Open and Honest Care in your Local Hospital The Open and Honest Care: Driving Improvement programme aims to support organisations to become more transparent and consistent in publishing safety, experience and improvement data; with the overall aim of improving care, practice and culture. Report for: The Newcastle upon Tyne Hospitals NHS Foundation Trust April 216
Open and Honest Care at The Newcastle upon Tyne Hospitals NHS Foundation Trust : April 216 This report is based on information from April 216. The information is presented in three key categories: safety, experience and improvement. This report will also signpost you towards additional information about The Newcastle upon Tyne Hospitals NHS Foundation Trust's performance. 1. SAFETY NHS Safety thermometer On one day each month we check to see how many of our patients suffered certain types of harm whilst in our care. We call this the safety thermometer. The safety thermometer looks at four harms: pressure ulcers, falls, blood clots, and urine infections for those patients who have a urinary catheter in place. This helps us to understand where we need to make improvements. The score below shows the percentage of patients who did not experience any harms. 94.7% of patients did not experience any of the four harms whilst an in patient in our hospital 98.1% of patients did not experience any of the four harms whilst we were providing their care in the community setting Overall 95.6% of patients did not experience any of the four harms in this Trust. For more information, including a breakdown by category, please visit: http://www.safetythermometer.nhs.uk/ Health care associated infections (HCAIs) HCAIs are infections acquired as a result of healthcare interventions. Clostridium difficile (C.difficile) and methicillin-resistant staphylococcus aureus (MRSA) bacteremia are the most common. C.difficile is a type of bacterial infection that can affect the digestive system, causing diarrhoea, fever and painful abdominal cramps - and sometimes more serious complications. The bacteria does not normally affect healthy people, but because some antibiotics remove the 'good bacteria' in the gut that protect against C.difficile, people on these antibiotics are at greater risk. The MRSA bacteria is often carried on the skin and inside the nose and throat. It is a particular problem in hospitals because if it gets into a break in the skin it can cause serious infections and blood poisoning. It is also more difficult to treat than other bacterial infections as it is resistant to a number of widely-used antibiotics. We have a zero tolerance policy to infections and are working towards eradicating them and have already made great progress; part of this process is to set improvement targets. If the number of actual cases is greater than the target then we have not improved enough. The table below shows the number of infections we have had this month, plus the improvement target and results for the year to date. Patients in hospital setting C.difficile MRSA This month 7 Annual Improvement 6 Target to date Actual to date 7* ^ * successful appeals for C.Diff For more information please visit: http://www.newcastle-hospitals.org.uk/patient-guides/keeping-hospitals-clean.aspx Further information about HCAIs and C.difficile appeals is on pages 5 and 6. ^ MRSA third party assignment agreed with CCG
Pressure ulcers Pressure ulcers are localised injuries to the skin and/or underlying tissue as a result of pressure. They are sometimes known as bedsores. They can be classified into four categories, with one being the least severe and four being the most severe. The pressure ulcers reported include all avoidable/unavoidable pressure ulcers that occured at any time during a hospital admission that were not present on initial assessment. This month 57 Category 2 - Category 4 validated pressure ulcers were acquired during Acute hospital stay and in the community. Number of Pressure Ulcers in our Severity Number of Pressure Ulcers in our Acute Hospital setting Newcastle Community setting Category 2 56 Category 3 1 Category 4 The pressure ulcers reported include all pressure ulcers that occurred from zero hours after admission In the hospital setting, so we know if we are improving even if the number of patients we are caring for goes up or down, we calculate an average called 'rate per 1, occupied bed days'. This allows us to compare our improvement over time, but cannot be used to compare us with other hospitals, as their staff may report pressure ulcers in different ways, and their patients may be more or less vulnerable to developing pressure ulcers than our patients. For example, other hospitals may have younger or older patient populations, who are more or less mobile, or are undergoing treatment for different illnesses. Rate per 1, bed days: 1.53 Hospital Setting In the community setting we also calculate an average called 'rate per 1, Clinical Commisioning Group population'. This allows us to compare our improvement over time, but cannot be used to compare us with other community services as staff may report pressure ulcers in different ways, and patients may be more or less vulnerable to developing pressure ulcers than our patients. For example, our community may have younger or older patient populations, who are more or less mobile, or are undergoing treatment for different illnesses. Rate per 1, Population:. Newcastle Further information about our work to reduce harms is on pages 4 and 5. Falls This measure includes all falls in the hospital that resulted in injury, categorised as moderate, severe or death, regardless of cause. This includes avoidable and unavoidable falls sustained at any time during the hospital admission. Falls within the community setting are not included in this report. This month we reported 7 fall(s) that caused at least 'moderate' harm. Severity Moderate Severe Death Number of falls 7 So we can know if we are improving even if the number of patients we are caring for goes up or down, we also calculate an average called 'rate per 1, occupied bed days'. This allows us to compare our improvement over time, but cannot be used to compare us with other hospitals, as their staff may report falls in different ways, and their patients may be more or less vulnerable to falling than our patients. For example, other hospitals may have younger or older patient populations, who are more or less mobile, or are undergoing treatment for different illnesses. Rate per 1, bed days:.19 Further information about our work to reduce harms is on pages 4 and 5.
2. EXPERIENCE To measure patient and staff experience we ask a number of questions.the idea is simple: if you like using a certain product or doing business with a particular company you like to share this experience with others. The answers given are used to give a score which is the percentage of patients who responded that they would recommend our service to their friends and family. Patient experience The Friends and Family Test The Friends and Family Test requires all patients, after discharge from hospital, to be asked: How likely are you to recommend our ward to friends and family if they needed similar care or treatment? We ask this question to patients who have been an in-patient and/or attended Acccident & Emergency (A&E) and has most recently been rolled out to Community Services. All scores (if applicable) are below: In-patient FFT score 98 % recommended This is based on 2131 responses A&E FFT score 92 % recommended This is based on 24 responses Community FFT score 97 % recommended This is based on 71 responses In addition to asking FFT questions we asked 62 patients in April 216 the following questions about their care in the hospital: Yes Always/Most of Time or Excellent/Good Do you feel able to ask any questions about your treatment or condition? 1% Are you involved as much as you want to be in decisions about your care and treatment? 97% If you have needed to use your nurse call button, has this been responded to in a timely manner? 98% Overall do you feel safe, secure and supported in this hospital? 1% How likely are you to recommend this ward to your family/friend if they needed similar care or Treatment? 1% A patient's story Mrs X was admitted to the Intensive Care Unit (ITU) following complex cardiac surgery. Her condition deteriorated when on ITU, requiring her to be connected to a ventilator and sedated, which meant she required all cares to be provided by staff. Following episodes of faecal incontinence and periods of immobility, she developed Category II pressure ulcers on her sacrum (buttocks). The staff involved in looking after Mrs X reviewed her care to identify why this occurred and to look for potential changes in practice. The lessons learned and changes made to practice are explained in the improvement story below in Section 3. Staff experience In the fourth quarter of 215/16 we carried out a survey on a sample of our staff, we asked 344 staff in the hospital the following questions: Extremely Likely/Likely How likely are you to recommend the Trust to friends and family if they needed care or treatment? 96% How likely are you to recommend the Trust to friends and family as a place to work? 77% See supporting information for more detail on the Staff Survey
3. IMPROVEMENT Improvement story: we are listening to our patients and making changes The staff involved in looking after Mrs X reviewed her care with the Senior Staff from the unit and staff from Tissue Viability to see if they could identify any lessons to learn and recommend changes in practice to reduce the chances of a similar patient developing skin damage. This review identified that Mrs X experienced several days of diarrhoea, before the use of a bowel management system was considered. (Bowel Management Systems are used to manage faecal incontinence related to diarrhoea, but are not suitable in all circumstances) Prior to being ventilated, Mrs X needed to be prompted regularly to change her position, she developed a bruised sacrum immediately following a period of immobility, where gaps in positional changes were identified (4 hourly turning regime instead of 2 hourly) and this then deteriorated into a pressure damage. It was unclear from the documentation whether the immobility was due to treatment being undertaken that prevented positional changes taking place or if there were gaps in care delivered. A systematic analysis of the root causes identified lessons to be learned: *Several gaps in documentation were identified, where it was not clear whether the patient had always been turned. *Mrs X was assessed as Very High Risk of pressure damage from admission and increasing risk factors including renal dialysis and intubation meant a 2 hourly repositioning regime should always have been in place. *Mrs X experience several episodes of diarrhoea (type 5-7 stool), lasting 7 days before bowel management was considered. Although initially continent, following intubation faecal incontinence was an issue. *Mrs X was assessed as being unsuitable for a bowel management system (BMS) due to haemorrhoids by unit staff, but advice was not sought from the Colorectal team about this (Mrs X s haemorrhoids were not severe and therefore she may have been a candidate for a BMS). The use of a faecal collector bag : an alternative to a BMS, may also have been an option. As a result of the issues identified, bedside teaching about the lessons learnt in this case related to pressure ulcer prevention took place focusing on the importance of adhering to turning regimes and completing associated documentation thoroughly and seeking advice from Colorectal Specialists. The 24 hour bedside observation charts have recently been amended to enable staff to clearly document reasons why turns have not been completed e.g. monitoring or infusion line insertion. The Tissue Viability link nurses and Tissue Viability lead are also currently working together to deliver group teaching sessions to staff on pressure ulcer prevention and the prevention of moisture associated skin damage. Faecal collector bags are now on regular supply on the unit and staff members are using these appropriately for patients who are unsuitable for bowel management systems. Supporting information The Trust regularly reports a low rate of harm from the Safety Thermometer. This is demonstrated on the graph below which shows that the Trust (blue line) has reported a low rate of harm maintaining 95.63% or above harm free care and a 12 month average of 96.37%, both of which are above the national average of 94.16%. In order to achieve and maintain this position the Trust has done significant work to minimise Falls, Infections and Pressure Ulcers. This report is an opportunity for us to share with you some of our learning and what we have done to reduce harm.
Falls Prevention Prevention of patient falls, particularly those which may cause patients harm, is a key priority for the Trust. There has been a lot of work done to make sure all staff working in our hospitals take responsibility for preventing falls. This has included: *A new falls assessment for all adult in-patients (some hospitals only do a falls assessment on patients who are aged 65 and over) *A falls prevention campaign called No Falls On My Patch. This includes posters being displayed in all wards and departments to highlight falls prevention. * Call Don t Fall posters are displayed at patient bed spaces and in toilets and bathrooms to prompt patients to press their call bell when they need assistance. *We have over 1 beds that lower to the floor for the highest risk patients who may fall out of a standard bed. These beds reduce the risk of injury for our patients. *For patients who do not bring in footwear or don t have appropriate footwear for their stay in hospital, we can provide well-fitting slippers and also non-slip slipper socks so that all patients have access to safe footwear. *All patients who are assessed as being at risk of falling whilst in hospital have regular comfort and safety checks using the FOCUS Chart. These checks include making sure the patient has everything they need close by, including a drink and the call bell. Also, staff can offer assistance with activities such as going to the toilet for those patients who are not safe enough to do this on their own. *We have a specialist Falls Prevention Coordinator who reviews all falls incidents and carries out an investigation if a patient suffers serious injury following a fall e.g. a broken hip. Lessons learnt from looking at data about when and why falls have occurred and Root Cause Analysis are shared with clinical staff through briefings at professional forums, link nurse meetings and formal falls prevention education. We are committed to reducing harm and review the circumstances when patients have fallen to identify learning we also review the clinical evidence and network with other care providers to see what we can learn. Safety Thermometer - Funnel plot for Falls with Harm (Newcastle is the selected trust) and demonstrates the Trust's positive position when compared with others. Pressure Ulcers The Trust is committed to reducing the incidence of Trust acquired pressure damage to an absolute minimum. At times, pressure ulcers develop and this is inevitable, for example when patients have to be nursed flat on a mattress and cannot be turned because they are too medically unstable to do this; or when they spend long times in theatre (some patients can be on a theatre table for 12-14 hours for very long life-saving operations). Nevertheless, the majority of pressure damage can be prevented with frequent and regular repositioning regime. We have been working very closely with all our wards to embed turning regimes in every ward routine; we have invested in a selection of excellent mattresses that redistribute pressure to minimise risks and improve comfort; we have invested in renewing all the pillows so that patients can be repositioned from side to back to side with comfort and efficacy; we have invested in a Time2Turn campaign where care plans, documentation and turning discs assist nurses and all other health professionals to turn patients. Finally we have designed a patient leaflet to remind patients and carers that we are partners in the fight against pressure damage and that they can help and support us achieve our very ambitious target.
Pressure Damage Numbers by Category, Category II and Moisture Lesions being our highest numbers of damage The above line graph demonstrates a steady reduction over time from April 13 to October 15. In December 14 and then in December 15 we saw a sudden increase; this was disappointing but not unexpected as the Trust saw a marked increase in emergency admissions with increased numbers of very sick patients and staff working very hard to meet the needs of patients. This pattern of increased emergency activity, which decreases as pressure reduces demonstrates the link between number of sick frail patients where damage can occur very quickly. Every instance of harm is formally reviewed using a Root Cause Analysis tool to ensure that lessons to learn are identified; These lessons are then shared across the organisation and used to inform education for staff as well as develop practice improvements such as those identified in our improvement story this month. Whilst number of pressure ulcers have shown variation, the overall trend is down and staff are encouraged to report even very small skin breaks as this ensures all damage is identified and treated appropriately. The Tissue Viability Team continues to work with all Trust staff to achieve zero tolerance to Trust acquired pressure damage. Achieving our aim is a continuous challenge but we are determined to succeed, and several wards have already achieved significant numbers of harm free days. We have some exciting success stories, for example, one busy surgical ward that used to have 2-3 pressure ulcers per month, has now been pressure damage free for almost two years (Ward 46 at the Royal Victoria Infirmary); this was following the implementation of strict turning regimes for all their patients at risk of developing pressure ulcers as well as intensive skin care. Strong leadership and team-working complemented their action plan and sustained their progress during the last two years. When pressure ulcer develop, an open and honest investigation takes place to ascertain the origin of the skin damage. Any lessons to be learnt are shared to all staff through our Trust-wide monthly Safety Briefings. Infection Prevention and Control Preventing healthcare-acquired infection (HCAI) is a top priority for the Trust and the infection prevention and control team work very closely with clinical staff to help them reduce risks and deliver safe care. These are some of the ways we try and achieve this: We talk and listen to each other If there is a case of C. difficile or MRSA blood infection, we take this very seriously. We want to know what has happened and why, so we meet with the doctors and nurses caring for the patient to review the care given; the most senior nurse and doctor in the Trust are also involved in this. We look at what went well; identifying areas of good practice but also talk about what we could have been done better. We share this with all other departments in the Trust so that everyone learns. We also regularly meet with the infection prevention and control experts from other local Trusts to share ideas and experiences. We also benchmark with other similar Trusts to share best practice and learning. We remind staff what is best practice Hand hygiene is the most effective action staff can take to prevent the spread of infection. We have eye-catching posters, designed specifically for the Trust, to remind staff, patients and visitors how and when to clean their hands. We also use soaps, hand gels and moisturisers which are kind to the skin. We run regular campaigns to raise awareness on how to reduce HCAI; most recently we have focused on an awareness campaign on Clostridium difficile, which was targeted at all groups of clinical staff in both the hospital and the community. A range of campaigns to promote best practice are in development for the coming year. We deliver care in a safe, clean environment We work with Hotel Services and Estates to ensure our wards and departments are clean and well-maintained. In addition to our routine cleaning staff, we have Rapid Response Cleaning Teams who are not based on one ward or department, but are ready and available to go to any area that requires additional cleaning. We have also increased the frequency of routine of cleaning that occurs throughout the wards. How do we know what we think happens, does happen? We undertake a whole range of observations of practice and audits so that we can be assured we are delivering safe care and reducing harm. Examples of these i include assessment of staff knowledge, practice and cleanliness. C.difficile Appeals There is an appeal process in place in relation to C.difficile cases as it is recognised that not all cases are avoidable. Last year the Trust successfully appealed 27 of the 94 cases recorded, which demonstrates that all care was appropriate and well documented. Up to date progress on this years appeals can be seen in Section 1 of this report. MRSA Third Party Assignment Third Party assignment of an MRSA bacteraemia provides an acknowledgement of the complex nature of MRSA bloodstream infections and is designed to capture instances where an MRSA case cannot legitimately be assigned to either the Trust or the CCG. Following the Post Infection Review (PIR), cases considered to be Third Party are reviewed via an arbitration process which is lead by the Regional Director of Nursing or the Regional Medical Director, this panel is responsible for the final case assignment (See Section 1). Staff Family & Friends Test (FFT) Staff Family & Friends Test (FFT) is completed by staff across the year via an online survey. It is a chance for our employees to anonymously feedback views on our
organisation, with each Directorate getting invited to take part in one of the quarters. Within the region we are the best performing Trust for recommending us as a place for care and in 2 nd place for being recommended as a place to work. When compared to a National Benchmarking Group we are again the best performing Trust for recommending us as a place for care and within the top 3 Trust s recommended as a place to work.