Board Papers/2014/0… · Web viewWESTON AREA HEALTH NHS TRUST. TRUST BOARD MEETING. OPEN SESSION. TUESDAY 4 NOVEMBER 2014. HARM FREE CARE REPORT. 1. Introduction. This report outlines

WESTON AREA HEALTH NHS TRUST

TRUST BOARD MEETING

OPEN SESSION

TUESDAY 4 NOVEMBER 2014

HARM FREE CARE REPORT

1 Introduction

This report outlines the progress made to the end of September 14 in the Trust’s commitment to the Sign up to Safety Campaign which aims to make the NHS the safest healthcare system in the world, halving avoidable harms over the next three years. The data sources used for this report are as follows:

NHS Safety Thermometer Incidents Standardised Hospital Mortality Indicators (SHMI) Global Trigger Tool (GTT) Central Healthcare Knowledge System (CHKS)

The data from these sources enables the Trust to continuously monitor all incidences of harms to identify and generate topics for the trust wide quality improvement agenda.

2 Harm Free Care

The NHS Safety Thermometer is the measurement tool for a programme of work to support patient safety improvement. It is used to record patient harms at the frontline, and to provide immediate information and analyses for frontline teams to monitor their performance in delivering harm free care. Data is collected on a single day each month at each NHS Trust which records the presence or absence of four harms.

Pressure ulcers Falls Urinary tract infections (UTIs) in patients with a catheter New venous thromboembolisms (VTEs)

Pressure ulcer, CAUTIs and VTE harms are categorised into new and old harms. New harms are recorded if occurring under the care setting of the reporting trust. Old harms are categorised as follows:

19 May 2023/tt/file_convert/5ebcc90dbd55bc0dc753d073/document.docx

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“Old” pressure ulcers are defined as being a pressure ulcer that was present when the patient came in under our care, or developed within 72 hours of coming under our care.

“Old” UTIs are defined when treatment started before the patient came under our care.

“Old” VTEs are defined when treatment for the VTE started, or the VTE was acquired before the patient came under our care.

Falls are categorised according to the severity of harm as defined by the NPSA (please see Section 1.1 for NPSA categories).

In September 2014:

A total of 20 patients had one harm from the Safety Thermometer data:

One female patient was harmed out of 36 (2.7%) between the ages 18-70. 11 female patients were harmed out of 76 (14.47%) patients over the age of 70. One male patient was harmed out of 24 (4.16%) patients between the ages of 18-70. Seven male patients were harmed out of 83 (8.43%) male patients over the age of 70.

In September 2014:

A total of two patients received new harms from the Safety Thermometer data. Both were female and over the age of 70 who had pressure ulcers.


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0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

New Harm Free: patients with New-Harm Free Care

2.1 Incidents (Severe and Moderate Harm) April 2014 to September 2014

Incident reporting systems and policies are integral to patient safety and enable the Trust to analyse the type, frequency and severity of incidents that occur. Apart from April the number of incidents reported has remained constant which shows the Trust has a good reporting culture. With regards to the level of harm for incidents reported, the majority of incidents reported are defined as no/low harm, with 2662 of the 2704 incidents being reported under these levels of harm. For the remaining 42 incidents these were reported under moderate (35 incidents) and severe (seven incidents). The NPSA have defined moderate/severe harm as below: Moderate – Any unexpected or unintended incident that resulted in further treatment, possible

surgical intervention, cancelling of treatment, or transfer to another area, and which caused short-term harm to one or more persons.

Severe – Any unexpected or unintended incident that caused permanent or long-term harm to one or more persons.

Of the 42 incidents reported under these categories the majority are to do with pressure sore damage (Grade 3 and 4) and fractures sustained from falling. To note from a retrospective review of incidents and using the definitions above, nine of the 35 incidents reported under moderate should have been reported as low harm and four of the seven reported under severe should have been reported as moderate harm. ACTION: Currently the Quality Improvement team are undertaking a reconfiguration of incident reporting/management which will entail further work around definitions of incidents to ensure reported incidents are being correctly categorised with regards to the harm sustained


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Apr May Jun Jul Aug Sep0

100

200

300

400

500

600

1.9% 1.9% 2.2% 1.4% 1.0% 0.8%

361

465439

489 492458

Moderate/SevereTotal

3 Mortality Data

3.1 Standardised Hospital Mortality Indicators (SHMI)The SHMI is the ratio between the actual number of patients who die following hospitalisation at the trust and the number that would be expected to die, on the basis of average England figures given the characteristics of the patients treated there.

SHMI =

ObservedDeathsExpectedDeaths

Observed Deaths: This is a count of the number of deaths which occur in hospital or within 30 days of discharge for each Trust. If the patient is treated by another Trust within those 30 days their death will only be attributed to the last non-specialist acute NHS Trust to treat them. Specialist Trusts, Mental Health Trusts, Community Trusts and independent sector providers are excluded from the SHMI.

Expected Deaths: The risk of the patient dying in hospital or within 30 days of discharge is estimated from statistical models based on the following variables:

The condition the patient is in hospital for Other underlying conditions the patients suffers from The age of the patient The sex of the patient The method of admission to hospital (elective/non-elective /unknown)

The expected number of deaths is obtained by summing the estimated risks for all finished provider spells for a Trust.

The latest published data of the SHMI covers the year to March 2014 and has a value of 1.03, please see below. This indicates that mortality within the Trust and 30 days after discharge for period covered is as expected given the age and co morbidities of the patients treated. For this period, 66.84% of deaths occurred within the hospital, and 33.16% deaths occurring outside the hospital.

SHMI data showing mortality within the Trust and 30 days after discharge


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SHMI data showing in-hospital mortality only

A further analysis is undertaken of the main treated condition of the patients who have died, together with the top ten diagnoses at discharge of patients in order that the Trust can focus on the priority areas for improvement.

Top ten diagnoses on discharge April 2014 to September 2014

1. Pneumonia2. Urinary Tract Infection

3. Unspecified haematuria4. Multiple myeloma

5. Cellulitis of other parts of limb6. Anaemia, unspecified

7. Secondary malignant neoplasm of bone and bone marrow8. Fitting and adjustment of urinary device

9. Pain localised to other parts of lower abdomen10. Malignant neoplasm: Bladder, unspecified

10. Other and unspecified abdominal pain10. Malignant neoplasm: Breast, unspecified

10. Gastrointestinal haemorrhage, unspecified10. Chest pain, unspecified

10. Follow-up examination after surgery for malignant neoplasm

0 10 20 30 40 50 60 7063

5554

4343

3632

3029

2828

25252525


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SHMI data of observed and expected deaths of Trust’s Top 2 Diagnoses on Discharge April 2014 to September 2014

3.2 Mortality Reviews using the Global Trigger Tool (GTT)

The Global Trigger Tool is an easy-to-use method of reviewing mortality to identify “triggers” or clues with the potential to cause harm. The triggers are categorised into event severity and this information is used to prioritise the Trust wide quality improvement programme. Currently, the following QI projects are either underway or in the planning stages following GTT analysis:

Early Warning Score (EWS) is at the planning stage with junior doctors. Acute kidney injury AKI (in relation to category rising urea and creatinine) Pneumonia (both hospital acquired and community acquired) Sepsis 6 (in relation to category “positive blood culture”) Cardiac arrest


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April 2012 - March 2013

July 2012 - June 2013

October 2012 - September

2013

January 2013 - December

2013

April 2013 - March 2014

010203040506070

UTI(Source: SHMI)

Observed Expected

Dea

ths

April 12 to March 13 July 12 to June 13 October 12 to September 13

January 13 to December 13

April 13 to March 140

50

100

150

200

250

300

Pneumonia(Source: SHMI)

Observed Expected

Deat

hs

The graph above shows pneumonia mortality data as expected for our patients. However, because pneumonia is the top diagnosis at discharge, quality improvement projects on the diagnosis & management of pneumonia has started.

The graph above shows UTI mortality data as higher than expected. The Trust has implemented a new pathway in March 14 for the diagnosis & management of UTI.

1. Pressure Ulcers

In September 2014:

A total of 17 patients had a pressure ulcer from the Safety Thermometer data:

One female patient was harmed out of 36 (2.77%) between the ages 18-70. 11 female patients were harmed out of 76 (14.47%) patients over the age of 70. One male patient was harmed out of 24 (4.1%) patients between the ages of 18-70. Four male patients were harmed out of 83 (4.81%) male patients over the age of 70.


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0%

2%

4%

6%

8%

10%

12%

14%

Pressure Ulcers - All: patients with an old or new pressure ulcer

In September 2014:

A total of two patients acquired new pressure ulcers – Grade 2 and 3 from the Safety Thermometer data. Both patients were female and over 70.

Pressure ulcer incidence by grade (Data source: Datix)


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0%

0.5%

1%

1.5%

2%

2.5%

Pressure Ulcers - New: patients with a new pressure ulcer

Oct 13

Nov 13

Dec 13

Jan 14

Feb 14

Mar 14

Apr 14

May 14

Jun 14

Jul 14

Aug 14

Sept 14

0

10

20

30

12 12

17

2422 21

15 16

118

10 9

3 2 14

13 2 2 3

0 1 20 1 0 0 0 1 0 0 0 1 1 2

Pressure Sore incidents Hospital Acquired Grade 2, 3 and 4 October 2013 to September 2014

Hospital Acquired Grade 2Hospital Acquired Grade 3Hospital Acquired Grade 4

Actions on Pressure Ulcers

Awareness and education of both pressure ulcer risk and prevention is continuing throughout the Trust with presentations to the senior nurses at the Ward Wednesday meetings, Teaching Thursdays and the “Trolley Dash” – an enhancing tool which was received favourably by all areas and will continue. Round table meetings after investigations of pressure ulcers are carried out to share learning with the teams and a Pressure Ulcer Pathway is currently being developed.

Further improvement is being led through an improvement programme supported by the Hub with an identified group of front line staff meeting regularly to agree actions and next steps.

2. Falls

In September 2014:

A total of three patients sustained falls from the Safety Thermometer data – two were female patients and one male patient, all over the age of 70.


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0%

1%

2%

3%

4%

5%

6%

Falls - All: patients who have fallen

In September 2014, no falls causing harm were reported from the Safety Thermometer data.


10

0%

1%

2%

3%

4%

5%

Falls with Harm: patients with harm from a fall

Apr 14 May 14 Jun 14 Jul 14 Aug 14 Sep 14 Oct 14 Nov 14 Dec 140

10

20

30

40

50

60

7064

5956 55

5247

0 0 0

Patients Falls April to September 2014

Falls incidents by bed days

Actions on Falls:

All patients over 65 and patients who are 50 to 64 years who are judged by a Clinician to be at a higher risk of falling because of an underlying condition (NICE 2013) are assessed for falls risk. The risk assessment involves a multifactorial assessment of the patient and interventions are identified in accordance with the Falls Care Guide.

The Trust is currently piloting on Kewstoke Ward a post-fall “SWARM” assessment which is completed by a Senior Nurse as soon as possible following a fall. The Senior Nurse interviews both the patient and staff and assesses the environmental factors and patient factors. The completed SWARM forms will be analysed for possible trends.

Patients who have sustained hip fractures are reported back to the community each month to ensure that falls referrals have been received and patients have been reviewed by the Community Physiotherapist if appropriate.


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3. CAUTI – Safety Thermometer

In September, three patients had CAUTIs reported from the Safety Thermometer data, all male patients over the age of 70.


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0%

0.5%

1%

1.5%

2%

2.5%

3%

3.5%

Catheters & UTIs: patients with a catheter and a UTI

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

Catheter & New UTI:

No patients acquired new CAUTIs from the Safety Thermometer data.

Actions on CAUTIs

Catheter insertions in August were at 26.03% continuing a rising trend in September 28.05%. This equates to 57 and 62 patients respectively. Work in underway to address this and a group has been set up with the Lead Nurse for Urology as the Trust lead. There have been no hospital attributable catheter acquired urinary infections reported on the day of the Safety Thermometer for the past six months.

4 VTE

In September, two patients did not have a documented VTE risk assessment from the Safety Thermometer data. One male patient aged 18-40 and one female patient >70.


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0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

VTE Risk Assessment: patients with a doc-umented VTE risk assessment

Five patients did not receive VTE prophylaxis from the Safety Thermometer data. Two male patients >70, two male patients 18-40 and one female patient 18-70.

September’s Safety Thermometer data did not show any hospital acquired VTEs.


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0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

VTE Prophylaxis: patients given VTE prophy-laxis

0%

1%

2%

3%

4%

5%

6%

All VTEs:

VTE Actions

The VTE Committee meet monthly to monitor compliance with VTE risk assessment and VTE prophylaxis. All hospital acquired thromboses are investigated using root cause analysis. Overall this analysis is failing to show major deficiencies in either the VTE/bleeding risk assessment or the administration of appropriate thromboprophylaxis. Results of the RCA analyses are now being collated on a quarterly basis to be presented at the respective governance meetings of the emergency and elective divisions. The Committee covers all aspects of the NICE guidance recommendations to date and has a robust action plan.

5 Health Care Associated Infection

Clostridium difficile

Weston Area Health NHS Trust has a local threshold of 12 hospital attributable cases of Clostridium difficile for the financial year 2014/15. Two cases of hospital attributable Clostridium difficile were reported in August and three in September. A review of all cases has been undertaken by the Consultant Microbiologist and Infection Prevention and Control Nurses. Criteria determined nationally have been applied to assess whether there have been any lapses in care and whether that case could have been avoided.


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Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-140

1

2

3

4

Clostridium difficile

The antimicrobial stewardship programme continues apace and involves both the Consultant Microbiologist and Antimicrobial Pharmacist. Issues with inappropriate prescribing are addressed in a timely fashion and this feedback is leading to a reduction in the amount of inappropriate prescriptions. The inaugural meeting of the Antibiotic Stewardship Group has now been held. There is continued focus on the use of co-amoxiclav and how to reduce this. The Trust has launched an antimicrobial app which can be downloaded for free onto individuals’ Iphones. This will enable the medical staff instant access to our current antimicrobial guidelines with the aim of improving compliance even further. Other actions include replacement of washer disinfectors on Kewstoke and Hutton with macerators.

MRSA Bacteraemia

There has been one incidence of MRSA bacteraemia in July against a null target. The root cause analysis highlighted blocks to communication within both medical and nursing handovers and measures have been introduced to rectify this.


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Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-140

1

2

MRSA Bacteraemia

Monthly internal audits are undertaken by Infection Prevention and Control Link Practitioners. The audits look at three areas of hand hygiene – environment, observation and technique. The Director of Infection Prevention and Control is supporting the completion of these audits by releasing time for the link practitioners to undertake and submit these audits. Overall Trust-wide compliance was reported at 99% in August and 95% in September. Validation audits continue to be undertaken for assurance purposes. The ‘Bare Below the Elbow’ initiative is embedded in practice and compliance continues to be excellent within the clinical areas.

6 Medication Safety

Reducing medication errors reduces the risk of a patient being harmed. Medication errors can result in people being admitted or readmitted to hospital and medication errors whilst an inpatient can increase the length of stay. The NPSA estimates that preventable harm from medicines could cost more than £750 million each year in England.

Actions

There is a multidisciplinary medication incident group which identifies themes from incidents and develops solutions e.g. Insulin. A Trust Medication Safety Officer has been allocated. The Medication Safety Thermometer has been rolled out Trust-wide from July 2014 and a revised drug chart was launched in May 2014.


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Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-140%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Hand Hygiene Compliance

Medication incidents from April 2014 to September 2014


18

04080

120160

7 Hub Improvement Programme

7.1 Treatment Escalation Plan (TEP)

The aim of the project is to gain informed consent for treatment decisions and reduce harm from unwarranted treatments and discussions in patients identified as at risk of dying during their current admission. The project team have devised a TEP form and used PDSA cycles to measure its effectiveness. The Team meet each week to discuss issues arising from using the form, and adapt it if necessary.

7.2 Hazard Reporting

The aim of the project is to increase the numbers of near misses, hazards and concerns reported by Doctors at Weston General Hospital by 100% by introducing a telephone reporting system (anonymous if doctor wishes) alongside the current Datix reporting system for actual harm.

A dedicated phone line was installed in the Hub for doctors to report any hazards, near misses or unsafe conditions that they had experienced. The pilot was conducted over a two week period on Berrow and Kewstoke Wards and Doctors were given the option of reporting anonymously if they wished. A Senior Consultant reviewed the hazards on a daily basis, categorised and escalated them to the relevant department. Feedback was given directly if the Doctor left name. Otherwise, feedback was given to Doctors one week after pilot started.

The results for the first pilot showed an increase from two reports on Datix from Doctors Trust-wide in May 2014 to 29 reports in the pilot period from only two wards. The next PDSA cycle will be on the same wards but the phone will be available to all staff groups. It is also planned to implement Datix risk which allows risks to be captured at every level from the day to day risks faced by the staff on the ground to the strategic risks at Board level or above. These risks can then be prioritised according to a wide range of different criteria enabling principal risks to be fed upwards to the Board.

8 Sign up to Safety Pledges

Weston Area Health NHS Trust is committed to setting out actions that we will undertake in response to the five Sign Up to Safety Pledges which are:

1. Put Safety First

As this report highlights, the Trust is committed to reducing avoidable harm in the NHS by half.

2. Continually Learn

Serious incident (SIRI) feedback meetings. Quarterly meetings will be arranged and opened for all staff to attend. The aim will be to feedback on the SIRI’s that have occurred in the quarter giving a brief overview of the types of SIRI’s by groups. To build on the feedback element of lessons learned, investigators of SIRI’s will be invited to present a short case study of their investigation and discuss the lessons learned and how these have been shared/embedded.


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3. Honesty

A Duty of Candour Policy has been written and is out for consultation with key members of staff. The policy includes incidents that have caused moderate/prolonged psychological/severe harm or death and the Trust acknowledging, apologising, investigating and explaining when something has gone wrong. The duty includes informing the patient/next of kin within ten working days (verbally) that harm has occurred and offering a sincere apology along with an explanation of what has happened (this must be documented in the medical records). This is then followed up by letter reiterating the verbal discussion and offering apologies. Following the investigation the patient/Next of kin will then receive feedback on the investigation outcome and actions taken to prevent reoccurrence.

4. Collaborate

On 14 October the NHS England Patient Safety Collaboratives were launched. This confirmed the position of SAFER CARE SOUTH WEST (the five year South West Safety Collaborative) within the West of England Academic Health Science Network (WoEAHSN). WoEAHSN covers the geography of the Northern part of the previous South West Strategic Health Authority and in addition three Universities, Commissioning Groups, Ambulance Trust and Primary Care.

Sign up for Safety, a national safety initiative is working alongside the AHSN based Safety Collaboratives to build a culture of safety and of quality improvement through the use of campaign approaches.

The Safer Care South West will be reviewing its work plan this autumn. There is a commitment to using the same collaborative model and improvement methods going forward and to partnering where possible with Academic and Industry.

The previous work streams; peri-operative, critical care, general physical care, medicines and leadership will continue. The measurement strategy will be simplified for existing work streams so that new areas of work can be introduced. These new areas will be; emergency laparotomy, acute kidney injury, sepsis, ends of life priorities of care.

Following the appointment of a “Safer Care South West Programme facilitator” for Weston General Hospital, nurse-led groups have been developed to look at opportunities for improvements, regarding pressure ulcer prevention, falls prevention and avoidance of catheter urinary tract infection.

Work relating to safer anticoagulation has also commenced by Pharmacy staff, Laboratory Technicians and Doctors who prescribe anticoagulant therapy.

The aim will be to enable collaboration on ideas and shared learning across all providers in the AHSN as well as local focus on issues that matter.


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Wherever possible, existing data sets will be used to measure quality and reliability. Wherever possible, new measurements will be located within the work flow to minimise duplication. The overall aim however is to make change through testing, local measurement of processes and over time of measurement of improving outcomes, the latter being through established systems such as coded data/ SHMI for example.

5. Support

As part of the Sign up to Safety Campaign, a Human Factors Training Programme has started for all staff to apply human factors science to looking at patient safety concerns by Dr Tricia Woodhead. Training in human factors can help staff to act as a barrier against harm and to reduce the likelihood of incidents occurring, thus creating a culture of safety. Human factors training studies the relationship between human behaviour, system design and safety. As part of the Sign up to Safety Campaign, Dr Woodhead has conducted two training sessions for all staff on applying human factors. To date, staff attending these human factors training sessions have included a Physiotherapist, members of the Complaints and Governance Departments, a Junior Doctor and several Nurses.


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Appendix 1

Driver Diagram for the Treatment Escalation Plan QI Project


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Appendix 2

Driver Diagram for the Hazard Reporting QI Project


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Documents

Board Papers/2014/0… · Web viewWESTON AREA HEALTH NHS TRUST. TRUST BOARD MEETING. OPEN SESSION. TUESDAY 4 NOVEMBER 2014. HARM FREE CARE REPORT. 1. Introduction. This report outlines