Ayrshire and Arran NHS Board

Paper 6 Ayrshire and Arran NHS Board Monday 11 December 2017 SPSP Update: Acute Adult Programme Author: Laura Harvey, QI Lead for Acute Services, Person Centred & Customer Care Sponsoring Director: Liz Moore, Director of Acute Services Date: 13 November 2017 Recommendation The Board is asked to note current progress across acute services in relation to the SPSP Acute Adult Programme and our current organisational priorities: Falls, Pressure Ulcers, Catheter Acquired Urinary Tract Infection and Delirium Summary Three papers detailing key aspects of the acute adult safety programme have been discussed at recent HGC meetings providing assurance that sustainable improvement has been achieved. The focus of these papers included hand hygiene, safety briefs, theatre safety and peripheral and central venous catheter practice. This paper highlights current activity in relation to core measures from the Acute Adult Scottish Patient Safety Programme: Falls and Falls with Harm Pressure Ulcers Catheter Acquired Urinary Tract Infection In addition to these national measures, this paper will report on current activity and progress with the management of acute delirium as a local priority. Key Messages: Previous papers provided assurance around the Essentials of Safety, whilst this paper highlights progress against the core Acute Adult programme indicators New approaches to improvement support are having a positive impact Clinical ownership of improvement is essential for sustainability Data suggests improvements in managing Falls and Pressure Ulcer acquisition Good progress is being made in implementing the CAUTI bundle and Delirium Care 1 of 10

Glossary of Terms 4AT CAU CAUTI CCR HCG HEI IA ISF NA PU QI RDU SCN SPSP SSKIN TIME UHA UHC The 4As Test for Cognitive Function Combined Assessment Unit Catheter Acquired Urinary Tract Infection Care and Comfort Rounding Healthcare Governance Committee Healthcare Environment Inspectorate Improvement Advisor Improvement Science Fundamentals Nursing Assistant Pressure Ulcers Quality Improvement Renal Dialysis Unit Senior Charge Nurse Scottish Patient Safety Programme Surface, Skin, Keep patient moving, Incontinence, Nutrition Trigger, Investigate, Manage, Explain University Hospital Ayr University Hospital Crosshouse 2 of 10

1. Introduction Over the last 18 months, a number of improvements have been made in the provision of support to the acute adult programme across acute services. The main aim being to reduce harm and support the delivery of high quality person centred care consistently across all areas. The upgrade of the QI portal provided an ideal opportunity to take stock of the current position and develop plans for moving forward, in a way that would result in sustainable improvement, whilst also providing the ideal opportunity to support and coach staff in the importance of measurement for improvement. As discussed in previous HCG papers, we started by reviewing performance against the Safety Essentials, introduced by SPSP in 2013. As a result of this review, some bespoke work was supported to ensure that this was fully embedded across the appropriate areas and measurement for assurance was agreed. This approach has proven very successful. There has been a clear shift across clinical areas in relation to how and why we collect data. Historically, clinical staff without prior improvement knowledge considered data collection as audit and of limited value. With support and coaching from the QI team, the importance of measurement for improvement has been established with compliance improving significantly. Our new approach is in line with the national programme as the focus is shifted to outcomes measures of core indicators. These core indicators are; Falls and Falls with Harm Pressure Ulcers Cardiac Arrest Catheter associated Urinary Tract Infections Sepsis Medicine Management Within NHS Ayrshire & Arran, priorities have been identified on a risk based approach and these have been agreed by the professional leads in acute services. Our current priorities are; Falls and Falls with Harm Pressure Ulcers Delirium CAUTI Cardiac Arrest and Sepsis improvement work is being delivered as part of our Deteriorating Patient Network and led by the QI Lead for this area, whilst Medicine Management is delivered and led by pharmacy colleagues. Governance and assurance of all strands of the acute improvement work will eventually form part of the relevant governance groups but initially, an Acute Adult Steering Group will be reintroduced, with new work stream leads to support the delivery of the programme. A working group will report directly to the steering group in the first instance. Updates will be shared through the respective governance structures. 3 of 10

Oct 16 Nov 16 Dec 16 Jan 17 Feb 17 Mar 17 Apr 17 May 17 Jun 17 Jul 17 Aug 17 Sep 17 Oct 17 Rate per 1000 OBDs This approach to the governance and assurance of acute adult safety is currently being progressed. 2. Falls and Falls with Harm In 12 months (September 16 until end of September 17) 904 falls were reported across UHA and UHC (504 in UHC and 364 in UHA). Of these, 62 falls resulted in harm approximately 7% of the total falls. Currently, all inpatient areas use the Falls for All Bundle, an evidence based sticker that helps identify those patients at risk of falls. Patients assessed as being at the greatest risk are then commenced on the Falls Bundle for Vulnerable Patients which identifies a number of interventions to reduce risk. The charts below show the falls rate (per occupied bed days) in both acute hospitals. It demonstrates a shift from May 2017 with a slight reduction in fall rates. This would suggest that the increased focus and improvement support afforded to this priority is starting to have an impact Chart 1 Falls Rate All Acute Sites NHS Ayrshire and Arran 10.0 ALL FALLS RATES 8.0 6.0 4.0 2.0 Median 0.0 4 of 10

1/9/16 1/10/16 1/11/16 1/12/16 1/1/17 1/2/17 1/3/17 1/4/17 1/5/17 1/6/17 1/7/17 1/8/17 1/9/17 Total no of falls with harm Falls with Harm In the healthcare setting, falls with harm continue to be one of the highest occurring adverse events. Injuries from falls, particularly where a fracture occurs are associated with higher patient morbidity and mortality rates. In the 12 months to 30 September 2017, 12 patients fractured a limb as the result of a fall whilst an inpatient. Chart 2- Falls with Harm Count 18 16 NHS Ayrshire and Arran All Acute Sites Falls with Harm Count Median 14 12 10 8 6 4 2 0 Date Falls Improvement Work In order to reduce the incidence of falls, further improvement work is currently being progressed. This includes; The development of a falls toolkit to provide staff with the necessary information to explore and apply the interventions, in addition to ensuring a higher level of supervision which is currently the main intervention used. Promoting the use of Falls Walks which have been successfully implemented in community hospitals and is associated with a reduction in falls of over 30%. Testing and spread of the post falls bundle to ensure correct patient management following a fall with additional risk assessment that reduces the risk of further falls. National data suggests that approximately 32% of patients who fall will go on to have a further fall whilst an inpatient. Areas with the highest rates of falls and falls with harm are prioritised to ensure they have the full support of the improvement team. This includes the use of the Quality 5 of 10

Oct 16 Nov 16 Dec 16 Jan 17 Feb 17 Mar 17 Apr 17 May 17 Jun 17 Jul 17 Aug 17 Sep 17 Oct 17 of Care Indicators programme which has been discussed in previous HCG papers. In the test area alone, a drop in patient falls of 50% has been sustained since the programme began. This work is now being progressed in Renal Dialysis Unit & 3B in UHC, and St 8, UHA. Role Development Falls Co-ordinator In addition to the improvement work being progressed, a Falls Co-ordinator role for acute services is being advertised as a short term secondment opportunity. The Co-ordinator will work closely with the clinical and improvement teams to provide support, advice and practical assistance in the management of patients at risk from falls, and in ensuring an evidence based approach is employed and that all clinical areas are using the appropriate bundles to inform practice. 3. Pressure Ulcers Acquired pressure ulcers remain a priority indicator both nationally and locally. In 2016, an increase in acquired PUs was measured within acute services and this resulted in an increased focus on this type of harm. Currently, the SSKIN Bundle is used to monitor patient s skin condition and ensure the correct level of care is received. Historically the bundle formed part of the Care and Comfort Rounding chart but compliance has been variable and in the areas that have reported an increase in pressure ulcer acquisition, compliance with the bundle was found to be poorer. As chart 3 below shows, acquisition rate is variable but again, a shift downwards from May 2017 is visible. This represents that when pressure ulcer focussed care was established as a priority, and a number of actions were taken, specifically to support, improvement in this area was evident. Chart 3 Pressure Ulcer Rates All Acute Sites NHS Ayrshire and Arran 10.0 Pressure Ulcers graded 2-4 8.0 6.0 4.0 2.0 Median 0.0 6 of 10

Pressure Ulcer Improvement Work A number of initiatives are being progressed to reduce pressure ulcer acquisition in the acute service setting; The Acute QI team are working in collaboration with the Tissue Viability Team to provide education and training on PU prevention and the correct use of the SSKIN Bundle. Collaboration with the Documentation Group to ensure any changes to the Care and Comfort Tool supports improved PU care Increased coaching in areas with a higher than expected PU rate. 4. Delirium Care Patients with acute delirium are increasingly becoming more common within the acute hospital setting. In addition, we are managing patients with more frailty and with multiple morbidities. The acute service environment is not ideal for these complex patients and there are a number of interventions that can be implemented to reduce the risk of patient harm. Previous attempts to spread the 4AT assessment tool and the TIME Bundle were adhoc and could only be supported when the EMHT had the available capacity. Training designed to increase delirium awareness was poorly attended. As a result, a new approach was required. Testing of a new TIME sticker is currently underway in both acute sites and within EACH. (Figure 4) Figure 4 TIME Sticker currently being tested TIME Bundle 4AT Score... Your patient has a possible delirium. Have you considered? Infection Yes No Antibiotic commenced Yes No N/A Date bowels last moved:... Eating Yes No Drinking Yes No Has new meds been started/dose changed/stopped Yes No Is the patient in pain Yes No Blood taken (post onset) Yes No N/A Requested Urinalysis/CSU (post onset) Yes No N/A Requested Imaging Yes No N/A Requested AWI in place Yes No Getting to know me Yes No Explain to patient/family (Use delirium leaflet) Yes No Document care using code z cognitive impairment in patient profile 7 of 10

To date, the sticker (prompt) is being well received and is resulting in improved compliance and better recognition and management of acute delirium. Testing is being carried out in a further three acute service areas and will then be spread across all inpatient areas. In addition, a Learnpro module has been sourced to improve delirium education. Test areas are completing the module and feeding back on usefulness prior to spread. Improvement support will be given to all areas during spread and regular measurement of both process and outcomes measures will be carried out on a weekly basis until compliance of >95% is sustained over 6 months, at which point, only outcomes will be measured. This ensures that data collection does not become a burden to improvement efforts but instead is used as a measurement for improvement. Outcome data will be provided in future Board reports. 5. CAUTI From a national perspective, there has been, to date, a lack of clarity around this supplemental measure, with evidence of its effectiveness quite difficult to ascertain. As a result, it was dropped as a primary indicator and reporting was not required. However, in August HEI announced they will be undertaking themed inspections and the first identified theme is catheter care and management. The improvement team have therefore been working closely with our infection control colleagues to ensure our practice is evidence based and we have the correct protocols and processes in place. Part of that work is the implementation of a CAUTI bundle. Locally, we had been testing the bundle in a number of clinical areas. Some work had been undertaken to update the bundle to focus more on catheter use and not acquired infection. The evidence now suggests that the only way to reduce catheter infection, is to reduce catheterisation and the new bundle reflects this change of focus. Testing to date has been successful and full spread of the Bundle will be complete by February 2018. Outcome data will be presented in future papers. 6. New Approaches to Improvement Following the restructure of the QI resource and past challenges in sustaining improvement, a new coaching approach to improvement is being supported and initial results suggest this change of focus is having a positive impact. Part of this changed approach means a much more bespoke service within different clinical areas depending on needs, which draws on the QI knowledge. Data suggested, for example, that there were a high number of patients falling in the single rooms within CAU at UHC. As a result, the following work is being progressed: A Quality Improvement Team of 10 staff members has been set up that includes nursing and AHP staff A closed facebook group for CAU QI has been set up 8 of 10

Testing of the vulnerable patient bundle and a new frailty tool is being carried out A QI zone has been set up with whiteboard updates on progress and problems A number of small tests of change include: Falls sticks in use in all areas Use of red triangle to identify patients who will take risks and shouldn t be left unattended when using toilet etc Registered Nurse and Nursing Assistant conducting 1:1 education on Care and Comfort Round (CCR) Falls leaflets handed to patients/carers if they have had a fall or are admitted with a fall Completion of over bed boards compliance being measured The team ownership of the improvement work has been a successful element of this piece of work and will be replicated in other areas. This, in addition to the Quality of Care Indicators Programme means quality improvement is now becoming an integral part of all clinical staff s role and this ownership is essential for sustainability. The outcome of this work will be reported in future reports. 7. Conclusion Changes to reporting work by the Acute Adult SPSP team has meant the team are now able to provide more support to a smaller number of projects. This has demonstrated service of early improved engagement with for clinical teams and allowed support to progress a number of core projects. The QI team are now working with clinical areas to help identify their improvement priorities and develop unit driver diagrams to deliver improvements. The data suggests this approach is resulting in more positive outcomes and this will continue to be closely monitored to ensure continued improvement and sustainability. 9 of 10

Monitoring Form Policy/Strategy Implications Workforce Implications Financial Implications Consultation (including Professional Committees) Risk Assessment Best Value - Vision and leadership - Effective partnerships - Governance and accountability - Use of resources - Performance management Compliance with Corporate Objectives Single Outcome Agreement (SOA) The activities of the SPSP Acute Programme will support the delivery of the Healthcare Quality Strategy None None Work stream Leads have been actively involved in the development of this paper. Failure to make progress in delivering sustainability and spread of the SPSP Acute Programme will have a negative impact on the quality and safety of care. Delivery of the SPSP programme will improve efficiency and effectiveness Supports compliance with objectives on quality, safety, improved patient experience and a learning organisation Improved healthcare governance will have a positive impact on SOA objectives. Impact Assessment Impact assessment not required as this is an internal document. 10 of 10