this peer review which was conducted as part of their Supporting Professional Activities as NHS employees. Travel expenses were paid for by the NHS. No other payments were made. Page 12