NHSNHSGuidelinesGuidelines, , ProceduresProcedures

& & IssuesIssuesGrzegorz Chodkowski (MD)Grzegorz Chodkowski (MD)

Riga, Radisson SAS

2009

NHS Guidlines, Procedures and Issues

• Waiting Times

• Copying Letters to Patients

• Hospital at Night (HAN)

• Hospital Hygiene & Infection Control: MRSA & Clostridium Difficile

• National Institute for Health & Clinical Excellence (NICE)

• National Patient Safety Agency (NPSA)

• Clinical Governance

• Swine Flu

• Continence Care

• Chaperone persons

• NHS Cuts

• Staff assault

Waiting Lists

Waiting Times

Source: Department of Health Quarter Report

Copying Letters

to Patients

Copying Letters to Patients

• In response to Government guidelines, this Trust is giving patients the option to receive copies of letters sent to their doctor after an outpatient appointment orinpatient/day case admission.

• The policy concerning Copy Letters to Patients (CLTP) was first set out in the NHS Plan (2000) which made a commitment that patients should be able to receivecopies of clinicians’ letters about them as of right. Detailed information andguidance is also available on the Department of Health website, http://www.dh.gov.uk/ .

• Our patient information leaflet explains some of the benefits of receiving copies ofletters and how to arrange to receive these. Copies can be obtained in a variety offormats including Braille, large print, audio or translated into another language.

• Once a patient/carer has indicated that they wish to receive copies of letters, thesewill continue to be provided for all attendances/admissions until the patient/carertells us that they no longer wish to receive copies of clinical letters.

• It is important for patients and carers to be aware that the purpose of the letter is to give the patient’s General Practitioner (GP) medical information about the patient’sillness, care and treatment.

Hospital at Night

(HAN)

Hospital at Night

The Hospital at Night project began in various pilot sites around the country

in April 2003, with aim of enabling the European Working Time Directive

(EWTD) and reducing the hours worked by junior doctors.

Medical cover provided in hospitals during the out-of-hours period has been

changed.

Medical cover requirements are no longer defined by professional

demarcation and grade. Cover is now based on the competence of staff in

attendance.

The project aims to enable and possibly enhance care for patients given the

changes in permitted working hours of doctors in training.

Hospital at Night

• The HAN project offers a method of preserving, and even enhancing, doctors' training by reduced hours available.

• The HAN model consists of a multidisciplinary night team, which has the competences to cover a wide range of interventions. It also has the capacity to call in senior and specialist expertise when necessary.

• This model contrasts the traditional model of junior doctors working in isolation.

National Institute for

Health and Clinical

Excellence

NICE is the independent organisation responsible for providing

national guidance on the promotion of good health and the

prevention and treatment of ill health.

On April 2005 NICE joined with the Health Development Agency to

become the new National Institute for Health and Clinical

Excellence (also known as NICE).

Head injuries (June 2003)

Preoperative tests (June 2003)

Referral for suspected cancer (June 2005)

Laparoscopic surgery for inguinal hernia (September 2004)

Laparoscopic surgery for colorectal cancer ( December 2002)

Gemcitabine for pancreatic cancer (May 2001)

Herceptin for advanced breast cancer (March 2002)

Tension-free vaginal tape for stress-incontinence (February 2003)

Infliximab for Crohn’s disease

National Institute for Health

and Clinical Excellence (NICE)

NICE guidance can help patients and Carers:

• Receive care in line with the best available evidence of clinical an

cost-effectiveness

• Empower patients to be accountable for their care, knowing how they

will be cared for in a consistent evidence-based approach, thus

building patients confidence in NHS services

• Improve their own health and prevent disease

• Help put NICE guidance into practice

Benefits of Implementation

NICE guidance can help healthcare professionals:

• Ensure care provided is based on the best evidence available

• Ensure clinicians meet the standards set by regulatory bodies and that

they consider NICE guidance when exercising their clinical judgement

• Enable all staff dealing with patient queries to have confidence in

the approaches to care

• Effectively target resources and efforts at the areas that offer the

most significant health improvement.

Benefits of Implementation

• Meet the Standards for better health

• Core standards – technology appraisals and IP

• Developmental standards – nationally agreed guidance

• Enable organisations to meet the requirements in the

government’s standards-based planning framework National

standards, local action, health and social care standards and

planning framework, 2005-2008

• Benefit from any identified disinvestment opportunities, cost savings

or opportunities for re-directing resources

• Meet government indicators and targets for health improvement

and reducing health inequalities

• Help local government fulfil its remit to promote the economic and

social well-being of its communities.

• Provide a focus for multi-sector partnership working on health,

involving patients and the public in implementing NICE guidance

NICE guidance can help organisations:

Benefits of Implementation

Clinical

Governance

Swine Flu

National Patient

Safety Agency

(NPSA)

Infection Control

Infection control is a key concern for any professional involved with patients

that are subject to our duty of care. Any contact with the healthcare

environment and care professionals should have a positive outcome for the

individual and not result in a worsening of their circumstances.

Universal precautions

Universal precautions is an approach to the unknown risk presented by

the handling of products and provides a safe system for the healthcare

professional.

This is done while maintaining a consistent approach to the patient in

order that confidential information of infection is not identified by the

behaviour of the healthcare professional.

Universal precautions is a method of care delivery that recognises all

body products from all patients constituting a risk, and therefore

stipulates the use of a barrier between healthcare professionals and

body products.

Infection Control

Caution should therefore be taken with all blood and body products.

The following is a list of less common body products that still

constitute a risk:

• Blood and wound excaudate

• Faeces

• Urine

• Salvia

• Breast milk

• Semen

• Vaginal secretions

• Cerebral spinal fluid

• Synovial fluid

• Pleural fluid

• Peritoneal fluid

• Amniotic fluid

• Unfixed organs and tissue

The most effective barrier is the disposable glove.

Infection Control

• Patients in hospital can be very vulnerable to picking up infections because theyare already ill or may be undergoing surgery, and their ability to fight infection islow.

• We are very keen to protect you and your family from acquiring an infectionduring your stay in hospital.

• It cannot be stressed too highly that effective handwashing is one of the effectiveways to prevent the spread of infection.

• You can help us prevent the spread of infection by paying particular attention to washing your hands before and after visiting the hospital.

• Remember that if you are suffering from a heavy cold, flu-like symptoms, vomitingor diarrhoea YOU SHOULD NOT visit the hospital. Please inform the relevantward/dept. If you have symptoms of diarrhoea or vomiting, you must not visituntil you have been free of symptoms for 48 hours.

MRSA( Methicillin-resistant Staphylococcus aureus )

MRSA

Source: Department of Health Quarter Report

MRSA is the identified organism in 20% of

all staphylococcal aureus cultures in the UK.

Its incidence seems to be growing in number

and is increasingly responsible for major

illness.

Managing MRSA is a significant responsibility

of all healthcare workers in every

environment.

Methacillin resistant

staphylococcal aureus (MRSA)

Proactive management:

Consider every source contaminated

Isolate all new admissions until proven negative of MRSA carriage

Pre-admission screening

If at all possible manage patients away from healthcare environment

if known positive.

Have robust process of screening :

Three consecutive negative screens

Each swab taken on different days

Swabs to be from more than one site on each screening

When MRSA has been identified in an environment:

Identify the source

Isolate with barrier nursing

Treat infected patients and staff

Terminal clean

Close ward or hospital

Health and Safety

Health and Safety is both the responsibility of both the employer and the employee,

stated within the Health an Safety at Work Act 1974.

Employers have a duty to maintain Health and Safety standards and have to take

reasonable steps to ensure the health safety and welfare of their employees at work.

Health and Safety Obligations

As an employee, you have a duty to take reasonable care of your own and other’s

health an safety. Employees must read and be familiar with :

Fire policy

Health and Safety manual

Infection control policy and procedure

Risk Assessment:

Employers must conduct regular risk assessments in the areas of work

In the year 2004/05, the Health and Safety Executive reported that in the UK, 220

workers and 361 members of the public were killed, and 363,000 people suffered an

injury due to accidents at work.

Needlestick Injury

A needlestick injury is any injury where the skin has been breeched with an infected sharp. This can include grazes as well as puncture wounds.

Similarly, splashes of blood or blood stained fluid into the eye is considered as carrying the same risk but of a different order.

Following a mucocutaneous exposure, via the mucous membrane, the average risk is estimated to be less than one in one thousand.

Where intact skin is exposed to HIV infected blood, no risk of HIV transmission is considered.

With HIV/AIDS, the chance of contracting the infection from a needlestick injury is one in 300, whereas with hepatitis C it is one in 30 and hepatitis B it is one in three.

More than a third of all incidents happen after the completion of procedures such as cannulation and phlebotomy, often as a result of resheathing needles. Health professionals should not under any circumstances resheath needles.

Needlestick Injury

The Occupational Health Department has a vital function in maintaining the

well being of staff. The department also responds to issues of health and

risk that have an impact on the individual employee in the workplace.

The chronology of care provided by Occupational Health Departments

begins with the pre-employment interview, which is both surveillance and

proactive, providing:

*Advice and guidance

Vaccinations, for example Hepatitis B

Subsequently Occupational Health manage issues that can arise, including:

Work related injury or stress.

Latex allergy

Needlestick injury

Confidential advice on any health problem

Occupational Health

A Needlestick Injury is an Emergency

Stop what you are doing immediately

Force the wound to bleed

Wash under running water

Report immediately to your immediate manager

Report to Ocuppational Health/ Accident and Emergency (as per protocol)

Needlestick Injury and Post Exposure Prophylaxis (PEP)

Consider with the Accident and Emergency clinician/Occupational Health

clinician whether or not to take PEP.

This is a short course, generally around three months, of anti-retroviral triple

therapy which is thought to be of value in preventing seroconversion when an

individual has been expose to the HIV infection.

The most usual regime offered is a three drug combination of:

*AZT

*3TC

* Indinavir or Nelfinavir

These drugs are started immediately. A case control study amongst healthcare workers exposed to HIV has found that the administration of AZT for four weeks after exposure was associated with an 80% reduced risk of seroconversion.

AZT treatment at this stage is believed to block the infection of immune system cells by HIV, so prompt AZT treatment is likely to block the establishment of HIV infection in an individual who has been exposed to the virus.

It is assumed that a combination of two or three drugs may be even more effective than AZT alone at blocking HIV infection.

The Decision to commence PEP

Risk assessment:

Was the donor patient HIV positive?

Was the patient known to have a high viral load at the time of inoculation?

Was the injury received a deep injury from a large diameter needle?

Despite the benefits of PEP, there is evidence that the standard regime of AZT, 3TC and Indinavir is poorly tolerated.

Nine out of 18 healthcare workers at three London hospitals who commenced this regime stopped or changed therapy due to side effects within four weeks.Six of the nine who started Indinavir required more than two weeks off work. Among the other 9, only one required more than 7 days leave. There were no discontinuations among the five people who received saquinavir.

PEP – Department of Health guidance

If exposed in the course of your work you may well have access to triple therapy on site which could save time.

Local policy will include instructions to inform occupational health in the instance o exposure.

Training on prevention of needlestick injuries and post exposure procedures, including AZT treatment, should also be included.

Ideally administration of PEP, should commence within1hour of exposure. If not at least within 24 hours of exposure.

All NHS Trusts should have a post-exposure policy. Starter packs of triple therapy should be available on site for use following occupational exposure.

Swine Flu

Source: NHS Annual Audit 2007/008

Health Inequalities

Continence Care

• All patients in the hospital with bladder or bowel problems will be offeredappropriate assessment, treatment and management if they wish. Thiswill be done sensitively with respect to their privacy and dignity.

• Nursing and medical staff will be trained to carry out baselineassessments on patients with bladder and bowel problems and will knowwhen to refer to appropriate specialists.

• Regular training of staff will be provided and will be based on recognisedbest practice statements and national guidelines. Patients will have accessto health care professionals with knowledge of treating and managingbladder and bowel conditions; treatment and management will be evidence based, in line with best practice statements and nationalguidance.

• Products available to manage incontinence will be used as necessaryafter initial assessment. These products will be recognised as beingeffective and staff will be trained and competent in their use.

• Regular audit of continence assessment and treatment will be done inorder to monitor and improve the service. This will also apply to continence management products used within the Trust.

• Patient will be discharged with adequate supplies of continenceproducts to meet their immediate post-discharge needs; they will be referred to appropriate community services for further assessment andsupply.

Continence Care

NHS Cuts

Voluntarism

Staff Assault

ThankThank YouYou!!

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