PHYSICIAN ASSOCIATES
ROLE MODELLING
PA School at SASH By Rachel Forbes-Pyman
A powerful form of education By Dr Sarah Rafferty
P.4
P.8
PLUS: Written by healthcare professionals for healthcare professionals
• C-diff – root cause analysis and lessons learned P.3 • Improving hip fracture care P.6 • Datix trigger lists P.7 • End of life care – everyone’s responsibility? P.8
Vol.2 Issue 1 2016
Embracing innovation and culture change to transform patient care By Dr Kathy McLean Medical director NHS Improvement
O
n 16 July 2015 Health Secretary Jeremy Hunt announced our ground-breaking NHS partnership with US based Virginia Mason Institute (VMI). I am delighted to be part of this programme in which VMI is mentoring five NHS hospital trusts over five years.
In particular, SASH demonstrated that they had the full commitment of the Trust Board to adopt the new methodology, a robust learning culture and showed how they had benefitted from knowledge transfer from previous programmes of work.
Who is VMI? In 2002, Virginia Mason Medical Centre, Seattle, There was a huge amount of interest from USA, embarked on a trusts all over the country who wanted to system-wide programme part of this. Surrey and Sussex Healthcare to change the way it NHS Trust (SASH) and other trusts delivers healthcare and underwent a rigorous selection process in the process improve before being chosen patient safety to participate in the and quality. programme. The four It did so by other selected trusts are “Perhaps more adopting Barking, Havering and than ever we need principles Redbridge University of the Toyota Production Hospitals Trust; Leeds System (TPS) and to adapt, innovate Teaching Hospitals creating the Virginia and embrace Trust; University Mason Production System Hospitals Coventry and culture change to (VMPS). Their journey Warwickshire NHS of improvement was improve patient Trust and Shrewsbury accelerated by a preventable and Telford Hospitals patient death which was care.” NHS Trust. During the investigated and from which selection process all five the learning was shared trusts were required to publically. The management demonstrate a culture that is open to new and clinical workforce committed to the approaches and a willingness to change goal of this never happening again. The the status quo.
hospital committed to an approach that delivered ‘defect-free’ patient pathways, meaning that where possible clinical care was standardised and patients were pulled along care pathways in an efficient and patient focussed way. Virginia Mason subsequently had an overwhelming number of requests from other healthcare providers for staff to share their experience and knowledge in applying lean principles, and in particular VMPS, into healthcare. In response, Virginia Mason Institute Continued page 2
Comment
WELCOME TO THE JOURNAL The Journal is a clinically-led publication produced quarterly by Surrey and Sussex Healthcare NHS Trust (SASH). It is written and edited by healthcare professionals for healthcare professionals. It aims to improve interprofessional engagement, collaborative practice and knowledge-sharing across the Trust, whilst helping to embed a culture of continual learning and quality improvement. Editorial Board Editor Maxine May Tel: 01737 768511 x 2633 maxine.may@sash.nhs.uk Medical director Dr Des Holden
An exciting challenge: the right challange
O
ur lead article this issue describes why the NHS has partnered with Virginia Mason. We have chosen three ‘value streams’ to begin with: getting cardiology patients into cardiology beds more quickly; improving outpatient booking and the identification and management of patients with diarrhoea. Whilst these areas will affect several teams, over the five year partnership most areas of care will experience SASH + for themselves. The challenge we face is to continually improve efficiency of patient care as demand continues to increase faster than finances can support. I do not believe that the NHS will survive by trying to do more of the same, ever more efficiently. The paper written by Simon Stevens, CEO of NHS England (Five Year Forward View)
acknowledges this and describes and encourages all who work in the NHS to find ways, through partnership, workforce development and technology to improve the care for patients locally. This is not only an exciting challenge but it is the right challenge. Please get involved in one or more of the many programmes of work within the Trust that are working to improve pathways for patients and please use the Ideas to Innovation portal, available through all PCs, to share your good ideas. Thank you. Dr Des Holden Medical director
des.holden@sash.nhs.uk Consultant physician Dr Natalie King natalie.king@sash.nhs.uk Consultant oncoplastic breast surgeon Miss Shamaela Waheed shamaela.waheed@sash.nhs.uk Head of library services and knowledge management Rachel Cooke rachel.cooke@sash.nhs.uk Guest editor Core medical trainee Dr Priya Patel priya.patel14@nhs.net
Continued from page 1
was created. VMI is a not for profit arm of Virginia Mason and they now provide education and training to healthcare providers all over the world in adopting lean methodology. Lean in healthcare is all about putting the patient first and eliminating waste, ensuring that the right services are delivered to the right people at the right time. 2
TheJournal@sash.nhs.uk
How does the NHS Partnership with Virginia Mason Institute work? The Transformation Programme is designed to transfer this international learning into the NHS for the benefit of each hospital involved, and it is the vision over time, to spread the learning to the wider health system. This is more than a series of projects; it is about introducing a management system to build trusts’ capability and capacity to drive transformation through systematic cultural and organisational change. The programme involves intensive support with a range of coaching and mentoring for leaders and staff across each trust, coupled with formal training and certification in lean methodology to build capacity and sustainability. Fundamentally, the programme will be owned by each trust board and will be clinically and operationally led, while supporting front line staff to solve the challenges they encounter each day. This local ownership is important and I know that for the Trust this is about developing the SASH + way. I went to Seattle to see both the hospital and the Virginia Mason Institute first hand. I was impressed by the commitment to standardisation, safety and their patient first ethos. These will be key elements of the programme for SASH too.
The Journal Vol.2 Issue 1 2016
Looking forward SASH’s guiding team visited Seattle in the autumn of last year, and I know they returned full of ideas and enthusiasm about the potential to make improvements for patients. This is a long journey, it is not about quick fixes and over the next period there will, I’m sure, be a huge amount of activity in the Trust to engage staff along the way. The first Rapid Process Improvement Workshop in cardiology was, I hear, really impressive. As SASH - and indeed all the five trusts take their first steps on this transformation programme I am genuinely excited to see how they progress. I will continue to play my part in supporting that working closely with Des Holden and others in the team. Good luck.
Under the spotlight…
Clostridium difficile: Trust-apportioned cases
Root cause analysis (RCA) and lessons learned (1 April 2015 - 29 February 2016) Figure 2. Management of diarrhoea - SAS campaign
By Ashley Flores
Nurse consultant infection prevention and control
A
s per the Department of Health (2015) objectives for Clostridium difficile infection (CDI)1, the Trust objective is to have not more than 15 Trustapportioned cases during the financial year 2015/16. The same number applies to 2016/17. The contractual sanction that can be applied to each CDI case in excess of the objective is £10,000. For each case of Trust-apportioned CDI an RCA investigation is carried out. Following this, the co-ordinating commissioner will use their discretion to assess whether each CDI case will count towards the aggregate number of cases on the basis of whether there have been any ‘lapses in care.’ A ‘lapse in care’ is defined as evidence that policies and procedures were not followed, regardless of whether the lapse contributed to the root cause of the infection. Examples of lapses in care include: delays in stool sampling; isolation practice; antimicrobial prescribing; inadequate staffing levels; environmental cleaning and the fabric of the estate.
Brighton and Hove, Crawley, Horsham and Mid-Sussex clinical commissioning groups (CCGs) have implemented a ‘Lapse in Care Assessment Tool,’ 2 which is used to RAG rate each case: Green - no lapse identified; Amber - lapse in care identified but did not / would not alter the outcome; Red serious lapse in care identified and a different outcome could reasonably have been expected had this lapse not occurred.
In order to increase staff awareness of the importance of diarrhoea assessment, stool sampling, isolation and prompt treatment of CDI, we are running our Stop Assess Send (SAS) campaign across the Trust (above).
• awareness of treatment regime for CDI • time to isolation. Conclusion Each RCA action plan is followed up and signed off by the relevant division and lessons learned are disseminated within the division and across the Trust. Lessons are disseminated during statutory and mandatory training; at ward managers meetings; the infection control taskforce meeting and via infection control champions.
“The Trust objective is to have not more than 15 apportioned cases during the financial year 2015/16”
Up until 29 February 2016 there were 34 cases of Trustapportioned cases of CDI. So far, 30 cases have been reviewed and RAG rated by the CCGs. Outcomes of assessments: Pending: 4, Red: 2, Amber: 10, Green: 18. The main themes from the RCA investigations are as follows:
• delay to stool samples (three cases were Trust-apportioned but patients were admitted with diarrhoea, and stool sample not sent within 72 hours of admission) • multi-disciplinary review of patients with diarrhoea and documentation of this • inconsistent completion of the clinical assessment section of Bristol Stool Chart
and isolation (figure 2) • antimicrobial stewardship programme • infection prevention and control annual programme which includes hand hygiene initiatives • PII (period of increased incidents) measures instituted where two or more cases are epidemiologically linked • maintenance of isolation of patients with toxigenic strains (PCR positive and toxin positive cases) for duration of inpatient-stay (regardless of symptoms).
“Management of diarrhoea is included as part of the Virginia Mason programme and there is a work stream to address lessons learned”
Examples of initiatives in place: • algorithm for the clinical assessment of diarrhoea • increased presence of infection prevention and control nurses on the ward to facilitate review of diarrhoea and cases of Clostridium difficile • internal ‘Stop Assess Send’ (SAS) campaign to increase awareness of the importance of prompt stool assessment
Management of diarrhoea is included as part of the SASH+ improvement work and there is a dedicated work stream to address lessons learned. There is also a programme of simulation learning in development by the infection prevention and control antimicrobial stewardship team (IPCAS), due to launch this year. Details are available from the team and have been circulated to the infection control champions. Footnote: 1/ NHS England (2015) www.england.nhs.uk 2/ CCG ‘Lapse in Care Assessment Tool. Available on the infection control pages on the Intranet
TheJournal@sash.nhs.uk
The Journal Vol.2 Issue 1 2016
3
Patient-centred care
KSS SCHOOL OF PHYSICIAN ASSOCIATES By Rachel Forbes-Pyman
Physician associate and KSS PA lead
I
n recent years Surrey and Sussex Healthcare NHS Trust (SASH) has been an enthusiastic advocate for the role of the physician associate (PA). There are currently 12 PAs employed at SASH with two more starting shortly in the emergency department. This makes our Trust the largest employer of PAs in the south. We also support PA student placements in medicine; surgery; paediatrics; obstetrics and gynaecology and emergency medicine. The role of the physician associate helps to ensure continued high quality care in hospitals and facilitates more efficient working of medical teams. It also enhances continuity of care because PAs do not rotate to different departments. The reason that individual trusts decide to employ PAs vary. At SASH we have seen significant changes to the medical on call system to support an ever increasing acute medical take. This was compounded by a reduction in foundation doctors working in the Trust due to their training stipulating that they need more community and psychiatry experience. This led to there being less continuity of care at a ward level. PAs were employed to help address these changes. “The KSS
diploma in Physician Associates Studies. The course is delivered across 90 weeks, over two years and aims to draw graduates in life and health sciences. The theory elements are taught mainly by lecture, problem-based learning and small group discussion. Each student also has to undertake a minimum School of 1400 hours of clinical placements in a broad range of Physician In November 2014 Health of clinical specialties. Once Associates ... Education Kent Surrey qualified the generalist nature and Sussex (HEKSS), who will be the first of of their training allows PAs to oversee postgraduate training work interchangeably across for clinical staff in the region, its kind in different specialties. identified the need to train the UK.� non-doctors as part of the The KSS programme medical workforce and so will culminate in the approached SASH about their work with PAs establishment of The KSS School of and asked that we help advise on a regional Physician Associates which will be based at programme to set up physician associate SASH. The School will help to ensure that courses in the local area. During 2016 there PA students and qualified PAs have good will be three physician associate courses quality training and access to continued launching across the Kent, Surrey and Sussex professional development. The School (KSS) region at The University of Kent and will be the first of its kind in the UK. It Canterbury Christ Church University, The will also help to ensure that PAs working University of Surrey and Brighton and Sussex within Kent, Surrey and Sussex are Medical School. On qualification it is hoped meeting the standards set by the Faculty of that the large majority of these PAs will work Physician Associates at the Royal College of in the local region. Physicians, which launched in July 2015. In order to qualify as a physician associate, applicants must complete a postgraduate 4
TheJournal@sash.nhs.uk
The programme team at SASH includes Jo Piper as project manager, Dr Natalie King
The Journal Vol.2 Issue 1 2016
as head of school and Rachel Forbes-Pyman as KSS PA Lead. Michael Wilson, chief executive, is the executive sponsor for the programme. Additional consultants, PAs and other interested parties from across the region will have input into the development of the KSS School of PAs. Over the coming weeks the KSS School of PAs website will go live whilst the official launch date for the KSS School of PAs will be announced in a future publication of The Journal. If you require any information in the meantime please contact joanne.piper@sash.nhs.uk.
Clinical case
Respiratory support on the wards By Claire Rowley
Lead nurse critical care outreach team
T
he critical care outreach team often gets called to patients who are short of breath. This can be for numerous different reasons, for example, chest infection, acute pulmonary oedema and exacerbations of chronic obstructive pulmonary disease (COPD). Getting the basics right with these patients can make a massive difference to their recovery time: • Positioning the patient in an upright position will open up the chest, allowing the lungs to fully expand • Remember that nebulisers administered via a nebuliser administration box (as used on most wards) will be given via air NOT oxygen. So, if a patient is on large concentrations of oxygen then consider administering through oxygen and ensure close monitoring of the saturations • Nail varnish will affect a probe’s ability to accurately pick up a patient’s oxygen saturation, so ideally remove the varnish,
use another digit or the ear. Also, cool peripheries cause wavering oxygen saturations, so warm the fingers or use the ear lobe Timely administration of drugs is crucial in respiratory distress, whether this is antibiotics for infection, nebulisers for respiratory ease or diuretics for patients in acute pulmonary oedema. The tool used to deliver oxygen is as important as the oxygen itself. There are a number of ways to administer oxygen - nasal cannula, Venturi face masks, humidified oxygen and non rebreathe masks are most commonly used on the wards. Remember that oxygen is a drug, and therefore must be prescribed. Other forms of oxygen and flow administration come in the form of non-invasive ventilation and Optiflow*: Biphasic positive airway pressure (BiPAP) is used predominantly for type 2 respiratory failure where carbon dioxide is being retained in the blood circulation. It is delivered via a specific machine, with or without oxygen.
Continuous positive airway pressure (CPAP) is used for type 1 respiratory failure as it works by applying a small amount of positive pressure into the alveoli at the expiratory phase of breathing. *Optiflow is a relatively new form of respiratory treatment. The specialist equipment enables the flow rate and oxygen concentration to be titrated independently of each other via a warm humidified nasal cannula circuit. Remember, get the basics right and you could prevent further deterioration or even save a life. Footnote: 1/ The UK Sepsis Trust (no date): Raising Awareness of sepsis. Available at: www.sepsistrust.org.
Respiratory Case Study
She was assessed using the airways, breathing , circulation, disability and exposure (ABCDE) assessment for acutely unwell patients.
sepsis, she was catheterised for measurement of urine output. Her Early Warning Score was 11 and so increased frequency of monitoring was commenced.
S
Airways: Her airway was patent and did not need immediate support.
Disability: She was alert but confused with indicators of an acute delirium but had no focal neurology (GCS 14) and her blood glucose was normal.
(Situation): Called urgently
to see a 74 year old lady with respiratory distress.
B
(Background): The patient
has COPD and has been admitted with a probable chest infection.
A(Assessment):
She is tachypnoeic with low oxygen saturations and is using all of her accessory muscles.
R(Recommendation): She requires immediate assessment.
Breathing: She was tachypnoeic with a respiratory rate of 30. Her oxygen saturations were low at 74% despite four litres of oxygen delivered via her nasal cannula. On this basis her oxygen was switched to 40% humidified and her saturations rose to 87% (aiming for 88-92%). She was using her accessory muscles to breathe and an arterial blood gas sample was taken. This showed that she was retaining carbon dioxide (type 2 respiratory failure). She was given nebulised salbutamol and ipatroprium to help open her airways and a chest x-ray was ordered. Circulation: She was febrile with a temperature of 38 degrees and was treated using the Sepsis Six method1 which included a full set of bloods, blood cultures and a lactate measurement and administration of fluids and antibiotics. Given the indicators for
Exposure: Further examination did not reveal any further abnormalities. Subsequently as her type two respiratory failure did not respond to nebulised bronchodilators she was commenced on noninvasive ventilation using BiPAP to which she responded well. She continued to improve and was able to come off of respiratory support and be discharged home a week later. Using the correct method of assessment and responding to abnormal physiology helped to detect an acutely deteriorating patient. Application of the correct oxygen and delivery system ensured this lady’s respiratory system was supported whilst the medical treatment could take effect.
TheJournal@sash.nhs.uk
The Journal Vol.2 Issue 1 2016
5
C linical effectiveness Audit R esearch & development E ducation & training
Improving hip fracture care By Dr Iain Wilkinson
Lead consultant for orthogeriatrics
T
he care of patients following a hip fracture has changed greatly over the last ten or so years. Much of this change was started by the publication of the Blue Book1 (a joint publication between the British Orthopaedic Association and the British Geriatric Society). This set out the expected standards of care for hip fracture care and paved the way for the development of the National Hip Fracture Database (NHFD) and the ‘best practice tariff ’. These two initiatives have driven forward the standard of care of all patients with hip fractures. The Kent Surrey and Sussex (KSS) Academic Health Science Network (AHSN) has recently started a programme
working with hip fracture units around the Kent Surrey and Sussex region to drive further improvements in care. The AHSN’s programme uses the principles of other successful quality improvement programs (in Enhanced Recovery Programs for example) to set and measure recordable data which reflects good care standards (e.g. time to analgesia). The data sets are evidencedbased and have been debated and agreed at a series of collaborative events attended by the orthogeriatric units in KSS. Data collection will start shortly and will be assimilated in the current NHFD web collection tool which each unit is using already. Data will be analysed on a regular basis and then collated and sent back to trusts to allow us to view our own performance and adapt our
practice. Importantly though, we can also compare ourselves against other units and use this as a basis of identifying and then spreading good clinical practice throughout the region. The opportunity to be part of this process is exciting but also poses challenges for us at SASH. In the future we will need to adapt our current methods of care and the data collection will aid us to identify where and how. Using data in this way - with appropriate, evidenced-based measures of quality care, will help us to remove any variation in practice with the result that we ensure excellent quality care to every patient every time. Footnote: 1/ BGS/BOA (2007) The Care of Patients with Fragility Fractures.
CONSIDERING VITAMIN D DEFICIENCY IN AT-RISK PATIENTS By Dr Kate Brockett Junior doctor
A
s junior doctors working in the care of the elderly department we were aware that many of the patients had presented following a fall. During admission and hospital stay any underlying causes that could be identified were sought and addressed. One risk factor that seemed to get less attention however was vitamin D status, yet it is known that low levels increase the risk of bony injury following a fall and are thought to also increase likelihood of falling1,2.
On the basis of this we decided to look at the number of patients over 75 years of age admitted to East Surrey Hospital 6
TheJournal@sash.nhs.uk
Dr James Dusting Junior doctor
following a fall who had vitamin D levels checked. We found that during March 2015 just 12% of these patients were tested and of these 67% were found to be deficient. This prompted us to display screensavers as well as posters in clinical areas to raise awareness of the need for more consideration and intervention. On re-audit in May 2015 there was a modest increase in testing rates from 12% to 15% of over 75s presenting post-fall. Of those 15% tested on re-audit there was again a high vitamin D deficiency rate of 63%. How to address this is open to discussion, with some preferring testing first and others blanket treatment.
The Journal Vol.2 Issue 1 2016
NICE guidance suggests vitamin D supplementation for at risk groups with discretionary testing reserved for those presenting with symptoms following falls or those deemed at particularly high risk3. Whichever way, either through testing, treating or both, an increased level of intervention would appear worthwhile. *Sadly James died on 27 August 2015, shortly after writing this article. He is missed by his colleagues. Footnote: 1/ NICE (2013) Guideline CG161, ‘Assessment and prevention of falls in older people’ 2/ McCarroll, K.G et al. (2012) Vitamin D and orthostatic hypotension, Age and Ageing, 41 (1), pp.810-813. 3/ NICE (2014) Guideline PH56, ‘Vitamin D: increasing supplement use among at-risk groups’.
Patient safety
MRI referrals: Increased vigilance needed for patients with pacemakers By June Millams
MRI superintendent radiographer
I
n a busy hospital it can be hard to ensure all aspects of care are met and sometimes simple things such as requesting a scan, when not done with the greatest of attention, can have significant consequences for patients. Recently, five patients were referred for MRI scans with a pacemaker in place. Most, if not all doctors, will know pacemakers are a contraindication for MRI scanning. This is because scanning a patient can ca use the pacemakers to malfunction and may result in unnecessary fatalities which can be prevented. To help reduce this error the safety section on the Cerner electronic referral form stops referrers requesting MRIs in patients with a pacemaker, along with other contraindicated devices. However, referrals are still coming through. Anecdotal evidence seems to point to a lack of information and communication. This leads to more than two dozen deaths being attributed to MRI scans globally which have been inadvertently carried out on patients with pacemakers1-3. What appears to be needed
is education of referring clinicians to the contraindications to MRI and MRI safety in general4. The most publicised case in the UK involved a patient called Molly Brown in 2004. At an inquest the medical staff treating her were criticised for their ‘elementary error’ in not declaring the presence of her pacemaker that was identified within her medical notes. Simple checks could have also alerted the medical team to Mrs Brown’s condition4. Mrs Brown herself denied the presence of her pacemaker when radiographers administered the safety questionnaire with her and individually were found not at fault. This could become a growing theme with an aging population and with dementia on the increase, this scenario could so easily happen again. As clinicians we must be ever vigilant to identify those with pacemakers and recognise this is a contraindication to MRI scanning. Although there are now MRI compatible pacemakers, we are not in a position to scan these presently and their presence still needs to be identified by referrers as these devices are still not MRI safe. They require scanning under ‘very specific, manufacturer determined scanning conditions’ and the pacemaker itself requires pre-programming into MRI Mode by cardiac technicians prior to scanning.
DATIX TRIGGER LISTS By Dr Anna Riccoboni Consultant anaesthetist
A
patient safety incident is any unintended, unexpected healthcare related event which could have or did cause harm to patients. It is reported that 5% of hospital inpatients will be unintentionally harmed by a preventable event.1 In 2012/13, such events cost the NHS an estimated £3.3 billion in additional hospital stay and negligence claims.2 The Francis Report (2013) stated: “Reporting of incidents of concern relevant to patient safety, compliance with fundamental standards or some higher requirement of the employer needs to be not only encouraged but insisted upon.” We have an obligation to minimise the risk of causing harm to patients by creating a safety culture which supports and encourages staff to identify, report, investigate, learn, take action and make appropriate changes to reduce the risk of harm and recurrence of incidents. A patient safety incident report from the National Reporting Learning Systems (NRLS) conducted in 2013 (April to September), demonstrated that we, at SASH, were the fourth lowest in terms of comparative reporting rate per 100 admissions, across 46 medium acute organisations.
Dr L. Suntharanathan and Dr Robert Adams Junior doctors An audit was conducted in theatres in October 2014 which actively sought the occurrence of incidents. A theatre education session was implemented and re-auditing over a three week timeframe showed incident reporting figures increased. This may well be a coincidence or because we have increased awareness but one which should not be ignored. Further work is being carried out focussing on supporting staff to report incidents in theatres, including the introduction of a generic trust-wide trigger list which can act as a prompt for incident reporting and the institution of speciality specific trigger lists. Footnote: 1/ Vincent, C., Neale, G., Woloshynowych, M. (2001) ‘Adverse events in British hospitals: preliminary retrospective record review’, British Medical Journal, 322, pp.517-519. 2/ Frontier Economics (2014) Exploring the cost of unsafe care in the NHS. Available at: www.frontier-economics.com.
Fatalities could still occur if this is not done and thus referrers will still need to identify their presence. Footnote: 1/ MRI on patients with the Medtronic Revo™ MRI Surescan® Pacemaker: Medtronic Product information. 2/ Irnich, W., Irnich, B., Bartsch, C., Stertmann,W.A., Gufler, H., Weiler, G.(2005) ‘Do we need pacemakers resistant to magnetic resonance imaging?’ Europace, 7, pp.353–365. 3/ Medicines and Healthcare Products Regulatory Agency (MHRA) (2014), Safety Guidelines for Magnetic Resonance equipment in Clinical Use. 4/ Patient killed by heart blunder (2015) Available at: www.thetimes.co.uk
Trigger list for incident reporting in gynaecology Clinical incidents: • damage to structures (e.g. ureter/bowel/ bladder) • delayed or missed diagnosis (e.g. ectopic pregnancy) • anaesthetic complications • VTE • failed procedures (e.g. TOP/sterilisation) • unplanned ITU admission • omission of planned procedures (e.g. failure to insert IUCD at time of hysteroscopy) • unexpected operative blood loss >500ml • moderate/severe ovarian hyperstimulation • procedure performed without consent • unplanned return to theatre • unplanned return to hospital within 30 days Organisational incidents: • delay following call for assistance • faulty equipment • conflict over case management • potential service user complaint • medication error • retained swab or instrument • violation of local protocol
TheJournal@sash.nhs.uk
The Journal Vol.2 Issue 1 2016
7
Reflective practice
End of life care is everyone’s responsibility By Elaine Edwards
Macmillan lead nurse for palliative and end of life care
E
ver since I was a student nurse I have had an interest in end of life care. The first death that I ever encountered was that of my Nana when I was 15 years old. She was in her eighties and her quality of life was becoming gradually poorer. I remember visiting her in in a geriatric hospital, where she looked a shadow of her former self. I can still remember being fearful of the environment; the smell, the other elderly patients calling out and my Nana being very confused. It felt so sad seeing my lovely Nana this way. It was only a little while after this visit that we received the call to say she had died. Dame Cicely Saunders was right when she said: “How people die remains in the memory of those who live on”, as even now these memories remain with me. It remains a sad fact that some people will come into hospital and never leave and
it may not even have crossed their minds that this is how their life would end. Francis Bacon, British statesman and philosopher, said: “It is as natural to die as to be born”. Sometimes I think we as a society forget that. More people are leaving hospital for other care settings for end of life care, but still approximately 48% of deaths occur in acute hospitals in England1. We only get one chance to get it right and for that 48% I am passionate about getting end of life care right here at SASH. I feel it is a great privilege for any healthcare professional (HCP) to be able to care for people at the end of their lives. The palliative care team has been working towards creating guidance for all HCPs to assess and provide holistic care for people at the end of their lives and have recently launched the new end of life care plan*. Many people ask me how I can do the job I do and that it must be difficult and sad, especially when you are caring for someone young. Whilst I can’t change the fact that their death may be inevitable, I can help in some way by making the
experience easier and slightly more bearable; wanting to help them drives me to do this work. Anyone dying is sad and age doesn’t really play a part in the sadness of death. Some younger people are much more accepting of death than someone older and want to make the most of whatever time they have left. I remember one lady who was 101 years of age, who told me on no account did she want to go in a side room as she would know then that she was dying. She told me she had a lot of living yet to do. Just because someone gets to a certain age that doesn’t mean that they are ready to die or not grieving for the life they had or will leave behind. As healthcare professionals we need to be mindful of this and acknowledge that facing death is a unique experience for each and every person. Footnote: 1/ Public Health England (2015) National End of Life Care Intelligence Network *The end of life care plan is available on the Intranet.
ROLE MODELLING: A POWERFUL FORM OF EDUCATION By Dr Sarah Rafferty Chief of education and consultant anaesthetist
“
W
e must acknowledge . . . that the most important, indeed the only, thing we have to offer our students is ourselves. Everything else they can read in a book” – D.C Tosteson. Most of us look to our more experienced colleagues when learning how to behave as we start our professional careers. We notice a gentle word, a passion for getting it right, a stance against poor care. Organisational culture is created by individuals and the way that they behave and it is a powerful tool for teaching clinical practice. Colleagues become our role models, our examples of the values and behaviours that belong in our workplace. This is a powerful form of education and much of it we copy in an unconscious way. 8
TheJournal@sash.nhs.uk
Sylvia Cruess, a professor of medicine from McGill University in Canada, described role-modelling in a 2008 British Medical Journal paper1 as a powerful mix of conscious and unconscious activity, requiring both observation and reflection. It works most effectively when we observe a behaviour, think about it actively, apply it to our own practice, think about it again and adopt it as our own. If we have a mentor or tutor supporting us through this process it becomes more effective but even if we unconsciously observe ‘good’ or ‘bad’ behaviour it still impacts upon us. This means that, if we recognise that our colleagues learn from us, any aspect of how we act may be unconsciously copied. It is not necessary to be a senior member of an organisation to be a role model, although we naturally expect that seniors will display appropriate values and behaviours. One of my
The Journal Vol.2 Issue 1 2016
key role models when I started here at SASH was a newly qualified nurse in theatres who seemed determined constantly to do exactly the right thing for each patient in a calm unfussy way. That behaviour had an impact on the whole team and we all ‘upped our game’. When actively teaching, giving learners time to discuss the best approaches to their clinical work will make role model based learning more effective. Ask what they have observed and why it struck them as important, how it might relate to their own work? We improve our own role modelling by being aware of the impact of what we are modelling, demonstrating clinical excellence and by discussing the values and behaviours that we aspire to at SASH. Footnote: 1/ Cruess, S. (2008) ‘Role modelling—making the most of a powerful teaching strategy’, British Medical Journal, 336, pp. 718-721.
Collaborative practice CASE STUDY: Mrs M, an 85 year old lady, was brought to the emergency department by ambulance following a fall at home in which she sustained a fractured wrist. Previously Mrs M was very independent, living alone and managing all of her activities of daily living. She was jointly assessed in the ED by an occupational therapist and physiotherapist.
SASH AND THE BRITISH RED CROSS By Anna Candler
Lead emergency department occupational therapist
By Helen Gallon
Lead emergency department physiotherapist
T
he emergency department (ED) therapy team (occupational therapists and physiotherapists) provides a responsive, extended hours, seven day service supported by dieticians and speech and language therapists. The team receives an average of 191 referrals per month and the average age of patients referred is 83 years old. Seventy percent of the referrals made are for patients who have fallen.
By Michelle Lawson British Red Cross service co-ordinator
adapt in order to provide high quality care1. The ED therapy team was keen to address issues proactively, helping to create a sustainable healthcare system for the future. The team recognised that patients had needs beyond which the current statutory services could provide. Therefore, in 2015 it began developing a collaborative working relationship with the British Red Cross - a voluntary sector agency that helps vulnerable people in crisis.
The role of the ED therapy team is to: • provide rapid, patient-centred assessment and treatment • work in partnership with multiprofessional and multiagency teams to organise appropriate care and rehabilitation • facilitate and co-ordinate safe and timely discharges avoiding un-necessary admissions • reduce re-attendances
The team is co-located at SASH and provides a seven day service entitled ‘support at home’. The scheme is delivered by fully trained volunteers under the management of a service co-ordinator. It is a free service which is available to all adults living in the Surrey county area. It offers flexible, individualised, short-term (up to six weeks) practical and emotional support for patients who are referred with the aim of maximising their independence and quality of life.
With the NHS facing the biggest challenges in its history, it must
Footnote: 1/ NHS Five Year forward review (2014)
The therapy team prescribed mobility aids and assistive equipment and advised Mrs M on ways to manage her activities of daily living safely so that she could remain as independent as possible. Mrs M was very keen to return home, however, she was anxious as to how she would manage as her family lived 200 miles away. Consequently, a referral was made to the social care team to arrange a package of care to support her with washing and dressing and meal preparation at home. A second referral was made to the British Red Cross which: • provided clothes from their supply store as her own clothes had been cut off in order to receive emergency treatment • took her assistive equipment home and set it up • met Mrs M at home and helped her settle in • offered short term, practical support to do her shopping, assisted with basic domestic tasks and escorted her to fracture clinic appointments • provided ongoing emotional support to rebuild Mrs M’s confidence in her home environment With this support in place, Mrs M felt confident to return home and regain her independence. This is just one example of how the therapy team has worked collaboratively with the British Red Cross to make a positive difference to someone when they are feeling most vulnerable. As a team we understand the complex needs of our patients and strive towards providing outstanding patientcentred care whilst facilitating safe and timely discharges from the ED. Our two teams plan to continue to develop this collaborative relationship and aim to build upon and spread the benefits across the organisation.
TheJournal@sash.nhs.uk
The Journal Vol.2 Issue 1 2016
9
Case study from the Board
Clinical stories no.3
A case study about how the treatment of a patient who fell whilst in our care and later died of pneumonia, led to changes in the way we deliver care. By Dr Des Holden Medical director
The Trust Board at SASH has been commended for its prioritising of and focus on safety and quality of care, yet it is apparent many staff have no sight of the role, or interest in clinical matters, which the board has. Through The Journal we are publishing a series of cases presented at the Trust Board that have led to change.
the Trust Board is committed to reducing and the variation between hospitals can be significant. The Board looks at the number of falls that have resulted in harm on a monthly basis through its Integrated Performance scorecard and through the monthly review of serious incidents and asks for presentations whenever a theme develops.
As a result far more patients with a fractured hip are now assessed, given analgesia and rehydration quickly and have their operation carried out more quickly. The mortality for this group of patients is now consistently better than expected (as reported by Dr Foster). The Trust Board, through the Safety and Quality Committee (SQC), is now focusing on falls. Good progress has been made in reducing the number of falls with harm, particularly on Tilgate ward. However, the improvement has plateaued and we believe further improvement will need a new strategy, less focused on assessment and technology and more on human factors, staffing, leadership and learning. The SQC discussed this at its March meeting and has set this as a key quality and safety priority for 2016-17.
This sad case highlights two particular issues. The first is that fractured neck of femur is a very serious condition, affecting in particular the frailest “The Trust Board, patients we admit, and Case 3 a proportion of patients through the who suffer this fracture Safety and Quality will die. The second issue n elderly man who lived alone Committee (SQC), it highlights is that flow was admitted with patients into an acute is now focusing on of confusion and sunburn, hospital bed for treatment falls...” having been found in his and then back out of garden on the ground. hospital for continued care He was treated conservatively by being in a care or nursing home setting doesn’t The Board has a joined up strategy rehydrated and fed and with appropriate always happen as smoothly or as quickly as for improving the safety of patients. It skin care. Although he improved and was it should. This is because these pathways recognises that patients should only be judged not to require an acute hospital are complex and have to be assessed and admitted when a hospital bed is the best bed, the multidisciplinary review felt negotiated between different health and place for care. It promotes ambulatory he was not able to return to living alone social care partners. pathways and other alternatives to immediately on discharge and he was admission and getting therefore awaiting assessment from The Trust Board has taken admitted patients to the “...further social services, when during the night several presentations on right bed first time. It has improvement he fell and fractured his hip (fractured the fractured neck of femur agreed that length of stay will need a neck of femur). He was operated on service either directly or is an important factor in but developed pneumonia and despite through the Safety and bed occupancy and, where new strategy, treatment he sadly died. Quality sub-committee. extended, increases the risk less focused on Four years ago the mortality of falls. That is why it funds assessment and When a patient falls whilst in our for patients with broken the out of hospital care care, and sustains a significant injury, hips was 2.5 times higher model and challenges health technology and the incident is declared externally than it should have been. and social care partners to more on human to our commissioners, the clinical This was because patients do more to move medically fit for discharge patients commissioning groups (CCG) and were not seen fast enough, factors, staffing, to alternative facilities. investigated as a serious incident (SI). and couldn’t be admitted leadership and That is also why the Board There is a timescale for completing an to specialist trauma beds or learning.” competed for its place investigation and an action plan is needed get to the operating theatre on the Virginia Mason to put in place measures which reduce the enough. The Board oversaw programme (see page 1), chance of the incident happening again. a plan to improve each of building capability across our hospital to Considering the number of patients we these aspects. It opened extra capacity as admit and care for per year, our rate of wards and in partnership with Surrey County design standard work, reduce interventions falls and of falls where harm occurs is Council and East Surrey CCG (the integrated that do not add value to patient care and implement clinical pathways which give below the national average. Nonetheless, re-ablement unit) to allow trauma beds to be reliable high quality outcomes. this is an area of preventable harm that more effectively ring-fenced.
A
10
TheJournal@sash.nhs.uk
The Journal Vol.2 Issue 1 2016
Improving our practice
Evidence based medicine By Dr Martin Dachsel
Consultant in acute medicine
E
vidence based medicine (EBM) is now more than 20 years old. It has been one of the biggest shifts in clinical practice replacing tradition, anecdote and theoretical reasoning from basic science with evidence from high quality randomised controlled trials and observational studies, taking clinical expertise and patients’ needs and wishes into account1. One of the best known organisations in producing high quality EBM is the Cochrane Collaboration. For gathering the evidence for EBM, it is important that all trials of any particular treatment are available for appraisal. Historically, journals mainly published trials with positive findings. When not all trials are registered and negative trials are not reported, treatment may be used on patients without the knowledge of benefit and potential harm. AllTrials (www.alltrials.net) is an international initiative to ensure that all clinical trials are registered at inception and no findings are withheld from publication. In acute medicine, I use EBM on a daily basis. If I assess a patient with a community acquired pneumonia, the CURB-65 Score can aid in identifying patients who can be safely treated with oral antibiotics at home rather than being admitted. The Pulmonary Embolism Severity Score (PESI) determines a risk class for patients using 11
characteristics which were associated with mortality, subsequently identifying patients where outpatient anticoagulation is a safe option. EBM can also change the treatment of common medical conditions. At the start of my career, all patients with chest pain were treated with 15 litres of oxygen via a non-rebreath mask regardless of their oxygen saturations. A Cochrane review subsequently showed no benefit of oxygen in patients with an acute myocardial infarction, in fact oxygen might be potentially harmful2. This is thought to be caused by the paradoxical effect of oxygen reducing coronary artery flow and increasing coronary vascular resistance, which will further reduce stroke volume and cardiac output. The guidelines were changed to assess the oxygen saturation first and for patients with chronic respiratory diseases to allow lower oxygen concentrations in their blood in the case of myocardial infarction. Another example is the treatment of acute fluid resuscitation with starch solutions (HES). A systematic review and metaanalysis from 2013 showed an association of patients treated with HES and an increase in mortality3. In fact, none of the patients were helped; 1 in 44 patients developed renal failure needing renal replacement therapy and 1 in 69 patients died. Starch solutions were subsequently removed from the hospital formulary. In summary, EBM has been a major change in the landscape of medicine and will continue to improve outcomes and save lives.
Selected web resources for evidence based medicine: AllTrials (www.alltrials.net): campaign for all trials to be registered. Cochrane (www.cochrane.org): high quality producing non-profit, non-governmental organisation. The NNT (www.thennt.com): independent non-profit group of physicians which evaluate therapies based on their benefits and harm. Too much medicine (www.preventingoverdiagnosis.net): movement led jointly by clinicians, academics and patients, which aims to reduce harm from over-diagnosis, over-treatment and over-screening. Footnote: 1/ Greenhalgh T, Howick J. (2014) ‘Evidence based medicine: a movement in crisis?’ BMJ, 348. Available at: www.bmj.com. 2/ Cabello, J. et al. (2010) ‘Oxygen therapy for acute myocardial infarction (Review)’, The Cochrane Library. Available at www.cochrane.org. 3/ Zarychanski, R.and Abou-Setta, A.M. (2013) ‘Association of hydroxyethyl starch administration with mortality and acute kidney injury in critically ill patients requiring volume resuscitation: a systematic review and meta-analysis’, JAMA, 20, 309(7), pp.678-88. Available at: www.ncbi.nlm.nih.gov.
Contact the library team for help with using sites such as the Cochrane Collaboration or to borrow books on evidence based medicine. For details of other evidence based resources visit the library service’s website: www.surreyandsussexlibraryservices.nhs.uk/ useful-resources/online-library/
Overwhelmed by information? We can help you stay up-to-date By Rachel Cooke
Head of library services and knowledge management
The library and knowledge service subscribes to KnowledgeShare, a service that provides you with evidence updates that are personalised to your needs. KnowledgeShare identifies the latest evidence that matters and presents you with short, targeted emails that are specific to your professional interests. Users of the service are notified about new guidelines, policy documents and a
wide range of summarised evidence as it is published (no more than once a fortnight). This service is available to all Surrey and Sussex Healthcare staff (both clinical and non-clinical). All you need to do is sign up at https://www.surveymonkey.com/s/ joining-knowledgeshare, or pop into the library and complete a form. If you are not already a library user you will need to complete a library registration form as well.
“Thanks for that, you are my eyes and ears!“ Outreach nurse practitioner “Thank you very much – I find this personalised service exceptionally helpful.” Consultant paediatrician “I think you know me too well! Perfect articles.” Macmillan chemotherapy nurse
This service was developed by our library colleagues at Brighton and Sussex University Hospital. Here is some feedback from their staff concerning the service: TheJournal@sash.nhs.uk
The Journal Vol.2 Issue 1 2016
11
Publications authored by SASH staff A literature search carried out by the library team identified the following articles that have been written by SASH staff: Abou-Ltaif, S. (2015) ‘Unusual fundus autofluorescence appearance in a patient with hydroxychloroquine retinal toxicity’, Case Reports in Ophthalmology, 6(2) pp.186-190. Binks, C. and Duane, B. (2015) ‘Mother-to-child transmission of streptococcus mutans’, Evidence-based Dentistry,16 (2) pp. 39-40. Chougule, S.S, Stefanakis, G, Stefan, S.C, Rudra, S, Tselentakis, G.(2015) ‘Effects of fat pad excision on length of the patellar tendon after total knee replacement’, Journal of Orthopaedics,12 (4) pp.197-204. Ferrier, V. and Sage, F. (2015) ‘Developing a local teaching programme on sono-anatomy for anaesthetic trainees’, Regional Anesthesia and Pain Medicine, 40(5) SUPPL.1, e107-e108. Flett, A.S., Maestrini, V., Milliken, D., Fontana, M., Treibel, T. A., Harb, R., Sado, D. M., Quarta, G., Herrey, A., Sneddon, J., Elliott, P., McKenna, W., Moon, J, C. (2015) ‘Diagnosis of apical hypertrophic cardiomyopathy: T-wave inversion and relative but not absolute apical left ventricular hypertrophy’, International Journal of Cardiology,183, pp.143-148. Grime, C. J., Greenaway, C., Clarke, S., Balfour-Lynn, I, M. (2015) ‘Critical timing of gastrostomy insertion in a child with cystic fibrosis’, Paediatric Respiratory Reviews,16 Suppl 1, pp.19-21. Melville, J., Ranjan, S., Morgan, P. (2015) ‘ICU mortality rates in patients with sepsis before and after the Surviving Sepsis Campaign’, Critical Care, 19 (S5). Powell, N., Bruce, C.G., Redfern, O. (2015) ‘Teaching a ‘good’ ward round’, Clinical Medicine, 15(2) pp. 135138. Sakathevan D, Banerjee P. (2015) ‘Multiple long bones peri-prosthetic fractures in an elderly patient. The challenge of biological bone failure - a case report’, Journal of Orthopaedics, 12 pp. S137-S139. If you have written an article, book or chapter of a book then please contact rachel.cooke@sash.nhs.uk to ensure your publication is included in the next issue of The Journal. All articles can be accessed via the library team at Crawley or East Surrey Hospitals. Published by: Surrey and Sussex Healthcare NHS Trust, Redhill, Surrey, RH1 5RH www.surreyandsussex.nhs.uk Available in different formats, including large type, upon request. We welcome your feedback. Complete our online survey by scanning the QR code above, or visit https://www.surveymonkey.com/s/the_journal
12
TheJournal@sash.nhs.uk
Achievements and professional recognition Congratulations to… …Dr Iain Wilkinson, lead consultant for orthogeriatrics, whose poster entitled ‘Threshold Concepts’ has won the Fergus Anderson prize for the best scientific poster presentation at the British Geriatric Society (BGS) meeting 2015. His work on educational threshold in geriatric medicine looks at the changes in perception of self (ontological shift) in the process of learning. Identification of these key concepts that drive this in geriatric medicine allows them to be taught to other people who look after older patients. … Dr Iain Wilkinson and Dr Jo Preston SpR have been awarded a HEKSS grant to produce podcasts about issues pertaining to older people. Working with a faculty drawn from across Kent, Surrey and Sussex, the MDTea (Education on Ageing) is a series of 20 podcasts coming out every two weeks. In each episode the MDTea will present a topic relevant to daily clinical practice and the perspectives of the whole MDT. The podcasts will be professionally produced and will be available on itunes/stitcher or alternatively at www.thehearingaidpodcasts.org.uk/ mdtea. …Helen Gallon, team leader physiotherapy and Anna Candler team lead ED occupational therapist who had their poster on the work of the emergency department therapy team displayed at the NHS England event Implementing the Urgent and Emergency Care Vision in London. Helen was also recently awarded a NHS Leadership Academy award in Healthcare Leadership and an accredited Pg Cert with distinction.
…Stuart Hicks (right), trauma CNS and Alan James, trauma lead. Their thoracic trauma guidelines developed for SASH, were commended by NHS England and the South West London and Surrey Trauma Network and have now been implemented into the major trauma centre and the six other trauma units in our network. Guidelines are available on the Intranet. …Amy Lee, lead antimicrobial pharmacist who has been awarded a Master of Science (MSc) in Infection Management (Pharmacy) by Imperial College London. … Dr Shuaib Quraishi and Dr Sarah Denny who presented a poster on simulation at the ‘Developing multi professional health educators for the future’ conference. Their work focussed on getting core medical trainees ready to be registrars by putting them through a scenario based simulation course focussing on leadership, teamwork and crisis management skills. They were successful in attracting funding from HEKSS to enable the course – which is now mandatory for all CMTs in HEKSS - to take place. ... Natalie King, consultant physician, who has been appointed as the Fellow representative on the Board of the Faculty of Physician Associates at the Royal College of Physicians. ... Maxine May, editor and communications officer who has been awarded a Master of Arts (MA) in Internal Communication Management with distinction by Kingston University. …Nathaniel Johnston, head of workforce development who has been awarded a Pg Cert in Organisational Development by the University of Southampton.
MOUTH CARE MATTERS Earlier this year staff from twelve trusts across Kent, Surrey and Sussex were invited to a workshop at SASH to learn about the Mouth Care Matters initiative. There was an excellent turn out from senior nurses, dieticians and speech and language teams. The event began with presentations from the team including powerful patient stories of the impact of poor mouth care. There were interactive sessions on mouth care recording and mouth care products followed by a session on how we can work together to successfully roll out the programme to the other trusts. There was positive feedback from delegates who attended
The Journal Vol.2 Issue 1 2016
the event and excitement at the prospect of each trust having their own Mouth Care Matters team. By Ms Mili Doshi – consultant in special care dentistry