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Nothing to be Fearful of…….. Using Remote Video Auditing to Monitor Patient Safety in the NHS

Nothing to be Fearful of…….. Using Remote Video Auditing to Monitor Patient Safety in the NHS. Dr S heldon Stone , Royal Free Campus, University College London Medical School. WHAT I WILL TALK ABOUT. Hand hygiene as an example Usual monitoring by direct observation and audit/ feedback

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Nothing to be Fearful of…….. Using Remote Video Auditing to Monitor Patient Safety in the NHS

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  1. Nothing to be Fearful of……..Using Remote Video Auditing to Monitor Patient Safety in the NHS Dr Sheldon Stone, Royal Free Campus, University College London Medical School

  2. WHAT I WILL TALK ABOUT • Hand hygiene as an example • Usual monitoring by direct observation and audit/ feedback • Disadvantages of that: selective, not 24/7, feedback often delayed not individual, labour intensive • Video Remote Feedback: 24/7, immediate feedback; data protection; privacy and dignity • CHIVAR study to examine PPE and hand hygiene in side rooms…how we are addressing these issues • Future role: more patient safety behaviours?

  3. Hand hygieneBMJ editorial 5th May 2013; WHO technical guides 2009; Joint Commission Monograph 2009; Stone et al ICHE 2012 • Hand hygiene remains a problem • WHO: direct observation, audit, feedback : 20-30 mins a week a ward : 200 moments • Problems observation: selective not 24/7 : reactivity (Hawthorn) : labour intensive : training & reliability • Feedback: may not be: immediate : individualised : allied to personal goal setting

  4. Feedback Intervention(FIT)on 60 wards in 16 hospitalsFuller et al PLoS One 2012 Personalised goal setting & action planning augments effect of immediate individual feedback Delivered to HCWs individually and in groups in 20 minute sessions weekly as part of a 4 weekly audit cycle by ward co-ordinator ( Week 1: HCW observed for 20 minutes with immediate feedback Following instances of non-compliance- nurse was helped to formulate a personal action plan to improve behaviour eg:if nurse didn’t clean hands after touching patient equipment the action plan was “I will use AHR even if only touching equipment” Week 2: as week 1 but for non nurse HCW Week 3: observation (no feedback) of group HCWs Week 4: group feedback and action plans

  5. Trial and Results • 16 hospitals: 60 wards (16 ITU and 44 Acute Care of Elderly • Intention to treat and per protocol analyses showed effective with absolute sustained increases of 10-13% (ACE) and 13-18% (ITU) and 30% rise in soap • Strong Fidelity to intervention effect ie the more a ward did it the stronger the effect • There were implementation diffculties (ACE) • Studies of this suggest implementation would increase if : entire trust expected to do ward co-ordinators were senior monitored and training refreshed

  6. Results: Effect of fidelity to intervention on implementing wards • If the intervention was done once a month the odds ratios (relative probability) for performing hand hygiene at any one moment would double • If it was done twice a month this would rise again (to 2.25) and three times a month to nearly 2.5. • If intervention done weekly as intended: this would rise to nearly 3 (2.75)

  7. Conclusion • This study put direct observation, and feedback on a firmer footing than previous studies, the intervention producing a moderate but significant and sustained improvement with a strong fidelity to intervention effect • Provides the strongest evidence yet that this is an effective technique, when coupled with a repeating cycle of personalised goal setting and action planning. • Although a further implementation study is required, infection control staff could consider employing this intervention to supplement their current audit and appraisal systems.

  8. However • Takes work..training, monitoring, refreshing • Still dependent on direct observation by somebody else to provide objective evidence that it is working by showing increased compliance in a trust although could use consumables as a surrogate marker

  9. Hand Hygiene Performance Results Published in Clinical Infectious Diseases Medical Journal • Audit Application: Hand hygiene compliance in a 17 bed ICU in US • Feedback Methods: real-time time-in-line metrics posted to digital boards • Results: hand hygiene rates rose from ~10% to ~90% in four weeks

  10. Advantages • Real time feedback • 24/7 • Group feedback • Labour is not for the ward co-ordinator • Could be applied to other patient safety behaviours

  11. Potential disadvantages • Original study looked only at entry and exit of side rooms..can it be extended to inside patient rooms? • Data protection • Identification patients and staff • Cost…offset by reduced insurance premiums and lower HCAIs ?? • Reliability of observers in India?

  12. CHIVAR study • Feasibility study: can VRF improve compliance with institutional guidelines for use of PPE (and correct hand hygiene) on entry and exit to isolation side rooms • Study design: Interrupted time series (3m baseline, 6m intervention) • Participants: 3 hospitals in England, 1 each in USA, Pakistan, Holland • Setting: Isolation rooms in one ITU and 1-2 general medical or surgical ward per hospital. • Intervention:VRF with real time feedback via LED boards on ward, end of shift emails to ward manager who will feedback/discuss results weekly with ward team, setting team goals and action plans (emails to staff)

  13. Addressing the data protection issues etc…what did we do • Meeting 1- infection control, DIPC (medical director) • Meeting 2: legal dept, comms, human resources, data protection officer: :worth doing but legal minefield : need consent from individuals • Meeting 3: data protection officer- turn the resolution down so people cannot be identified!…..brilliant! Legals happy!

  14. CHIVAR Study • Personal Protective Equipment Compliance • Blurring of images and steep angle is key.

  15. Addressing the data protection issues (etc) • Data Controller at the RFH has informed the Information Commissioner's Office (ICO) about the study (no issues). • Since the images do not show PID they can be processed in India (non-EU) • Data security - a “penetration test“ has been carried out by an independent contractor. • All of the tests demonstrated adequate security and that the network appeared to be safe. • Each site will require a written contract with Arrowsight. A draft contract has been written • Data retention- for individual sites to decide as part of contractual process • Appropriate signage will be required.

  16. Staff issues • “Staffside” (Unions): happy with it • Needs to go to Board so policy from top • Comms need to issue press release to stop “ROYAL FREE DO NOT TRUST OWN STAFF TO CONTROL INFECTION!” • Comms will develop positive messages for internal release based on ward staff perceptions • Identified ward leads have been positive • Now meeting ward teams

  17. Other Areas of InterestPatient Safety & Efficiencies • Pending CHIVAR…. • Look at extending it to general ward areas for a wider variety patient safety behaviours in infection control (gloves, catheters, catheters, wounds) • Patient confidentiality issues will need addressing with patient representatives and governors • Emergency department • Operating theatre (Adam)

  18. Future • Needs further feasibility and pilot studies then trial to assess effectiveness and cost effectiveness in infection control patient safety interventions • Compared to other “lower tech” methods such as FIT but note that a behaviour change methodology will probably be needed to supplement the VRF • For hand hygiene it would be the gold standard of 24/7 observation!!

  19. Compliance in ITUs (left fig) & ACEs (right figure) • Although hand hygiene decreased over study, these OR in ITUs equate to absolute increases in hand hygiene compliance of 13-18% on ITUs and of 10-13% on ACE wards which were sustained over time

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