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Making Quality Everyday Business Aneurin Bevan Health Board

National Learning Event – 11th May 2012

ABHB Vision

The vision statement for the Aneurin Bevan Health Board is:

• Working with you for a healthier community

• Caring for you when you need us

• Aiming for excellence in all we do

ABHB Aims – Reducing

Mortality and Harm

• Aim: To have a RAMI in line with top performing UK organisations and eliminate seasonal and weekly variation in RAMI by June 2013.

• Aim: To establish the Global Trigger Tool as a measure of patient harm and reduce adverse events per 1000 patient days to 10 by June 2013.

CHKS Risk Adjusted Mortality

Adverse Events per 1000

Patient Days

RGH

NHH

ABHB MORTALITY DRIVER DIAGRAM

Reduce

Unexpected

Deaths in order to

have a RAMI in

Line with Top

Performing UTE

Organisations by

June 2013.

Leadership

ICT & Supporting Work

Observation Policy

Objectives Primary Drivers Secondary Drivers Action

Prevent Deterioration of

Patients

(RRAILS)

(Rapid Response to Acute

Illness)

End of Life Care

Prevent HCAI

Prevent Hospital Acquired

Thrombosis, General and

Maternity

Improve

Cardiac Care

CHF

Acute

Coronary

Syndrome

Stroke

Fractured Neck of Femur

MEWs (and MEOWs and Community

Hospitals)

Appropriate Response to MEWs Triggering

Recognition and Management of SEPSIS

Appropriate DNARs in Place

MRSA

C DIFF

VAP

CVC

SSI, General & Maternity

DVT Risk Assessment

6 Campaign Interventions

Timely Management of TIA

Acute Stroke Care

Early Recovery and Rehabilitation

One MEWS Chart

MEWS Chart signed by trained staff

Appropriate handover/SBAR/ Escalation

Outreach Team

Hospital at Night

SEPSIS 6 Admission, Recognition, Response

SEPSIS Resus Bundle

SEPSIS Management Bundle

Hand Hygiene

Environmental Measures

Antibiotic Stewardship

VAP Bundle

Insertion and Maintenance Bundles

Normothermia

Glycaemic Control

Antibiotic Prophylaxis

Appropriate Hair Removal

Primary Care End of Life Pathway

ABHB Health Community DNAR

Appropriate DVT Prophylaxis

Patient Information

First 3 Hours

First 24 Hours

First 3 Days

First 7 Days

ABHB HARM DRIVER DIAGRAM

Reduce Harm (adverse

events per 1000 patient

days) to 10 by June

2013

Improved Team Working Safety Briefings

Outcomes Primary Drivers Secondary Drivers

Enhanced Recovery after

Surgery

Reduce Patient Falls in Hospital

and Intermediate Care

Reduce Pressure Damage

Improve Medicines

Management

Reduce HCAI

VC

UTIs

Identifying Depression in Long

Term Conditions

1st Episode Psychosis

Improve Care for People with

Dementia

SBAR

WHO Checklist

Risk Assessment

TCAB

Risk Assessment

TCAB

Reduce Inappropriate use of

Antipsychotics

Medicine Reconciliation

Missed Doses

Positive Patient ID

Anticoagulants

Insulin

Peripheral Lines Bundle Insertion

and Maintenance Bundle

CAUTI Initiation and Maintenance

Bundles

Case Identification

Appropriate Intervention

Early Diagnosis and Identification

Information to Carers and Patients

Improved Care on General and

EMI Wards

Falls Bundle

Hourly Rounds

Daily Goals

Real Time Document

Quiet Time

Skin Bundle

Hourly Rounds

3 – Monthly Review for

Patients with Dementia

Action

Priorities for Reducing

Mortality and Harm

• MEWS to NEWS

• MEWS in the Community and Mental Health

• RRAILS and SEPSIS

• Fractured Neck of Femur

• Falls in Hospital

Taking Forward the

Driver Diagram • The 1000 Lives Steering Group has representation

from all the Divisions and Localities and aims to embed the priorities for reducing mortality and harm in the Divisions and Localities.

• In particular, the Group receives presentations from each of the mini-collaborative areas, embeds the spread of interventions in the Divisions and Localities, and addresses the requirements of a measurement system for all the interventions, ABHB-wide.

• New priorities/drivers to reduce mortality/harm are identified through triangulating data from concerns, mortality audit and review of CHKS data, and interventions developed to make further changes

100 000 bed days –

Every Day Counts to

Megan • Campaign to bring together Clinical

Effectiveness/Safety with Organisational Efficiency and Patient Experience, dovetailing with the 1000 Lives plus Programme

• Will use the IHI Model for Improvement as the core improvement tool in conjunction with LEAN

• Will use a Mini-collaborative format, with the first two collaboratives meeting in July 2012

• Will use the Patient and Family Centred Care approach to improving patient experience

Development of Local

Faculty • Over the next year, ABHB plans to develop the Aneurin Bevan

Continuous Improvement (ABCI), which will act as the Faculty for Improvement in the Health Board. The faculty will be populated by team members from the 1000 Lives Plus team, the Service Improvement team and the OD team to form a core of 20 or so staff who work full time to support continuous improvement.

• ABCI will initially be established on the Health Board intranet site, and will be developed as a physical centre for teams to come to meet and learn, with a particular focus on clinical and professional development on the improvement agenda. In addition, specific locations will be developed across Health Board sites to facilitate local continuous improvement events.

• In addition to a core team of full time staff, the ABCI Faculty for Improvement will support improvement experts embedded in clinical teams and will oversee a programme of training to ensure that all Health Board staff have some familiarity with continuous improvement methodology.

• IHI Model for Improvement will be core improvement tool used within ABCI

• The Faculty for Improvement will support the 100 000 Bed Days: Every Day Counts to Megan

Taking Forward Patient

Stories - 1000 Voices Stories can have different purposes, and the purpose

of the story should be clear from the start. Stories

can be for:

• Improvement - Patient stories to inspire, learn and improve

• Engagement - to engage the media and staff

• Training - Patient stories to see through the patient’s eyes

Although we use the term “Patient Stories”, stories

can be captured from patients, volunteers, carers

and staff.

Taking Forward Patient

Stories - 1000 Voices

ABHB is focussing on the following areas:

• Setting up a core team to oversee Patient Stories

• Developing a governance framework and “how to” guide

• Setting a process to identify themes

• Developing Capacity and capability for capturing patient stories

• Setting up a central database of stories, with helpful indexing, and control over access, depending upon the consent given

• Embedding the capture and use of stories through out the organisation

Progress with the mini-

collaboratives

Transforming Care

Current Situation

• 60 Wards/Departments (74%) have commenced transforming care

• The programme has been well received by front line teams, particularly the “intentional rounding”, which has impacted on patient experience positively

Transforming Care

Achievements

• Direct patient care time has increased from 40-72% in At Arvans Ward, Chepstow, demonstrated through the Activity Follow

• There has been a reduction in falls on C7E, RGH, coupled with 100% compliance with the CAUTI maintenance bundle for 78 days

• The Well Organises Ward has been introduced, impacting on stock control and the environment of care on D5W, RGH, coupled with no medication errors for 210 days

• Divisions plan to ensure Transforming Care has commenced across all wards by July 2012, with focus on outcome measurement

Transforming Care

Barriers

• Lack of TC facilitators and dedicated time to support the wards

• Ward changes due to reconfiguration and redesign

• Ward Manager vacancies and sickness, leaving a leadership vacuum on the wards for TC implementation

Pressure Damage

Current Situation

• The SKIN Bundle has been rolled out across all Adult Wards

• Fortnightly Hospital Acquired Pressure Ulcer Surveillance Meetings, chaired by an Assistant Director of Nursing, have been established to undertake reviews of all grade 3 & 4 Hospital Acquired Pressure Ulcers. The appropriate Senior Nurse has to attend and present a report outlining the investigation and if it is deemed that the PU was avoidable the Senior Nurse prepares an action plan. The implementation of action plans is also monitored by this group.

• The reporting process has changed since October and the Health Board is now collecting data re all pressure ulcers over the month and all patients from an increased number of areas, as opposed to a snapshot, single-day survey. Numbers since October have therefore increased.

Pressure Damage

Results

• A single grade 4 hospital acquired pressure ulcer in February is the first grade 4 hospital acquired pressure ulcer since incidence reporting commenced in October 2011. A Clinical Investigation is currently underway, led by the appropriate senior nurse.

• In February, two grade 3 pressure areas were acquired in Scheduled Care, RGH and one grade 3 was acquired in County Hospital. All three are being fully investigated.

• Zero hospital acquired pressure ulcers were found in Newport, Monmouthshire, Family & Therapies, Adult Mental Health in February. This is the 5th Month for Newport Locality of zero hospital acquired pressure ulcers.

Next Steps

• Each Division to set a target for reduction, as per the Delivery Framework.

Dementia

Memory Assessment Clinics

• 6 Dementia Co-ordinators working together to standardise: pre-diagnostic counselling, cognitive assessment, post diagnostic interventions through one Memory Assessment Service Record

• New Clinics in South Powys and Monmouthshire

• Will review Alzheimer Society Information Pack at the next meeting

Dementia

General Wards

• Pilot wards C7E and 3.2 are focussing on the identification of delerium and dementia and the implementation of “this is me” documentation

• Good support form the Mental Health Liaison Nurses who provide training and advice for the ward nurses

• Good results in reduction in falls, patient and carer satisfaction, dementia friendly changes to the ward environment

• Y Bannau in Brecon has now completed its initial audit

• Identifying wards for further spread

Dementia

Elderly Mentally Ill Wards

• 5 pilot areas Working on the demetia pathway, Life History Books, Assessment of physical needs

• Checklist for the 48hrs of admission devised and being tested

• Carer’s satisfaction survey being revised and will be tested in the pilot areas.

Dementia

Carers

• The UK Carers’Survey is being facilitated in all Boroughs

• A Carer is working with the team to develop a care pathway for carers

• “Psychological Therapies for Carers” course is run in Blaenau Gwent and Caerphilly and is being spread to South Monmouthshire

• Guidelines on “Managing Behaviour that Challenges” and alternative interventions have been developed

Depression

Current Situation

• Pilot work is underway to improve detection of depression in respiratory medicine and cancer services

• Caerphilly COPD clinic is screening all new patients with HADS

Depression

Results – quotes from frontline staff

“We need to ask and we need to ask the right questions."

"Just through our conversations, I'm thinking differently about depression. I'm more likely to think of it, more

likely to ask, more likely to treat."

"The PHQ-9 has indentified problems with depression in some patients that weren't obvious at assessment

and that have surprised us."

Depression

Challenges

• Measurement in this area has proved

particularly challenging, but different ways

of approaching the issue are still being

considered.

Stroke - Acute

Stroke - TIA • Rapid Access TIA clinics available 5 days per week

at both RGH and NHH

• Data collection on going to evaluate current provision and aid further development

• A TIA referral package has been devised and disseminated

• Local TIA meetings held regularly to monitor compliance and make changes

• Special meeting identified that the main issues are currently: data inputting, imaging at the weekend, access to vascular surgery

Stroke - Rehabilitation

• ABHB Stroke Rehabilitation sub-group

has been established

• Specialist lead identified in each of the 5

rehabilitation units

• Data collection in progress in each unit

RRAILS and SEPSIS

• Bundles piloted and spread underway

• MEWS to NEWS change completed and

currently being reviewed

Achieve consistent 95% compliance with the 4 care bundles

Implementation of bundles and full data collection

NHH: 4/3, 3/4, 3/3

RGH: D5W, CCU, D3W

YYF

Implementation of bundles

A&E

SAU. D5E, D3E, D4W, A&E

Intended spread

EAU, 3/2, 2/3 Senior Nurses/outreach to discuss further spread

D4E,C4E,C4W,C6W Senior Nurses/outreach to discuss further spread

1/1, 2/1, 2/2, 3/1, 3/2

RRAILS and SEPSIS

RRAILS and SEPSIS

Outstanding Issues

• Data collection in A and E requires review, specifically the best process to use (symphony or safety briefing)

• Ensure that there is a unified approach to the development of integrated Patient Status at a glance boards with Patient Planning Boards

Urethral Catheter care bundle

• Background:- Research suggests catheter use can be prolonged and likelihood of infections increase if regular assessment is not undertaken.

• A maintenance care bundle was produced to target this problem and indentified a large variation in catheter practice identified.

• Current status – 11 wards participating across acute and community hospital sites plus involvement from 2 nursing homes.

Urethral Catheter care bundle

Process and Outcome data

available % Total Compliance with full bundle by week

nhWard 4/1

0%

20%

40%

60%

80%

100%

120%

01/0

8/10

29/0

8/10

26/0

9/10

24/1

0/10

21/1

1/10

19/1

2/10

16/0

1/11

13/0

2/11

13/0

3/11

10/0

4/11

08/0

5/11

05/0

6/11

03/0

7/11

31/0

7/11

28/0

8/11

25/0

9/11

23/1

0/11

20/1

1/11

18/1

2/11

15/0

1/12

12/0

2/12

11/0

3/12

08/0

4/12

% c

om

pli

an

ce

% Total Compliance w ith full bundle

Total number of catheters days by week

nhWard 4/1

0

10

20

30

40

50

60

70

01/08/1

0

29/08/1

0

26/09/1

0

24/10/1

0

21/11/1

0

19/12/1

0

16/01/1

1

13/02/1

1

13/03/1

1

10/04/1

1

08/05/1

1

05/06/1

1

03/07/1

1

31/07/1

1

28/08/1

1

25/09/1

1

23/10/1

1

20/11/1

1

18/12/1

1

15/01/1

2

12/02/1

2

11/03/1

2

08/04/1

2

Nu

mb

er

Total number of catheters days

Urethral Catheter care

bundle - Where Next

• Facilitate data inputting at ward level

• Support spread through baseline data

collection implementation and sustainability

• Evaluate insertion bundle pilot- plan progress

• Continue to report data from ward to Board

PVC care bundle

• Background:- – A PVC is one of the most common medical device

– Work commenced in May 2010, in response to an increase of MSSA bacteraemia

– The team was also successful in an application to be mentored by Tayside through the IHI foundation

There are two care bundle associated with the PVC an insertion and maintenance

Current status – 15 wards/departments implementing

PVC care bundle Process

and Outcome data

available

MSSA BACTERAEMIA

Apr 2011 - current

0

2

4

6

8

10

12

Apr-

11

May

-11

Jun-1

1

Jul-1

1

Aug-1

1

Sep

-11

Oct

-11

Nov-1

1

Dec-

11

Jan-

12

Feb-1

2

RGH

NHH

ABHB

Linear

(ABHB)

% Compliance with complete bundle by month

WARD 4 1

0%

20%

40%

60%

80%

100%

120%

Sep 11

Oct 11

Nov 11

Dec 11

Jan 1

2

Feb 12

% c

ompl

ianc

e

% Compliance with complete bundle

PVC care bundle -

Where Next?

• Support wards in implementation and

sustainability

• Determine areas for intended spread and plan

collection of baseline data and training.

• Continue to report data from ward to Board

Transforming Theatres – Patient Safety

Two drivers:

• Preventing Surgical Site Infections

1. Antibiotics Within One Hour of Knife to Skin

2. Hair Removal Via Clippings

3. Normothermia

4. Blood Glucose Monitoring

• Creating a team culture attuned to detecting and rectifying intra-operative errors

1. Pre-List Briefings

2. WHO Checklist

Achievements

• Spread across all theatres

• Well embedded within practice, engaged staff

• Support for measurement from QPSIM team

• Linked with transforming theatres

• Good compliance with measurement, reaching reliability

• Successful 1000 lives day held for theatres

• Good measuring system via ORMIS

• Setting up regular reports to divisional Q&PS meeting

• Work to improve WHO checklist

Barriers

• Duplication of questions on ORMIS

• Difficulty in measuring outcomes i.e. Surgical Site Infection rates

• WHO checklist measurement

Next Steps

• Pull together measures into 1000 lives careplans across sites in ABHB

• Looking at diabetic control

Transforming Theatres – Patient Safety

% Receiving DVT Prophylaxis ABHB

0

1020

30

40

5060

70

8090

100

Aug-0

7

Nov-0

7

Feb-0

8

May-0

8

Aug-0

8

Nov-0

8

Feb-0

9

May-0

9

Aug-0

9

Nov-0

9

Feb-1

0

May-1

0

Aug-1

0

Nov-1

0

Feb-1

1

May-1

1

Aug-1

1

Nov-1

1

Feb-1

2

RGH

SWH

NHH

CDMH/YYF

% With Completed VTE Risk Assessment ABHB

0

1020

30

40

5060

70

8090

100

Mar-

11

Apr-

11

May-1

1

Jun-1

1

Jul-11

Aug-1

1

Sep-1

1

Oct-

11

Nov-1

1

Dec-1

1

Jan-1

2

Feb-1

2

Mar-

12

RGHSWHNHHCDMH/YYF

% Antibiotics Within One Hour Timeframe ABHB

0

1020

30

40

5060

70

8090

100

Aug-07

Nov-07

Feb-08

May-08

Aug-08

Nov-08

Feb-09

May-09

Aug-09

Nov-09

Feb-10

May-10

Aug-10

Nov-10

Feb-11

May-11

Aug-11

Nov-11

Feb-12

RGHSWHNHHCDMH/YYF

% Blood Glucose Within Range ABHB

0

1020

30

40

5060

70

8090

100

Aug-0

7

Nov-0

7

Feb-0

8

May-0

8

Aug-0

8

Nov-0

8

Feb-0

9

May-0

9

Aug-0

9

Nov-0

9

Feb-1

0

May-1

0

Aug-1

0

Nov-1

0

Feb-1

1

May-1

1

Aug-1

1

Nov-1

1

Feb-1

2

RGHSWHNHHCDMH/YYF

% With Perioperative Normothermia

ABHB

0102030405060708090

100

Au

g-0

7

No

v-0

7

Fe

b-0

8

Ma

y-0

8

Au

g-0

8

No

v-0

8

Fe

b-0

9

Ma

y-0

9

Au

g-0

9

No

v-0

9

Fe

b-1

0

Ma

y-1

0

Au

g-1

0

No

v-1

0

Fe

b-1

1

Ma

y-1

1

Au

g-1

1

No

v-1

1

Fe

b-1

2

RGHSWHNHHCDMH/YYF

% Surgery With Hair Removal Via

Clipping ABHB

0

20

40

60

80

100

Au

g-0

7

No

v-0

7

Fe

b-0

8

Ma

y-0

8

Au

g-0

8

No

v-0

8

Fe

b-0

9

Ma

y-0

9

Au

g-0

9

No

v-0

9

Fe

b-1

0

Ma

y-1

0

Au

g-1

0

No

v-1

0

Fe

b-1

1

Ma

y-1

1

Au

g-1

1

No

v-1

1

Fe

b-1

2

RGHSWHNHHCDMH/YYF

% Patient Discussed at Pre-list Briefing

ABHB

0

10

20

30

40

50

60

70

80

90

100

Ma

y-0

7

Se

p-0

7

Jan

-08

Ma

y-0

8

Se

p-0

8

Jan

-09

Ma

y-0

9

Se

p-0

9

Jan

-10

Ma

y-1

0

Se

p-1

0

Jan

-11

Ma

y-1

1

Se

p-1

1

Jan

-12

RGHSWHNHHCDMH/YYF

% WHO Checklist Completed ABHB

0

1020

30

40

5060

70

8090

100

Sep-0

9

Nov-0

9

Jan-1

0

Mar-

10

May-1

0

Jul-10

Sep-1

0

Nov-1

0

Jan-1

1

Mar-

11

May-1

1

Jul-11

Sep-1

1

Nov-1

1

Jan-1

2

Mar-

12

RGHSWHNHHCDMH/YYF

Transforming Theatres – Patient Safety

Thromboprophylaxis

Preventing Surgical Site Infection Team Culture

ABHB – Chronic Heart Failure Progress

Measurement spread from pilot area (patients referred to Heart Failure Specialist Nurses)

to CHF cases on all wards at Nevill Hall site.

Beginning measurement at Royal Gwent site May 2012

PDSA: aide memoire sticker for patients with CHF on general wards – limited success due to withdrawal of pharmacist hours

MDT and CHF nurse meetings continuing

IV diuretics in community for chronic CHF (British Heart Failure Project) to reduce readmissions

Utilising data from Heart Failure National Audit in Nevill Hall Hospital and commencing Royal Gwent Hospital

Closer collaboration between Heart Failure Nurses and Quality & Patient Safety Measurement department to maximize cases for inclusion

ABHB – Chronic Heart Failure - Results

ECG and Echo

0102030405060708090

100

Jan-1

1

Feb-1

1

Mar-

11

Apr-

11

May-1

1

Jun-1

1

Jul-11

Aug-1

1

Sep-1

1

Oct-

11

Nov-1

1

Dec-1

1

Jan-1

2

Feb-1

2

Mar-

12

% C

om

pli

an

ce

Echo ECG

Discharge Medications

0

10

20

30

40

50

60

70

80

90

100

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

Jun-1

1

Jul-11

Aug-1

1

Sep-1

1

Oct-

11

Nov-1

1

Dec-1

1

Jan-1

2

Feb-1

2

Mar-

12

% C

om

plia

nc

e

ACE or ARB B Blockers

Warfarin (AF patients only) and Discharge Planning

0

10

20

30

40

50

60

70

80

90

100

Jan-

11

Feb-1

1

Mar

-11

Apr

-11

May

-11

Jun-

11

Jul-1

1

Aug

-11

Sep

-11

Oct-1

1

Nov-

11

Dec-

11

Jan-

12

Feb-1

2

Mar

-12

Warfarin Discharge Planning

Readmissions for CHF within 30 days (Source: NWIS)

02468

1012141618202224

Apr-

10

May-1

0

Jun-1

0

Jul-10

Aug

-10

Sep

-10

Oct

-10

Nov-1

0

Dec-1

0

Jan-1

1F

eb-1

1

Mar-

11

Apr-

11

May-1

1

Jun-1

1

Jul-11

Aug

-11

Sep

-11

Oct

-11

Nov-1

1

Dec-1

1

Jan-1

2F

eb-1

2

Mar-

12

% R

ead

mis

sio

ns

Nevill Hall ABHB

Notes: discharge planning - change in data question from January 12; warfarin low denominator numbers

ABHB – Chronic Heart Failure

Barriers

Use of data from National Heart Failure Audit means: Data 2 to 3 months old to allow for coding Labour intensive, obtaining and examining patient notes

Loss of dedicated 1000 Lives Pharmacy hours

Next Steps Further analysis of data to identify poor performing wards regarding:

Prescription of discharge medications

Referral to Heart Failure Nurse Specialists

Spread of measurement to Royal Gwent Hospital

TEAM: Jackie Austin, Consultant Nurse; Dr P Campbell, Consultant Cardiologist; Dr A Edwards, GP; Alex Simpson, Pharmacist; Denise Hockey, Heart Failure Specialist Nurse & Team; Rachel Fletcher, Quality & Patient Safety Improvement Manager; Rachel Kindred, Quality & Patient Safety Measurement Co-ordinator; Anne Phillimore, Executive Lead;

ERAS in ABHB

Background

• ERAS is an evidence based programme of care that aims to improve the quality of peri-operative care, thereby improving clinical outcomes, reducing morbidity, and enabling early discharge.

• Launched in Elective Colorectal surgery, across Wales, in October 2010, and Elective Orthopaedic surgery (Hip and Knee Arthroplasty) in June 2011.

• Lead by an Advanced Nurse Practitioner, appointed in May 2011.

• Clinical leads for each speciality team, co-ordinated by the ANP and supported by the clinical MDT.

• Care pathway lead by Care bundle documentation, derived from the Driver diagram.

ERAS Achievements

in ABHB • Teaching: An important element of the ERAS programme is education,

both for patients and staff. So far teaching has been established in the following areas - Medical students, Student Nurses, Ward based MDT, GPOOH, GP in hours via CPD sessions, D/N’s, Practice Nurses

• Patient Stories: In order to quantify our patient experiences we are about to commence recording patient stories , as part of a 1000+ lives mini collaborative.

• Study Day: ANP attended the Theatre study day in November 2011 at Tredegar House with a patient who had experienced ERAS himself. This stimulated a very interesting discussion and an opportunity for theatre staff to ‘catch up’ on their own performance.

• Engaging Primary Care: Initial meeting with Dr Liam Taylor (Assistant Med. Dir. General Practice) to ensure ERAS was introduced Health Board wide. Communication now established with NKN’s lead for MSK (Dr Simon Donovon) after roll out to Orthopaedics

• For the Future: A Patient Party during the summer. Patients will be invited back to meet the teams and discuss the good and not so good points of ERAS in ABHB. We hope to learn from this experience and put into action any suggestions that will improve our service

ERAS Results

Data is being collected for Colorectal Surgery across all sites and is beginning across all

sites for T&O. Below is an example of the data being collected in the Royal Gwent Hospital.

Average Length of Stay 3 Colorectal

Consultants

0

5

10

15

20

May-1

1

Jun-1

1

Jul-11

Aug-1

1

Sep-1

1

Oct-

11

Nov-1

1

Dec-1

1

Jan-1

2

Feb-1

2

Mar-

12

Apr-

12

Days

Length of

StayMedian

Number of Patients Readmitted Within 28 Days

0

1

2

3

May-1

1

Jun-1

1

Jul-11

Aug-1

1

Sep-1

1

Oct-

11

Nov-1

1

Dec-1

1

Jan-1

2

Feb-1

2

Mar-

12

Da

ys

Readmissions

Median

(B2) % of pts complying with Immediate Care Bundle

ABHB - RGH 3 CONSULTANTS

from May 2011 to Apr 2012

0

10

20

30

40

50

60

70

80

90

100

May

201

1

Jun

2011

Jul 2

011

Aug

201

1

Sep

201

1

Oct

201

1

Nov

201

1

Dec

201

1

Jan

2012

Feb

2012

Mar

201

2

Apr

201

2

Months

% p

atie

nts

(B3) % of pts complying with Intra-operative care bundle

ABHB - RGH 3 CONSULTANTS

from May 2011 to Apr 2012

0

10

20

30

40

50

60

70

80

90

100

May

201

1

Jun

2011

Jul 2

011

Aug

201

1

Sep

201

1

Oct

201

1

Nov

201

1

Dec

201

1

Jan

2012

Feb

2012

Mar

201

2

Apr

201

2

Months

% p

atie

nts

(B4) % of pts completing Post Operative Care Bundle

ABHB - RGH 3 CONSULTANTS

from May 2011 to Apr 2012

0

10

20

30

40

50

60

70

80

90

100

Ma

y 2

01

1

Jun

20

11

Jul 2

01

1

Au

g 2

01

1

Se

p 2

01

1

Oct

20

11

No

v 2

01

1

De

c 2

01

1

Jan

20

12

Fe

b 2

01

2

Ma

r 2

01

2

Ap

r 2

01

2

Months

% p

ati

en

ts

(B5) % of pts completing the Discharge/follow up bundle

ABHB - RGH 3 CONSULTANTS

from May 2011 to Apr 2012

0

10

20

30

40

50

60

70

80

90

100

May

201

1

Jun

2011

Jul 2

011

Aug

2011

Sep

2011

Oct

201

1

Nov

201

1

Dec

201

1

Jan

2012

Feb

2012

Mar

201

2

Apr 2

012

Months

% p

atie

nts

Outcome Measures

Process Measures. These measures

are of overall

bundle compliance.

Each intervention

in the bundle is

measured – if one

intervention is not

met the bundle

compliance is 0%

ERAS Spread Plan Reliable implementation of

bundles / drivers and full data

collection in place in these areas

Implementation of bundle /

drivers underway but not yet

reliable in these areas

Intended to spread to these areas

next

Colorectal RGH, 5 Consultants

Laparoscopic & Open surgery. C7W

T & O SWH,

3 Consultants established in knees

and 1 Consultant starting with hips

and knees

T & O RGH Elective Hips and

Knees. 3 Consultants due to

commence 8/5/2012

Colorectal NHH, 2 Consultants

Laparoscopic and open surgery 3/3

& 3/4

T & O NHH

2 Consultants established in hips

and knees and 2 starting in both

Urology RGH 2 Consultants,

Cystectomy and Radical

prostatectomy

Due to commence May 2012

# NOF pathway RGH

Newly commenced within the ERAS

pathway

Gynaecology (Gynae Oncology

initially ) July / August 2012

# NOF Pathway NHH.

Newly commenced within ERAS

pathway

Maxillo –facial surgery. Plan to

explore possibility of CHO loading

for radical neck dissection

Regular clinical hub meetings to assess the efficacy of the document and allow for group directed changes, as

part of the PDSA cycle approach.

Prevention of Falls in the

Community (Torfaen)

Current Situation

• Have better understanding and interpretation of the data.

• Use data to identify service gaps thus enabling improved planning for future falls service provision (introduction of Frailty).

• Falls screening tool developed across all Localities.

• Falls assessment tool developed across all Localities.

• Falls pathway developed across all Localities(currently under review).

• Falls training awareness sessions rolled out.

• GPs kept fully informed of falls intervention provided.

• Tool to enable workforce planning.

• Sharing best practice at falls collaborative events and shared learning.

Torfaen Community Falls Prevention

Data: run charts 4 (iii) % patients who have an updated or closed plan as

appropriate and update the falls log

Falls

from Apr 2010 to Mar 2011

0

20

40

60

80

100

120

Apr

2010

May

2010

Jun

2010

Jul

2010

Aug

2010

Sep

2010

Oct

2010

Nov

2010

Dec

2010

Jan

2011

Feb

2011

Mar

2011

Months

% patients who receive the full Monitoring Bundle

Falls

from Apr 2010 to Mar 2011

0

10

20

30

40

50

60

70

80

Apr

2010

May

2010

Jun

2010

Jul

2010

Aug

2010

Sep

2010

Oct

2010

Nov

2010

Dec

2010

Jan

2011

Feb

2011

Mar

2011

Months

2 (ii) % patients who complete a basic falls risk assessment

using an agreed risk assessment tool

Falls

from Apr 2010 to Mar 2011

0

10

20

30

40

50

60

70

80

Apr

2010

May

2010

Jun

2010

Jul

2010

Aug

2010

Sep

2010

Oct

2010

Nov

2010

Dec

2010

Jan

2011

Feb

2011

Mar

2011

Months

4 (iii) % patients who have an updated or closed plan as

appropriate and update the falls log

Falls

from Apr 2010 to Mar 2011

0

20

40

60

80

100

120

Apr

2010

May

2010

Jun

2010

Jul

2010

Aug

2010

Sep

2010

Oct

2010

Nov

2010

Dec

2010

Jan

2011

Feb

2011

Mar

2011

Months

Torfaen Community Falls

Prevention: Challenges &

Achievements

• Challenging to attempt all 4 care bundles

due to the timescales and implementation of

the Frailty programme.

• Our biggest achievement is being able to

provide evidence that the service response

to fallers reduces when falls team members

are unavailable

Maternity - Achievements • Transforming Care

– Nevill Hall Hospital (NHH) Ward 2/1 commenced work in February 2011

– Completed activity follow through in Ward 2/1 NHH

– Quiet time Achieved Ward 2/1 NHH

– Good involvement of from all staff including house keepers

– Ward B4 Royal Gwent Hospital RGH commenced work in October 2011 and Snorkelling session completed

• DVT Risk Assessment document agreed, implemented 1/11/2011

• MEOW’s Charts in use across maternity services

• Admissions, Recognition & Response Bundles – Working well on Ward B4 and AAU at RGH - note service change

– Working well in NHH DAU - note service change

– Senior Midwifery Manager to meet with Ward B5 manager and Birth Centre manager to plan roll out

– Senior Midwifery Managers to meet to discuss roll out of all care bundles to 2/1 in NHH

• Sepsis Six Bundle – Sepsis Six tool adapted for maternity services

– In use on Ward B4 and AAU plan roll out to Labour Ward in RGH

• Quality & Pt Safety Improvement & Measurement Department involvement – Local meeting set up to validate data

– A3 Structured Progress Report followed by Clinical Governance Day presentation

Maternity - Process Measures

% compliance with Sepsis Six bundle by month

Ward B4

0%

20%

40%

60%

80%

100%

120%

Jul 1

1

Aug 1

1

Sep 1

1

Oct 11

Nov 11

Dec 11

Jan 1

2

Feb 1

2

Mar

12

Apr 12

% c

om

plia

nce

% compliance with Sepsis Six bundle

% compliance with admission bundle by month

Ward B4

0%

20%

40%

60%

80%

100%

120%

Jul 1

1

Aug 1

1

Sep 1

1

Oct 11

Nov 11

Dec 11

Jan 1

2

Feb 1

2

Mar

12

Apr 12

% c

om

plia

nce

% compliance with admission bundle

Measurement carried out across multiple wards

- currently reviewing process to capture complete dataset

Maternity - Next Steps

Reducing Hospital Acquired

Thrombosis – Team Members • Dr S Noble

• Dr S Lewis

• Leeanne Larcombe

• Sue Hanson

• Sam Jones

• Denise Cressey

• Dr G Robinson (exec)

• Kate Hooton

• Carla Hiscott

• Rachel Fletcher

• Regular data and

feedback to

– HAT steering group

– Thrombosis Committee

• HAT Rate to be

incorporated into

regular QI report to

Q&PS Committee

Reducing HAT - Achievements • Risk Assessment Tools (RAT) for elective & acute surgery,

medicine tested and approved

• Risk Assessment tools incorporated into clerking packs for surgery and medicine

• Risk assessment tools incorporated into policy for surgical thromboprophylaxis

• Champions for Mental Health, Obstetrics and Plaster of Paris devising tools

• Pharmacy working with frontline clinicians to embed risk assessment tools ie. Increase of 0-80% use of RAT in OSU (joint replacement surgery)

• HAT rate being devised for health board – currently RCA on each case being carried out

Next Steps

• Change colour of Risk Assessment forms for patients undergoing surgery so that they are visible in casenotes

• Meeting with radiologists to identify VTE via RADIS system codes

• Complete RCA for cases of HAT

• Circulate HAT Rate data to divisions

Hospital Acquired

Thrombosis – ABHB

HAT Rate.

• HAT Rate median currently 0.25% pending validation on

reviewing casenotes

• Expectation that this will reduce as Risk Assessment becomes

more reliable