Patient Driven Care - 1000 Lives Plus

Insert name of presentation on Master Slide

Patient Driven CareReducing mortality & harm in Welsh Ambulance

Services NHS Trust

National Learning Event - 8th November 2011

Deliver and sustain

excellent services

that meet the needs

of patients and

maximise clinical

outcomes.

Treat patients well and

help them with their

problems

Deliver safe, high

quality services

Provide timely access

to services.

Primary

DriverSecondary Drivers

Improve stroke care

Deliver Effective care

pathways & pro-

active community

orientated care

Rapid Response to acute illness

(PHEWS)

Reduce harm and variation

Zero tolerance of HCAI

Reducing HCAI

Falls prevention in the community

Improve cardiac services

Stroke

‘Focus on’ pathways

Improve major trauma &

Acute illness services

Engage workforce

Leading the way to quality and

safety improvement

Ensure timely access

to services

Improve clinical leadership

Acute coronary syndrome

Fractured neck of femur

MDT in Control Centre

Priority improvement

projects

Welsh Ambulance Services NHS Trust

Healthcare Associated Infection

• Vehicle cleanliness is at the forefront of the Trust’s reducing Healthcare

Associated Infection plans.

• Previously vehicle and station infection control audits have been difficult to

monitor due to the data collection processes.

• An online Infection Prevention & Control Vehicle and Station Audit Tool

has now been developed to enable timely and central reporting and to

monitor compliance.

• A PDSA has been developed to test the tool’s efficacy and evaluate its use.

• The PDSA will be undertaken in 4 ambulance stations in the Ceredigion

region during December 2011.






RRAILS – Pre Hospital Early Warning Scoring

(PhEWS) Tool

• The use of an early warning system in the pre-hospital setting could benefit

patients when there are capacity problems in accepting Emergency

departments. A pre hospital early warning score has been developed and

desk top tested using 300 patient care records.

• A PDSA to test the tool in the live environment commenced on 1st

November for patients awaiting admission Wrexham Maelor emergency

department.

• This study should allow patients to be prioritised in line with their clinical

condition, for admission to the department.

• Crews from 6 ambulance stations in North Wales are participating, the

study will initially consist of the first 30 patient episodes.


RRAILS – Pre Hospital Early Warning Scoring

(PhEWS) Tool

• Patient Criteria

• Inclusion

• Patients aged 18 years and over

• Patients brought to the ED by the Ambulance Service and awaiting

admission to the department.

• Exclusion

• Patient below 18 years

• Patients who have been/or are actively being resuscitated (as these

patients are taken directly into the resuscitation room)

• Patients who are declared life extinct before arrival at hospital


Score 3 2 1 0 1 2 3

BP sys <70 71-80 81-100 101-199 >200

CRT > 2

H.R <40 41-50 51-100 101-110 111-129 >130

R.R <9 12-17 18-20 21-29 >30

O2 Therapy Yes

CNS AGGRESSIVE NEW

CONFUSION

AWAKE VERBAL PAIN UNRESP

PAIN NONE Pain but

coping.

No analgesia.

Had

analgesia.

Coping

Had analgesia

Not coping

AGE 70 +

TEMP <35 35-37.7 37.8 +

Pre Hospital Early Warning Score (PHEWS)

PCR No: Incident No: Date: Call Sign:

Peripheral Venous Cannula YES NO Time inserted: ANTT YES NO


Pre Hospital Early Warning Score (PHEWS)

This scoring system should be used each time a set of vital sign observations are

recorded.

The total score should be documented on the observation chart in the appropriate

place.

If the total score is an isolated 3 or a combined 3 to 5, the observations will need to

be repeated within 15min. You will also need to notify the duty officer and/or the ED

Triage Nurse.

Observation of vital signs should be continued frequently until PHEWS reaches 3 or

below with clinical intervention e.g. Oxygen or fluids.

VSO=Vital Signs Observations

ANNT= Aseptic No Touch Technique used

VSO Time Time Time Time Time Time Time

BP sys

CRT

HR

RR

O2

CNS

Pain

Age

Temp

Total


GP Enhanced

Multidisciplinary Team Clinical

Contact Centre (MDT) PDSA

• The Welsh Ambulance Services NHS Trust is undertaking a Plan Do Study Act

(PDSA) Cycle to identify whether a GP enhanced multidisciplinary team (MDT), in

the Clinical Contact Centre (CCC) at Vantage Point House, will increase the

number of patients that are directed to the most appropriate point of Health and

Social Care, thus reducing inappropriate conveyances and ultimately

assessment/admissions at the local Emergency Departments. The team consists of

a doctor, paramedic and nurse

• The primary role of the Multidisciplinary Team in the CCC at VPH is to support the

‘on-scene’ Ambulance Crew via the telephone. This will be achieved by;

– Assisting in the development of a differential/ working diagnosis.

– Providing critical thinking and support to ambulance crews

– Advising on optimal pathway

– Facilitating access to pathways


GP Enhanced

Multidisciplinary Team Clinical

Contact Centre (MDT) PDSA

• The scope of the PDSA will include all patients who call 999 within the South East

Wales Region.

• The parties participating in the change are;

• The Welsh Ambulance Trust NHS Services(WAST)

• Aneurin Bevan Local Health Board(ABHB)

• Cardiff and Vale Local Health Board(C&V)

• The PDSA commenced 17th October 2011.

• The Primary Exclusion criteria for the trial are all patients with immediately life-

threatening conditions, serious injury and/or at risk of short term deterioration will be

transferred direct to definitive care.



GP Enhanced

Multidisciplinary Team Clinical Contact

Centre (MDT) PDSA


• An electronic Clinical Reporter has been developed linked to the

ambulance call stack to enable clinical records to be selected and

automatically populated ahead of any intervention from the multi-

disciplinary team.

• This process enables data capture and reporting.

• Next Steps

• The PDSA will run for a 4 to 6 month period

• Monthly reports on outcome data will be made available

Falls prevention in the community

• Older people who fall account for approximately 10% of all 999 calls to the

Welsh Ambulance Services NHS Trust and many patients transported to

A&E are subsequently discharged without further intervention

• There is a risk that patients who do not require conveyance managed at

home, without referral into a falls pathway, may re-access the Trust

following subsequent falls

• The Trust has continued to work with colleagues across Wales to further

develop referral processes

• Referrals into Ceredigion commenced during July 2011 and work is

progressing to facilitate referrals into Pembs before the end of the current

year.


Referral pathways in place

Falls referrals made by Paramedics

into established pathways


0

20

40

60

80

100

120

140

160

180

May-11 Jun-11 Jul-11 Aug-11

Number of falls referrals

Number of falls referrals

Falls prevention in the

community – next steps

• Numbers of referrals reported have dropped significantly in the last quarter.

This has been attributed to the data capture method in place as calls made

to the service relating to falls have remained fairly constant.

• Revised data capture processes are currently being explored via a process

mapping exercise to identify blocks and variation in practice.


Falls pathway for nurse triage

• Patients who have fallen and subsequently assessed by NHS Direct nurses

had not been previously been referred into any falls prevention/

assessment teams across Wales.

• A falls screening tool was developed and a small scale PDSA undertaken

during May/June 2011 in one locality. No referrals were made.

• The referral criteria was reviewed and widened and another PDSA cycle

undertaken in July/August. No referrals were made.

• A Champion has been identified in each of the clinical contact centres to

raise awareness and encourage referrals.


Acute Coronary Syndrome

• Primary PCI has been identified as more efficacious for the treatment of

STEMI compared to thrombolysis and is associated with reduced mortality

rates and better patient outcomes.

• From 31st October the primary PCI service has been extended in the Mid

and West Region from the Cardiac Centre at Morriston Hospital and is

available for patients that can be transported by the Trust within 90 minutes

of recognition of symptoms to door.

• A clinical pathway has been developed to ensure that patients benefit from

the service which includes pre-alert to Morriston to prepare for the patients

arrival.


Stroke Care

• Compliance against the pre hospital Stroke Bundle continues to be

monitored monthly. The stroke bundle comprises of

– FAST assessment recorded

– Blood glucose recorded

– Blood pressure recorded

– Compliance with documenting FAST test on patient care records has continued

to improve following its introduction into training and CPD sessions.


FAST Compliance – Patient Care

Records where condition code

relates to Stroke/TIA and FAST test

documented


0

10

20

30

40

50

60

70

Jan-11 Feb-11 Mar-11 Apr-11 May-11 Jun-11 Jul-11 Aug-11 Sep-11

Perc

en

tag

e

Month

Fast Test Compliance

Stroke Care

• National research has shown that early diagnosis and treatment improves

survival rates and outcomes for stroke patients.

• The Trust with Morriston and Princess of Wales Hospitals (ABMU) agreed

to undertake a pilot where ambulance crews undertook the ROSIER test for

Stroke patients prior to their arrival at A&E Departments.

• ROSIER testing enables patients to gain entry onto the Stroke pathway

more quickly. All paramedics within the region were trained in its use.

• Data for the month of September has been collected and is currently being

analysed to inform next steps


Leadership

Trust Target – To undertake 2 Executive Patient Safety Walkrounds each month in different locations and service areas.

Issues and action plans from WalkRounds presented to Patient Safety & Safeguarding Group for monitoring and to escalate unresolved issues

Recent changes following WalkRounds include improved access to cleaning materials for crews at A&E departments, improved communication between health colleagues and Patient Transport Services and a decision to move to disposable laryngoscopes.

• A Walkround calendar has been produced and is posted on the Trust

Intranet for access by all staff.

• A Walkround tracker has also been developed to monitor the progression

of the action plans.


Patient Stories

• Patient stories continue to influence service improvements and continue to

open each session of the Trust Board

• Her last journey home

• The Trust has produced a leaflet ‘What Type of Ambulance is Required’ in

conjunction with the Aneurin Bevan Local Health Board. The leaflet aims to

inform staff of the most appropriate ambulance to arrange for patients

being transported home.

• Posters to accompany the leaflets will be displayed in staff locations as well

as face-to-face presentations. These leaflets/posters will be rolled out

across the rest of the NHS over the coming months.


Patient Stories

• Dignity Matters – Linda

• Feedback has been passed to the paramedics who treated Linda when she

had a fall. To compliment the falls pathway a new patient information leaflet

‘You've had a fall’ is available and provides advice and information on

causes of falls and how to avoid injury as well as useful contact and

resource details for information and support.

• This digital story is also being used as part of a training package for

paramedics to highlight best practice in relation to patients dignity.



Patient Stories

• Concern for Dad

• A Training Directive is about to be issued to all front line staff relating to

managing laryngectomy issues.

• Sessions are also being incorporated into the Paramedic Continuing

Professional Development programme which will aim to familiarise staff

with the different types of tubes used, how to notice a problem and how to

manage this problem.

• The Trust will also strive to develop links with those working with

Laryngectomy and Tracheotomy patients so that they can be ‘flagged’ on

our control systems making them recognisable at the time of a ‘999’ call.


Utilising SBAR for Domestic

Abuse Handovers

• Routine Enquiry into Domestic Abuse was introduced into WAST in November

2010.

• The Domestic Abuse Routine Enquiry/HITS screening forms part of the patient

assessment for patients meeting the criteria where it is safe to do so.

• HITS screening is carried out by paramedics who have undertaken domestic abuse

training

• A retrospective snapshot audit has been completed that looked at a convenience

sample of Patient Clinical Records (PCRs) relating to calls attended by WAST

during January 2011.

• The aim of the audit was to assess compliance to the Policy and Guidance on

Patients and Service Users who are Experiencing Domestic Abuse

• The audit objectives were to examine compliance to the Routine Enquiry

(HITS/DA1) for all appropriate patients and to examine compliance to the recording

of situations when HITS/DA1 enquiry was not appropriate

•



Abuse Handovers

• Findings

• 1.6% (40/2478) of the PCRs sampled complied with the audit criteria of having a HITS

assessment recorded or HITS correctly recorded as ‘not appropriate’.

• In 42% (3/7) of cases where a positive HITS assessment was recorded, the patients were not

taken to a local emergency department for further treatment but it was documented that

advice had been given for the patient to contact NHSDW for a Domestic Abuse (DA2)

assessment. There was no evidence that the patients had subsequently made contact with

NHSDW for a domestic abuse assessment

• There was evidence that a patient had accessed NHSDW to request a Domestic Abuse (DA2)

assessment following advice from a WAST paramedic, but this incident fell outside the time

period for the audit.

• The audit identified one incident where a positive HITS assessment was recorded and the

nurse in the receiving unit of the emergency department was unaware of HITS assessment.

The paramedic documented that they had recommended to the patient that they contact

NHSDW for a Domestic Abuse (DA2) assessment.

• As there was no reference to a HITS assessment in 98.4% (2438/2478) of PCRs it can only

be concluded that Routine Enquiry was not considered for these patients.



Abuse Handovers

• Next Steps

• Communication to be circulated to staff reminding them of the requirement to

document when HITS assessment is not appropriate to improve future reporting.

• To develop a collaborative piece of work between WAST and Hospital Emergency

Departments to review the domestic abuse pathway by looking at outcomes of

thosepatients conveyed to the Emergency Department presenting with a positive

HITS disclosure.

• Further audit of non-conveyed patients where there is evidence of Routine Enquiry

pathway having been implemented, e.g. MARAC.

• Future development of Patient Clinical Record (PCR) forms to include a printed

HITS assessment to assist with the recording of information.


Contact details

Chris Powell

Nursing Practice & Clinical Practice

Lead/1000 Lives Plus Key Contact


[email protected]

Tel: 07872415430


mailto:[email protected]

Documents

Patient Driven Care - 1000 Lives Plus