Date of Meeting: 9 September 2009 Appendix Appendix 1: GTT ... · The commonest triggers from GTT over these 3 months continue to be lack of observations or Early Warning Scores (EWS)

Author : Jo Miller, Assistant Director of Nursing (Patient safety & clinical effectiveness)/DIPC and Dr L Jordan, Clinical Lead LIPS Document Approved by: Francesca Thompson, Director of Nursing

Date: 25/08/09 Version: 2

Agenda Item: 1.1 Page 1 of 21

Report to: Public Trust Board Agenda item: 1.1 Date of Meeting: 9 September 2009

Title of Report: Patient Safety Report 2009/10 - Quarter 1 Status: Standing Item Board Sponsor: Francesca Thompson Director of Nursing Author: Jo Miller, Assistant Director of Nursing

(Patient Safety & Clinical Effectiveness)/ DIPC Appendix Appendix 1: GTT

Appendix 2: Definition of Harm Event Triggers

1. Purpose of Report (Including link to objectives) To update Trust Board on the progress against the Patient Safety Strategy 2008-2012.

2. Summary of Key Issues for Discussion This report details the current progress on work undertaken by the patient safety team

• Harm Event Monitoring • Reduction in Hospital Associated Infections • Detection of the deteriorating Patient • Leadership intervention • Reduction in High Risk Medication • VTE Risk Assessment • Prevention of Falls • Safer surgery • Prevention of pressure ulcers

3. Recommendations (Note, Approve, Discuss etc) Trust Board is asked to note the report.

4. Standards for Better Health (which apply) C1a, C4a, C4d, C5b, C5c, C5d, C7a, C7c, C11a and C11b.

5. Legal / Regulatory Implications (NHSLA / ALE etc) Litigation linked to clinical claims.




6. Risk (Threats or opportunities link to risk on register etc) Hygiene code 188, this risk is linked in conjunction with the work being carried out in reducing hospital associated infections. Incorrect medication 133 risk is linked to reducing the high risk medication errors.

7. Resources Implications (Financial / staffing) None identified.

8. Equality and Diversity All aspects of this report will ensure that equality and diversity is addressed.

9. Communication Not applicable

10. References to previous reports Not applicable

11. Freedom of Information Public




Table of Contents Page Introduction 3 1.1 Harm Event Monitoring 5

1.2 Reduction in Hospital Associated Infections 8

1.3 Deteriorating Patient 10

1.4 Leadership 13

1.5 High Risk Medication 14

1.6 VTE 15

1.7 Preventable Falls 15

1.8 Preventable Pressure Ulcers 16

1.9 Safer Surgery 16

1.10 Conclusion 18

Appendix 1 GTT 19

Appendix 2 Definition of Harm Event Categories 20




INTRODUCTION

The patient safety quarterly report presents a summary of the work from the patient safety team over the past 3 months. It reflects the progress with respect to the implementation of the patient safety action plan developed in the last quarter. The patient safety team continues to identify issues that require addressing in areas that impact upon the achievement of the organisations objectives, in addition to identifying the areas for future work for the team. The patient safety team consists of a core group of staff: Dr Tim Craft, Chair of the steering group, Jo Miller, Assistant Director of Nursing (Patient Safety & Clinical Effectiveness)/DIPC Dr Lesley Jordan, Clinical lead for LIPS Regina Brophy, Chief Pharmacist Dr Alexandra Ward Alexandra Lucas, Head of Patient Safety. Spreading of Patient safety programme across the organisation

- Patient Safety afternoon - June This was very successful and well received by the large number of staff that attended from different disciplines. It included workshops for some of the patient safety work streams and as a result a number of staff have expressed an interest in participating in these work streams both in their own areas and trust wide.

- Patient safety work streams

The patient safety team continues to develop a proactive transformational programme to improve safety in conjunction with agenda of the Leading Improvement in Patient Safety Programme. In addition, the patient safety team are working with the current teams of clinical effectiveness, risk, patient safety and infection control together to bring clinical synergies and effectiveness to the whole patient safety objective.

- Safer Patient Initiative

The Trust has signed up to the South West Strategic Health Authority Quality and Patient Safety Improvement Programme. The pre work for this is currently underway. The Trust is sending twelve members of staff to the first of three workshops in October 2009.




OVERALL AIM Reduction Hospital Standardised Mortality Rate to 70 by 2012. The aim of the patient safety strategy is to improve patient safety at the RUH, which will be reflected by reduction in the Hospital Standardised Mortality Rate (HSMR). The graph below shows the HSMR up to and including data for May2009. The Decrease in the HSMR is also reflected in the harm events monitoring which shows a decrease in triggers for May and June.

Graph 1

1.1 Harm Event Monitoring

Random note review Harm event monitoring using Global Trigger Tool (GTT) has continued by reviewing 20 random sets of notes per month. This has continued to highlight areas that the Patient Safety Team has concentrated on their action plan. (See appendix 1 for GTT) The percentage of harm events and triggers per 1000 patient days recorded from the random note review is shown below:




Percentage harm events & triggers from monthly GTT

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Harm events Triggers

Graph 2

The harm event rate per 1000 patient days has varied from 2.46 to 0 %. There were no harm events recorded for May, with the number of triggers also decreasing in May. Again in June triggers continued to decrease, but there was a small rise in the harm events.

a) Triggers The commonest triggers from GTT over these 3 months continue to be lack of observations or Early Warning Scores (EWS) or response to EWS, but these have decreased in numbers. Abrupt medication stop and readmissions have also decreased from May as shown in graph below:

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Early warningscores

Readmission with30 days

Abrupt medicationstop

Graph 3 Other triggers recorded were:

- Complication of procedure ( 2 in total over the quarter)




- Transfusion ( 3 in total in quarter) - Positive blood cultures ( 2 in total over the quarter) - DVT following admission ( 1 in total in May)

b) Harm Events

The severity of harm events recorded is shown in the graph below (for details of severity scoring see appendix 2)

Graph 4 In this quarter there were no events with a severity category greater than F. Three of the harm events were recorded as readmission to hospital, these accounted for two of the category E and one category F. The remaining two category F harm events were recorded as complication of treatment, and a positive blood culture. Details of harm events recorded: Category E (Temporary harm to patient requiring intervention)

2 readmissions Category F (Temporary harm requiring initial or prolonged hospitalisation) 1 readmission 1 positive blood culture

1 complication of procedure The harm event monitoring is ongoing monthly work which during the last quarter the patient safety team have devolved a proportion of this work to specific individuals identified in each division. These individuals have continued to be monitored by the patient safety team for consistency.

Severity of harm events

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Mortality Review The second full mortality review of 50 consecutive deaths from June 2009 is in the process of being completed by Dr Craft and Dr Jordan. Once completed the separate report will be presented to Operational Governance Committee. The mortality review from November has been presented to operational and clinical governance committee’s as well as to the medical division and medical clinical governance with support for increased involvement with the patient safety work streams. Plans to take this report to the Surgical Division and Clinical Governance meeting.

Progress on Action Plan

1.2 Reduction in Hospital Associated Infections- The target for these are infection specific

Central line (CVC) bacteraemia The aim of patient safety team is to reduce CVC bacteraemia to zero (for all bacteria not just MRSA), by ensuring all CVC line insertions and aftercare are compliant with the central line bundle as process measures and also aim to incorporate routine measurement of cvc bacteraemia as an outcome measure J. Miller and L. Jordan will audit compliance with availability of CVC packs and chloroprep on the wards in the next quarter. J. Miller and L. Jordan have also produced initial baseline data for recording CVC bacteraemia rate in conjunction with the IV task force and infection control. With an aim to maintain ongoing data collection with the IV task force to demonstrate effectiveness of the interventions. This will be reported in the next quarters report.

A central line project group has also been established by L. Jordan with representatives from across the Trust, to produce guidelines for safe insertion CV lines and ensure compliance with CVC care bundles. The draft document has been reviewed and amended by all members and is nearing completion and a checklist developed for insertion which will enable easy monitoring of compliance with insertion bundle. The daily care plan has also been updated and incorporated in the document. A pre packed pack is also being investigated and this would contain everything required for insertion. It would also contain the checklist. This is also in the final stages before being agreed and taken to procurement. Further progress will be reported in the next quarter. The graph below shows the Trust’s compliance with the CVC care bundle for the last quarter.




Graph 5

The Graph below shows the percentage of compliance for hand hygiene audit during the last quarter.

Graph 6

Peripheral venous cannulae (PVC) infection

The patient safety team are working very closely with senior nurses and other members of the IV task force. The patient safety team have assisted the task force in achieving small sustainable changes by using the PDSA cycles, and rolling these out to ward areas. Please see the IV task force report for further information. Clostridium Difficile The patient safety team are working closely with infection control in promoting hand washing, appropriate isolation and recognition of cases of C. Difficile. Introduction of safety briefing has assisted in this (see safety briefings).

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CVC care bundlecompliance Trust wide

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Hand Hygiene Auditcompliance Trust Wide




1.3 Detection of the Deteriorating Patient The aim is 100% of wards to have a standard. 100% compliance against that standard by October 2009

One of the out come measures used by the patient safety is the cardiac arrest data. This data is collected on a monthly basis, by the clinical audit department. Graph 7 shows the total number of cardiac arrests calls (Total no calls) these are then divided into the number of cardiac arrest and peri-arrest. As there is not a 24/7 outreach service further analysis is required to differentiate the number of patients requiring peri-arrest care, and those for which required resuscitation. With work continuing on the deteriorating patient intervention there should be an increase in the peri-arrest calls and a decrease in the number of cardiac arrest calls.

Graph 7

Vital Signs (Early Warning Scores) This remains the commonest trigger from random monthly note However since May the number of triggers has decreased as shown in the previous graph. It was also pleasing to note some very well recorded charts.

This may reflect the considerable amount of work being carried out on several wards across the trust, specifically looking at developing a standard

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for vital signs monitoring and then measuring compliance against that standard. When there were drops in compliance certain themes were picked up, notably a lack of understanding by some staff completing the neurological assessment. Further education has been organised and included in the education programme for both registered and unregistered nurses.

On Hamilton ward where we began the work on the deteriorating patient there has been a vast improvement with the vital signs monitoring and action taken. The graph below shows the progress on Hamilton ward for recording the frequency of observations.

Graph 8

Graph 9

The decrease in compliance for May was due to the incorrect recording of the EWS, this was due to a lack of education around the APVU scoring. This has now been rectified with relevant training being given to both permanent and temporary staff. The surgical admissions unit is also demonstrating compliance with the completion of vitals signs and has reached 98% compliance in June.

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Vital signs AssessmentFrequency Recorded

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All Oberservationsrecorded Hamilton Ward




Graph 10 This work has commenced on Haygarth ward in the last quarter.

Graph 11 The decrease in compliance in April and May was due to the incorrect recording of the EWS, this was due to a lack of education around the APVU scoring. This has now been rectified with relevant training being given to both permanent and temporary staff. For this period there will be a dedicated band 7 nurse working solely on the deteriorating patient intervention, which will allow this work to progress at a fairly rapid pace. The data collection for these areas has been collected using the productive ward vital signs audit tool

SBAR There is a version 5 vital signs chart being launched in September which, which has a printed code for actions taken when a patient triggers an elevated early warning score. This will allow the patient safety team to audit the use of SBAR in a more robust way.

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All oberservations recordedcorrectly on Haygarth ward




UTOPIA UTOPIA is an important element in improving the treatment of the deteriorating patient. The impact of the knowledge gained is one of the indications in the reduction of the triggers in EWS. Education The patient safety team are also providing education regarding patient safety, by delivering regular patient safety lectures and updates to Nursing, Medical and Allied Health Professionals. Patient safety is planned to be part of the induction for new F1 doctors in August.

1.4 Leadership Intervention

Executive Patient Safety Visits The number of visits performed, number of actions and number of completed actions to date is shown below:

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Number of visits

Number of new actions

Number of completed actions

Graph 12

The graph below shows the percentage of areas with the RUH visited up to the end of quarter 1.

Graph 13

Percentage of areas Executive Safety Visit

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The Executive patient safety visits have been extremely well received from both executives and ward/department staff. During quarter 1 the Director of Nursing and the Assistant Director of nursing did a night visit to enable the permanent night staff to be included. Ward Safety Briefings The patient safety briefings have been successfully implemented in Charlotte ward and Helena Ward. Both these areas are maintaining 100% compliance with these.

Graph 14

Graph 15 There are a large amount of other areas within the Trust which are about to commence or who have commenced the safety briefings.

1.5 Reduction of High Risk Medication Errors the aim is 100% decrease in high risk medications

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Patient safety briefings onHelena Ward

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Percentage of safetybreifings on Charlotte Ward




Insulin Insulin prescribing, administration, and storage are the first area to be targeted. There has been a new chart developed which is to be initially trialled on Hamilton Ward. The graph below shows the data for the last quarter on Hamilton Ward.

Insulin Data Hamilton Ward

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not missing insulin doses

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with correct insulin dose and clearly written (UNITS)

Graph 16

1.6 VTE Risk Assessment The aim is 100% of all inpatients to be risk assessed by April 2009

The plan for the VTE intervention is to ensure that 100% of all patients admitted to hospital have a risk assessment. The hospital thrombosis committee are developing work on ensuring compliance with the risk assessment tool. The next report will include data collected to demonstrate compliance.

1.7 Prevention of falls the aim is a 50% reduction in falls by March 2010

The patient safety team have agreed a target of 50% reduction of falls by April 2010 and have identified a lead for this project. There is a great deal of work already being undertaken within the Trust with regards to falls and the patient




safety team lead will work with falls prevention team. A number of measures have already commenced: - The falls prevention group has now been reinstated. - There are plans to starting using the safety crosses which are part of

the productive ward tools. The safety cross will be used on Victoria ward and will monitor the number of falls on Victoria for a month initially, prior to being used elsewhere. This is due to start in July, more details and data will be included in the quarter 2 report.

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Graph 17

The graph above shows the number of falls in the trust for the last two quarters.

1.8 Prevention of hospital acquired Pressure Ulcers the aim is zero tolerance of grade 4 pressure ulcers, 20% reduction of grade 3 pressure ulcers and 10% reduction of grade 2 pressure ulcers.

The patient safety team together with the tissue viability nurse have agreed the above target and a patient safety lead have been identified. The Tissue viability report is not included in this quarters report, but will be available in the next report.

1.9 Safer Surgery

Theatre checklist The initial document adapted from the NPSA original document was commenced in theatre 8 and PAW theatres but was found to be too long and therefore was not received with full engagement. It was appreciated that the comments were valid and a further draft document was produced which was




very similar to the NPSA document. This was then commenced in day surgery theatres and then rolled out to all other theatres. By the end of June, there is still not universal engagement with compliance on average about 50% in day surgery theatres. Feedback is being collected on the current form with audit data for compliance to make further progress. The SHA also recommend that the checklist includes a preoperative briefing. Lesley Jordan and Jo Miller are taking 2 members of the theatre team to SHA training day on theatre safety checklist in July and will combine knowledge from the meeting and the feedback to adapt the form further and increase its compliance. Surgical Site Infection Bundle Some data is available from the saving lives audit of surgical site infection bundle and there are plans to develop this further with regular note review and production of standards for antibiotic prophylaxis. Bringing requirement for antibiotics preoperatively into the preoperative briefing as suggested will also increase compliance with administration before surgical incision. The graph below shows the compliance with the surgical site infection care bundle.

Graph 18 A temperature audit was also performed in April, the results of which are shown below.

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Compliance withSurgical Site Infectionscare bundle (theatres)




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New policies have therefore been introduced that all patients have temperature measured in anaesthetic room and warming commenced if necessary, as well as increasing the number of blankets that patients have on the way to theatre. All patients must have temperature taken on ward before theatre and policies for return of patients from PACU are also being revised This is ongoing work and ongoing data collection is planned to produce monthly run charts for each theatre complex to show progress..

1.10 Conclusion

The patient safety team remain on target for with the Patient Safety Strategy objectives. The third mortality review has been commenced and is due to be presented at Operational governance committee in October 2009 before presenting to each division to gain further engagement and support for patient safety action plan across the trust. The harm event monthly continues. All divisions have nominated staff to assist in the harm event monitoring with the majority of staff now trained in the use of the global trigger provided by the patient safety team. The RUH has been selected as a pilot site for a new web based database for the collection of the GTT data; we are still awaiting a date for the commencement of the use of this tool. The senior Nurse for Patient Safety continues to liaise with the NHS Institute for Innovation and Improvement around this.




The post of Assistant Director of Nursing (Patient Safety & Clinical effectiveness)/DIPC has now been appointed to.







Appendix 2 Once the triggers have been decided to have caused a harm event, then the severity of that event is then scored ranging from E-I as outlined below.

E - Contributed to or resulted in temporary harm to the patient and required intervention

F - Contributed to or resulted in temporary harm to patients and required

initial or prolonged hospitalisation G- Contributed to or resulted in permanent harm H – Required intervention to sustain life I - Contributed to the patients death

Documents

Date of Meeting: 9 September 2009 Appendix Appendix 1: GTT ... · The commonest triggers from GTT over these 3 months continue to be lack of observations or Early Warning Scores (EWS)