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Cwm Taf Health Board Insert name of presentation on Master Slide
Mortality and harm reduction
in CWM TAF HEALTH BOARD
8th November 2011
Cwm Taf Health Board
Leadership
Improve
information &
communication
Review quality of coding data
Review standard of record keeping
Share Learning from mortality and Global
Trigger tool (GTT) reviews
Establish Quality Improvement & Safety
Steering Group
Improving
Leadership
Reduce Mortality
& harm
GTT each acute site monthly
PCCT Pilot in 1 local GP practice
Undertake 50 mortality reviews consecutively
Take forward GTT findings for year 2009/10
with specific reference to quality of record
keeping
Pilot shared notes within community hospital
setting
Using Trend data to target mortality reviews to
areas of apparent concern
Expand mortality and GTT review teams
Cwm Taf Health Board
Leadership • Quality Improvement &
Safety Steering Group being embedded into Governance arrangement
– Primary & Secondary Care Representation
• Director Walk rounds continued to take place on a Friday to both Acute & Community Hospital Setting (July 2010 to September 2011 - 54
• Walk round process currently under review
Monthly Number of walkrounds undertaken
Cwm Taf Health Board
0
1
2
3
4
5
6
7
8
9
May
2010
Jul 2010 Sep
2010
Nov
2010
Jan
2011
Mar
2011
May
2011
Jul 2011 Sep
2011
Cwm Taf Health Board
Mortality
• Improved Quality of Coding
• Mortality reviews are undertaken on a weekly basis alternating between the two district hospitals using Global Trigger Tool
• Fully engaged with CHKS to gain a full understanding of the data and to inform priorities and reviews.
• Using trend data to target areas of apparent concern
• The reviews have highlighted effective use of the outreach team, appropriate use of the end of life pathway and Do not resuscitate process.
• Monthly speciality multi disciplinary reviews of mortality and morbidity cases continue to be held as part of the clinical auditprogramme - Trauma & Orthopaedics , General Surgery & 30 day mortality after anaesthetic
Reduce Harm & Mortality
Cwm Taf Health Board
Global Trigger Tool
• A weekly review of 10 randomly selected notes continues to take place on a weekly basis alternating between Prince Charles Hospital and the Royal Glamorgan Hospital.
• The review team has been expanded and now includes senior nurses on a rotational basis. Reviews are complete to July 2011 discharges.
• The reviews have demonstrated an improved compliance with the MEWS chart and appropriate and effective use of the outreach service.
• The top triggers for the Health Board are currently readmission within 30 days and complication of procedure or treatment
Reduce Harm & Mortality
Cwm Taf Health Board
Surgical Complications • The WHO/NPSA Surgical Checklist has been
implemented across the Health Board.
• Normothermia measures are in place and data captured and reported on a monthly basis.
• Appropriate Hair removal introduced across the Health Board with monitoring and reporting processes developed.
• Walking patients to theatres as per NICE guidelines has been implemented at Prince Charles Hospital from August 2011.
Compliance with peri-operative normothermia
Cwm Taf Health Board
0%
10%
20%
30%
40%
50%
60%
70%
80%
Jul
2010
Aug
2010
Sep
2010
Oct
2010
Nov
2010
Dec
2010
Jan
2011
Feb
2011
Mar
2011
Apr
2011
May
2011
Jun
2011
Jul
2011
Aug
2011
Sep
2011
Compl iance Average (45%) Lower l imit 15%) Upper l imit 75%)
Compliance with appropriate pre-operative hair removal
Cwm Taf Health Board
0%
20%
40%
60%
80%
100%
120%
Jul
2010
Aug
2010
Sep
2010
Oct
2010
Nov
2010
Dec
2010
Jan
2011
Feb
2011
Mar
2011
Apr
2011
May
2011
Jun
2011
Jul
2011
Aug
2011
Sep
2011
Compl iance Average (91%) Lower l imit 84%) Upper l imit 98%)
Compliance with WHO / NPSA Surgical Checklist
Cwm Taf Health Board
0%
20%
40%
60%
80%
100%
120%
Jul
2010
Aug
2010
Sep
2010
Oct
2010
Nov
2010
Dec
2010
Jan
2011
Feb
2011
Mar
2011
Apr
2011
May
2011
Jun
2011
Jul
2011
Aug
2011
Sep
2011
Compl iance Average (100%) Lower l imit 100%) Upper l imit 100%)
Cwm Taf Health Board
Clostridium Difficile
• Achieved 46% reduction 2009/2010
• Achieved >20% reduction in 2010/2011
• Achieved lowest Clostridium difficile rate/1000 admission in Wales 2010/2011
• Monthly RCA performed and shared with Directorates
Healthcare Associated Infections
CWM TAF HEALTH BOARD
CLOSTRIDIUM DIFFICLE INCIDENCES
0
1
2
3
4
5
6
7
8
9
10
11
12
13
Oct
201
0
Nov
201
0
Dec
201
0
Jan
2011
Feb
2011
Mar
201
1
Apr 2
011
May
201
1
June
201
1
July
201
1
Aug
2011
Sept
201
1
MONTH
NU
MB
ER
Merthyr/Cynon
RCT
Non-Inpatients
CTHB
Cwm Taf Health Board
Hand Hygiene
• Weekly Hand Hygiene Audits undertaken by ward/department.
• Verification Audits undertaken by Infection Prevention & Control Team
• Audit repeated if score below 85%
• Feedback provided to Clinical Teams at time of audit on a weekly basis
Healthcare Associated Infections
CWM TAF HEALTH BOARD
IPC HAND HYGIENE
VERIFICATION AUDIT RESULTS
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Oct 2010
Nov 2
010
Dec 2
010
Jan 2
011
Feb 2
011
Mar
2011
Apr
2011
May 2
011
June 2
011
July
2011
Aug 2
011
Sept 2011
MONTH
______ Average Monthly Score
_____ Compliance with hand hygiene
Cwm Taf Health Board
CAUTI Care Bundle
• Insertion and maintenance care bundle in use in Dewi Sant Hospital and Surgical wards at Royal Glamorgan Hospital (RGH)
• Surveillance set up to identify catheter associated urinary tract infections based on WHAIP/CDC definition
• Regular multi disciplinary meetings held
• Spread to other wards planned – 12 areas identified
• Compliance data submitted monthly via AQF data collection tool
HAI - Compliance with urinary catheter maintenance
bundle
Cwm Taf Health Board
0%
20%
40%
60%
80%
100%
120%
May
2010
Jul 2010 Sep
2010
Nov
2010
Jan
2011
Mar
2011
May
2011
Jul 2011 Sep
2011
Compliance Average (99%) Lower limit 97%) Upper limit 100%)
HAI - Compliance with urinary catheter insertion
bundle
Cwm Taf Health Board
0%
20%
40%
60%
80%
100%
120%
May
2010
Jul 2010 Sep
2010
Nov
2010
Jan
2011
Mar
2011
May
2011
Jul 2011 Sep
2011
Compliance Average (90%) Lower limit 28%) Upper limit 100%)
Healthcare Associated Infections
Cwm Taf Health Board
PVC Care Bundle
• Draft care bundle implemented on 3 pilot wards within Royal Glamorgan Hospital and Prince Charles Hospital
• Insertion and maintenance bundle being revised to aid completion at ward level
• Surveillance set up across Health Board to identify line associated bacteraemia‟s
• MRSA, MSSA & line associated bacteraemia‟s investigated by IPCT
• Root Cause Analysis performed monthly and data to be shared with Directorates
Healthcare Associated Infections
Cwm Taf Health Board
• A fully established multidisciplinary Thrombosis Committee
• Thromboprophylaxis Policy approved June 2010
• Hospital Acquired Thrombosis is now an agenda item on Directorate Clinical Governance Meetings
• Thromboprophylaxis Risk Assessment Forms localised and launched in December 2010
• Full engagement of the Nursing Staff in the implementation of reducing Hospital Acquired Thrombosis initiatives
• Thromboprophylaxis education programme developed
• Audit programmes are being developed and implemented
• Mechanisms for establishing the Hospital Acquired Thrombosis rate are currently being formulated.
Hospital Acquired Thrombosis
Cwm Taf Health Board
Critical Care
Both the Ventilator bundle and Central Line Insertion / Maintenance bundles have been fully implemented in ITU on both sites. Data is captured on a monthly basis. A plan for spread is required.
ICC - Compliance with ventilator care bundle
Cwm Taf Health Board
0%
20%
40%
60%
80%
100%
120%
May
2010
Jul 2010 Sep
2010
Nov
2010
Jan
2011
Mar
2011
May
2011
Jul 2011 Sep
2011
Compliance Average (98%) Lower limit 92%) Upper limit 100%)
ICC - Compliance with central line insertion bundle
(Adult ITU)
Cwm Taf Health Board
0%
20%
40%
60%
80%
100%
120%
May
2010
Jul 2010 Sep
2010
Nov
2010
Jan
2011
Mar
2011
May
2011
Jul 2011 Sep
2011
Compliance Average (92%) Lower limit 43%) Upper limit 100%)
ICC - Compliance with central line maintenance
bundle (Adult ITU)
Cwm Taf Health Board
0%
20%
40%
60%
80%
100%
120%
May
2010
Jul 2010 Sep
2010
Nov
2010
Jan
2011
Mar
2011
May
2011
Jul 2011 Sep
2011
Compliance Average (100%) Lower limit 100%) Upper limit 100%)
Cwm Taf Health Board
• MEWS – On all wards in Cwm Taf PCH/RGH adults and audited monthly.
• RRAILS – Currently Implemented On Ward 4 PCH Orthopaedics (Admission Bundle, Recognition Bundle, Response Bundle, Sepsis Six and SBAR) Ward 20 RGH
• RRAILS 2 minute safety briefing and handover checklist introduced on ward 4 PCH
• OUTREACH service implemented currently 9-5, 7 days a week
• SEPSIS SIX currently implemented in A&E PCH
• MEWS/NEWS comparison completed
• Outreach currently auditing score- to- door
• In the process of organising the introduction of NEWS
Rapid Response to
Acute Illness
Cwm Taf Health Board
Rapid Response to
Acute Illness• RRAILS working well on ward 4 PCH, working towards
releasing time to care
• 2 minute safety briefing has been a success and therefore staff are keen to roll out
• Need to roll out RRAILS to other wards
• MEWS Compliance still an issue, however observations are recorded and scored, outreach offers continual training on mews and is currently focusing on obstetrics and gynae
• SEPSIS SIX in use but needs to be updated
• Outreach is working really well, good feedback from all staff, ongoing training is essential on MEWS and sepsis
Rapid Response to Acute Illness
Cwm Taf Health Board
Main aims of
outreach service• Identifying the deteriorating patient and
averting/facilitating timely admissions to ITU
• Support and seamless care to patients
transferred from ITU to the wards
• Education of ward staff in the identification
and management of the deteriorating patient
Rapid Response to Acute Illness
Cwm Taf Health Board
MEWS Scores on
initial referral:
0
10
20
30
40
50
60
MEWS 0
MEWS 1
MEWS 2
MEWS 3
MEWS 4
MEWS 5
MEWS 6
MEWS 7
MEWS 8
MEWS 9
MEWS 1
0
MEWS 1
1
MEWS 1
2
Rapid Response to Acute Illness
Cwm Taf Health Board
Appropriate Referral
To Outreach
0
20
40
60
80
100
120
140
Gen
eral con
cern
High
Mew
s
Ass
ista
nce
Pot
ensial fo
r det
erea
tion
Res
p Fai
lure
Sep
tic
Fluid M
anag
men
t
Low B
P
<Not
ent
ered
>
Fluctua
tion
GCS
Low U
rine
Out
put
Con
sulta
nt R
eq
Reason Ref erred
Rapid Response to Acute Illness
Cwm Taf Health Board
Impact of Outreach
Cardiac Arrest Data• 7 months prior to outreach
– Total arrests: 70
– Arrests at night: 43 (61%)
– Arrests 09:00-17:00: 27 (39%)
• 7 months with outreach presence (09:00-17:00 minimum)– Total arrests: 79
– Arrests at night: 62 (78%)
– Arrests 09:00-17:00: 17 (22%)
• Outreach pts; 3 Arrest call after-hours(2x unexpected, 1x potentially preventable, although awaiting clarification resus
status)
Rapid Response to Acute Illness
Cwm Taf Health Board
SEPSIS 6
• Initial Management prior
to ITU referral
0
2
4
6
8
10
12
O2 Cultures iv Abx iv fluids Lactate Urine
output
Intervention
No o
f pati
en
ts
Surgery
Medicine
Rapid Response to Acute Illness
Diagnosis of Sepsis prior to ITU Referral?
Yes
32%
No
68%
Blood Cultures before Antibiotics?
Yes
11%
No
68%
Unclear
21%
Cwm Taf Health Board
NEWS x x x x
x x x
x x x x
x x x x
x
x
x x
7 x x x x
x
6 x x
5 x x x
4 x x
3 x x
2 x x x
1 xxx x x
x
1 2 3 4 5 6 7 8 9 10 11
10
9
8 New + Ve Responding To Both
7
6 trigger point NEWS
5
Missed By Both Not Intervening
4 When Using News
3
2
1
1 2 3 4 5 6 7 8 9 10 11
MEWS Trigger point
NEWS MEWS
MEWS/NEWS COMPARISON
Rapid Response to Acute Illness
Cwm Taf Health Board
Main Problems
Identified
• Failure to recognize sepsis
• Poor initial investigation and management
• Late referral to ITU
• Even when antibiotics, fluids prescribed,
often delay in administration
Rapid Response to Acute Illness
Cwm Taf Health Board
Learning
• Presentation to each group of F1
• Presentations to Student Nurses
• Medical Students on Outreach ward
rounds
• Establishment of a Critical Care Delivery
Group to review RRAILS.
Rapid Response to Acute Illness
Cwm Taf Health Board
ACTION BY WHOM BY WHEN PROGRESS
Complete comparison of MEWS/NEWS using set methodology Outreach Team October 2011 2x2 comparison grid completedActions identified
Identify changes needed to current documentation Outreach Team November 2011
Substitute MEWS for NEWS in 2 areas (1 PCH & 1 RGH) to pilot and gain local champions
Implementation Team November 2011
Evaluate changes Implementation Team January 2012
Awareness raising sessions / add to induction programme Medical / Nursing
Implementation Team February 2012 and ongoing
Student nurse awareness sessions Implementation Team November 2011
Global introduction Implementation Team March 2012
NEWS
Implementation Plan
Rapid Response to Acute Illness
Cwm Taf Health Board
MR
SA
c.D
iff
Me
d E
rro
rs
Fa
lls
Pre
ssu
re
Ulc
ers
Co
mp
lain
ts
609 609 609 199 419 429
Transforming Care
Highest Days since
Transforming Care
Cwm Taf Health Board
The Targets
Increase Direct Care Time [DCT] to at least 70%
-Average increase of 19%-Highest DCT to date is 80%
Increase Patient satisfaction to at least 95%
-Average increase of 7%-Highest result to date is 98%
Increase Staff satisfaction to at least 95%
-Average increase of 5%-Highest result to date is 92%
Transforming Care
Cwm Taf Health Board
0
1
2
3
4
5
6
7
8
9
10
Dec-0
9
Jan-1
0
Feb-1
0
Mar-
10
Apr-
10
Ma
y-1
0
Jun-1
0
Jul-10
Aug-1
0
Sep-1
0
Oct-
10
Nov-1
0
Dec-1
0
Jan-1
1
Feb-1
1
Mar-
11
Apr-
11
Ma
y-1
1
Nu
mb
er
of
Incid
en
ce
Month
Pressure Ulcers
Example
Introduced Skin
Bundle
Transforming Care
Cwm Taf Health Board
Falls
• The day hospitals, district nurses, ward nurses and rehabilitation teams have been working on trigger and assessment bundle with the NLIAH collaborative. An action plan has been developed for 2011/12 that include the following key actions: – implementation of the trigger/assessment bundles for
inpatients
– working with NPSA for those who have fallen in our care
– developing skills in multi factorial assessments, for those who carry out interventions and those who assess.
– Participating in SAFER 2 research with Ambulance services using trigger, assessment and if sufficient patients, intervention bundle.
Cwm Taf Health Board
0
1
2
3
4
5
6
7
8
9
10D
ec-0
9
Jan-1
0
Feb-1
0
Mar-
10
Apr-
10
May-1
0
Jun-1
0
Jul-10
Aug-1
0
Sep-1
0
Oct-
10
Nov-1
0
Dec-1
0
Jan-1
1
Feb-1
1
Mar-
11
Apr-
11
May-1
1
Nu
mb
er
of
Incid
en
ce
Month
Patient Falls
Example
Introduced patient Care
Rounding
Transforming Care
Cwm Taf Health Board
0
1
2
3
4
5
6
7
8
9
10
Feb-1
0
Mar-
10
Apr-
10
May-1
0
Jun-1
0
Jul-10
Aug-1
0
Sep-1
0
Oct-
10
Nov-1
0
Dec-1
0
Jan-1
1
Feb-1
1
Mar-
11
Apr-
11
May-1
1
Nu
mb
er
of
Incid
en
ce
Month
Medication Errors
New Process was introduced
Staff member returned to work
and not aware of new process
Example
Transforming Care
Cwm Taf Health Board
0%
10%
Ward 3, PCH Ward 11, PCH Dare Ward, AGH C Ward, AGH
8%
11%
27%14%
3%
7%
1% 1%
% Time Spent Looking, Collecting and Returning - Pilot Wards
Before
After
Transforming Care
Cwm Taf Health Board
0%
10%
20%
30%
40%
Ward 3, PCH Ward 11, PCH Dare Ward, AGH C Ward, AGH
28%26%
28%
37%
17%20%
0%
23%
% Interruptions regarding Patient Status - Pilot Wards
Before
After
Transforming Care
Cwm Taf Health Board
0%
10%
Ward 3, PCH Ward 11, PCH Dare Ward, AGH C Ward, AGH
12%
9%
7%
13%
6%
3% 3%
9%
% Time Spent in Handovers - Pilot Wards
Before
After
Transforming Care
Cwm Taf Health Board
0
20
40
60
80
100
120
Ward 3, PCH Ward 11, PCH Dare Ward, AGH C Ward, AGH
52
109
22
59
24
55
6
35
Total Interruptions to nursing Staff Results - Pilot Wards
Before
After
Transforming Care
Cwm Taf Health Board Transforming Care
Achievements
• 50% reduction in time taken for handovers
• 28% reduction in time wasted locating
equipment and information
• 45% reduction in interruptions to nursing staff
• 69% reduction in time spent in medicines
administration
• 68% reduction in Admin
Cwm Taf Health Board
•„This is Me‟ –This leaflet was developed by the Alzheimer's Society , it aims to provide professionals with
information about the person with dementia as an individual. This will enhance the care and support
given while the person is an unfamiliar environment
•Patient Care Round [PCR]–is the scheduling of regular nursing rounds, at least once every two hours ,that incorporates
specific actions linked to the Fundamentals of Care. The intended outcome of PCR is improved
patient safety and experience.
•Relative Rounding -This is dedicated time for patient/relative/carer communication,
whereby nursing staff actively seek out relatives/carers,
giving them the opportunity to ask any questions.
•Patient Rest Time - Being in hospital can be physically and emotionally tiring for patients, an undisturbed
rest period gives them the opportunity to recuperate.
•Nursing Documentation
•at the bedside -
Patient documentation is often time consuming and frequently performed at the nurses
station .Moving patients documentation to the bedside puts nursing staff back at the patients
bedside.
Relatives are asked to contact the ward between 10am and 12pm midday with all non-urgent
telephone enquiries. This ensures that the nursing staff can give the information and time
needed and are not being pulled away from patient care activities.
•Phone Calls after 10am -
Other Initiatives
Cwm Taf Health Board
Anticoagulation: INR
Cwm Taf Total % of INR tests >5 and >8
(inpatients & outpatients)
Medicines Management
MMA - % patients (or results) with INR >5 in hospital &
community
Cwm Taf Health Board
0.0
0.5
1.0
1.5
2.0
2.5
3.0
3.5
May
2010
Jul 2010 Sep
2010
Nov
2010
Jan
2011
Mar
2011
May
2011
Jul 2011 Sep
2011
Percentage
Value Average (2.7) Lower limit (n/a) Upper limit (n/a)
MMA - % patients (or results) with INR >8 in hospital &
community
Cwm Taf Health Board
0.0
0.2
0.4
0.6
0.8
1.0
1.2
May
2010
Jul 2010 Sep
2010
Nov
2010
Jan
2011
Mar
2011
May
2011
Jul 2011 Sep
2011
Percentage
Value Average (0.7) Lower limit (n/a) Upper limit (n/a)
Cwm Taf Health Board
Patient leaves with
all information
and next
appointment date
Patient arrives at
RGH just before
appointment time
Receptionist
books patient into
clinic on PAS
system
Patient waits to be
called in
Patient called in
clinic and finger
prick blood test,
result,
consultation and
new date given
Process map –
Re-designed POCT service
Medicines Management
Cwm Taf Health Board
Patient Experience
How does service compare with previous
arrangements?
much better
better
no difference
worse
Medicines Management
Cwm Taf Health Board
Patient Experience –Hospital or GP monitoring?
A Pie Chart Showing Patients' Preference for a GP- or RGH-
Provided Anticoagulation Clinic
GP
28%
RGH
35%
No Preference
37%
Medicines Management
Cwm Taf Health Board
Patient Story• Mrs M, age 52
• Warfarin for 6 years following heart valve replacement
• Originally unstable INR, monitored in UHW, then transferred to RGH out-patients
• Experience was of long waiting times, often here all morning (“Warfarin day out”)
• INR was quite unstable, sometimes required injections to stop it going too low.
• At first was apprehensive about change in service but quickly re-assured
• Biggest improvements are – Much lower waiting times
– Immediate INR result
– Finger prick test (patient also has own machine)
– Keeps own Yellow Book and new dose given there and then
• Mrs M feels INR control is now much better
• Attends clinic every 3-4 weeks
• Reassured that back up advice always available from clinic staff if needed (feels more “in control” herself)
• Discusses medication changes with pharmacists in clinic
Medicines Management
Cwm Taf Health Board
Patient Story
“I FEEL AS THOUGH I HAVE GOT MY
LIFE BACK – WARFARIN IS NOW A
PART OF IT”
Medicines Management
Cwm Taf Health Board
StrokeBundle Compliance – Prince Charles Hospital
April 2010 September 2011
Bundle 11st Hours
23% 100%
Bundle 21st Days
31% 82%
Bundle 31st 3 days
77% 64%
Bundle 41st 7 Days
0% 100%
Cwm Taf Health Board
StrokeBundle Compliance – Royal Glamorgan Hospital
April 2010 September 2011
Bundle 11st Hours
0% 100%
Bundle 21st Days
5% 91%
Bundle 31st 3 days
10% 100%
Bundle 41st 7 Days
0% 100%
Cwm Taf Health Board
1st Hours Bundle
% compliance with First Hours bundle
Cwm Taf Stroke patients
from Jan 2010 to Apr 2011
0
10
20
30
40
50
60
70
80
90
100
Jan
2010
Feb
2010
Mar
2010
Apr
2010
May
2010
Jun
2010
Jul
2010
Aug
2010
Sep
2010
Oct
2010
Nov
2010
Dec
2010
Jan
2011
Feb
2011
Mar
2011
Apr
2011Months
Cwm Taf Health Board
First Days Bundle
• CT scan – 82%
• Weekend admissions. Since whiteboard has been in use on AMU, all patients have been compliant
% compliance with First Days bundle
Cwm Taf Stroke patients
from Jan 2010 to Apr 2011
0
10
20
30
40
50
60
70
80
90
100
Jan
2010
Feb
2010
Mar
2010
Apr
2010
May
2010
Jun
2010
Jul
2010
Aug
2010
Sep
2010
Oct
2010
Nov
2010
Dec
2010
Jan
2011
Feb
2011
Mar
2011
Apr
2011Months
Stroke
Cwm Taf Health Board
First 3 Days Bundle
% compliance with First 3 Days bundle
Cwm Taf Stroke patients
from Jan 2010 to Apr 2011
0
10
20
30
40
50
60
70
80
90
100
Jan
2010
Feb
2010
Mar
2010
Apr
2010
May
2010
Jun
2010
Jul
2010
Aug
2010
Sep
2010
Oct
2010
Nov
2010
Dec
2010
Jan
2011
Feb
2011
Mar
2011
Apr
2011Months
Stroke
Cwm Taf Health Board
First 7 Days Bundle
% compliance with First 7 Days bundle
Cwm Taf Stroke patients
from Jan 2010 to Apr 2011
0
10
20
30
40
50
60
70
80
90
100
Jan
2010
Feb
2010
Mar
2010
Apr
2010
May
2010
Jun
2010
Jul
2010
Aug
2010
Sep
2010
Oct
2010
Nov
2010
Dec
2010
Jan
2011
Feb
2011
Mar
2011
Apr
2011Months
Stroke
Cwm Taf Health Board
Chronic Heart Failure
• Initial audit October 2010
• 1000 lives implementation January 2011
• Repeat audit February 2011
Heart Failure
• Collect information about:– Accuracy of documentation in
notes
– Referrals to heart failure service
– Prescribing of ACE/ARB and
betablockers
– Warfarin prescribing in AF
– Impact of prompt stickers
Cwm Taf Health Board
Audit• Baseline Audit
– 100 patients randomly selected with a discharge diagnosis of heart failure
(ICD coding 150.0 – 150.9)
• Repeat Audit
– 41 consecutive discharges from cardiology ward (44% documented heart failure)
Chronic Heart Failure
Diagnosed Heart Failure Baseline Repeat
Echo 67% 100%
Referred to Heart Failure nursing
service
42% 78%
ACE Inhibitor 90% 89%
Betablocker 68% 67%
Warfarin for AF 74% 100%
Cwm Taf Health Board
Enhanced Recovery
After Surgery
• A national audit has been developed for LHBs to understand where the process is non-
compliant and it‟s overall reliability. In order to complete this tool, data needs to be collated,
input and then analysed on an individual patient basis. The tool is being populated across
both DGH sites but only the PCH data has been submitted to the 1000 Lives Programme.
• The data gathered so far indicates that the re-focus on ERAS is giving us the momentum to
deliver improvements in ALOS outcomes. In RGH ALOS has reduced from 9.7 days to 8.2
days. PCH whilst fairly static, is maintaining a downward trend with the ALOS
reducing to 6.4 days from 6.7 days. By comparing this ALOS data alongside programme
compliance it can be concluded that the more compliant the programme, the shorter the
length of stay.
• There is considerable variability in the current bundle compliance rates. However in order to
use this information effectively, there is a need to distinguish between our non-compliance
through incomplete data collection and non-compliance through practice
Cwm Taf Health Board
ERASOctober 2010 to April 2011
Patients re-admitted within 28 days of surgery = 6
Procedure Length of stay Reason for re-admission Re-admitted
within
Lap. right hemicolectomy 7 days Bowel obstruction 3 days
Lap Anterior Resection +-
ileostomy
4 days Pr bleeding 3 days
Anterior Resection +/-
Ileostomy
5 days No reason 3 days
Lap Right hemicolectomy 4 days Nausea 3 days
Lap Anterior Resection 7 days Nausea 1 day
For Anterior Resection +/- 8 days Abdominal pain
/constipation
3 days
Enhanced Recovery After surgery
Cwm Taf Health Board
Work streams
• Executive Leads & Operational Leads Identified
• Work stream groups being established
• Baseline audits & scoping exercises being undertaken
• Enhanced Recovery After Surgery
• Mental Health
• Improving Maternity Services
• Reducing Falls in the Community
Cwm Taf Health Board
First Episode Psychosis
• A position statement has been presented to the Clinical Governance (Mental Health) meeting where the next steps were agreed.
• The DUP calculations have been submitted to All Wales FEP group.
• Feedback on Cwm Taf position within Wales from All Wales review group is currently awaited.
• Key staff have been nominated in appropriate clinical areas who will coordinate and feedback information on FEP uptake.
• Project leads attended the All Wales update workshop on 12th September to review outcomes across Wales.
Cwm Taf Health Board
Key Contact Information
Dr David Cassidy – Assistant Medical Director for Governance & Quality Improvement
Arlene Shenkorov – Clinical Audit & Effectiveness Manager
Kellie Jenkins-Forrester – Clinical Governance Manager
Patient Care & Safety Unit
Cwm Taf Health Board
Administration Block
Dewi Sant
Pontypridd
CF37 1LB