ORGAN DONATION A responsibility for all? By Dr Patrick Morgan
MOUTH CARE MATTERS Improving oral healthcare By Ms Mili Doshi
P.3
P.5
PLUS: Written by healthcare professionals for healthcare professionals
• Improving consent to blood transfusion P.4 • Improving outcomes for patients with dysphagia P.7 • Bone MDT – the way forward P.9 • Case study from the Board P.10
Vol.1 Issue 4 2015
Rocking the boat and staying in it: how to succeed as a radical in healthcare By Helen Bevan
Chief transformation officer NHS Improving Quality
A
not through the complacent adjustment of the conforming majority but through the creative maladjustment of a nonconforming minority’. I believe the hope of healthcare rests with the non-conformists, the radicals, the heretics and mavericks in our midst.
nyone who chooses to be a change agent or improvement leader in healthcare, doesn’t choose an easy life. There are so many So who are the radicals in forces opposing the changes we want healthcare organisations? to see; a system that rewards people for Research by Debra Meyerson ‘keeping the trains running’ rather than shows that the most effective radical change, those with the power radicals are those who have and/or a vested interest in keeping the learnt to oppose and conform at status quo, colleagues and leaders who the same time. Or, as she puts are sceptical, apathetic or it, ‘they are able scared of change. Many to rock the boat times in my career in and yet stay in it’. “I believe the improvement I have felt These are change isolated, vulnerable and leaders who hope of healthcare stand misunderstood. People up to challenge the have treated me like some rests with the status quo when they see kind of oddball when I there could be a better non-conformists, way. have craved to be taken They develop the seriously and appreciated the radicals, ability to walk the fine for my efforts as a line between difference the heretics and leader of change. Yet big and fit, inside and outside. mavericks in our These leaders are driven by change only happens in healthcare organisations their own convictions and midst” because of heretics and values which makes them radicals; the courageous, credible and authentic to passionate people who are willing to others in their organisations. take responsibility for change, who support their organisation in its mission Most importantly of all, they take but also challenge the status quo. action as individuals that ignite broader collective action that leads to big As Martin Luther King described it: change. These leaders already exist in ‘The saving of our world . . . will come, every healthcare organisation, in many
different roles and multiple levels. They aren’t typically the chief executives or senior clinical leaders, yet the impact of their change activities are often just as significant. In NHS Improving Quality’s White Paper1 The new era of thinking and practice in change and transformation: A call to action for leaders of health and care, Steve Fairman and I identify the current implications and opportunities for leaders, rebels, radicals and heretics of our health and care world. We also saw so many examples of this on NHS Change Day 2014, where organisation-wide and personal change efforts led to tangible improvements for large numbers of patients initiated by Continued page 2
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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 E: maxine.may@sash.nhs.uk Medical director Dr Des Holden
Consultant physician Dr Natalie King E: natalie.king@sash.nhs.uk Consultant oncoplastic breast surgeon Miss Shamaela Waheed E: shamaela.waheed@sash.nhs.uk Head of library and knowledge management Rachel Cooke E: rachel.cooke@sash.nhs.uk Continued from page 1
grass roots frontline leaders. It’s not just organisational. If each of us makes one small change, together we can change how the world works. Lois Kelly* has developed some fantastic resources for rebels at work and I would recommend a trip around her website to all healthcare radicals. Helpfully, she makes the distinction between a rebel and a troublemaker and I have adapted her table (figure 1). As rebels, we continuously seek innovative new ways of delivering care. We are committed to the patient-centred mission and values of our organisation. We are driven by our passion for TheJournal@sash.nhs.uk
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ur lead article talks about achieving change and staying in the boat – necessary to see change through. However, maybe a boat is not what we actually need and if we are spending a lot of energy staying in it we will spend less in realising we need something else. Change does require bravery and tenacity but it also requires a vision of what the better looks like. We could discuss whether our 3600 staff are all brave and tenacious but what I do not think is debatable is that they are all experts in their area of work and their contribution to care. My PhD supervisor used to tell me that ideas we’re cheap to which I usually replied, ‘but not worthless’ His main point was that if they remained ideas, without a plan, then at best they were dreams. To achieve our goal of becoming outstanding we need two things – a vision or dream and the drive to realise it. Last month we signed contracts with a company who are putting
E: des.holden@sash.nhs.uk
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CHANGE TAKES A VISION AND THE DRIVE TO REALISE IT
better care for patients. We are optimistic about the future, the potential for change and see many possibilities for doing things in different ways. We generate energy for change which attracts others to unite with us for a common cause Troublemakers also challenge the status quo but in a way that is very different to rebels. Troublemakers complain about the current state of affairs but their focus tends to be around their own personal position rather than achieving the goals of the organisation. They are angry about how things are and don’t have much confidence that things will get better in the future. They alienate other people because if others link with them, troublemakers will sap their energy. This just confirms what troublemakers probably know already– they don’t belong. There are a couple of points I wanted to make about rebels and troublemakers. Firstly, many organisational leaders view anyone who challenges the status quo as a troublemaker [and therefore this tendency must be consciously guarded against]. Secondly, lots of change leaders in healthcare start out as rebels but their voice doesn’t get heard, they begin to stridently question the status quo in a manner which is radical and self-defeating and they cross the line from rebel to troublemaker. As
The Journal Vol.1 Issue 4 2015
in place a system whereby your good ideas, arising from your unique expertise in the areas where you work can be articulated. The Induct system, which is also being put in place in the Brighton health economy and is used successfully elsewhere will help you jot down those unique ideas and insights and let us pick them up and work with them. Watch out for the launch of the system and the call for people to help evaluate and prioritise the very best. Please be brave and tenacious and please also dream (productively).
Dr Des Holden Medical director
rebels, we have a responsibility to look out for this and try to prevent it happening by building relationships and forming alliances with others who challenge the status quo.
Figure 1 Rebel Troublemaker Create complain mission-focused me-focused passion anger optimist pessimist energy-generating energy-sapping attract alienate possibilities problems together alone *Source: Adapted from Lois Kelly www.foghound.com Footnote: 1/ White Paper: The new era of thinking and practice in change and transformation. Available at: http://www.nhsiq.nhs.uk/resource-search/ publications/white-paper.aspx
Helen Bevan (@HelenBevan on Twitter) works with NHS Improving Quality, the national improvement team for the NHS in England as Chief Transformation Officer in the Horizons Team. Helen also edits The Edge - a free virtual hub for all who are committed to bold thinking and swift action for change in health and care. Subscribe online at: http://theedge.nhsiq.nhs.uk
Under the spotlight…
Organ donation – a responsibility for all? By Dr Patrick Morgan
Consultant in intensive care and anaesthesia
and Emma Little Specialist nurse in organ donation
O
rgan donation is a topic that is never far from the front pages of newspapers and is frequently discussed at all manner of forums. There are currently around 6876 people (of all ages) waiting for life-saving and lifealtering transplantation of donated organs. Every day three of these people die waiting. The success and survival rates following transplantation continue to improve year on year. For the first time last year, the transplant list has fallen in number. Every day 12 potential organ donors die but only four donate their organs1. Each organ donor could benefit nine recipients whereas a tissue donor could help 50 others. Since April 2014, 1067 people have donated their organs to a total of 2778 recipients nationwide.
bereavement - whereas many that refuse donation end up regretting that decision 2, 3. Most of us believe we live in an egalitarian society, therefore the decision to admit the probable organ donation patient to ICU for optimisation and care should be more straightforward than it is. It is often seen as admitting a patient with no chance of survival and who is facing imminent death ahead of a patient who will benefit from what ICU has to offer. This brings into question the views and wishes of the patient who is dying, especially if they are one of the 21 million or so people (31% of the population) who wish to donate.
“In the UK... we have the highest rate of families refusing to allow donation to proceed, even if the potential donar is on the organ donor list”
Age is not a barrier for donation. In January 2015, a six day old child from London donated both her kidneys and some liver cells. The oldest organ donor in the south east region is 85. The presence of malignancy and viral infections, such as HIV and hepatitis, are not necessarily exclusions to organ donation.
In the UK we have one of the lowest donation rates in Europe and the biggest barriers are non-identification and nonreferral of potential donors and unplanned discussions without involving the specialist nurse in organ donation (SNOD). We also have the highest rate of families refusing to allow donation to proceed, even if the potential donor is on the organ donor list. This suggests that as healthcare professionals, we should involve experienced staff such as the SNOD who is an expert in such discussions, early on in the process. NICE has recommended that in all clinical situations where end-of-life care is considered, that organ donation is discussed. An important but overlooked element in the donation process, is the positive effect families often report that it has on their own
organs as they have already stated that this is their wish. Accordingly, to not try our best to allow this to happen is against their wishes. These are contentious issues but ones that we face regularly and we have to make difficult decisions around the different facets of patients’ needs. Across the NHS there is a drive to increase the number of people on the organ donor register and to increase awareness of it. At SASH we hold a memorial to those who have donated their organs in order to improve the lives of others and to save some lives when we couldn’t save their own. We believe that the altruistic nature of donation in helping others without the desire for reciprocity or compensation, deserves more public recognition for their sacrifice.
“An important but overlooked element in the donation process, is the positive effect families often report that it has on their own bereavement”
Difficult decisions need to be made about prioritising each individual case on its merits. Who would agree that a 78 year old potential organ donor patient with a catastrophic intra-cranial haemorrhage be admitted ahead of a critically ill 36 year old patient struggling with respiratory failure due to pneumonia? The simple answer is to admit them both and do the best we can for both of them according to Rawls principle of distributing resources to everyone’s advantage. Also, if the 78 year old patient is on the organ donor register then it could be seen to be in their best interests to donate their
Further information: www.organdonation.nhs.uk Footnote: 1/ NHS Blood and Transplant. Organ donation and transplantation activity report 2012/13 2/ Morais, M. et al.(2012) ‘Families who previously refused organ donation would agree to donate in a new situation: a cross-sectional study’, Transplant Proceedings, 44, pp.2268-71 3/ Omrod, J.A. et al. (2005) ‘Experiences of families when a relative is diagnosed brain stem dead: understanding of death, observation of brain stem testing and attitudes to organ donation’, Anaesthesia, 60, pp.1002-8
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Clinical case
Clinical Patient-centred Update care
Improving consent to blood transfusion: The ICAG-pad By Simon Goodwin Specialist practitioner in transfusion
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hy should we have to improve consent to blood transfusion, don’t we have enough to do already? An understandable and reasonable question or view point. However, the advantages to improving consent to blood transfusion are valuable. Improving consent to blood transfusion is the most important of a number of initial approaches we are taking to implement the new national initiative of patient blood management (PBM). The evidence is clear, if we give less blood, we will have fewer complications, faster recoveries and shorter stays in hospital. Improving consent to blood transfusion supports PBM because: The decision to transfuse is automatically improved because this has to be justified to the patient. In order to mitigate the risks of transfusion the clinical team will be making a direct promise to follow transfusion policy; hence the transfusion will be safer. How can we find time on a typically busy day to improve consent to blood transfusion? An excellent question which poses a challenge. However, the responsibility to improve consent to transfusion belongs to the whole multidisciplinary team(MDT) and not
just the authorising doctor. The goal is not for the patient to be a transfusion expert but we do need to ensure that the patient understands why we recommend a blood transfusion and how the benefit outweighs any potential risk. Key principles are that the process should be simple, manageable and consistent; everyone involved should use the same language, e.g. you may get a high temperature rather than ‘pyrexial’, ‘febrile’ or ‘fever’. The ICAG-Pad is a tool that has been devised within the SEC regional transfusion committee to support the process and to promote consistency of approach. The pad is a combination of ideas. The pages are sticky labels with tick boxes to efficiently record in the clinical notes the indication for transfusion and that verbal consent has been obtained. The front and inside cover of the pad is an aide-memoir to reduce all the risks of transfusion into four risk categories: • Human / systems error • Transfusion related circulatory overload • Adverse immune responses • Transfusion transmitted infection.
By Dr Mark Salmon ST7 Anaesthesia
T
The Kent, Surrey & Sussex Air Ambulance Trust (KSSAAT; Helicopter Emergency Medical Service (HEMS) aircrafts operate 365 days a year from two bases. The crew, comprising a minimum of one doctor and one paramedic, can deliver at the scene a number of specialist clinical procedures, such as general anaesthesia, advanced pain relief and when required, blood transfusions and surgical interventions - normally only available in the resuscitation area of a hospital emergency department. 4
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By Ms Mili Doshi Consultant in special care dentistry
wards through the year, with support from myself and our transfusion champions with immediate benefit. The process is not absolute; different patients have different needs. Even when the patient is not able to give consent prior to transfusion, this discussion can be revisited if the situation changes and consent is feasible post transfusion. Once this system is embedded in normal practice, patients and staff will reap the rewards. Footnote: Advisory Committee on the Safety of Blood, Tissues and Organs (SaBTO), Patient Consent for Blood Transfusion, October 2011, British Committee for Standards in Haematology, Guideline on the Administration of Blood Components, December 2012.
Each of these categories can be mitigated to facilitate ownership and the promise to follow safe transfusion policy.
NHS Blood and Transplant, Patient Information Leaflet on Patient Blood Management.
The pad will be introduced onto our
Serious Hazards of Transfusion. Annual SHOT Report 2013.
Working in partnership to reduce blood wasteage Since early 2013, KSSAAT has carried blood for the resuscitation of patients who are severely bleeding. Each day, two specialist cool boxes are conditioned and packed here at East Surrey Hospital (ESH), containing four units of packed red cells, associated paperwork and a temperature data-logger. Each day, the two boxes are delivered to and collected from the KSSAAT base at Redhill Aerodrome by the service by emergency rider volunteers (SERV). Unused blood is then returned to us and subject to quality control, is returned to the blood bank for use. I recently carried out an audit examining blood use, focusing on frequency and case mix, blood wastage and record keeping. In
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‘MOUTH CARE MATTERS’IMPROVING THE ORAL HEALTH CARE OF HOSPITALISED ADULT PATIENTS
the period between July 2013 and December 2014, nearly 100 seriously injured patients received pre-hospital blood transfusions. In this time nearly 5000 individual units of blood were checked-out from the laboratory in ESH and delivered to KSSAAT. Around 200 of these were given to patients and the others returned for routine use at the hospital. Only 12 units (0.27%) were wasted and 100% of the units given to patients were traceable due to accurate documentation by ESH and KSSAAT. The unit wastage rate appears to be incredibly low, but we should always continue to strive for zero. With more helicopter emergency services interested in carrying blood, many organisations will be looking at the partnership between ESH and KSSAAT as an example of what can be achieved.
T
he 2014 chief of hospitals quality report recommended an area of improvement that the hospital should take to ensure that ‘a review of mouth care is undertaken so that staff are clear where this should be recorded in the patient’s care record.’ Recent hospital audits have shown we need to improve upon the number of mouth care assessments undertaken by nursing staff.
Oral health is linked to many systemic diseases including cardiovascular disease, diabetes and dementia1. It is now more widely accepted that there is an association between hospital acquired pneumonia and respiratory pathogen in the oral cavity and mouth care interventions can reduce the incidence of hospital acquired pneumonia in high risk groups2. Our Mouth Care Matters team is leading mouth care training sessions and ward based training, open to all nursing staff. These will be developed and rolled out across all Health Education Kent Surrey and
Sussex (HEKSS) trusts. The three hour interactive sessions will explain why mouth care is so important for patients who are hospitalised, how nurses can recognise and support the patients who need assistance with caring for their mouths and how to carry out and record mouth care assessments. SASH has recently secured funding from Health Education England for four dental care professionals. This small team will be based on the wards and provide specialist advice, support and training for all clinicians working across the hospital to improve the holistic care for our patients. Further information: Anyone who would like further information on the training please contact mili.doshi@sash.nhs.uk Footnote: 1. Azarpazhooh, A., Leake, J.L. (2006) ‘Systematic review of the association between respiratory diseases and oral health’, J Periodontol, 77, pp.1465-82. 2. Mustapha, I.Z., Debrey, S., Oladubu, M. et al. (2007)’ ‘Markers of systemic bacterial exposure in periodontal disease and cardiovascular disease risk: a systematic review and meta-analysis’, J Periodontol, 78, pp.2289-2302.
IMPROVING THE EXPERIENCE OF PEOPLE WITH CANCER By Jane Penny
Macmillan lead cancer nurse
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eople with cancer regard having a specialist cancer nurse to guide them through the pathway of treatment - to answer their questions and support their family - as the most important in improving their cancer care. This is the most important finding from the most recent National Cancer Patient Experience Survey (NCPES) carried out at the final quarter of 2014. Those with a cancer nurse specialist (CNS) were far more positive about their care and treatment than patients who did not have one in every survey undertaken since 2010. In the 2014 survey, there were significant differences on every question, bar one, between those who have a CNS and those who don’t. Groups that report less positively include young people, people from ethnic minorities, people with learning difficulties and non-heterosexuals. Those attending London hospitals traditionally report a worse experience, as do those aged under 25 and in some cases over 75s. Women tend to be less positive in general to men, as are those with rare cancers, patients with mental health issues and where the cancer has not responded to treatment. In general, people with breast, colorectal and prostate cancer gave more positive views whilst poorest scores were obtained from those with urological, sarcoma and brain central nervous system cancers. So what are the implications for SASH? SASH is reported currently as a middle ranking trust. We have shown improvement in some areas, including: receiving information about free prescriptions, bringing a friend to appointments, information on support groups, obtaining financial help and receiving help postdischarge. However, there is more work to do and we are committed to improving the experience for patients and their families. As the activity within cancer services increases, so we are working with Macmillan to increase our CNS team and this year we will be recruiting an additional CNS to work in urology and haematology. The formation of the Cancer Board in 2011 has helped to bring cancer teams from across the Trust together and in 2014 Dr Ed Cetti was appointed in his new role as chief of cancer services. In 2015 we will be taking this one stage further and working as part of a wider cancer alliance patient experience project to share best practice and improvements across the whole patient pathway.
Footnote: Since its origin in 2010, the NCPES has become one of the largest cancer surveys programmes in the world. The most recent survey was sent to every cancer inpatient and day case patient treated between September to the end of November in all 153 hospital trusts treating adult cancer patients in England. For more information about the survey please contact jane.penny@sash.nhs.uk
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Clinical effectiveness Audit Research & development E ducation & training
IMPROVING OUTCOMES FOR PATIENTS WITH DYSPHAGIA
John Hammond poster competition Chief of surgery
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arlier this year, anaesthetists past and present were invited to present posters for the annual John Hammond* poster competition. This took place at the North Downs & Weald Regional Anaesthetic Meeting where guest speaker Dr Magnus Nelson of Kent, Surrey & Sussex Air Ambulance Trust spoke about the success of new innovations which have improved service provision and the impact this has for us here at SASH (see page 4). Over 25 posters were submitted on work undertaken in audit, a service improvement project or interesting case study. The aim of the competition is to celebrate the excellent work and contribution to clinical practice. The posters on display were great collaborative examples of work between various members of staff with the authors varying from FY1 doctors to consultants. The competition was judged by senior members of the anaesthetics team with an additional prize at stake for the best poster as judged by our trainees. Marks were awarded for content and appearance with extra marks for the message or action plan.
Dr Fiona Lamb
Consultant anaesthetist and intensivist
The winners were: First prize (£75) Dr Victoria Ferrier, Dr Naomi Lucas, Dr Fred Sage and Dr Simon Parrington – Improving our fascia iliaca block service for patients with a fractured neck of femur (FNOF). Fascia iliaca block is a nerve block administered as soon as possible after admission to hospital with a FNOF. National guidance recommends this pre-operatively to reduce reliance on opiates for pain relief. An audit of the efficiency of the service provided by the anaesthetists was carried out and the reasons for delay examined. A total of 89% of requests were found to be out of hours when there were least staff available. The target was to block within 120 minutes of request; this was only achieved in 36% of patients with the most common delay being due to the fact that the anaesthetist was in theatre. In light of these findings a change was made to adapt the pathway to minimise non-staff delays. Second prize (and trainees favourite poster) (£50) Dr Mark Salmon - Pre-hospital blood transfusion
Team lead SLT (acute inpatients) and clinical lead SLT (adult dysphagia)
and Dr Fred Van-Damme Consultant anaesthetist
This poster reported on an innovative project between SASH Blood Bank and KSS Air Ambulance Trust to supply blood for pre-hospital emergency use. The audit demonstrated a low level of wastage and reported that blood has been used with the emphasis on safety and good record keeping - ensuring the mandatory traceability documents are completed and that the cold chain for the units is adhered to with specially designed temperature controlled boxes.
Dr Nina Ashraf-Kashani (ST5 Anaesthesia), Dr Victoria Ferrier (Regional Anaesthesia Fellow), Dr Mark Salmon (ST7 Anaesthesia) with guest speaker Dr Magnus Nelson Director Kent, Surrey and Sussex Air Ambulance Trust (KSSAAT) Healthcare NHS Trust
Pre-hospital Blood Transfusion Dr Mark Salmon MBBS FRCA DipIMC Kent, Surrey and Sussex Air Ambulance Trust (KSSAAT) Surrey & Sussex Hospitals NHS Trust (SASH)
BACKGROUND Since early-2013, Kent, Surrey and Sussex Air Ambulance Trust (KSSAAT) has carried blood for the resuscitation of severely bleeding patients.
PROCESS Specialist cool-boxes are conditioned and packed at East Surrey hospital (ESH). Each box is sealed and contains four units of Group O Rh -ve packed red cells, associated paperwork, and a temperature data-logger.
DELIVERY
METHODS
Two boxes are delivered to and collected from the KSSAAT base by the Service by Emergency Rider Volunteers (SERV) every day. Unused blood is returned to ESH and subject to quality control is returned to blood bank for use.
- Retrospective analysis of the KSSAAT HEMSbase patient database and the ESH transfusion department records. Establish the frequency of pre-hospital blood use. - Describe the case-mix, demographics, geography and mechanism of injury. - Including all patients treated by KSSAAT crews from the Surrey base during the period 01/07/2013 to 31/12/2014
OBJECTIVES Examine blood use so far: - Frequency and case mix. - Blood wastage. - Record keeping.
PATIENT RESULT AGE RANGE 21
RESULTS 24
Third prize (£25) – Dr Nina Ashraf-Kashani, and Dr Barbara Bray - A charter for our intensive care units.
Patients treated:
1705
Blood Given: Male: Female : Mean age: (M) Mean age: (F)
83 59 24 40.1 44.4
Mean units: Median ISS:
2 34
Mean PS:
62.8
(Injury Severity Score)
(Probability of Survival)
This idea was taken from a recent BMJ article about Joan’s bill of rights, written by one patient’s relative after her sister’s stay in an intensive care unit in the USA. In this, she lists the level of commitment of intensive care (ICU) staff to patients and their families that should be in place to ensure that the patient is always at the heart of their care. The authors have developed their own charter which will be displayed throughout the ICU. It includes simple things such as introducing oneself when entering a bed space each time - important
Ground transfer 38
13 6 0 0-9
Aircraft transfer
13
12 6
5
10-19 20-29 30-39 40-49
50-59 60-69 70-79
2
1
Deceased
80-89 90-99
JOB LOCATION
JOB TYPE Accidental injury 12
(n=29)
(n=29)
24
Intentional self-harm 9 RTC 57 Medical 3 Assault
TIME OF DAY 2 5 3 2 2 3 5 2 2 6 3 3 1 5 8 5 6 3 7 4 2
BLOOD WASTED Units allocated:
4368
DISCUSSION
Units transfused:
191 (4.37%)
This collection of data represents 18 months of an innovative project made successful by the hard work of many
Units wasted:
12 (0.27%)
people in many organisations. This will provide a useful baseline for future comparison.
Traceability:
100%
- Blood has consistently been used throughout the period in a wide range of job types, patients and scenarios.
DOCUMENTATION 1 Patient not found in KSSAAT records
- The unit wastage rate appears to be incredibly low, but all parties should continue to strive for zero. - Documentation was largely complete. Again the target must be zero errors but current procedures appear to be effective.
2 Patients recorded name mis-match
- With more HEMS services beginning to carry blood and more interest in data collection and outcomes; future
1 Patient number of units mis-match
work should try to establish evidence of benefit to patients and patients at whom this precious therapy should be
1 Patient incorrect dose in KSSAAT database
targeted.
Total errors: 5 (6%)
Many thanks to Karen Allnutt and the team at the Blood Transfusion Laboratory, East Surrey Hospital, and to Gary Wareham and the team at Kent, Surrey & Sussex Air Ambulance
as the patient may have impaired memory - and respecting sleep time that may have a profound effect on the patient’s subsequent recovery. Footnote: 1/ Dr John Hammond was a consultant in anaesthesia and intensive care at East Surrey Hospital from 1984 until his untimely death from malignant melanoma in 1995. He introduced modern technology and ways of working to our early intensive care unit introducing renal replacement therapy and invasive haemodynamic monitoring. He was an enthusiastic educationalist and a brilliant teacher as a clinical tutor. In gratitude our anaesthetic department and lecture theatre in the PGEC is named after him. John died in 1995 and every year in the 20 years since, the John Hammond Department of Anaesthesia and Pain Management has held this poster competition in his memory.
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mproving outcomes for patients is always our priority. Over a trial period last year, we carried out a study to establish the effect of speech and language therapy (SLT) intervention on patients with dysphagia.
Although the importance of SLT involvement with patients with oropharyngeal dysphagia is well supported by research1 we decided to examine the impact at local level. The SLT Dysphagia Outcome Measure looks at changes in the patient’s dysphagia severity and dysphagia risk. It compares scores in these areas prior to SLT involvement, after the initial SLT intervention and at discharge from the SLT service.
Surrey and Sussex
23 22 21 20 19 18 17 16 15 14 13 12 11 10 09 08 07 06 05 04 03 02 01 00 :0 :0 :0 :0 :0 :0 :0 :0 :0 :0 :0 :0 :0 :0 :0 :0 :0 :0 :0 :0 :0 :0 :0 :0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
By Dr Barbara Bray
By Claire Butler
SLT intervention could reasonably be expected to have more influence over changes in risk than over changes in severity and this article is limited to the results with regard to dysphagia risk.
primary diagnosis, 77% had a diagnosis of stroke and 14% had a progressive neurological condition. Of the total patients studied, 15% had a known deteriorating condition (including progressive neurological conditions, dementia and learning disability). On analysis 80% of patients had an improvement in their dysphagia risk immediately following initial SLT intervention. By the time of discharge from SLT this had risen to 86%, with 12% of patients seeing no change in their dysphagia risk status and only 2% experiencing deterioration.
Conclusions This preliminary study of dysphagia outcomes demonstrated that SLT intervention has a positive impact on the risks associated with dysphagia. These results were seen across a range of diagnoses, for patients under the care of all SLT specialities. Although not addressed in this article, “Speech and positive results were also for changes in language therapy observed dysphagia severity.
(SLT) intervention has a positive impact on the risks associated with dysphagia”
Dysphagia risk is measured by looking at a combination of aspiration risk (on current oral intake), nutritional risk (which incorporates Malnutrition Universal Screening Tool (MUST) score) and other risks, including impact on social function, and quality of life. A combination of all these factors is scored on a 12 point scale.
As a result, improvements in dysphagia risk indicate the combined effects of the following: • Reduced aspiration risk. • Improved nutritional intake. • Reduced impact of the swallowing difficulty. • Improved understanding of the swallowing difficulty and how best to manage it. Findings We studied data from 81 patients over a two month trial period, across the three inpatient SLT teams, covering the acute stroke unit (47%), critical care (1%) and the remaining wards (52%). Medical diagnosis was split almost equally between neurological and non-neurological cause. Of the 53% with a neurological
It is reassuring that although 15% of patients studied had a deteriorating diagnosis, only 2% demonstrated increased risk associated with their swallowing once they were under the care of the SLT.
We are now adapting the dysphagia outcome measure to involve more patients in identifying how their quality of life has changed following SLT intervention. We intend to repeat the dysphagia outcome measure regularly to ensure that we maintain and further improve the high quality of SLT dysphagia service which this tool has demonstrated. We would encourage other services to measure the outcomes of their own intervention as our experience is that the benefits of doing so far outweigh the time taken to complete the process. Further information: Please contact Claire.butler@sash.nhs.uk Footnote: 1/ Leslie, P., Carding, P.N., Wilson, J.A. (2003) Investigation and management of chronic dysphagia, BMJ, 326: 433-436
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Reflective practice
Collaborative practice
I’m sorry......it’s cancer By Dr Anna Coates Junior doctor
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don’t think I’ll ever forget my first attempt at breaking bad news. In fact, if anyone were to refer to a textbook, I’m not sure it could have gone worse. The day in question occurred within my first month of being an F1 doctor at another trust. A patient came to hospital with her daughter. She had no appetite and was dehydrated so admitted for fluids. However, four days later after failing occupational therapy assessments, it was clear there was a deeper problem; a CT head scan was carried out. At the end of the day I checked the scan results; it showed widespread brain metastases. I picked up my bag to leave, but walked straight into the patient’s daughter. “What did the scan show?” were her words.
I froze. It was completely the wrong time and setting to break bad news.
I personally felt guilty and completely inadequate.
I remember being told as a medical student how important this conversation was but her daughter was looking at me - her mother’s doctor - with panic written all over my face. She knew it was bad news. “It’s cancer” I said. The words just came out and she fell to pieces crying, “I can’t lose my mum.”
In retrospect, it was a huge privilege to be able to have that conversation. It gave me a chance to form a special relationship with the family and I felt a shift from feeling overwhelmed, to actually feeling like a doctor. I don’t think for one moment that breaking bad news is ever going to be easy. The after effects are something people don’t like to talk of and as a junior doctor it’s not something you feel equipped to do, but perhaps embracing emotion humanises you as a doctor and may result in a better outcome than you had anticipated.
Everyone has someone that means the world to them, and just the thought of losing someone so precious is horrifying. For me it’s also my mum and so looking at her I completely understood her despair. What was worse was it was me that had taken her mother away from her. I had delivered the news. If someone did that to me I don’t know how I would react. A BMJ article highlights that the moment bad news is delivered is ‘a defining point in the remainder of that person’s life.’ For a doctor of any grade that’s a huge responsibility.
Permission was previously sought from the patient to share medical information so patient confidentiality was not breached.
If you have a reflection that you would like to share please contact maxine.may@sash.nhs.uk
By Dr Donald Lyon
Consultant microbiologist
and Amy Lee
Lead antimicrobial pharmacist
J BONE MDT- THE WAY FORWARD IN ASSESSING BONE HEALTH By Pamela Trangmar Physician associate
EFFECTIVE COMMUNICATION – AN UNDERVALUED SKILL? Cathy White
Patient experience survey manager All healthcare professionals (HCPs) have to talk about difficult situations on an almost daily basis, turning complex and often uncertain information into something that can be understood by patients and their families and delivered with empathy and compassion. This may be when they are busy and under pressure. Whilst most of our HCPs communicate effectively, Your Care Matters feedback reveals that a proportion of negative feedback stems from poor communication during patient interactions: “I found the doctors rather intimidating and difficult to talk to, and didn’t receive answers that helped me.” “Unfortunately, one unfamiliar doctor, not one of my regular team.…used cold, clinical language that distressed and confused me.” Of course, we recognise that these comments need to be taken within the context of the large numbers of commendations and positive feedback that we receive every month, but each one represents a patient that has left us dissatisfied with the care, or information, they were given. In the worst scenario, ineffective communication can lead to issues with informed consent. 8
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Patients’ confidence can be gained, or lost, within the first few minutes of a consultation and the benefits of establishing a trusting relationship are evident:1 • A patient’s problems are identified more accurately • Fewer clinical errors are made • Patients are more satisfied with their care and can better understand their problems • Patients are more likely to comply with treatment or lifestyle advice • Patients distress and their vulnerability to anxiety and depression are lessened • The overall quality of care is improved by ensuring that patients’ views are taken into account • Patients are less likely to make a complaint According to Fong and Longnecker2: ‘Doctors with better communication and interpersonal skills are able to detect problems earlier, can prevent medical crises and expensive intervention and provide better support to their patients. This may lead to higher-quality outcomes and better satisfaction, lower costs of care, greater patient understanding of health issues, and better adherence to the treatment process.’ So what can we do to improve the quality of patient interactions? Here are some simple guidelines we would like to reinforce across the Trust:
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Summary of ‘top tips’2 • Clear introduction (using ‘hello my name is’... and asking the patient what they would like to be called) • Use clear language: avoid jargon • Be conscious of your non-verbal communication. Maintain eye contact • Establish a dialogue and ensure patients understand their diagnosis and treatment plan • Be flexible and tailor your approach to the individual patient • Mindful practice: observe your own performance during the consultation • Provide the information that patients want and consider the impact of the person’s condition on their work and home life. • Empathise and listen • Establish trust and rapport • Reflect on the outcomes of your interactions with others Footnote: 1/ NHS Scotland (2003) Talking matters – Developing the communications skills of doctors. Available at: http://www.gov.scot 2/ Fong, J. and Longnecker, N (2010) ‘DoctorPatient Communication: A Review’, Ochsner Journal, 10 (1), pp.38–43. Available at: http://www.ncbi.nlm.nih.gov
THE MICROGUIDE ANTIBIOTIC APP – SUPPORTING ANTIBIOTIC PRESCRIBING 24/7
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nnually we manage around 500 patients with femoral fractures. We are one of only a few trusts nationally with a multidisciplinary team (MDT) bone health meeting to specifically review patients with complex osteoporosis management. In our monthly meetings we review all potential treatment options.
The MDT is a vital link in providing the best possible care to our patients for their continued recovery and fracture reduction in the future. A number of these patients have pre-diagnosed osteoporosis and may already be on bisphosphonate treatment as per NICE guidance1. Sustaining fractures whilst on bone protection (be they typical or atypical) is an area that requires further specialist investigation. Treatment options for management of osteoporosis beyond oral bisphosphonates are: Denosumab and zolendronic acid which inhibit both bone resorption and formation.
zolendronic acid has similar rates of success as Denosumab leading to a 35% reduction in future fracture risk and an associated reduction in mortality. Zolendronic acid is the most potent of the bisphosphonates including Alendronic Acid which is first line treatment in Osteoporosis2. Before treating patients for osteoporosis, it is imperative that screening for secondary causes is carried out and vitamin D levels are normalised. At the MDT a patientcentred discussion takes place and they are often then seen in a clinic setting to discuss their options faceto-face. Footnotes 1/ NICE (2008) Alendronate, etidronate, risedronate, raloxifene, strontium ranelate and teriparatide for the secondary prevention of osteoporotic fragility fractures in postmenopausal women. Available at: www.nice.org.uk 2/ Ishtiaq, S, I, F. and Hampson, G. (2014) ‘Treatment of post-menopausal osteoporosis: beyond bisphosphonates’. J Endocrinol Invest, Epub ahead of print.
ust over one year ago we launched the MicroGuide antibiotic smartphone App to enhance information and support for prescribers. Users are able to access information on dosages - including dosing in renal failure - key side effects, contraindications and allergies. One major advantage of the App is version control, with universal updates to all users. The App supports and promotes good antibiotic prescribing which is urgently needed in the light of increasing antibiotic use and spread of multiresistant organisms. The UK five year antimicrobial Resistance Strategy (2013) identified the optimising of antibiotic prescribing as a key area for action. The App has been enthusiastically taken up, with 2,170 downloads and 7,937 ‘opens’ (the number of times the guide has been accessed) between December 2013 and November 2014. The most frequent ‘opens’ were community acquired pneumonia, moderate/severe (1613), lower UTI (1088), complex UTI (1053) and hospital acquired pneumonia (1015). We plotted these ‘opens’ over this period and found that the App has been used all day, with heaviest use during normal working hours (8am-6pm) but also regular use during evenings and overnight. Usage peaked mid-morning with the nadir being around 5am. Last summer we conducted an online survey of users; 79.2% thought it better than previous intranet-based guidelines, 95.8% found it useful or very useful for their clinical practice, 79.2% used it often or very often, and 87.5% thought it met their information needs. Only 58.3% were aware of the intranet browser version of the app, so there is a need for further promotion of this resource. Of those who fed back comments, a request for further drug dosing tools (e.g. gentamicin dose calculator) was most common.
Further information: The MicroGuide App (Horizon Strategic Partners) can be downloaded from the Apple App store and Google Play. The antimicrobial guidance can also be accessed at http://microguide.horizonsp.co.uk/viewer/sash/adult. To find out more please contact amy.lee@sash.nhs.uk
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Improving our practice
Case study from the Board
Lessons learned
Clinical stories no.2
was then monitored and further doses given correctly. Another incident raised by pharmacy related to trimethoprim being given to a patient on methotrexate as this can abruptly cause bone marrow to shut down causing potential infection, bleeding and anaemia.
Edited by Dr Ben Mearns
Clinical lead for acute and elderly medicine
A case study about how the treatment of one patient with cancer 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. Case 2
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patient with a known diagnosis of cancer was admitted with a deterioration of symptoms and during investigation it became apparent that he had entered the final stages of disease and was terminally ill. After planning for discharge it was agreed the patient would be admitted to a hospice on a Friday. Unfortunately, there was a delay in prescribing the discharge medications which resulted in the booked transport being unable to take the patient to the hospice. No further transport could be arranged and the patient stayed in the hospital until the Monday when he was transferred. The patient died only a few hours later on the day of discharge. End of life care is hugely emotive and has received a great deal of national attention. A national directive stopped the use of the Liverpool Care Pathway as despite many patients benefitting some had it used either inappropriately or with too little discussion. Our Quality Account describes all we have done to improve the care for people who are reaching the end of their lives but while we all know of cases where things have gone well, as a Board we feel there is much more we can do within the Trust and working
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with our partners in community services, hospices, the charitable sector and our commissioners to help patients and their families at a time of great vulnerability.
meetings on a regular basis during which they discuss if things went wrong in patient care and what can be learned from these patients that will help others.
As part of our commitment to seven day working, where the ambition is not to have any patients suffer because of the day of the week when they need care, we are working with Macmillan in the Trust to provide specialised end of life care nursing support every day of the week to in-patients. Currently, this is a six day service and will be further developed to an everyday service through further recruitment. This will help patients be discharged where this is their wish and in their best interest and will provide expert advice to those who are outside hospital but at risk of being admitted if a plan is going wrong. The decision to do this was taken at the Executive Committee for Quality and Risk and was discussed at the Safety and Quality Committee and the Board.
Now that this has become normal practice for medicine and surgical admissions (through leadership from Dr Natalie King and Mr John Grabham), we are moving to be able to look across divisions at themes such as death within a very short time of admission, or deaths after a very long stay. In this way we might be able to look at different parts of patients’ pathways of care and improve them further.
Hospitals are ‘judged’ on their inhospital mortality (HSMR) and on patient deaths while in hospital and within 30 days of discharge (SHMI). The clinical effectiveness committee looks at death in all the categories of admission and diagnosis coded by the Dr. Foster organisation and reviews cases for any area thought to be different than expected. The Trust Board receives these mortality rates on a monthly basis and for well over a year, these have both been lower (better) than expected. While it is good practice to review these figures, the rates do not tell us enough about individual patients’ experience to help drive change. For this reason we have changed the expectation about how we certify death and how we discuss and learn from the deaths of patients in our care. All four of the clinical divisions in the hospital have morbidity and mortality
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Finally, it is relatively easy to overlook small aspects of the complexity of discharging patients - the sequence medication preparation to take away, transport, time of day, discharge summary preparation, information on what to do if, etc. and for many patients this provides only an annoyance. For patients who are at the end of their lives it can take away a significant proportion of the time they have left and can leave an indelible memory for their families and is one of the main causes of complaint and the need to work with families after the care episode has finished.
Rapid end of life (EOL) discharge The rapid end of life discharge home service is a partnership between the Trust and Marie Curie Cancer Care, also supported by St Catherine’s Hospice. This service is currently a five day service and will be moving to a seven day service in May following recruitment of the second EOL care discharge liaison practitioner (DLP). The DLP actively facilitates the process of discharging patients at end of life, with a package of care that supports the patient in either their own home where appropriate, or to another care setting i.e. nursing home. If there is a gap between the date when the care package can be commenced and the date of planned discharge, the project provides health care assistants to support the patient at home, to bridge the gap before the care package starts.
I am delighted to deliver our latest lessons learned. It is very important that we operate a hospital that lives and breathes safety and when mistakes happen (as they will) we report the issue in a no-blame way to identify, act to improve and learn lessons. These stories exist because our staff have a culture of reporting incidents and are always positive to reflect how our whole team puts our patients first.
Identity matters A patient came down to the radiology department to have a CT scan as do many patients every day. The radiology staff quickly recognised that the clinical information on the request did not match the patient in front of them and so prevented a patient from receiving a significant radiation dose and reported the incident. Staff have also reported two other instances of uncertain identity related to stickers placed incorrectly on patients notes and more seriously on blood samples. Stickers are convenient but certainly can be easily stuck incorrectly and always look credible. A further example of mistaken identity arose when a patient with a similar name to the previous occupant arrived into the same bed space. Several members of staff became confused about which medications the patient should be receiving as the packets of tablets from the previous patient remained on the ward. Only with very methodical checking did the problem become evident and the team worked swiftly to resolve the issue. These examples show several ways that mistaken identity can happen and a patient may come to harm. Reassuringly, our team showing dedication to transparency and safety, reported every one of these incidents.
Here are three ways to help us improve safety: • Our IT systems can make ordering tests very easy and we must be vigilant, so take a few seconds before you click ‘sign’ to check the details. • None of us know everything about every drug – the BNF is easy, free and is available as a smartphone App – there’s no shame in checking. • Every time we see a patient or use the notes, just take a few seconds to check name bands and stickers and think – is this the correct patient? Get it right by checking, checking and checking again.
To eat or not to eat How often do our problems arise from poor
communication? It is very frustrating when everyone is doing their job well and yet a lack of clear communication, either written or verbal, leads to confusion. An incident report from the therapy team noted a case when doctors made a decision about swallow safety and feeding for a patient. Unfortunately, they did not write the decision clearly in the notes. This led to confusion on the ward and with the therapy team. Not knowing about these decisions can lead to a patient not being fed, or being fed unsafely and so it is essential that we communicate carefully. If you make a clinical decision – write it down.
Dangers of drugs A doctor had been asked to prescribe 2.5mg of oramorph (oral morphine) for a patient but mistakenly prescribed 10mls, which actually has 20mg of morphine in it – a significant overdose. This was given to the patient and identified as a problem quickly thereafter. The patient
It is so important that we prescribe correctly and if you do not know the dose of a drug or the strength of a preparation, wait and ask someone who does, or look it up. Also, make sure that interactions are known, or look the drug up in the BNF. Everyone makes mistakes but if we all rely on only prescribing what we 100% know then we will reduce error and improve safety.
Preventing unnecessary tests A patient was admitted and was felt to require an endoscopy as part of their investigation and treatment. Unfortunately, it became clear that they were fast approaching their end of life and the attending consultant wanted to ask the specialist team if they were able to cancel the test. However, the patient was taken for the endoscopy before the conversation could take place and the medical team felt that it should have been cancelled to allow the patient a more calm and dignified death. The patient received palliative care and later died peacefully in a calm and dignified way. We must ensure that we communicate quickly to cancel or amend tests to prevent the same thing happening again.
Conclusion These four lessons have a theme – acting on what we know and ensuring that we communicate the information in an accurate and clear fashion. If we all take just a few seconds longer to think when we prescribe, order tests or deliver care then we will become much safer as a result. Further information: If there is a topic you would like covered in future editions please contact ben.mearns@sash.nhs.uk
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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: Banerjee, P. (2014) ‘The efficacy of multimodal high-volume wound infiltration in primary total knee replacement in facilitating immediate post-operative pain relief and attainment of early rehabilitation milestones’, European Journal of Orthopaedic Surgery & Traumatologie, 24(4) pp.571-7. Candilio, L., Chen, A.W., Iqbal, R., Gandhi, N. (2014) ‘An interesting case of tachyarrhythmia’, BMJ Case Reports. Dachsel, R.M., Dachsel, R., Domke, S., Gros, T., Schubert, O., Kotrini, L., Ladegast, K., Vogel, J., Jordan, T., Zawade, S.(2015) ‘Optic neuropathy after retrobulbar neuritis in multiple sclerosis : Are optical coherence tomography and magnetic resonance imaging useful and necessary follow-up parameters’, Nervenarzt, 86(2) pp.187-96. Godfrey, R.L., Clark, J., Field, B. (2014) ‘Bilateral adrenal haemorrhagic infarction in a patient with antiphospholipid syndrome’, BMJ Case Reports. Goturu, A., Jain, N. (2014) ‘A differential to consider in a case of non-healing skin lesion’, BMJ Case Reports. Hartopp, A., Kelly, J., Pocock, N., Lawton, G., Parrington, S.(2014) ‘Fascia iliaca blocks in fractured neck of femur: An opioid sparing adjunct?’, Regional Anesthesia and Pain Medicine,39(5) SUPPL. 1 e p.162 Saraswathy, R., Anand, S., Kunnumpurath, S.K., Kurian, R.J., Kaye, A.D., Vadivelu, N. (2014) ‘Chromosomal Aberrations and Exon 1 Mutation in the AKR1B1 Gene in Patients with Diabetic Neuropathy, Ochsner Journal, 14(3) pp.339-42. Ziahosseini, K., Ali, S., Simo, R., Malhotra, R. (2014) ‘Uvulitis following general anaesthesia’, BMJ Case Reports. 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
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Achievements and professional recognition Congratulations to… …Dr Shaib Quraishi Specialty Registrar in Acute Medicine who has won the prize for best poster at the KSS AHSN EXPO & Award Event as judged by Professor Sir Bruce Keogh, Medical Director NHS England. …Mr Ijaz Sheikh, Consultant Opthalmologist, who recently presented on the topic of ‘diabetic macular edema paradigm shift - how to treat in 2015 and beyond’ at the international ophthalmology conference, Karopht, Pakistan. Mr Sheikh, who made three presentations and was expert panellist on medical retina conditions, was awarded the Gold Medal for best presentation. …The endocrinology department who had two posters presented at The Society for Endocrinology’s clinical cases meeting at the Royal Society of Medicine: ‘Hyponatraemia on the orthopaedic ward’ was presented by Dr Suchitra Raj (SpR) and Dr Kate Brockett (FY1) and ‘‘Homeopathy in the treatment of hyperthyroidism’’ was presented by Dr Sarah Denny (JCF) -(top right) winning the prize for best poster presented by
an undifferentiated trainee. All trainees would like to thank Dr Field, Dr Clark and Dr Zachariah for all their help with the cases and special thanks to Dr Field for his support on the day. …Dr Andy Allard whose quality improvement project on improving staff-patient communication using the inspiration of the #hellomynameis campaign, was awarded third prize at the annual regional CMT awards day. …Vicky Abbott, Nurse for Safeguarding Children, who has recently graduated with a PG Cert / MSc Health Safeguarding Children at Brighton University. … Simon Goodwin, Anne Durrell and Carol Sheppard who presented at the Regional Transfusion Committee Education Day with the following respective posters: Our new blood transfusion intranet site; obtaining cord and maternal samples and blood transfusion audit in the neo-natal unit where they have since made improvements to the documentation used and the observation schedule. … Helen Gallon (Team Lead Physiotherapist) and Dr Y Tham (STS Ophthalmology) joint prize winners of SASH’s second Leadership Project Poster Exhibition led by Miss Jean Arokiasamy.
CANCER STUDY DAY Our Macmillan clinical nurse specialist (CNS) team organised a study day to raise awareness of various aspects of cancer care in recognition of World Cancer Day on the 4 February. Feedback from delegates was very positive and staff came along to listen to presentations by Chief of Cancer Services Ed Cetti (photo right) and Elaine Edwards Macmillian Lead Nurse for Palliative and End of Life Care. The event provided an update on cancer care and end of life care within SASH whilst also helping increase the awareness of the work undertaken by our CNS team and highlighted the support, information and advice that
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staff and the people they care for are able to access. For any member of clinical staff who wishes to find out more about the work of the Macmillan CNS team, or needs to access cancer specific information, please contact elaine.edwards@sash.nhs.uk