Delivering Clinical Improvement for Patient Safety

1. Delivering Clinical Improvement for Patient Safety Eddie Docherty Consultant Nurse for Acutely Unwell Adults Susan Hannah Practice Development Lead - Clinical Improvement

2. Mortality Case Note Review Modified Early Warning Scoring Admission to HDU Unusually high DNAR orders Review of complex patients over weekend and holiday periods Note Keeping End of life care Discharge Letters Development of appropriate action plan 50 consecutive deaths IHI 3x2 matrix GTT applied to box 4 patients Review of additional diagnostic groups External validation Cardiac Arrest Review DNAR Review

4. Delivering Clinical Improvement for Patient Safety Outcome Primary Driver Secondary Driver Emergency Response Team created Testing of process for call and referral Complete. Live service testing May 2010 Spread June 2010. Measure use and type of calls. Emergency Response Team Reducing HSMR and Improving Outcomes for acutely unwell patients MEWS SBAR Safety Briefs ‘Back to Basics’ programme across the organisation over next 12 months. Measure compliance with MEWS & SBAR using SPSP approach -Sustainable spread.

5. Emergency Response TeamProcess design What did we need the team to do? Who should be on the team? How do we get the team to the patient- right patient & right time? How do we test it? How do we evaluate it? How do we sustain?

6. Patient in Cardiac Arrest? YES Activate the Cardiac Arrest team via 2222 NO • Emergency Response Team callout Criteria • General Ward Area • Airway • Any airway compromise • Breathing • Respiratory Distress/ progressive dyspnoea • Respirations less than 8/min or greater than 30 min(new, persistent) • Sa02 less than 88% on oxygen(new, persistent) • Increase in oxygen requirements to 50% • Circulation • HR >130 or HR< 40 • Blood pressure less than 90mmHg (new, persistent) • Symptomatic dysrythmia • Disability • Acute change in mental state • Decreased responsiveness (new, persistent) • Seizure activity • Exposure • Uncontrolled pain despite treatment • Staff concern eg sustained chest pain despite nursing intervention • Uncontrolled bleeding Does the Patient meet the ERT call out criteria or are they triggering a MEWS >4 Patients own team unavailable or unable to attend in 30 mins or request ERT activation Contact Patients own team, develop a continuing plan of care Activate the Emergency Response team* ERT team Assess and initiate appropriate intervention Documentation by ERT, follow up protocol activated Contact Patients own team and develop a continuing plan of care ERT Activation and feedback Pathway * Dial 0 Switchboard and ask them to fast page the Emergency Response Team

7. Integration Board level engagement Operational team- nurse consultant, 2 medical consultants & consultant anaesthetist –influencing & engagement Team member engagement- ownership and “marketing” Medical staff- non threatening, integrative WARD BUY IN- small cycles of change , test, retest, systems & PEOPLE

8. Engagement • Associate director of medicine and nurse consultant ‘road show’ • Clinical director level / ward manager/ critical care ‘champions’- influencing the key influencers • Taking it to the wards- not waiting for them to come to us. • Making sure its safe – AND PROVING IT one patient & one nurse- one area - one week

9. Back to Basics – what’s it all about? Situation - identified need to improve MEWS, communication and escalation, staff awareness of safety issues . Background - available data highlights areas for improvement in current practice through SBAR, Safety Briefs Assessment – measuring and testing change via audit and PDSA methods provides evidence of improvements and supports sustainability Recommendation – an approach to achieving sustainable improvements in practice with empowered, skilled staff who perform at an optimal level to reduce risk and ensure patient safety

10. Early recognition of deteriorating patientsComplete and accurate MEWS and action plan recordingRegularity of observations according to clinical concernNursing staff escalation to medical staff where expectedAppropriate response of medical staff to MEWSConsistent approach to documentation of decision making What do we need to improve?

11. Baseline data identifies specific issues using a developed audit tool for MEWS

12. How are we going to achieve this? Model focuses on a facilitated approach to driving improvements through clinical supervision and 1:1 approach to supporting ward staff Identified first four wards - testing a variety of approaches to implement all aspects of improvement through involving staff in processes (audit, improvement methodology, using data for change) Supporting staff to understand and engage with SPSP work and relating this to other key drivers within the organisation

13. Integration of Key National Drivers Building on Success Through Integration Scottish Patient Safety Programme Leading Better Care Better Together Healthcare Associated Infection Falls Programme Tissue Viability Nutritional Care Releasing Time to Care HEAT targets Lean Collaborative Programmes Rights Relationships & Recovery Joanna Briggs Initiative (JBI) NHS QIS BPS

15. Progress so far……….

16. The Challenges Engaging with and involving all staff in developments – very busy acute ward environments Tailoring facilitation to implement SBAR and Safety Briefs in specific clinical environments – testing a variety of approaches Resource intensive – dedicated facilitation for each ward required to achieve sustainability Ensuring an individualised approach while keeping a firm view on the desired outcomes within acceptable timescales

17. Work in Progress like big PDSA What changes are we going to make based on our findings? Build in Quality Assurance Processes Know exactly what we aim to achieve and how we will do it ActPlan Study Do Improvement Programme and developed spread plan What were the results? Measure and evaluate implementation Early Days yet.....