Gillan Belfon-Johnson Critical Care Matron North Middlesex Hospital

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1 * Gillan Belfon-Johnson Critical Care Matron North Middlesex Hospital

2 *What was the issue *Managing the issue * Education and Training * Giving nurses a platform * Managing diversity *Outcome *

3 Threatened Unsupported Limited Communication Limited development Scared to speak No team spirit No sense of belonging Excluded *

4 *Recruitment/retention challenges *Multiple subcultures * ICU/PCU * Nationality; race; tribes *Taught / Learnt behaviour *

5 *Increased pressure sores *Increased acquired infection *Delay in treatment *Increased length of stay *Delay to identify deterioration *North/south divide in quality of care between ICU/PCU *Increased late night discharges *

6 *Increase stress *Retention *Limited education and develop opportunities * Delay to complete standard task *Limited and incorrect knowledge of co-workers *Nurses perception of the behaviour *

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8 * Nurses auditing practice and feeding back Transfer trained Nurses from 0% to 81% Increased mentorship training from 9 to 40 nurses Recruiting Band 7 for audit and research Increased PDN from 1 to 3wte MDT trainers & CCU nurses Divide and conquer 5 teams Introduced Team study days Incidents Sis Audits Medical devices Organ support Supporting pt/family Team project Currently developing NMUH Critical Care course at level 7 with local university 13 nurses enrolled for 2017/18 - % to increase to 69% Team Bonding

9 Number of nurses in CCU verses Number of competent ICU nurses * Aug Sep Oct Nov Dec Jan Feb

10 *Management of any deteriorating No need to move an ICU nurse to HDU *Intubate and stabilise patient in HDU before patient were transferred to the ICU before intubation *

11 *Giving Nurses the platform to lead on change

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13 Training Time turning charts for patient door Two nurse review of pressure sore Pressure Sore CCU Pressure sore group Yellow star to identify patients at risk Introduce bedside information *

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16 *Nurse assessed 92 Staff Hand Hygiene Chief Executive gives appreciate card

17 *Band 7 nurse suggested recruiting at Philippine Bario- Fiesta

18 *Healthcare Support Workers Leads on Planning Christmas Oscar Ball 2016

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24 *We are Proud of our Diversity

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28 *Outcome

29 % of admission * / / / / /2017

30 % of admission * NIL Acquired MRSA in the last two years 2012/ / / / /2017

31 *Haemodialysis in HDU May 2016 Aug 2017

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33 M J August 2017 A A August S Grade 2 Pressure Sores August J 2.5 O 2 N 1.5 D Pressure sore training A 1 J M F Introduction of Stars to identify patients at risk Door turning prompt F M J Introduction of pressure ulcer A Two nurses to assess and grade pressure sores D M Pictures of grading and treatment plan at each bedside N J O S A J August 2016

34 *Nurse/Consultant lead Post ICU Follow-up Clinic * 7 Sessions since August 2016 * Multiple complications is identified and referred to appropriate professions * Clinical psychologist involvement in clinics * 100% feedback said they will recommend the clinic to friends and family

35 *The staff were sensitive and understanding of the patients and our request / needs. They were helpful and informative and flexible. *I am impressed with the lovely nurses who kept my family upto-date *When my mother was admitted to the ICU a nurse name Irene went through everything with us. I felt very reassured that my mom is in a safe hand *Nurses were very caring and they mad my mother feel she still had her dignity

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37 Storage Prescribing Critical Care Complex Medication Safety Cross Bulletin Problems Team Action plan To be action by 1. 1 st April Allopurinol not given to patient Nurses Patient not identified Nurses reminded to ensure all medication is given Gillan 2. 2 nd April- All cupboards in clinical room open in HDU Storage Gillan TEDS was ordered for patient but not put on. (HDU) Nurses Administration SAFETY CROSS Dispensing Found previous patient medication in PODS (HDU) 3. 3 rd April - Adrenaline found in grab box 4. 4 th April - Received medication bag from pharmacy, but medication does not belong to CCU it is for Charles Coward Ward Storage Doctor Pharmacy Doctors please be reminded that is is your responsibility to ensure that the grab box has the correct medication and is returned to the fridge Hema Adizem omitted for bed 17 no reason documented Nurses POD locker in 17, 18 open and medication not stored in Storage *

38 Administration 7 th September 2017 Storage Prescribing Dispensing Critical Care Unit Medication Safety Cross Bulletin Prescribing Administration SAFETY CROSS Dispensing Storage Green: 0-1 incidences; Amber: 1-3 incidences requires improvement; Red: > 3 incidences - Address as soon as possible Problem Paracetamol prescribed regularly but was not signed, Patient receive 3 doses Fentanyl infusion was prescribed but not signed, but was started by nurses without doctor s signature Clarithromycin 1g IV BD prescribed for H.pylori eradication treatment. Patient was on it for 2.5 days over the weekend before being spotted by pharmacist on Monday morning ward round. Dose should have been 500mg IV BD. Co-trimoxazole cream prescribed, clotrimazole Action Plan Pharmacist to complete induction with doctor; ICU specific prescribing assessment to be completed by all CCC doctors Nurses to be reassess by the PDN Same as above; plus doctors are encouraged to review infusion prescription. Nurses to ensure that prescription are signed before giving the drug. DATIX has been completed. Consultant to speak to doctor involved, doctors to check antimicrobial guidelines prior to prescribing, nurses to challenge drug doses that look incorrect. Nurses to challenge prescriptions when they are

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40 This is my family I feel more comfortable to approach other nurses if I need help I use to dread coming to work, but now I look forward to it I feel the unit has really progressed in the past two year I love the food in the diversity party I use to worry about the care I gave because of my limited knowledge and skills but now I better prepared to support the patient * I have learnt so much from the incident

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