National Learning Session - 10 th June 2011 Improving Care, Delivering Quality Reducing Mortality & Harm in Hywel Dda health Board Insert name of presentation on Master Slide
Reducing Mortality RAMI & GTT
Hywel Dda RAMI 2010 Hywel Dda RAMI 2010 200 150 100 50 0 Jan-10 Feb-10 Mar-10 Apr-10 May-10 Jun-10 Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10-50 -100 Jan-10 Feb-10 Mar-10 Apr-10 May-10 Jun-10 Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Expected Deaths 147.2 139.3 153.2 160.8 181.8 182 168.5 178 185.2 138.1 161.6 187 +/- Expected Deaths 40.8 14.7-6.2-43.8-48.8-43 -56.5-44 -46.2-25.1-27.6-21 RAMI 128 111 96 73 73 76 66 75 75 82 83 89
Weekly Audit of Inpatient Deaths Since the 28 th March 2010, Hywel Dda Health Board has been auditing inpatient deaths from both acute and peripheral hospitals. This equates to a total of 2128 patients of which 97.6% have been audited. Before these audits started the RAMI in the Health Board was over 100. Since March 2010 the Health Boards RAMI has consistently been below 100. As a result of this reduction in the RAMI It is estimated that there has been 306 fewer deaths than would have been expected within the Health Board. A weekly report of these audits is sent to the Medical Director and the Chief Executive.
Weekly Audit Year One Ceredigion Carms Pembs Total Total 333 (15%) Further Review 54 (16%) 1213 (56%) 95 (8%) 622 (29%) 101 (16%) Mild 31 48 29 108 Moderate 15 24 11 50 Significant 4 20 14 38 No concern 4 3 31 38 Not specified 0 0 16 16 Letters Sent 47 (87%) Response Rate 27 (57%) 91 (96%) 47 (52%) 99 (98%) 57 (58%) 2168 250 (12%) 237 (94.8%) 131 (55%)
Weekly Report Template
Thematic Analysis of Weekly Audits of Inpatient Deaths 60% 50% 40% 30% 20% 10% 0% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 59% 21% 21% 11% 34% 35% 30% 45% 44% No adverse events Pending further review Contributory Factors 13% Ceredigion (N=27) Carms (N=47) Pembs (N=57) 29% 0% Patient characteristics 62% 25% 20% Task Factors 50% 24% 4% Individual factors 63% 48% 84% Team Factors 33% 13% 12% Work Environment Ceredigion (N=8) Carms (N=21) Withybush (N=25) 48% 38% 36% Organisational/ Management Factors Once a Consultant has confirmed that the concern identified by the HDCC is valid they are analysed by the AMD for Quality & Safety to identify any themes. This work will help to identify which areas the Health Board needs to concentrate on in the future
Examples of Identified Themes Patient characteristics Co-morbidity was an important contributory factor On warfarin, increased INR Individual factors Staff working outside their expertise:- Surgical referrals are made to F1 doctors rather than middle grades and/ or Consultants
Examples of Identified Themes Team factors Poor teamwork:- Medical issues in orthopaedic patients difficulty getting an appropriate physicians opinion a recurrent problem Work Environment Lack of essential resources:- Lack of ITU beds
Risk Adjusted Mortality Index Pembrokeshire A key target of the Health Board Quality and Safety Strategy is that the Health Board reduces its RAMI to below 100 (the peer average). Pembrokeshire County has consistently achieved this since February 2010 As a result of the RAMI being below 100 there has been approximately 76 less deaths than would have been expected during 2010 140 120 100 80 60 40 20 0-20 -40 Jan-10 Jan-10 Feb- 10 Feb- 10 RAMI Pembrokeshire January - December 2010 Mar- 10 Mar- 10 Apr-10 Apr-10 May- 10 May- 10 Jun-10 Jul-10 Jun-10 Jul-10 Aug- 10 Sep- 10 Oct-10 Expected Deaths 40.2 38.9 35.6 38.6 47.7 37.7 43.3 45.8 49.2 33.9 36.7 47.4 +/- Expected Deaths 6.8-0.9-0.6-2.6-15.7-9.7-12.3-6.8-10.2-4.9-7.7-11.4 RAMI 117 98 98 93 67 74 72 85 79 86 79 76 Aug- 10 Sep- 10 Oct-10 Nov- 10 Nov- 10 Dec- 10 Dec- 10 Peer Average Expected Deaths +/- Expected Deaths RAMI
Global Trigger Tool Pembrokeshire A key target of the Health Board Quality and Safety Strategy is that the Health Board reduce its adverse event rate to below the base line of 27.33. The above chart shows that Pembrokeshire has managed to achieve this target in 7 out of 10 months in 2010 and has demonstrated continuous improvement since 2008/09.
Global Trigger Tool Ceredigion
Global Trigger Tool Carmarthenshire
Reducing HAI
Defined Types of HAI DEVICES/PROCEDURES Total Number UTI Blood Stream Central Line 2 (1%) 4% 4% Skin & Soft 8% Tissue Bone & Joint 22% Peripheral Line 52 (30%) 8% Catheter 22 (13%) Pneumonia 1. Baseline August 2010 12% SSI 15% Surgery this admission 21 (12%) GI Tract 12% Systemic infection Resp Tract 15% Surgery in last 12 months 0 2. ChloraPrep 0.67ml Sepp Implemented 2010 3. Peripheral Vascular Cannula Insertion Bundle revised roll out June 2011 Hand hygiene PPE Skin Prep Dressing (Chloraprep) Prescription Chart sticker 4. Short Term Urinary Catheter Testing June2011 Hand hygiene PPE Aseptic Technique Clean urethral meatus Sterile closed drainage system Documentation OUTCOME = MRSA Bacteraemias April 2010-March 2011 Prescription Chart sticker
Date Time Hand Hygiene Indication for Use VIP Score Dressing Dry & Intact Cannulae Access 70% Alcohol Administration set (replacement) Re-sited after 72-96 hours Yes / No Visual Infusion Phlebitis Score IV Site Healthy 0 No signs of phlebitis Observe cannula Slight pain or redness at IV site Pain at IV site, swelling, erythema 1 Possible signs of phlebitis Observe cannula Pain along path of cannula, erythema, induration 2 Early stages of phlebitis Observe cannula Pain along path of cannula, erythema, induration, palpable venous cord 3 Medium stage of phlebitis Resite cannula, consider treatment Pain along path of cannula, erythema, induration, palpable venous cord 4 Advanced stage of phlebitis Resite cannula, consider treatment Pain along path of cannula, erythema, induration, palpable venous cord 5 Advanced stage of thrombophlebitis Initiate treatment, resite cannula
CARE PLAN Problem... has an indwelling urethral catheter (A) PROBLEM NUMBER Actual (A) Potential (P) Date Desired Outcome Nursing Action Date Problem Solved To prevent ascending infection Catheter to be cleaned daily/prn with soap and water Ensure tubing is clean at all times Empty catheter bag 12 hourly/prn according to ward policy Report any abnormalities in colour, odour and concentration Report to nurse in charge if urine output is less than 500 mls in 12 hours Save CSU if urine shown signs of infection DAY Date Is the catheter still needed Drainage bag positioned below the bladder and off the floor Gloves worn for catheter manipulation (with hand hygiene pre/post) Urethral meatal hygiene performed Catheter circuit not broken Overnight link system discarded (leg bags only) Sign& position Yes No Yes No Yes No Yes No Ye s No Yes No 2 3 5 6 7 Catheter Drainage bag changed? YES/NO 28 IF CATHETER IS STILL REQUIRED AFTER 28 DAYS - CHANGE THE CATHETER, DRAINAGE BAG AND COMMENCE NEW DOCUMENTATION DATE CATHETER REMOVED / / Signature
20-minute period HH Opportunities (O) / HH Events (H) Ward manager / junior sister OOO HHH Staff nurse s OOO OO HHH H Student nurses OOO HHH CNS / NNP / Bed manager NA Consultant OOOO HHH Senior doctors e.g. registrars OOOOO HHHH Junior doctorsfy1, FY2 OOOO HHH HCAs OOOOOO HHHHHH Allied Healthcare Professionalsi.e. physio, speech therapy, OT, dietician, rehab(please state) Ancillary i.e. domestics, catering staff, porters, sewing room staff(please state) % compliance 100% 80% 100% NA 75% 80% 60% 100% 100% 75% NA O H OOOO HHH Others i.e. social worker, ECG techs, ward clerk, pharmacy, radiology, NA Overall Ward / Department Compliance = 35 Total of all observed hand hygiene events (H) 30 X 100 = 86% Opportunities As Designated by WHO 5 MOMENTS Campaign 1) Before patient contact 2) Before a clean / aseptic procedure 3) After body fluid exposure / after removing gloves 4) After patient contact 5) After contact with patient surroundings
Ceredigion Hand Hygeine Hand hygiene audits started in BGH in May 2010 No link nurse system in place Audits performed by IP&C nurse Audits done monthly Feedback to ward managers in the form of graphs and feedback forms
Compliance 100% 97% 100% 100% 100% 85% 75% 80% 78% 78% 76% 50% 40% 25% 0% Manager/ Sister Nurses Student Nurses CNS/NNP/ Bed Mngr Consultants Senior Dr Junior Dr HCA AHP Ancillary Other BGH
To benchmark or not to benchmark! 100 84 89 89 86 84 75 66 72.5 50 25 0 0 Jan Feb Mar Apr June July Aug Sep Oct Nov Dec BGH Health Board
Hand Hygiene - Pembrokeshire The County Infection Prevention & Control Team implemented monthly hand hygiene compliance audits in May 2009 in line with NPSA and 1000 lives. Hand hygiene compliance audits performed by infection prevention & control link nurses / hand hygiene champions in wards / departments and feedback posters for ward display boards compiled by ICT. The aim is for wards / departments to achieve 95% compliance to hand decontamination. Compliance rates since May 2009 have ranged from 69% to 89%.
urinary catheter bundle Pembrokeshire In Pembrokeshire a European prevalence study in November 2010 indicated no healthcare acquired infections with the 50 indwelling urinary catheters that were in place on the study day. Infection prevention & control link nurses conducted a urinary catheter audit in January 2011 with scores ranging from 85% - 100% compliance to catheter standards, which was extremely encouraging in the endeavour to reduce infections with urinary catheters. Feedback posters are compiled by the infection prevention & control team for ward display. Care bundles will be implemented following the trials in Carmarthenshire.
Chronic Heart Failure
Chronic Heart Failure Background In 2008 the strategy for caring for patients in Ceredigion was introduced: those patients who had an unscheduled hospitalization for HF were reviewed by the HFN postdischarge, for education regarding how to prevent future hospitalization and for up-titration of HF drug therapies initiated in hospital. The service is provided to the patient across primary and secondary care with outpatient clinics established across the county; home visits are provided when patients are housebound as frail patients are at highest risk of being rehospitalized.
Chronic Heart Failure Were are we now: During the past 24 months service all Bronglais hospital patients with HF were seen by the Cardiologist as an inpatient and those from Ceredigion were seen by the HFN following discharge (except during the periods of uncovered Medical or Nursing annual leave ). Data evidences: The survival rate in the first year after discharge (75%) is above the national average reported in the National CHF Audit (70%) (in which we participate) The average length of stay at BGH for patients admitted with CHF has fallen by 2 days since introduction of the new model (from 12.7 to 10.6) The local rate of referral to palliative care services is 5 times higher than nationally (making provision for a comfortable death at home avoids expensive and pointless terminal hospitalizations, and is central to reducing costs)
Rapid Response to Acute Illness
Situation: Introduction of admission, recognition and response and care bundles based upon the guidance from NICE G50 and the Surviving Sepsis Campaign. Background: 11% of deaths surveyed were as a result of unrecognized or untreated deterioration (NPSA 2007). 21% of ICU admissions avoidable (NCEPOD 2005) 2.3% of hospital patients and about 27% of intensive care patients diagnosed in severe sepsis/shock with a mortality 30-50% (Daniels 2010) Early recognition of the deteriorating patient and appropriate response would result in reduction in mortality and ICU admissions.
Rapid Response to Acute Illness 1. Admission Bundle 2. Recognition Bundle 3. Response Bundle 4. Sepsis Six 5. Ensure competence in - monitoring, measurement, interpretation and prompt response
Admission Bundle safety briefing form pilot. Aim to ensure early identification and communication of acute patient deterioration and initiate immediate implementation of required response. Health Care Support Workers and Registered Nurses enter all patients who s MEWS score is 1 on the safety briefing form to facilitate appropriate response by the registered nurse and medical staff. Staff Feedback It summarises the workload of the ward in terms of nursing acutely ill patients. It helps ensure that patient observations are reported by the Health Care Support Worker (HCSW) to the staff nurse (SN) and provides opportunity to evidence such reporting. It identifies patients who are at risk of acute deterioration and provides an effective format of handover to other health care professionals. It enables dissemination of the actions taken and ongoing assessment It helps initiate appropriate response, which is not only based on scores but
Date: Admission Bundle: Number of patients requiring observations Number of admissions Observations recorded within 2 hours of admission Registered Nurse Signature EARLY LATE NIGHT Recognition Bundle: Response Bundle: Situation Background Assessment Response Name Bed No Previous MEWS MEWS Score MEWS Time MEWS Trigger or X Response Code Initials of HCSW Reporting to Staff Nurse Registered Nurse Signature Response Code: 1 - CONTINUE WITH CURRENT PLAN FOR FREQUENCY OF OBSERVATIONS 2 - INCREASE FREQUENCY OF OBSERVATIONS 3 INFORM DR
Recognition and Response Observation chart revised to include: Frequency of observation, reviewer signature, ViEWS (track and trigger) system, trigger action documentation section and SBAR piloted on two wards in Glangwili Hospital March 2011.
Observation Chart Compliance 100% 80% 60% 40% 20% 0% Reviewers Int Recorders Int ViEWS Score Correct ViEWS Score O2 O2 Sats Resps Pulse BP Temp Time Freq of Obs Date Patient ID 51% 53% Pilot Site 1 (n 502) 100% 80% 60% 40% 20% 0% Reviewers Int Recorders Int ViEWS Score Correct ViEWS Score O2 O2 Sats Resps Pulse BP Temp Time Freq of Obs Date Patient ID 92% 81% Pilot Site 2 (n 423)
No. of patients who Triggered Vs No. of Triggers No. of Patients No of Triggers 160 140 120 100 80 60 40 20 0 148 83 19 21 Pilot Site 1 Pilot Site 2 (n 40) (n 231)
Overall Outcome 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 45% 38% 13% 5% Discharge In Patient Transfer Died (n 40)
Early Management of Severe sepsis/ Septic shock PLAN Adopt a zero tolerance" to the miss management of sepsis. Response to sepsis similar to response to MI's and Strokes. Develop Sepsis Simulation training for staff team. Introduce NEW Sepsis documentation to include: screening tool, sepsis six protocol and antibiotic guidance. Sepsis Six
Ensure competence in - monitoring, measurement, interpretation and prompt response Medical Staff Resuscitation department have developed and implemented a Junior Doctor Simulation Training programme, which looks at management of the deteriorating ward patient Nursing Staff Working collaboratively with Swansea University to develop competency standard & degree module for staff caring for level 1, 2, 3 patients.
CEREDIGION SEPSIS 6 BUNDLE 5 sepsis patients admitted To ICU since Jan 2011 2 patients from A&E, 1 of Whom was on the A&E Pathway.
Patient Stories
Patient Stories in Ceredigion INFORMATION SHEET ON PATIENT STORIES Thank you for agreeing to tell us your story. Your experience is important to us. We would like to hear your story in your own words about the health care you have received. WHY ARE YOU DOING THIS? This is part of our quality improvement work. We believe that if we listen to the stories from patients we can really hear and take on board what you have to say and feel about your experiences with health care. We want to gather a lot of information so that we can look at the services we provide and see how they might be improved. If you tell us what was good we can make sure that we do more of it. If you tell us about the things that are not so good we can try to change them and make sure they are better for the future. WHAT WILL BE EXPECTED OF ME? We will agree with you a suitable time and place to meet. You will tell one person from a team of health professionals your story. We will record your story to make sure that we really hear what you have to say. We will then go away and listen to the recording, together with other colleagues from the team, to draw out themes and issues of concern. This will help us to think about our services and how to improve them.
CAN I SPEAK IN WELSH? You can tell your story in the language that you feel most comfortable speaking in. When we contact you we will ask you about this so please tell us what would be your preference. WHAT IF I WOULD PREFER SOMEONE TO SPEAK ON MY BEHALF? Ideally we would like to listen to patients directly, however in some circumstances this may be difficult to do. In these instances we would still like to hear the story and this could be through a relative. We would want the patient to be present during the interview so as to give as much input as possible. WHO IS ON THE TEAM? The team is made up of different people who all work in health, some of whom are nurses, therapists, support staff or doctors. You may not know the person who will listen to your story but they will explain fully who they are. We will try to make sure that you can tell your story to someone that has not been involved in your care. We recognise that it could be difficult to talk openly and honestly in that situation. This may sound like a daunting experience but I promise it is not! In fact a lot of people find it helpful to have someone listen to their story and know that something will be done about it. We can let you know what we do with the information that we collect if you are interested.
Do I have to take part? You are under no obligation to take part. If you agree to take part you are able to withdraw from it at any point without prejudice and without needing to give a reason. Will taking part affect my health care? Any future treatment or care you or a member of your family may need will not be affected by taking part. What will you do with the information? The stories that we collect will be treated in confidence Any feedback that is given will be anonymous. Your name and details will not appear in any report. We would like to keep your story so that we can listen to it again in the future. I f you would prefer us not to keep the story we will destroy the recording as soon as we have learned from it. Consent We will ask you to sign a consent form to make sure that you are fully aware of what is being asked of you and that you feel confident you have been given sufficient information
Patient Stories Action Plan CEREDIGION 2011 Identify project group Provide training Provide refresher guide - preparing, consenting, gathering, coding, theming, sharing, storing Develop flier to advertise story telling Develop consent form and process List of places to advertise Notice boards on site Article in Cambrian News Information given to all patients/opd/ GP surgeries Identify enough kit to take stories Responses contacted and staff from the patient story group identified to take story Identify further support if required for patients Gather stories Action plan and feedback to services (CPGs, 1000 Lives+) Feedback to participants Making sure improvement happens report to Quality & Safety meeting
Transforming Care
Transforming Care Pembrokeshire Objective Measure Baseline average Review To increase % Direct care time to 70% Reduce locally defined adverse events by 50% Increase Patient satisfaction to 95% Increase staff satisfaction to 95% Activity Follow Well Organised Ward: LEAN Patient Status/ Safety at a Glance SKIN Bundle Falls RRAILS Sepsis Health Acquired Infection Data is used from the Fundamentals of Care audit Staff questionnaire RN 42% HCSW 60% Most areas have not repeated this measure Many examples of changes to practice = reductions in wasted time, resources etc to increase % of time for direct pt care Many areas have boards but work is progressing in Pembrokeshire to PDSA a core format for the board to ensure accurate & consistent information to safeguard pt safety and facilitate safe and effective handover using SBAR principles Please see 1000 Lives Plus submissions from the relevant areas 2009 2010 88.9% Max days between incidence of PU 137 days currently Base line and current data awaited from Management services Work is progressing to establish a mechanism for county based steering groups which could engage key stakeholders to reduce unnecessary barriers to progress at ward level and ensure that TC connections are made at the right time in the right place with the right person. e.g. Estates dept, Hotel facilities, IT, procurement etc..
The Hywel Dda Health Board Quality Improvement & Patient Safety Strategy to reduce waste, harm and variation 2010-2015 aims to reduce hospital acquired pressure ulcers by 50% and to this aim, the Health Board has co-ordinated the implementation of the SKIN care bundle to all ward areas within the Health Board. Inform the patient Provide information to patient and their family Encourage patient to reposition themselves Notify MDT Hand over should include PSPS and preventative strategies Involve physio, OT and moving and handling advisor in chair assessment, and correct handling of patient Refer to dietician Inform Consultant of patients risk assessment and update daily PRESSURE DAMAGE PREVENTION PATHWAY Conduct PSPS risk assessment within 2 hrs following admission Inspect the skin of vulnerable patients PSPS 6 No Risk- monitor 6-9 At risk- monitor, provide patient information leaflet 10-11 High risk initiate skin bundle, consider air mattress 12-16 Very high risk initiate air mattress and skin bundle Start the SKIN bundle Surface- ensure relevant equipment in chair and on bed. Keep moving, change position of patient at least 2hrly in bed and chair, Use glide sheets Incontinence, ensure skin clean and dry. Do not overuse pads/creams Nutrition, assess daily, ensure you are aware of patients fluid /food intake Recalculate and record the risk assessment score daily Patient develops/admitted with a pressure ulcer Record event on safety cross Record event on DATIX Include grade, location and where ulcer developed Senior nurse/sister to complete detailed root cause analysis on DATIX in response The Tissue Viability Team and Clinical Practice Development Nurses have worked in partnership to coordinate the implementation of the SKIN bundle Work to Date Pressure Damage Prevention Pathway developed Two safety crosses used in each area. These identify patients with either ward acquired or admitted with pressure damage Safety cross adapted to include additional information on new cases of pressure damage Incidence of ANY pressure damage reported via the DATIX system, which has been modified to give greater detail on each incident SKIN bundle amended to reflect local context in some clinical areas Implementation plans agreed for each county supported by extensive training programme Risk Assessment tool and Pressure Ulcer classification included on the back of the SKIN bundle document as a reference guide
Hywel Dda HB SKIN Bundle Pressure Damage Prevention Ward & Site: Acquired on the Ward 1 2 Month:. Admitted or transferred with 1 2 Date Patient ID label Pressure Ulcer site Please state: A = Acquired on the Ward T = Admitted/transferred Reported on DATIX (tick when completed) 3 4 3 4 5 6 5 6 7 8 9 10 11 12 7 8 9 10 11 12 13 14 15 16 17 18 13 14 15 16 17 18 19 20 21 22 23 24 19 20 21 22 23 24 25 26 25 26 Number of Days since Last Incident 27 28 27 28 Number of Days since Last Incident 29 30 31 29 30 31 No new pressure ulcer found Damage acquired Please fill in the small box on the right hand side to indicate the number of new cases. No new patient admitted/transferred with pressure damage Patient admitted/transferred with pressure damage Please fill in the small box on the right hand side to indicate the number of new cases. Section on the back of the safety cross for any new cases
Reducing Surgical Complications
Reducing Surgical Complications - Pembrokeshire Antibiotic stickers introduced for orthopaedic patients at WGH Diabetic regime - planned to be piloted on ward 1 WGH. SBAR - ward 3, WGH leading on embedding principles of SBAR for handover. Ward 3 doing PDSA cycles i.e. patients from Same day admit to ward areas, ITU to ward areas and following SBAR for purpose of handover. Safety brief also being piloted on ward 3 Sepsis bundle introducing to A+E and ACDU. Incorporated into ILS training, track and trigger work
WHO Surgical Checklist
Falls Prevention
Ceredigion Falls Mini Collaborative Mini multi-agency collaborative created in September 2010 Challenge of following patient journeys through care and interventions leading to: missed opportunities for timely intervention duplicated and inappropriate referral mechanisms inability to capture evidence to support business cases for change
Ceredigion Falls Mini Collaborative Progress to date: Care homes using the database as a catalyst for joining together data on falls with individual records WAST Exploring the opportunity of the WAST referral system to capture information and share it across organisational boundaries Testing multi agency screening tools for capture of information and to instigate appropriate sign posting / referrals Utilising the multi agency partnership to exploit opportunities around self help promotion of preventative measures.