Nottingham University Hospitals Emergency Department Quality Issues Related to Performance

Transcription

1 RCCG/GB/14/123 Nottingham University Hospitals Emergency Department Quality Issues Related to Performance Introduction NUH have failed to meet the 95% 4 hour wait standard for a number of consecutive months. The analytical focus on ED presented to the March Governing Bodies was designed to highlight areas that had contributed to the failure of the 4 hour standard for a prolonged period. There is not one single issue, but a number of factors that impacted on performance of the A&E department. The key points to note are: Time to initial assessment 95th percentile approximately 30 minutes over the standard of 15 minutes The volume of A&E attendances has remained stable between 2012/13 and 2013/14 financial years Between April 2013 and Mar 2014 there has been an increase of approximately 200 emergency admissions per week Despite a low volume of attendances, performance is below standard during the early part of the day Arrivals by ambulance have a poorer performance than other arrival methods In response to poor performance in NUH ED a number of measures have been put in place to ensure commissioners have oversight of quality issues. 1. Quality scrutiny panels review patient safety incidents quarterly for trends and patterns. 2. Patient Experience measures 3. Formal review of the Emergency Pathway was commissioned by CCGs in Quality Visits have been conducted. These are both planned and unannounced. A number of visits by Chief Officers have been conducted that are not formally recorded and reported in addition to the number below: Quality Visits have been undertaken to the following areas: Area Date Reason Comments ED (included C31 emergency Announced visit Overview of the department highlighted ambulance waits and ambulance arrivals, handover issues. Central area inspected re privacy and dignity.

2 gynae) Unannounced ED evening, including B The visit was arranged in response to the continuing non-achievement of A&E 4 hour target of 95%. Data demonstrated one of the busiest times in ED was from hours on Saturday night. Previous arranged visits have been conducted. We met a highly motivated and committed team of staff who were working together. We saw good flow through the department and good team working in the admissions unit. There was evidence of coordination and planning, data was available for decision making and there was the presence of senior management on the floor. All but two patients we spoke to were happy with the waiting time and all were happy with the treatment and care they had received. EMAS crews were not kept waiting, although there were three ambulances in the bay they had turned up simultaneously. We were impressed by the decision making and discharge planning on B3. We did not see any areas of concern. Senior management and senior clinical staff were on the floor and available Surgical Referral Unit City campus Previously the assessment unit: known patients were transferred across from QMC to City This unit was previously the Emergency Admissions Unit. Due to the re-design and re-configuration of services between QMC and City campus this ward has changed considerably. The SRU receives direct admissions for a number of specialist services. There are normally 16 beds however the ward can flex to 28 beds during peak times. Nurse staffing for the additional peaks this year has been predominately through NHS Professionals. Data is being collected to demonstrate a profile of admissions by speciality

3 D57 ED, B3, D57, Clinic 1 and Primary Care In response to a serious incident (Fall) where staffing and leadership were recognised issues 17 th /19 th / 20 th and 30 th December This review has been commissioned by Nottinghamshire CCGs in response to non achievement of the 4 hour ED standard during October and November The review has looked at the flow of patients through ED, Primary Care Streaming, Lyn Jarrett Unit and Clinic 1 in an attempt to determine the reasons for the deterioration in performance and understand if there are any further actions commissioners or the Trust could take to improve performance. during the year. This will aid the team to plan in advance for peak times and utilise staff effectively. The unit had seen a 40% increase in respiratory admissions which is an expected seasonal peak. As part of the emergency pathway, commissioners were keen to understand how D57 operated and identify any key issues. This had been a ward of high turnover and poor reputation. The action plan for the RCA had been fully implemented and commissioners could see a turnaround in relation to staffing and leadership. Able to talk to staff who informed commissioners the ward had improved. Part of the BFY work stream. Report shared. Microsoft Word Document Clinic The visit was in response to a number of 1st August st December 2013

4 announced visits across the emergency pathway by commissioners in order to understand the current picture. The final report indicated there were some quality concerns when the clinic was under pressure. In particular the clinic environment was a major constraint contributing to a reduced quality of service. ED NNE GPs A deep dive into the multifactorial issue of poor performance was agreed during the walk around. Clinic Return Visit following planned improvements 13 patient safety incidents (including 1 pressure ulcer moderate) Degree of Harm none 7, low 2, moderate 4. Complaints - 2 Understanding of the pathway from primary care to ED and suggestions for improvement from commissioners were made. Internal Measures: NUH are continuing to evaluate the ED Service on a weekly basis at a Senior Nurse Quality Meeting. This involves reviewing a range of quality measures including number of incidents and themes, high level investigations (HLI s), serious incidents (SI) falls, pressure ulcer s (acquired and inherited), the essence of care benchmarking, Nursing dashboard, Staff training, CQC Peer reviews, staff recruitment, documentation audits and the safety thermometer. The ED Governance Group meets monthly. The risk to quality due to poor performance has been entered onto the Trust Risk Register and is monitored monthly. A summary of some of the measures below: Falls The Number of falls has decreased in comparison to the same time period last year.

5 Falls by month 2014 Number of Falls JANUARY 3 0 FEBRUARY 2 1 MARCH 5 2 Infection There have been no MRSA Bacteraemia s or C-diff cases attributed to the ED. Pressure Ulcers There have been no acquired pressure sores attributed to the ED and the recording of inherited ones has increased dramatically. National Safety Thermometer The LJU has obtained 100% since Jan 2014 Patient Experience Friends & Family Score for the Adult ED is given to all patients who are discharged from the ED. The table below demonstrates a good sample size monthly over the winter period and no significant variation in the net promoter score since December where there was a step change improving the score from 62 to 70 with NUH performing very favourably against it s peers DATE DATA FROM NET PROMOTER SCORE PERCENTAGE OF PATIENTS DISCHARGED OCTOBER % 64 NOVEMBER % 62 DECEMBER % 70

6 JANUARY % 74 FEBRUARY % 72 MARCH % 69 APRIL % 74 NUH compares favourably with its peers: Average score for NHS England is 54 (response rate 18.5%) Chesterfield Royal Hospital - RFSDA Royal Derby Hospital - RTGFG Nottingham University Hospitals NHS Trust - Queen's Medical Centre Campus - RX1RA King's Mill Hospital - RK5BC Addenbrooke's Hospital - RGT01 Number of responses Number of eligible responses Percentage Score 752 3, % , % 54 2,217 8, % , % , % 57 The friends and family measure of patient experience is not used for Paediatric patients in the Emergency Department. The Patient Reported Experience Measure (PREM) questionnaire which has been designed by Picker and the Royal College of Paediatrics and Child Health (RCPCH) which measures Ambulance/Paramedic care, waiting, care and treatment, aftercare and overall care. NUH utilise the questionnaire quarterly, display key findings in the Department and prioritise and action as necessary. This series of questions (see attachments) has remained static with only a 1% variation between the last two quarters.

7 Patients re-attending the Emergency department have remained relatively static over the winter period see table below Unplanned Re- Attendance Nov 13 Dec 13 Jan 14 Feb 14 Mar 14 Apr % 3.16 % 3.25 % 3.05 % 3.16 % 3.04 % There were two peaks over the winter period of patients leaving without being seen these were Nov and Feb see table below Left Without Being Seen Nov 13 Dec 13 Jan 14 Feb 14 Mar 14 Apr % 1.81 % 1.30 % 2.35 % 1.80 % 1.95 % Complaints There has been an increase in the number of complaints in a year by year comparison the themes included missed diagnosis, lack of assessment lack of treatment and care, lost property and delays. Dec Jan Feb Mar Staff Training The ED staff mandatory training is at 94% overall the breakdown is outlined below ED Mandatory Training Infection Prevention & Control 95% Fire 94%

8 Information Governance 94% Failure to Rescue 86% Protection of vulnerable adults 86% Safeguarding children & young people 99% Health & Safety at work 98% Conflict Resolution 96% Values & Behaviours 97% OVERALL 94% Table 5 Nursing care Domestic violence intervention has continued to show a year on year improvement. The outcome of this is that ED has completed the DASH assessment form resulting in more ED cases being heard and actioned at MARAC. Disclosures in the ED have resulted in some patients going directly to shelters from the LJU. Domestic violence referrals & interventions 12/13 13/ EWS ED has, over winter, implemented a team leader role in the Majors area. The purpose of this role has been to lead on 3 areas: Patient experience (friends and family) Patient safety (patients receiving hourly observations) Length of Stay (patient preparedness)

9 The impact of this role in relation to patient safety and the recording of EWS has improved dramatically. Ambulance Handover times are monitored monthly and have remained relatively static over the winter period Month Avg Med Min Max Jun 13 15: Jul 13 14:13 13:01 00:00:03 01:04:43 Aug 13 14:29 13:02 00:00:19 01:15:55 Sep 13 14:32 13:03 00:00:14 00:53:15 Oct 13 15:00 13:39 00:00:00 00:46:00 Nov 13 15:27 14:23 00:00:00 00:58:50 Dec 13 15:53 14:35 00:00:00 01:05:15 Jan 14 12:30 12:09 00:00:00 00:50:50 Feb 14 13:23 12:45 00:00:00 00:55:23 Mar 14 13:55 13:22 00:00:00 00:56:34 System Response City CCG are the lead commissioners for Urgent Care. As such an Urgent Care Board (UCB) has been established to provide strategic oversight, evaluation, standardisation and communication across Greater Nottingham to ensure the delivery of a high quality and resilient urgent and emergency care system for the local community. The Greater Nottingham Health Community covers Nottingham City CCG, Nottingham North and East CCG, Rushcliffe CCG and Nottingham West CCG geographical areas. Conclusion

10 NUH have established internal mechanisms to monitor and mitigate against the risks of harm and poor patient experience as a result of reduced performance against the 4 hour ED target. Commissioners are scrutinising the service regularly through a number of mechanisms. Despite the poor performance the Trust are working to safeguard quality of the service. Commissioners feel assured that there are sufficient mechanisms in place. However it is more difficult to understand and measure the unintended consequences of poor performance against the 4 hour target such as increased length of stay or other quality metrics once the patient has been admitted. The Governing Bodies are asked to NOTE the report and to ensure sufficient focus is given to the quality issues related to under performance in ED.