Project Title:
Safe Intra-Hospital Transfers Project
Submitted by:
Mary Edwards, Steve Hutchinson and Paul Malcolm
Context:
The Norfolk and Norwich University Hospital (NNUH) NHS Trust is a 1000 bedded acute hospital. The projects aim was to improve the safety of patients during intra-hospital transfer. The project team was comprised of a consultant intensivist, consultant radiologist , critical care outreach team nursing lead and involved working closely with ward nursing and medical staff, hospital at night team, IT department and porters.
Problem:
There was a poor understanding of the risks of transfer. Patients were being transferred between wards and departments with out adequate assessment or monitoring and insufficient escorts. This was worse at night when there were less staff available. Harm was apparent from the critical incidents reported, cardiac arrests and deaths of patients in the radiology department.
Assessment of problem and analysis of its causes:
Initially we mapped the process and information gathered to help understand the size and scope of the problem. There are approximately 2,000 intra hospital transfers each week. We studied the intra-hospital transfers in the radiology department over a 2 week period and found that there were 1348 transfers of which 60 were of cause for concern. Questionnaires for nursing staff using theoretical scenarios revealed that the problems were lack of awareness and understanding of the risks, as well as lack of availability of equipment and staff
Intervention:
A risk assessment tool (RAT) was devised, based on the wards Early Warning Score, to measure the patient’s acuity of illness. Risk categories were used to enable staff to identify monitoring and escort requirements. Educational initiatives were introduced into the routine training of all levels of staff, who received training by the Critical Care Outreach Team to increase the awareness of the risks of patients on intra-hospital transfer.
Strategy for change:
The development of the RAT was undertaken with ward nursing staff with daily ‘Plan Do Study Act’ cycles to enable the tool to evolve. It was then trialed within 10 specialist surgical wards and subsequently rolled out over a 9 month period. More monitoring facility was provided for ward staff to access. Staff found the RAT easy to use and it was adopted for use for all in-patients being transferred to theatre, which was beyond its initial remit.
Measurement of improvement:
The radiology department was identified as a key area for data collection where improvement may be measured. Radiology staff collected data on unsafe transfers and this was then peer reviewed according to contributory risk (unstable physiology, lack of monitoring or lack of escorts) see attached chart.
Effects of change:
The first change we saw was a decrease in unsafe transfers. This was related to the implementation of the RAT and showed a reduction in the number of unstable patients. We also saw a fall in the number of issues related to monitoring but this was artificially influenced when new monitoring kit was being trialed. The most challenging issue to resolve has been escorts. We have succeeded in providing a resource for the high risk transfers with site nurse practitioners and critical care outreach team nurses being able to assist. The issue regarding staffing for a lower risk, stable transfers remains a persistent problem. The RAT has however enabled the transfer of surgical patients to be rationalised and this will save on unnecessary escorting of well patients to theatres
Lessons learnt:
The initial ground work is very time consuming but key to getting buy in from those who will be involved in the change process. By working with staff and asking for their assistance refining the system helps the change be owned and accepted by them. It is important that the tool is well tested and works before you move it to a new area. Implementing a change that has to be rolled out across such a large organization can be a lengthy process, but one that is worth doing well.
Message for others:
You need to fully understand the problem and not put preconceived solutions in place. Listen to those who will be using the system you are changing as they may hold the key to its success. Involving all those involved in the patients pathway was vital (porters) and getting the systems in place to support the new change (electronic reminders when ordering the porters). You need to be patient and persistent as embedding a new change may take longer than you first expected.
16
Casebook 2012