Introducing Controlled Drugs into the EoE Adult Critical Care Transfer Service Laura Coslett- Lead Pharmacist Critical Care Cambridge University Hospitals NHS Foundation Trust (CUH)
Introduction • The East of England Adult Critical Care Transfer Service (ACCTS), hosted by CUH, serves 18 hospitals across the region, 24/7. • Operational Base in at an off-site location. • ACCTS facilitates timely transfer of critically ill adults who require urgent escalation for specialist services, as well as repatriation and load-levelling transfers • Set up in Dec 2021. Phase 1 implemented non-controlled drug medications only- including storage at base location, stock management, drug transfer bags, and safe prescribing documentation • National recommended formulary for ACCTS also includes controlled drugs (CDs) Aim of Phase 2 Implement secure controlled drug management and storage at the off-site base location and develop approved SOPs to facilitate use during transfers. All must comply with legal requirements and Trust policies, to ensure robust clinical governance.
Rationale for CDs in ACCTS For controlled drugs that belong to the referring hospital- unopened vials, or syringes filled with prepared CD medications but NOT connected to the patient must NOT be accepted by ACCTS – This would technically constitute illegal supply of controlled drugs. Additional CD infusions may be required during patient transit if longer journey time, or clinical scenario requires additional agents. Outcomes anticipated from Phase 2 → Protect ACCTS clinical staff from legal perspective → Robust audit trails for CD use within ACCTS → Optimise patient care and safety in the high-risk transfer setting
Methodology Stakeholder Engagement ‘Supporters’ • ACCTS Leads- Consultant, Nurse and Pharmacist service leads • ACCTS clinicians providing service day-to-day (end-users) (??) • Consultant pharmacist for critical care Need Agreement and buy-in from • Estates/minor works team • Security Services • Pharmacy Transformation Project Manager • Dispensary Services • Courier services Chief pharmacist- CD Accountable Officer Associate Chief Pharmacist (manages risk registers) Medicines Safety Committee
Reflections & Learning Barriers encountered Input and agreement of numerous stakeholder • Complex to collaborate and communicate • Different professions, with different needs and priorities • Different schedules of stakeholders • Clinicians running services based across region, not just CUH Onerous Process • Unavoidable- strict legal and governance requirements • Inflexible legality vs practicality of use in critical scenarios • Negotiation to agree processes and accept risks (risk registers) • Success dependent on no ambiguity • Install infrastructure and agree processes prior to implementation • Off-site base location Niche of ACCTS • Extensive explanation and rationale to non-critical care stakeholders • Complicates collaboration • ‘backwards and forwards’ of questions and drafts • Unique circumstances- distinct from critical care units and acute ambulances • Relatively new service- new working relationships
Perceived low urgency for change • Service in place since 2021 without CDs • Need and Benefits of this service development are hard to ‘sell’ • Adds to workload of end-users
Results Remains a ‘Work in Progress’ • Physical infrastructure in place • Policy remains under development. Not yet approved by CDAO/Medicines Safety/ senior pharmacists • Outstanding ‘sticking points’: • CD registers and documentation for: • Base cupboard stock • CD transfer bag stock • signing whole bags in and out at start and end of transfer • Allowance for storage in locked but unmanned ambulances Ordering and Delivery • Stock ordered via controlled drug order book to CUH inpatient pharmacy. Delivered by courier using locked-box process
CD Stock cupboard • Stock received into CD stock cupboard and signed into CD stock register
• Learning sought from transfer services in other regions, and local Paediatric Retrieval Service
Transfer of cupboard stock to CD drug transfer bag
Policy development
• Stock signed out of CD stock cupboard register • Move CD from stock cupboard to drug transfer bag
• Detailed, specific description of each aspect: • ordering, delivery, base storage, record keeping, stock checking, movement of stock, administration, destruction, audit • Draft written and circulated for comment- multiple ‘rounds’
Physical Infrastructure • • • •
Delegated to those best able to coordinate and action Installation of cupboards, keysafes, swipecard access at base CD registers for base CD cupboard and for CD transfer bags Secure storage in ambulances
CD drug transfer bag • Stock signed into CD drug transfer bag CD register • Bag sealed with a tag to show complete and checked • CD drug transfer bag stored in CD cupboard when not in use during transfer •When CD drug transfer bag required for use, whole bag signed out of bag register
CD administration • CD drug transfer bag seal broken and CD administered to patient • Any remainder destroyed in CD destruction kit and disposed of in waste for incinceration on arrival at receiving hospital and documented in patient record
CD keys stored in a key safe (PIN code access) within a CD cabinet with swipe access changing key safe PIN quarterly Key cupboard is separate to the CD cabinet in which the CDs are stored
Documentation • Record dose administered against patient name in CD drug transfer bag CD register • Document in the next row any part dose that was destroyed and not used
Restock CD drug transfer bag and re-seal
References and Acknowledgements NHS England and NHS Improvement Transfer Service Toolkits for Adult Critical Care to Support the National Transfer Services June 2021 The Faculty of Intensive Care Medicine & Intensive Care Society. Guidance On: The Transfer of the Critically Ill Adult, 2019 Cambridge University Hospitals NHS Foundation Trust Controlled drugs policy. Version 29; Approved August 2023 EoE ACCTS Leads Anne Booth, Hannah Donald. CUH Consultant Pharmacist Critical Care David Sapsford. Transformation Project Manager, Pharmacy Gail Garood.
Continuous Critical Care ElectroEncephaloGraphy Dr Lara Prisco, MD, MSc, AFRCA, AFFICM Consultant Anaesthetist and Intensivist Senior Clinical Research Fellow NIHR Doctoral Research Fellow
Background In recent years, continuous critical care EEG (CCCEEG) has become part of the internationally recognised gold standard of critical care. Apart from its main use to detect and monitor seizures [1], CCCEEG is widely used for additional indications (Tab.1)[2]. CCCEEG is the cornerstone diagnostic and prognostic test in anoxicischaemic encephalopathy post-cardiac arrest. It is also possible to use an advanced real-time software able to estimate trends and patterns in the neuronal electrical behaviour in diseases that put the brain at risk of developing strokes such as subarachnoid haemorrhage and traumatic brain injury [2]. This technique is called Quantitative EEG (QEEG, Fig.1) and can promptly trigger further investigations to identify patients at risk of stroke or intermittent seizures. CCCEEG requires dedicated hardware and software and has been implemented with different intensity and training of staffing.
Standards & Objectives CCCEEG is a well-established practice in North America and Europe and is strongly recommended in seizure and coma management in the American and European Neurocritical care guidelines [2,4]. However, in the United Kingdom CCCEEG is not a standard service, and there are only few centres where continuous EEG is offered by the Neurophysiology departments for limited indications (i.e., Status Epilepticus). We aim to develop, in phase 1 a Neuro ICU-led service, and in phase 2 the first fully staffed CCCEEG service across adult Neuro, General, and Cardiac Intensive Care Unit at Oxford University Hospitals NHS FT (Tab.2).
Progress so far In 2018 we have secured funding form the Oxford Hospital Charity for 2 acquisition machines (Fig. 2) and one review machine. In October 2019, we have recorded our first Neuro ICU-led CEEG on Neurocritical Care at OUH.
Figure 3. Studies showing recommended length of CEEG recording in comatose and non-comatose ICU patients.
Recordings Characteristics There is no exact definition of how long CEEG should be recorded for, however, based on Fig.3 studies above, we have proposed the following durations of CEEG: • Medium-/long-term EEG (4-12 hours) with NICU Consultant reporting based on case-by-case discussion (indication B and C à target >100 patients/year). • Semi-continuous EEG (<4 hours) with neurophysiology consultant reporting based on case-by-case discussion (indication A à target >25 patients/year). • Continuous EEG to monitor the level of sedation to avoid over-dosage of anaesthesia (indication D à target >200 patients/year). • Neurocritical Care Research Group for NICU-related project (only if equipment free and NOT used for clinical purposes).
Table 1. Clinical Indications and target population with estimated sample sizes, implementation required, and patients & projected healthcare benefits. Indication A.
Target population
Detection of seizures and early treatment and monitoring of status
Technique Implementation
Acute admission with diagnosis of seizures and/or status epilepticus (>25 patients/year).
epilepticus
A.
Diagnosis of ischaemia
Acute admission with subarachnoid haemorrhage, stroke and traumatic brain injury at risk of ischaemic secondary brain injury (>50
Acute admission with devastating subarachnoid haemorrhage, stroke, traumatic brain injury, anoxic-ischaemic encephalopathy, or persistent
Prognostication
QEEG with seizure detection algorithm QEEG with ischaemia detection algorithm. QEEG frequency-based trends. QEEG asymmetry trends (amplitude-based trends).
patients/year).
A.
Raw continuous EEG.
Raw EEG, reactivity.
coma >48 hours after sedation lifting (>50 patients/year). A.
Monitoring depth of sedation/anaesthesia
New Intervention
Adjustment of anaesthetic/ antiepileptic dose in real-time and 24/7.
QEEG trend for burstsuppression ration. QEEG frequency-based trends.
patients/year).
Reduction of cumulative dose of anaesthesia. Reduction of days on mechanical ventilation. Reduction of NICU length of stay of >30%.
Trials of increased cerebral perfusion pressure.
Earlier detection of ischaemic complications (strokes) and prompt treatment (if possible).
Transcranial doppler and/or CT/CTP brain. Structured approach to prognostication. Earlier information available to clinicians to support ancillary tests (transcranial doppler, brain scans, evoked potentials, blood biomarkers, neuroimaging).
Acute admission with acute neurological or neurosurgical disease requiring mechanical ventilation and sedation/anaesthesia (>200
Patients & Healthcare Benefit Reduction in cumulative brain damage and long term sequalae of undiagnosed ongoing seizures.
Titration/adjustment of anaesthetic dose in real time and 24/7 based on individual patient's EEG.
Structured and better informed clinical decision-making process of withdrawal of life-support.
Reduction of cumulative dose of anaesthesia. Reduction of days on mechanical ventilation. Reduction of NICU length of stay.
Guideline-based Quality Measures
Figure 1. Example of QEEG and corresponding raw EEGs showing seizures.
Figure 2. Type of ICU acquisition machine.
Table 3. Staffing models, from the least resource-dependent (mixed-staffed) to the optimal model (24/7 Neuro-telemetry). Mixed staffing model Initiation
Maintenance
Review
Available NPT (business hours) ICU staff in emergent situations By trained ICU staff with NPTs assistance during business hours
Monitoring of QEEG trends by trained ICU staff Delayed review by NP
Reporting
Data management responsibility
Written report at end of monitoring In selected cases, more often verbal reports (business hours) Member(s) of ICU staff
Transitional model
24/7 Neuro-telemetry
NPT (business hours) ICU staff in emergent situations (out-of-hours)
NPT
NPT during business-hours Trained ICU staff/on-call NPT (out-of-hours)
NPT
Real-time review by NPTs and report of important events to NP NPT, with reporting of (business hours) important events to on-call NP Out-of-hours monitoring of QEEG trends by trained ICU staff Verbal reports to clinical team when important EEG changes occur (business hours) Written report at end of monitoring NPTs
1. Patients with GCSE who remain in coma should have urgent EEG applied and interpreted to monitor for NCS/NCSE and treatment response 2. Patients with acute supratentorial brain injury and AMS, and patients with coma 72 hours after cardiac arrest should have urgent EEG applied and interpreted to monitor for NCS (after confounders are excluded) 3. Patients who have unexplained coma and in whom no acute brain injury was found after thorough investigation should have urgent EEG applied and interpreted to monitor for NCS 4. Patients with seizure high-risk pattern identified on interictal EEG should have CCEEG applied to monitor for NCS 5. Patients who have severe aneurysmal SAH and are sedated or in coma (with unreliable neurological assessment) should have urgent QEEG applied and interpreted to monitor for delayed cerebral ischemia in the high-risk period of vasospasm 6. Patients requiring intravenous sedation or pharmacologically induced coma may benefit from CEEG monitoring to optimize seizure suppression, burst suppression, or complete suppression while avoiding oversedation, hemodynamic complications, and other adverse effects 7. Critically ill patients with episodic stereotypical movements or other clinical events of unclear explanation that raise concern for seizures should have CCEEG applied for clarification of the nature of these events 8. Patients with high-risk for seizures and with pharmacological paralysis (for ex: hypothermia, extra-corporeal membrane oxygenation) should have CCEEG applied to monitor for seizures Figure 4. Project/Service Improvement Timeline.
Verbal reports to clinical team when important EEG changes occur Minimum daily written report NPTs
Legend: NPTs – neurophysiology technologist(s); NP – neurophysiologist.
Future Milestones Due to COVID-19 leave the project remained in phase 1 (ICU-led service) from 2020 until now. We aim to submit a business case and discuss with the NHS Buckinghamshire, Oxfordshire, and Berkshire West Integrated Care System the possibility to fund a fully staffed service with join Critical Care & Neurophysiology leadership to optimize technique, reporting, ensure safe governance, and enhance sustainability of the service in the long-term (24/7 Neuro-telemetry, Tab.3). A joint business case with the Paediatric ICU, who recently obtained a charity grant for equipment, will be submitted to the Trust Management Board in 2024 (Fig.3).
References 1) Prisco L et al. A pragmatic approach to intravenous anaesthetics and electroencephalographic endpoints for the treatment of refractory and super-refractory status epilepticus in critical care. Seizure 2020 Feb:75:153-164. 2) Herman S et al. Consensus Statement on Continuous EEG in Critically Ill Adults and Children, Part I: Indications. J Clin Neurophysiol 2015;32: 87–95 3) Herman S et al. Consensus Statement on Continuous EEG in Critically Ill Adults and Children, Part II: Personnel, Technical Specifications and Clinical Practice. J Clin Neurophysiol. 2015 Apr; 32(2): 96–108. 4) Claassen J et al. Recommendations on the use of EEG monitoring in critically ill patients: consensus statement from the neurointensive care section of the ESICM. Intensive Care Med 2013 Aug;39(8):1337-51
Implementing the Q-NRG, Indirect Calorimeter, in the Department of Critical Care, Queen Alexandra Hospital Portsmouth Sarah Gavin Lead Critical Care Dietitian
Introduction • Indirect calorimetry is the gold standard method of calculating energy expenditure in critically ill patients (Duan 2021, Crit Care). • It is ~30% more accurate than the best validated estimation equation (Frankenfield 2009, JPEN). • Funding was awarded for a Q-NRG indirect calorimeter in the Department of Critical Care, Queen Alexandra Hospital (DCCQ) in September 2022. • The calorimeter became operational in July 2023, following a delay in installation due to supply shortages.
Aim To embed the Q-NRG into daily practice and for it’s use to be initiated by the bedside nurse.
Methodology • As a scoping exercise, I spoke with several dietitians in other trusts, who were already in possession of a Q-NRG indirect calorimeter. • I gathered information about their experiences with it’s use and implementation. Consensus was gained from stakeholders (including DCCQ matrons, consultants and critical care nursing staff) that it would add patient benefit.
Reflections • Dietitian led use of the Q-NRG has the potential to limit the impact of the machine due under resourcing of the post. • However, building my expertise and confidence, defining patient groups most likely to benefit, troubleshooting and refining inclusion/exclusion criteria are required below rolling out to wider team. • Implementation and interpretation has been more complex than expected. • Although it is gold standard in research, it is new in clinical practice. • There is limited peer support with this new technology locally, nationally or internationally and no well-established pathways. • Nurse led Q-NRG will require more training and potentially more machines. This will be phase two of the project. • The training staff received was very useful to increase interest and understanding. • My experiences so far using the Q-NRG have been met with enthusiasm, engagement and interest from both doctors and nurses in DCCQ.
• A protocol was developed and ratified. • I arranged several training sessions on the Q-NRG for staff on the unit. • Before installation I had the opportunity to attend an educational session with a team who were very experienced with indirect calorimetry in Brussels (Belgium). • It became clear that successful implementation would require a longer timescale and be divided into two phases.
Conclusions • The first phase of implementing the Q-NRG indirect calorimeter has so far been successful in DCCQ. • It is now dietitian led rather than nurse led. • Future projects will include nurse led indirect calorimetry. • I am currently collecting data from the tests to measure outcomes for our patients. References: Duan, JY., Zheng, WH., Zhou, H. et al. Energy delivery guided by indirect calorimetry in critically ill patients: a systematic review and meta-analysis. Crit Care 25, 88 (2021). https://doi.org/10.1186/s13054-021-03508-6, Frankenfield DC, Coleman A, Alam S, Cooney RN. Analysis of estimation methods for resting metabolic rate in critically ill adults. JPEN J Parenter Enteral Nutr. 2009 Jan-Feb;33(1):27-36. doi: 10.1177/0148607108322399. Epub 2008 Nov 14. PMID: 19011147.
Building a research culture in our ICU Dr Hywel Garrard Intensive Care Department, Stepping Hill Hospital, Stockport
Introduction During the Covid-19 pandemic, Stepping Hill Hospital engaged in 2 significant trials in critical care; REMAP-CAP1 and GenOMICC2. Both trial led to significant developments in the treatment and understanding of Covid 19 and critical illness. For many colleagues in critical care, and for myself, this was the first time we had engaged in clinical research and seen the real-world applications and benefits from research. During the pandemic, Stockport NHS Foundation trust ran an industry sponsored Covid 19 vaccine trial which generated significant income that was used to expand and develop the Research Department. These two factors intersected and inspired me to become Critical Care research lead, with the aim of becoming the most research active district general hospital in the Northwest of England.
Methodology I drew from experience and new knowledge gained in the Leap2 leadership program run by the Intensive Care Society. I began by appraising the current research portfolio, recognising that there were no Covid 19 patients in our ICU, which left only one trial that was open to recruitment of eligible patients. I familiarised myself with the key members of the research department and listened to how they had been recruiting patients. I identified weaknesses in this method and attempted to course correct with the staff in place. It became apparent this was not possible, so I formulated a new strategy. I recognised this recruitment required motivated and capable staff regularly on the ICU. I identified our cohort of ACCPs as clinicians fitting this description. I engaged with each individually using a variety of communication styles. A re-appraisal of ACCP roles was underway and a Trust Lead ACCP had been recruited. I chose not to lean into this development in recruiting ACCP to engage in the GenOMICC trial. One ACCP was already interested in research and had been active during Covid19 in research; I worked with him and integrated him into the team of research nurses in place. With a regular member of the team able to recruit in the ICU, I used WhatsApp messaging to set up a group to co-ordinate the recruitment of patients.
Results I became research lead in the Autumn of 2022. I wished to evaluate the recruitment to GenOMICC in a six-month window one year apart after the implementation of my changes. We had recruited a total of 229 patients to the GenOMICC trial as of October 31st, 2023. In total 206 were recruited prior to May 2022. In the 6month period from the beginning of May 2022 until the end of October 2022, 2 additional patients were recruited. I began to introduce the changes to the recruitment soon after starting the Leap2 course in Spring 2023. In the 6-month period from the beginning of May 2023 until the end of October 2023 9 patients have been recruited to GenOMICC. This represents a 550% increase in recruitment to GenOMICC over the same six-month period year on year. We are currently the 24th highest recruiting site to the study out of 211 recruiting sites. The breakdown of sites in the Northwest of England is not available from the trial organisers at the time of preparing this poster.
Conclusions Using knowledge and skills acquired on the Leap 2 program, I have been able to lead the critical care research team to recruit significantly more patients to the GenOMICC trial. Applying this success to other trials is an aspiration, but currently constrained by the inability to open to more trials due to a backlog in the research department.
A Graph Showing Increase In Patients Recruited To The GenOMICC Trial for May until October 2022 and 2023 235 230 225 220 215 210 205 200 195 190 01/05/2023
01/06/2023
01/07/2023
01/08/2023
01/09/2023
01/10/2023
References 1. The Writing Committee for the REMAP-CAP Investigators. Effect of Hydrocortisone on Mortality and Organ Support in Patients With Severe COVID-19: The REMAP-CAP COVID-19 Corticosteroid Domain Randomized Clinical Trial. JAMA. 2020;324(13):1317–1329. doi:10.1001/jama.2020.17022 2. Pairo-Castineira, E., Clohisey, S., Klaric, L. et al. Genetic mechanisms of critical illness in COVID-19. Nature 591, 92–98 (2021). https://doi.org/10.1038/s41586-020-03065-y
550% More Patients Recruited
Critical Care Medicines Support Workers: Role Development and associated efficiency, quality and cost improvements Rhona Sloss Lead Pharmacist for Critical Care and Theatres, St Bartholomew’s Hospital, London Begin ward working (e.g. critical care)
Introduction Medicines support workers (MSW) were introduced to the critical care units at St Bartholomew’s Hospital (SBH) during the COVID19 pandemic to relieve the burden on nurses from medicines management activities.
1 Year L2 NVQ (on the job)
MSW are AfC Band 3 and do not require any prior qualification but do receive on-the-job training. The are managed by the nursing team but liaise closely with critical care pharmacists (Figure 1). As a relatively new role introduced during unusual and challenging circumstances, the role has yet to be fully developed and potential benefits realised.
Specialist Critical Care Pharmacist
Senior Critical Care Nurse/Matron
Critical Care Pharmacy Technician (Optional)
Shift Nurse in Charge Line report
Liaison
The aim of this project was to develop the role of MSW and assess improvements in efficiency, quality and cost effectiveness.
Critical Care Medicines Support Worker
Figure 1: MSW training and management structure
Methodology • Identified key stakeholders to form a working group • Nurses, Pharmacists, Pharmacy Technician, MSW Working • Defined collective aims and objectives Group
CD Book Transfer
• Identified possible roles and responsibilities that MSW could take on • Defined what support MSW would need to take on additional roles Role Scoping • Prioritised additional roles according to need/practicality • Developed a staged training plan for MSW for each task • Liaised with relevant stakeholders regarding governance approval Training • SOPs devised to summarise tasks and responsibilities
POD locker checks + recycle meds
New Roles for MSW
Medicines Returns
Emergency Reversal Cupboard Checks
Stock Top Ups + Ad Hoc Orders
Pharmacy room tidy + checks
• Regular meetings to review progress and adapt as needed • Review of quality, efficiency and cost improvements Review • Continuous planning for next stage of development
Figure 2: Scoping of New Roles for MSW
Results
Quality
Efficiency Time taken to transfer CD books from ICU to Pharmacy Pharmacist 3.07 hours MSW 0.58 hours
Medicines Management Audit 100% 80% 60% 40% 20% 0%
SBH ICUs Oct-22
Oct-23
Pharmacist Time Saved
Nursing Time Saved
4.15 hours per week
15.75 hours per week
Cost Saving Staffing Resource Savings £1,786 per month Medicines Returns Savings – Next Step….
Figure 3: SBH ICU Medicines Management Audit
Conclusion Creation of a multidisciplinary working group, training and support structure has facilitated successful development of MSWs roles in critical care at SBH. The additional roles they have been trained to undertake have shown quality, efficiency and cost saving benefits. There is scope for their roles to be developed further using this established structure to release MDT time and realise further cost savings.
Next Steps..
Medicines Returns
Grab Bag Checks
Monthly Audits
Traffic light project Mohammad feroz (Clinical fellow ITU) Northampton general hospital
Abstract For doctors new to the NHS or ITU, it can be a challenge to settle in, and a little bit of extra support during their initial days can go a long way in improving their NHS experience. We designed a support system with 2 components Traffic light project- to help with procedure and policies Buddy 2.0 – to help settle in and navigate NHS We conducted empathy interviews of doctors who worked on our unit before the support system was introduced and compared to doctors after Doctors felt supported , mentored and guided They still felt overwhelmed and anxious This project need support from management, consultants and HR Doctors who benefited will lead this further
Results We conducted empathy interviews of doctors who worked on our unit before the support system was introduced and compared to doctors after
Introduction The aim of this support system was to provide extra support to doctors new to our unit We identified that the initial transition period is the most stressful period and if provided with proper support this could lead to increased staff satisfaction and retainment
Methods and Materials Teaching was provided to nurses and ODPs about the project. They were taught about what they should and should not expect from a person wearing the badges. Example- nurses should not approach them with complex drugs prescriptions like vancomycin, prescription for CRRT etc ODPs were asked to help ensure that people with badges received support and guidance from a senior colleague when undertaking any procedures The idea is that they know what to do but how to get it done here is a different ball game it takes time and patience to learn Posters explaining the system were produced and put up around the unit for further visibility
Discussion As you can see this project is not a magic fix.but I believe it’s a step in the right direction Doctors still felt overwhelmed and nervous, but they felt supported,protected and excited about their journey into NHS
.
.
References General Medical Council (2021) ‘The state of medical education and practice in the UK 2021’. Available at https://www.gmc-uk. org/-/media/documents/somep-2021-fullreport_pdf-88509460.pdf (accessed 31 May 2023) .General Medical Council (2020) ‘Unfair treatment affecting many SAS and LE doctors, GMC survey’. Available at https:// www.gmc-uk.org/news/news-archive/ unfairtreatment-affecting-many-sas-and-le-doctors-gmc-survey
Service Improvement Project: CICU 360o Feedback Michaela Jones
Introduction Feedback is an invaluable and effective tool for improving performance and the ability to give and receive constructive feedback is crucial for the development of staff as it can identify gaps and opportunities for improvement.
Despite its importance, staff on the Cardiac ICU feel that they do not receive adequate feedback and if they do, the process is not effective. In addition, senior staff feel that they do not receive adequate feedback for individual team members as part of the appraisal process which can lead to an appraisal that may not reflect the actual performance of their team member. In response to this issue the use of a 360o feedback tool as a method of providing staff feedback and for improving the appraisal process was proposed.
Figure 1: Plan on a page – CICU Staff Feedback Project
A 10 question pre implementation survey and a MS 360o Feedback Tool were co-created and designed.
Methodology The project lead and project team were identified comprising of a critical care matron and three sister/charge nurses.
Minor modifications were made to the MS 360o Feedback Tool and a pilot date for use within the senior team agreed.
Conclusion
Project time was allocated. Consultations were conducted with HR business partner, the leadership development manager in the organisational development team and IT MS 365 Analyst team. A short survey using MS forms was devised to collect baseline data. Different feedback tools were appraised with IT MS 365 Analyst team. A service improvement methodology was used to develop a MS 360o Feedback Tool. The MS 360o Feedback Tool was trialled within the project team.
Results A strategy plan (figure 1) was agreed, and the project team delegated key tasks within different workstreams.
The project team were a self-selected group interested and enthusiastic about this work. They have completed the initial planning phase ready for implementation. The short base line survey will provide data to understand the current issue/problem and define the case for change. This data will be used during the engagement and communication phase promoting the benefits of 360o feedback to enhance the quality and credibility of the performance appraisal process. The MS 360o Feedback Tool has been co-created and designed to be a quick and easy to use feedback tool linked to the Trust values and behaviours. Feedback will be collated, analysed and anonymised. By involving different staff viewpoints in the appraisal process, it can reduce the bias and subjectivity of a single appraiser providing a more accurate and holistic picture of an individual’s performance. Furthermore, by using a process in which staff receive anonymised feedback from different people that they work with may increase the acceptance and ownership of the feedback, as they can see how their work is perceived by different staff members.
Acknowledgements Superspreaders and project team Leah Compton-Bennet, Sonia Martins and Kristy Young. Cardiac ICU, University Hospital Southampton NHS Foundation Trust.
Weight & Anthropometry on ICU, a Service Evaluation Alice Brown, Royal Brompton Hospital, London, SW3 6NP. Nutrition & Dietetic Department, Royal Brompton & Harefield Hospitals, part of GSTT.
Introduction
Results
More than half of adult patients admitted to Intensive Care Units are malnourished on admission1.
Less then 10% of patients were weighed on a weekly basis following admission to ICU.
Dietitians assess patients nutritional status, taking in to account any recent changes in weight. Accurate, measured weights are very important in relation to accurate and effective drug dosing, for instance weight based drugs such as Enoxaparin. The gold standard for determining energy expenditure is Indirect Calorimetry however very few units have access to this due limited resources2. The majority of ICU Dietitians use a mixture of weight based (kcal/kg) and predictive equations which rely on having an accurate body weight, where possible.
Patients that were weighed were more likely to be awake and alert and have a trache in situ. These patients were more likely to be weighed using a hoist scale once safe to sit out. Patients who remained sedated and ventilated (ETT) were less likely to be weighed.
Conclusion Gaining regular, accurate, measured weights on ICU is challenging. Often patients are unable to provide a weight or weight history on admission. Weighing scales and equipment are not always available and bed scales are not accurate enough for drug dosing weights. Weights may fluctuate due to fluid changes, with critically ill patients gaining several kilos in fluid.
Methodology A retrospective audit was carried out which included 30 adult patients (>18yo of age) who were admitted to the Royal Brompton and Harefield Hospitals during a three-month period (June to August 2023). Patients were included if they remained on ICU for more than 14 days. Data collection was undertaken for a total of 30 patients. Data was collected from an electronic patient record, starting from admission to ICU up until discharge from ICU. Data collection included demographics, ventilation, sedation, SOFA scores, height, weight, BMI, and any anthropometric measurements. Data on the number of weights during admission, and method for weighing were also collected. Clinical outcomes such as ICU LOS and Hospital LOS were also collated.
Critically ill patients are often immobile and cannot be weighed due to haemodynamic instability. Anthropometric measurements (e.g. calf circumference, mid-upper arm circumference) are un-measurable when oedema is present. Anthropometry measurements should be considered as a guide only and used with clinical judgement. The lack of A&E and patients not routinely being transported on trolleys reduces the opportunity for using weighing pat-slides. Adjusting body weight in amputees can increase the risk of error when calculating BMI.
References 1.Mogensen KM, Robinson MK, Casey JD, Gunasekera NS, Moromizato T, Rawn JD, Christophe KB. Nutritional status and mortality in the critically ill. Crit Care Med. 2015 43(12), 2605-2615. 2.Singer P, Blaser AR, Berger MM, et al. ESPEN guideline on clinical nutrition in the intensive care unit. Clin Nutr. 2019;38(1):48-79.
Developing a novel way to share information on ICU E-noticeboard project Dr Fran Tait SpR ICM & Anaesthesia, LeaP 2 delegate 2023
Introduction Information sharing to medical and other staff groups was haphazard and often allowed to go out of date, often a selection of A4 print outs on noticeboards that could be easily missed, information from induction wasn’t widely accessible and any updates or new initiatives struggled to reach target groups.
MDT input
New initiative for Blood pressure management in new admissions
We needed a regularly updated source of information for the MDT working on ICU.
Methodology 1. 2. 3. 4. 5.
Update for common prescribing error on ICU
Registered project with local audit/QI team. Engaged key stakeholders : Doctors of all grades, Physiotherapists, pharmacists, nursing staff and dietetics & wider ICU team. Gathered current information being shared in disorganized and rarely updated fashion and review its relevance Developed prototype noticeboard and sought feedback. Started sharing at the start of the day prior to handover and then prior to 12:30 meeting.
Publicising new projects
Results Headline/front page
Descriptor of noticeboard
Publicising UK-ROX platform trial the unit is recruiting to
Sharing learning from a safety event
The project was well received in the department. Most notably a 100% uptake in clinical opportunities shared on the noticeboard, enhancing learning and improving opportunities for doctors on the ICU. As it gained traction messages started coming to me with things I could add to the noticeboard. I left the department and handed over the project with the plan to continue the project, aiming to improve the way it is shared and allow people to access and add their own updates, truly integrating the noticeboard.
Conclusion Initially I felt this was a small and relatively unambitious project but it grew naturally, as more people saw it, more wished to use it to share information. Engaging with the wider MDT and seeking information to share with others helped me make links with the team and strengthened working relationships.
Acknowledgements Thank you to Dr Chris Hebbes for providing IT support. To all doctors on the ICU at the Leicester Royal Infirmary who engaged with the project and assisted me in sharing it on a daily basis when I was not at work. Thank you to Dr Evi Poimenidi for carrying the project forward now that I have left the unit. References: https://www.icnarc.org/Our-Research/Studies/Uk-Rox, https://www.ed.ac.uk/usher/edinburgh-clinical-trials/our-studies/ukcrcstudies/a2b, https://www.wyccn.org/uploads/6/5/1/9/65199375/peripheral_vasopressor_guide_fianl.pdf
Developing a lead educator role across a Critical Care Network Liz Staveacre Chief Nursing Information Officer, RUH, Bath
Prev. Assoc. Director/Lead Nurse North West London Critical Care Network
Results
Introduction
The post was submitted to the Recruitment team in August 2023. However, due to a recruitment freeze across the ICB and the loss of a project lead, the post has not yet been recruited to.
Critical Care Practice Development Nurses (PDNs) work within Intensive Care units to coordinate and deliver education, training and continuing professional development (CPD) with a minimum recommended ratio of one PDN to 75 registered nurses (RNs) (GPICS, 2022). A key responsibility of the PDN is to achieve and maintain a minimum of 50% of RNs in each unit having a post-registration Critical Care qualification in specialism (QIS).
Conclusion The NWLCCN has long been an innovator in developing network systems and processes to the benefit of both patients and healthcare professionals. Working across four acute provider trusts to monitor and improve service delivery and coordinate commissioned pathways the primary focus of the Network is on the quality of care provision and equity of access to critical care services. This includes the ability to benchmark, share ideas, information and best practice with the aim of reducing variation and improving outcomes.
In 2021, Health Education England recognized that the ratio of PDN:RN should be improved to 1:50. Across North West London Critical Care Network (NWCCN) all eight ICUs had achieved this, but were not achieving the 50% QIS. All training utilised the National Standards for Critical Care Education (2016) but each team runs its own programme with variable standards and regularity. Additionally, most of the PDNs in North West London (NWL) support high numbers of Internationally Educated Nurses (IENs) in transitioning to working in the NHS with variable timescales and little standardization.
This project had several key enablers and challenges to overcome. Enablers - Full agreement from all stakeholders that this was a much needed role that could add value to the education provision across NWLCCN. In order to achieve this consensus, a great deal of groundwork, discussion and negotiation was carried out by the project lead. Implementation - Securing finance agreement for a 2 year fixed term post was a key enabler, without this resource the project would not have gone ahead.
Aim: To reduce variation of RN & IEN education and support across NWLCCN by developing shared resources and coordinating delivery to improve standards and outcomes and improve the % of staff with a QIS by introducing a dedicated and experienced Network Lead Educator.
Methodology
Challenges - There were initial concerns regarding the logistics of the post – where would it be based? How much time would be spent on each site? Ultimately agreement was reached that the main base would be the network office with a significant proportion of each week spent across the four Trusts. - Creation of outcome measures was difficult without fully understanding the existing landscape and it was agreed that the first 3 months of the role would focus on mapping existing education, analysing commonalities identifying gaps and developing a cross-network programme with associated outcome measures. - The appointee would require both education and senior nursing management/leadership. As the project lead was not going to be in post it was unclear who would fulfill these roles. - The key challenge was the actual processes of recruitment which was held up by a recruitment freeze across the ICB. Recruitment was stalled by several weeks due to the complex internal processes required to get the job out to advert. The governance process for Networks varies nationally. While networks are directly commissioned by NHS England and have clear service specifications, they are restricted by the systems in which they operate.
After extensive national enquiries, it was established that this role did not currently exist in any other critical care network. The initial concept and outline project plan was presented to the Network Joint Clinical Board who gave approval to progress and approved funding to develop a fixed term contract for 2 years. In order to ensure the role specifically met the requirements of NWLCCN, the existing PDN forum was used as an expert working group to develop the idea, agree the scope of the role and discuss potential outcome measures. The PDNs felt that there was a strong case for including Deteriorating Patient education and to further explore the potential for this input was sought from the Networks Critical Care Outreach group. A draft job description and person specification was designed using a modified Delphi method and included input from the Network Lead Nurses group and the NWL Directors of Nursing. Once all stakeholders had been identified and consulted the post was submitted to the NWL Integrated Care Board, who act as host to the network, for final sign off.
Acknowledgements With thanks to Bincy Padiyara, Network Manager, and the members of the Practice Educator Working Group, North West London Critical Care Network
References The Faculty of Intensive Care Medicine / Intensive Care Society (2022) Guidelines for Provision of Intensive Care Services, Version 2.1