Agenda item 7(v) THE NEWCASTLE UPON TYNE HOSPITALS NHS FOUNDATION TRUST DELIVERING HARM FREE CARE FALLS AND PRESSURE DAMAGE UPDATE Patient Stories The use of patient stories can be very effective in communicating to staff the importance of ensuring all interventions are in place and documented. The following patient stories will be used in education sessions with staff. Pressure Damage Mr P was a 47 year old gentleman who had been diagnosed with rectal carcinoma and was in the palliative phase of the disease. Metastatic disease protruded through the skin at the lower end of his spine. Initially, he was at home, being looked after by carers to allow his wife to continue to work. He was only comfortable sitting in a chair and refused to be nursed in bed, despite district nursing and tissue viability input. He developed moisture lesions due to urinary incontinence. Eventually he was admitted to hospital for pain control, he was placed on a low air loss mattress and a referral to tissue viability was made to assess his wounds. Mr P was not comfortable on the low air loss mattress; despite being one of the top pressure reliving product on the market, it did not suit his needs. We decided to place him on a StaticAir mattress, a hybrid non-powered mattress that combines air displacement with high quality foam. Mr P became more comfortable and the clinical team were able to palliate his pain and other symptoms. This demonstrates how staff need access to a range of mattresses and have a good knowledge of them to achieve patient comfort and this will be personal to each patient. Falls Ms A is a 64 year old lady who was admitted due to reduced neurological function as a complication of a lymphoma with cerebral metastatic disease. Prior to admission Ms A had had a number of falls due to gait and balance disorder associated with her condition so staff were aware of her high risk of falling whilst an in-patient. Throughout admission she was assessed appropriately using the Neurosciences Falls Care Bundle and all the relevant risk factors and associated interventions were identified and put in place including hourly checks on the FOCUS chart. Ms A was assessed by the ward Physiotherapist who concluded that she was safe to mobilise independently around the ward and had the cognitive ability to ask for assistance if she felt she required it. The ward staff highlighted Ms A s risk of falling at each handover and she was nursed in a bay which is closer to the Nurses station for higher level observation. Despite all of these measures being put in place Ms A went on to have a fall in the bathroom. Ms A was able to recall the event and said she had simply turned too quickly causing her to lose balance and she fell to the floor and unfortunately sustained a fractured hip.
This case study highlights that the at risk patients are not simply the over 65 year olds who are predominantly admitted to the Medicine/COTE directorate. It also highlights that despite the appropriate assessment and intervention plan being put in place, falls with harm can still occur. Catheter Associated Urinary Tract Infection Mrs M was admitted following a fall at home and unfortunately sustained a pubic ramus fracture. Mrs M has a medical history of symptomatic cervical spine with degenerative bony changes. During her stay in hospital MRI scan confirmed that there were degenerative changes throughout the cervical spine. Mrs M had back pain and difficulty mobilising and was found to have some sensory and motor changes in her upper limbs during her stay. During her hospital admission she also experienced urinary retention, possibly related to her cervical spine issues. As a result she was catheterised for a period of 7 days, then a trial without catheter was attempted without success and Mrs M had to be re-catheterised. A continence and catheter assessment was undertaken and a decision was made with Mrs M to remove the urinary catheter with a view to starting intermittent selfcatheterisation. Intermittent self catheterisation is the gold standard method for bladder emptying in patients with neurogenic bladder dysfunction. The technique is safe and effective and results in improved kidney and upper urinary tract status, lessening of veicoureteral reflux, emptying the bladder regularly and completely and improvement of continence. In addition to the clinical benefits, patient quality of life is enhanced by the increased independence and security offered by selfcatheterisation and the reduction in catheter associated urinary tract infections/urinary tract infections, which can be very severe and debilitating. Intermittent self catheterisation was successfully achieved by Mrs M with ward staff supporting and encouraging her to achieve independence of her bladder health. These patient stories illustrate the breadth of knowledge we require staff to have in every day routine practice to prevent and respond to harm. The Patient Services Teams responsible for these areas of practice lead on the underpinning practice development, education and provide specialist advice across the whole Trust as illustrated in the following paper.
Agenda item 7(v) THE NEWCASTLE UPON TYNE HOSPITALS NHS FOUNDATION TRUST DELIVERING HARM FREE CARE FALLS AND PRESSURE DAMAGE UPDATE EXECUTIVE SUMMARY This paper provides an in-depth analysis and practice update in relation to Falls, Pressure Damage and Catheter Associated and Urinary Tract Infection (CAUTI) as a supplementary paper to the Integrated Quality Account. It takes stock of progress in 2016/17 and outlines the priorities in 2017/18. In 2016-2017 the most challenging area has been pressure damage prevention which is showing a small increase in the number of incidents of Hospital Acquired Damage for Category II damage. No Category IV were reported during these twelve months, furthermore, incidents of moisture lesions damage continue to reduce. All of this work is part of the Trust s commitment to delivering Harm Free Care. The Trust has well established and respected clinical experts leading this work who; work regionally and nationally to ensure Trust care is exemplary and evidence based whilst also sharing our work with others to contribute NHS reductions in harm. RECOMMENDATION To i) note the content of the report and comment accordingly and (ii) to support ongoing work. Helen Lamont Nursing and Patient Services Director Fania Pagnamenta Nurse Consultant Tissue Viability Rachel Carter Falls Prevention Co-ordinator Jackie Rees Nurse Consultant Continence Frances Blackburn Deputy Director of Nursing 15 th May 2017 2
Agenda item 7(v) THE NEWCASTLE UPON TYNE HOSPITALS NHS FOUNDATION TRUST DELIVERING HARM FREE CARE FALLS AND PRESSURE DAMAGE UPDATE 1. INTRODUCTION / BACKGROUND The delivery of Harm Free Care for all patients is a national and Trust priority. The Trust consistently report above (better than) the national mean average for delivery of Harm Free Care using Safety Thermometer data (Appendix 1, graph 1). The Trust s overall rate of Harm free Care has varied throughout 2016/17 with the percentage of harm free care being better than the Trust mean in the period July to December 2016 dipping slightly below mean in the periods April to June 2016 and January to March 2017. Analysis of the types of harm demonstrates that this is a combination of increased Pressure Damage and variation in the other harms (Appendix 1, graph 2). The Trust has committed to aim to further reduce the incidence of harm from pressure ulcers, CAUTI and falls. Whilst the Trust consistently reports better than the national average for Harm Free Care (i.e. less harm), there are still further improvements which could be achieved. In relation to pressure ulcers the reduction the Trust achieved in in previous years, has not been sustained other than for moisture lesions (Appendix 2, graph 1). In relation to patient falls, there has been a reduction in the total number of falls over the last year which has added to the overall reduction since 2013 (Appendix 3, graph 1). This is most significant in the categories of most serious harm from falls (moderate, major and catastrophic incidents) (Appendix 3, graph 2.). In relation to CAUTI (Catheter Associated Urinary Tract Infections) there has been a reduction in harm from new UTI (Appendix 4, graph 1) which correlates with gradual decrease in prevelance of urinary catheters as measured by Safety Thermometer (Appendix 4, graphs 2, 3, 4 and 5). The speciality teams for each harm regularly analyse local data to monitor the number of harms reported and this is outlined in more detail for pressure ulcers and falls within this report. The report also outlines the current workstreams which are ongoing to try and minimise their incidence and the future initiatives which are planned by the individual teams to ensure we continue to deliver Harm Free Care. 2. HARM FREE CARE The Trust monitors carefully individual harms and as detailed below has significant work streams to minimize patient harm rates. The extract from the Safety Thermometer tool (Appendix 1, graph 2), shows the rates for the four types of Harm captured within Safety Thermometer (Falls, Pressure Damage, Catheter
Associated Infections and Urinary Tract Infection (CAUTI and UTI) and new Venous Thrombotic Embolism (VTE). The data shows that pressure damage accounts for the most harm on any given day, with the other areas contributing on a smaller scale. In part this is because a patient with pressure damage and a long length of stay will be counted repeatedly in Safety Thermometer whereas falls are only counted if harm occurred and the fall was within 72 hours of the day of data collection, and if CAUTI is present at the time of data collection. This paper focusses on work and data in relation to Pressure Damage and Falls and CAUTI, as they are the most significant causes of Trust acquired harm in terms of absolute numbers. 3. PRESSURE ULCERS Pressure ulcers are a key quality issue for the NHS. The published results of the Safety Thermometer data does influence public perception of the quality of care delivered by the Trust, it is noted that the Trust is good performer in the context of Safety Thermometer data, which reports Trust acquired ulcers as harm. However the Trust incident data during 2016-2017demonstrates that it has been difficult to sustain a reduction in category II and III pressure ulcers across all clinical areas. The best strategy for pressure ulcer prevention is turning patients as often as possible, at times hourly turns are necessary: this is time consuming for staff on the ward and a change of ward routine and effective staffing, is necessary to enable and embed this practice. Therapy mattresses, heel elevation, other equipment (such as SkinIQ) are great adjuncts but never replace good turning practices and good skin care. Tissue Viability staff review all patients who develop pressure damage whilst in our care, this ensures data is validated, which requires an experienced eye. Advice and education is provided to staff and patient/carers alike. i) Incident Data Analysis DATIX is the method by which staff report any category of ulcers and moisture lesion. The report highlights whether these ulcers are Trust acquired (hospital acquired and District nurses case load acquired) or non- Trust acquired. These reports are the most accurate and useful to analyse. The trend since January 2013 is a general reduction (Appendix 2, graph 1), especially with regards to moisture lesions and the most severe pressure ulcer (Category IV); however this general reduction is not consistently maintained. In fact, during 2016-2017, there was an increase of 1.2% in adult in-hospital population and 3% within paediatrics compared to the data collected in 2015-2016. This mostly occurred in the first six months of the year, during the second part of the year, incidents have reduced in comparison to the previous year.
ii) Update on work undertaken in 2016-2017 and priorities for 2017-2018 The Pressure Ulcer task force meet bi-monthly. A tri-dimensional perspective is required for successful pressure ulcer prevention: clinical leadership, team work and education. a) Leadership: - Targets: The first step in this journey is to take ownership at ward level. During 2016-2017, wards were asked to demonstrate a reduction of 20% from the previous year s incidents. This has been an ambitious target; nevertheless, 12 wards were able to achieve it. At Freeman Hospital, Ward 6, 8, 10, 34 and 35 and at the RVI, Ward 15, 19, 40, 48 and 49 achieved a 20% or higher reduction in hospital acquired pressure ulcers. Five wards achieved reduction which was less than 20%, 16 Wards maintained a similar position to the previous year, whilst 24 Wards reported more incidents. In light of these results, internal targets have been set for 2017-2018, tailored to each ward and based on past performance, giving an overall Trust target reduction of 20%. - Regional collaborative work: The Trust has participated in a regional Pressure Ulcer Reduction collaborative, led by South Tyneside Foundation Trust following funding from Academic Health Science Network. During 2016-2017, further funding was secured which offered opportunities for three staff to participate in a coaching programme. This programme, which will continue during 2017-2018, includes clinical leaders learning Quality Improvement techniques that enable them to lead their local working group in NCCC, Care of the Elderly and the Nursing Care Home Support Team. The aim of the collaborative is to achieve a reduction of acquired pressure ulcers with a cycle of auditing, test-implement-test PDSA (Plan Do Study Act) cycles. The objectives are to take ownership of the data, by measuring the number of pressure ulcers and moisture lesions. The final objective is to introduce new practices individualised to each ward to enhance pressure ulcer prevention and test/audit if these make any difference. - Setting up local Task Force groups: Directorates who have significant pressure damage related harms, has been tasked with establishing their own local Working Group to drive a reduction in the incidence of skin damage. - Publication of findings: a number of papers have been published by the Trust s Tissue Viability Team during 2016-2017 to share our methodology for quality improvement. Further papers are planned for 2017-2018. - Regional and National benchmarking: the Nurse Consultant (Tissue Viability) regularly benchmarks clinical practice and outcome
with neighbouring Trusts as well as the Shelford Group. Variations in reporting thresholds are evident and have been escalated to the DoH. - Stop the Pressure: an NHS Innovation initiative is currently working on definitions in order to standardise reporting nationally. b) Team work: - Recognition of the nurse staffing requirements: the single most important action for the prevention of pressure ulcers is a strict regime of positional changes (i.e. turning patients) and this will take nursing time, and prioritisation of care at individual shift by shift level. - Root Cause Analysis of all Trust acquired category III or IV pressure ulcers continues by clinical teams and tissue viability prior to reporting as Serious Untoward Incidents (SUI). Learning has been: - Patients not turned sufficiently and consistently - Inconsistent documentation - Staff not recognising that when patients deteriorate, their risk of developing pressure ulcers increases, very rapidly and time window to prevent damage is very short i.e. one to two hours. - FOCUS charts audits: Regular audits of the FOCUS charts are undertaken, aiming to reach 100% and sustained them for a period of six weeks, as there is strong evidence that this enables wards to prevent ulcers from developing. c) Education: - Ongoing education regarding pressure damage prevention and the embedding of the Time2Turn initiatives continues. A new card was added to the Give me 5 minutes of your time set of educational card, where emphasis is placed on recognising that red skin is a warning sign and interventions should be increased. The slogan for this campaign is: Check for Red; React on Red and will be ongoing during 2017-2018. - Presenting any lessons learnt at the Safety Briefing: lessons learnt from the Root Cause analysis featured in three briefings in 2016/17. - A new electronic training package is being developed and will be released later this year. iii) Further considerations SkinIQ: The data continues to demonstrate that there is an inversely proportional correlation between the incidence of skin damage and SkinIQ usage. SkinIQ has undoubtedly been instrumental in the sustained reduction
of moisture lesions that we have seen since data collection began (from 50 to 15 moisture lesions per month). NHS Improvement Stop Pressure Damage Programme: All NHS Provider Trusts were requested to submit a report and Action Plan to NHS Improvement in relation to all of its work to reduce pressure damage. The Trust s report was submitted as required and the associated Action Plan is being progressed via the Pressure Ulcer Task Force (report is available on request). 4. FALLS Inpatient falls are the most commonly reported patient safety incident with over a quarter of a million falls in acute and community hospitals and mental health units in England reported to the National Reporting and Learning System (NRLS) each year. Whilst it is recognised that inpatient falls are common, it is also acknowledged that the prevention of falls is highly complex as there is no single intervention when done on its own that will prevent falls. Best practice evidence is that each patient s falls risk should be individually assessed and therefore patients with different risk factors will need different intervention plans. Inpatient falls are increasingly being used as a marker of quality of care and are a major concern in relation to patient safety. A significant number of falls result in death or severe or moderate injury, at an estimated cost of 15 million per annum for immediate healthcare treatment alone (NPSA, 2007) through measures such as Safety Thermometer and the National Audit of Inpatient Falls (NAIF) that Trusts are being regularly benchmarked against quality measures such as falls per 1000 occupied bed days and harm per 1000 occupied bed days. i) Data Analysis The Falls Dashboard provides graphical analysis of falls data on a monthly basis. Appendix 6 shows the Falls Dashboard for 2016/17. The top, middle graph demonstrates Trust monthly performance for falls/1000 bed days 2016/17 vs 2015/16. The average falls/1000 bed days rate for 2016/17 is 6.0 compared to 6.2 in 2015/16. A falls/1000 bed days rate of 6.0 means the Trust consistently reports lower than the National Acute Trust Average of 6.6 falls/1000 bed days. Furthermore, the Trust falls resulting in serious harm/1000 bed days rate for 2016/17 is 0.12 which is significantly lower than the national acute Trust average of 0.19 falls with serious harm/1000 bed days. Appendix 3, graph 2 shows the breakdown of severity of serious harm from falls for 2016/17 and demonstrates the reduction in moderate incidents (consistently short bone fractures and less severe head injuries) and major incidents, the majority of which are hip fractures. The falls resulting in death
(catastrophic) most frequently occur in patients with multiple co-morbidities and poor health who are often on anticoagulation therapy making them extremely high risk of falls and serious injury. There has only been 1 of these incidents in the last 6 months. All of the incidents graded moderate and above have had a full Root Cause Analysis (RCA) investigation and these are summarised later in the report. It is recognised nationally that falls prevention strategies take time to embed within acute in-patient services and significant reductions in falls and harm will only be seen once these strategies are truly embedded into practice. The Trust No Falls On My Patch campaign has been ongoing since 2011 and multiple workstreams have been led by the Falls Prevention Coordinator and the Falls Taskforce Group. The results of audit show that compliance with the Trust Falls Care Bundle is continuously improving. NICE (2014) and the Royal College of Physicians (RCP FallSafe, 2010) emphasise that driving up compliance against all elements of a multifactorial risk assessment and intervention plan (Falls Care Bundle) is the only recognised way of reducing inpatient falls. ii) Falls with Serious Harm Root Cause Analysis Review Falls with serious harm are monitored through a comprehensive Root Cause Analysis (RCA) process and these are reviewed every 6 months to examine areas of good practice and areas for improvement. The results from the RCA review for the 6 month period October 2016 March 2017 are demonstrated in Appendix 7. Within this period there were 25 inpatient falls requiring an RCA, in summary: Positive results: The majority of patients had the Falls Risk Assessment Tool commenced within the recommended 12 hours of admission (96%) where appropriate. The Falls Care Bundle was completed accurately for 88% of the patients who fell. 100% of patients had safe footwear provided where appropriate at the time of the fall and 96% of the patients had safe footwear on at the time of the fall. 100% of patients who fell had a call bell to hand, whether that was beside the bed space or a pull cord in the bathroom/toilet area. 100% of patients had been identified as being at risk of falls as per the Falls Care Bundle guidelines. However: Only 36% of these patient falls were witnessed and 68% of patients were being nursed in a directly observable bed at the time of the fall. Furthermore, the majority of inpatients were mobilising against advice (76%), all of which highlights the difficulty of maintaining observation for patient safety for all patients.
60% of patients had a history of falls prior to admission and 36% had had one or more falls, prior to the fall causing serious harm, since admission. This is a significant indicator in falls risk and these patients are the highest risk of falling again in hospital. Newcastle and Gateshead Clinical Commissioners have raised with the Trust concern that in some RCA reports the investigation has highlighted that patients with suspected fracture have not been lifted from the floor using the most appropriate manual handling techniques, in line with the Trust s Post Fall Guidance. Significant work is ongoing jointly with the Manual Handling Team and Falls Prevention Co-ordinator to embed this guidance into practice and the Trust have provided a detailed response to the Commissioners. iii) Continuing Work The Falls Taskforce group continues to meet monthly. The group remains well attended and has led work through the following initiatives: iv) Ongoing Initiatives a) Falls project funded by the North East and North Cumbria Academic Health Science Network (NENC AHSN). This project came to an end on 31 st Mar 2017. The initial project working with South Tees Hospitals NHS Foundation Trust and County Durham and Darlington Foundation Trust came to an end on 31 st July 2016 but The Newcastle Hospitals secured further funding to conduct share and spread of the project across the directorate of medicine/cote for a further 6 months. The Falls Project Practice Development Coordinator is now finalising the reports from the project which will be shared with Trust Board and Commissioners via the AHSN. The aim of the project was to drive up compliance against evidence based Falls Care Bundles measuring compliance using the Royal College of Physicians (RCP) FallSafe guidelines and NICE CG161 best practice guidelines. b) Circulating key messages and lessons learnt from 6 monthly RCA reviews. This has been an integral part of communicating key messages at large scale, particularly in relation to inadequate post fall management of patients, specifically those with suspected hip fractures and head injury. c) Trust wide circulation of the Post Fall Assessment Checklist this documentation has now been shared across the organisation and is in use on all adult in-patient wards following a successful pilot on Older People s Medicine wards at the Freeman Hospital. This document is multidisciplinary and ensures patients receive safe and timely care post fall whilst also ensuring all aspects of post fall care are documented to the necessary standard. Poor documentation post fall has previously been highlighted as an area of improvement during the RCA process therefore this document will assist with this and improve quality of care.
The audit process for measuring compliance with this documentation will be multidisciplinary with medical staff, nursing staff and the Falls Prevention Coordinator conducting the audit over coming months. Results of this audit will be reported in a future paper. However, early results show that there is further work to do to ensure that this is embedded across the organisation and used after every adult in-patient fall. This is supported by the RCA process where a number of recent incidents have highlighted that incorrect moving and handling techniques (particularly post hip fracture) have been used. This has either been as a result of lack of awareness of the Adult Post Fall Protocol and Post Fall Assessment Checklist or a lack of presence of trained staff at the time of the fall on the use of the Mangar Camel and Ferno scoop stretcher. The Falls Prevention Coordinator and Moving and Handling team have already done a significant amount of work to train individuals on both the use of the Post Fall Assessment Checklist and the moving and handling equipment but this needs to continue over coming months and years with the turnover of new staff. d) Education of staff has continued through the development of a new e- learning mandatory training package which went live on 1 st April 2017. The Falls Prevention Coordinator also continues to provide face to face training on the HCA Academy and at the Trainee Assistant Practitioner study days and directorate study days for newly qualified Nursing staff. e) Bi-monthly Falls Champions Groups are on-going and are attended by nursing, physiotherapy and occupational therapy representatives from a number of directorates. These groups encourage two-way communication between clinical staff and the Falls Prevention coordinator and give the Falls Champions the responsibility to relay key messages regarding falls prevention to their wards and teams. f) Royal College of Physicians (RCP) National Audit of Inpatient Falls (NAIF) 2017. This is due to take place in May 2017 and consists of an organisational audit and a case note review of 30 patients over a 2 day period. The Trust leads for the audit are Rachel Carter (Falls Prevention Coordinator) and Dr Simon Kerr (Consultant Geriatrician). The last audit took place in 2015 and the key elements of the results and recommendations have previously been reported to Trust Board. Whilst some improvements have been made in relation to key recommendations these remain a priority for the Falls Prevention Coordinator and the Falls Taskforce Group. 5. CATHETER ASSOCIATED INFECTIONS (CAUTI) AND URINARY TRACT INFECTIONS (UTI) i) Improving practice for catheter associated infection (CAUTI) and urinary tract infection (UTI) UTI are the largest single group of health care acquired associated infection accounting for 19% with between 43% and 56% of UTIs associated with a
urethral catheter. 15-25% of hospitalised patients may have a urinary catheter inserted during their hospital stay. UTI s can be one of the highest admission sources for patients to be admitted into secondary care, especially from Care Homes. UTIs lead to longer stays in hospital for patients and up to 5% of hospital acquired UTIs develop into secondary bacteraemia; this is often painful for the patient and can be life threatening. The risk of developing a health care associated infection such as a UTI cannot be eliminated entirely, but with appropriate infection control practices and adopting evidence based practice, empowering patients and staff, the risks to patients can be reduced considerably. The Trust is performing well in relation to CAUTI and UTI, consistently reporting below the national average in acute care. The work to avoid harm from CAUTI and UTI specifically involves interdisciplinary working between primary, secondary and tertiary care settings and a number of work streams to avoid hospital admission have been developed and implemented. The priorities at the moment are to sustain the reduction in serious harm from urinary catheters CAUTI by reducing infections by 30% ensuring that catheters are only inserted and remain in situ when clinically indicated. To achieve this it is advocated that all patients in acute care with catheter in situ must be reviewed at least daily. The focus has been to improve health care practice relating to UTI e.g. antibiotic prescribing/catheter review and stewardship, appropriate MSU and CSU sampling and incorporating staff education and training. ii) Data analysis CAUTI and UTI are reported monthly using the Safety Thermometer, the Nurse Consultant contacts the clinical areas who report new CAUTI or urinary catheters in situ >28 days and works with clinical staff to embed best practice. The Clinical Governance and Risk Department highlight any concerns relating to urinary catheter insertion and care reported via DATIX; any concerns can be addressed at local level. The undertaking of specific audits recommended from national guidelines including NICE Quality Standard Statements for CAUTI/UTI assist to inform practice. iii) Continuing work The Nurse Consultant and the Catheter Care Sub Group meet monthly and are progressing a number of initiatives. On-going initiatives: a) Expansion of the No Catheter No CAUTI campaign and dissemination of key messages across all health care settings. Providing evidence based clinical advice to clinical areas for urinary catheter insertion, care and removal through active clinical support and engagement has assisted to embed best practice in clinical areas
where there has been an identified increase in the incidence of CAUTI/UTI and catheters in situ <28 days. b) Surveillance the Nurse Consultant continues to undertake surveillance of CAUTI/UTI through the Safety Thermometer. A review mechanism is in place to identify new CAUTI and catheter inserted >28days. c) Trust wide circulation of new developments including the successful development of a new catheter care plan which incorporates the HOUDINI framework, this is a framework and decision aid which aims to reduce the use and duration of a urinary catheter and the associated risks of CAUTI. d) Recognising health care professionals educational requirement through offering continued development of education and training, education cards promoting harm free care, pathway of care for CAUTI/UTI, decision aid for diagnosis and management of suspected UTI, recommended procedures for the collection of MSU and CSU for microbiological testing and patient information leaflets. The Nurse Consultant continues to provide face to face training on the preceptorship programme, HCA Academy, Trainee Assistant Practitioner study days and with medical staff training. The focus has been raising awareness about using urethral catheters safely and effectively, emphasising early removal when clinically acceptable, the importance of avoiding CAUTI and antibiotic stewardship. Local product formulary which has been adopted locally within the North East, this is an evidence-based continence formulary to safeguard the interest of the patient, ensuring that there is a variety of products available to manage patient need, and that practitioners have adequate information to support their practice when choosing continence appliances and to promote rational prescribing which is cost effective. National and regional collaborative work the Trust has participated with the Health and Innovation Network Urinary Catheter Care Project, the Unplanned Admissions Consensus Committee and is active with the IPC Health Care Associated Infection Action Plan. This national work has secured opportunities for the Trust to be involved with the National Institute for Health Research, topics relating to urinary catheters and catheter washouts. The Nurse Consultant has established a local group involving neighbouring Trusts to collaboratively work together to develop a patient catheter passport which covers the North East of England. In addition, the Trust is leading the way in developing an app for urinary catheter care. 6. SUMMARY The Trust is currently performing well in relation to delivery of Harm Free Care in respect of patient falls and CAUTI. It is continuing to focus on prevention of pressure ulcers which is proving to be challenging. To drive further improvement the Trust will need to maintain the effort of the Time 2 Turn and No Falls On My Patch and no catheter no CAUTI campaigns. It is important this work is
co-ordinated to ensure that wards are not bombarded with competing practice development messages at the same time. To support this Patient Services is coordinating a Year of Harm Free Care `activities which will streamline engagement with front line staff. The Tissue Viability, Falls and Continence team will endeavor to continue the targeted education and training of staff and the on-going analysis of data to determine key learning which will be disseminated across the Trust. Ongoing monthly data and headline messages will be reported to the Trust Board and Council of Governors via the Integrated Quality Account. 7. RECOMMENDATION(S) To i) note the content of the report and comment accordingly and (ii) to support ongoing work. Helen Lamont Nursing and Patient Services Director Fania Pagnamenta Nurse Consultant Tissue Viability Rachel Carter Falls Prevention Co-ordinator Frances Blackburn Deputy Director of Nursing 15 th May 2017
Appendix 1 Graph 1: Actual and mean Trust average percentage of patients receiving Harm Free Care on Safety Thermometer vs UK mean Average Graph 2: Summary of Types of Harm on Safety Thermometer 14
Appendix 2 Trust Pressure Damage Incident Data Graph 1: CAT I,II,III, IV and Moisture Lesion from January 2013 to date (Trust Acquired Only) 15
Total number Apr-13 Jul-13 Oct-13 Jan-14 Apr-14 Jul-14 Oct-14 Jan-15 Apr-15 Jul-15 Oct-15 Jan-16 Apr-16 Jul-16 Oct-16 Jan-17 Number of falls Appendix 3 Graph 1: Total number of falls per month and linear trend (April 2013 - March 2017) 400 350 300 250 200 150 100 50 0 Number of Falls Linear (Number of Falls) Month Graph 2: Number of patient falls resulting in moderate, major or catastrophic harm and linear trend per month (April 2016 - March 2017) 8 7 6 5 4 3 2 1 0 moderate major catastrophic Linear (moderate) Linear (major) Linear (catastrophic) Month 16
UTI per month Appendix 4 - CAUTI Graph1: 10 8 6 4 2 0 Catheter and New UTI per month for 2015/16 and 2016/17 2015/16 2016/17 Graph 2: Graph 3: 17
Appendix 4 (cont.) Graph 4: Patient Safety Thermometer - (March 2016 to April 2017) Graph 5: Patient Safety Thermometer March 2016 to April 2017 18
Appendix 5 Trust acquired Pressure Ulcers, set against a 20% reduction target. Location Name 2014-2015 2015-2016 Target Pressure Ulcers APRIL TO JUNE Pressure Ulcers JULY to SEPTEMBER Trend Predicted by end of March 2017 * Ward 33 10 13 10 4 3 13 NCCC Ward 34 25 17 14 4 7 25 Ward 35 33 32 26 5 2 11 Ward 21 FH 40 36 29 5 5 = 20 Ward 24/24A FH 8 7 6 2 1 5 Ward 25 FH 4 3 2 0 1 3 Cardio Ward 27 FH 2 1 0 0 0 = 0 Ward 29 FH 10 13 10 4 2 10 Ward 30 FH 9 9 7 5 2 11 Ward 49 RVI 30 34 27 3 3 = 12 Ward 50 RVI 7 5 4 2 2 = 8 ENT Ward 10 FH 7 15 12 1 3 10 Ward 9 FH 35 25 20 10 9 37 Ward 13 FH 40 15 12 10 10 = 40 Ward 14 FH 25 27 22 3 18 57 Ward 15 FH 21 32 26 6 9 33 Ward 16 FH 2 13 10 6 3 15 Ward 18 FH 34 14 11 5 3 14 Medicine Ward 19 RVI 0 13 10 0 2 6 Ward 30 RVI 36 34 27 13 11 46 Ward 31 RVI 32 48 38 15 10 45 Ward 41 RVI 19 25 20 0 8 32 Ward 48 RVI 9 30 24 7 2 13 Ward 51 RVI 7 10 8 0 1 3 Ward 52 RVI 32 35 28 7 10 37 Ward 19 FH 12 11 9 5 1 8 MSU Ward 20 FH 6 7 5 4 2 10 Ward 22 RVI 48 54 43 6 14 48 Ward 23 RVI 41 41 33 11 7 32 19
Ward 42 RVI 8 7 6 2 2 = 8 Ward 15 RVI 12 9 7 1 1 = 4 Neuro Ward 16 RVI 5 6 5 0 1 3 Ward 43 RVI 4 5 4 1 3 10 Ward 18 RVI 33 38 30 10 6 28 Peri-op Ward 38 RVI 45 43 34 9 10 39 Ward 37 FH 62 64 51 14 17 65 Ward 20 RVI 0 0 0 0 1 3 Plastics Ward 37 RVI 3 0 0 0 1 3 Ward 47 RVI 3 2 1 0 1 3 Ward 5 RVI 3 4 3 1 3 10 Ward 12 FH 10 8 6 3 6 21 Ward 36 RVI 11 15 12 2 5 17 Ward 44 RVI 7 8 6 5 4 17 Surgery Ward 46 RVI 0 0 0 0 1 3 Ward 5 FH 20 13 10 4 5 19 Ward 6 FH 10 14 11 2 1 5 Ward 8 FH 49 54 43 4 7 25 Urology Ward 38 FH 10 7 6 1 2 7 Renal Ward 2 FH 14 8 6 0 3 9 Ward 3 FH 10 13 10 3 4 15 Women Services Ward 32 FH 16 32 26 8 4 20 Ward 40 RVI 1 6 5 0 2 6 920 975 775 213 241 936 20
Appendix 6 Falls Dashboard 21
Appendix 7 Graph 1: Results of Falls RCA Review October 2016 - March 2017 Falls Measures 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% History of falls prior to admission 15 10 History of falls since admission 9 16 Falls risk assessment commenced within 12 hours of admission 23 1 1 Falls Care Bundle in place 21 3 1 Identified as 'at risk' prior to the fall 24 1 Patient nursed in directly observable area 17 9 Visible to staff at the time of the fall Call bell to hand Dementia/ Delirium/ Confusion (other) diagnosed Appropriate footwear available 9 17 25 25 16 8 Yes No N/A Appropriate footwear in situ 24 1 Mobility aid available 20 2 3 Mobility aid in use 10 11 4 Bedrails risk assessment completed 16 8 1 Appropriate use of bedrails 17 7 1 Mobilising against advice 19 6 Minimum staffing levels in place 21 4 22