The journal spring summer 2017

Surrey and Sussex Healthcare

Journal

NHS Trust

The

Spring/Summer 2017

MRI conditional pacemakers What is the difference...

between a Peripherally Inserted Central Catheter PICC and a midline

Advanced clinical practitioners

The Danish way of working

After action review

Publications

Patient story Potassium blood test

Written by healthcare professionals for healthcare professionals

Comment

Contents Page: 2 Comment

Welcome to the latest edition of The Journal, with its new look and new production team.

If you are thinking there has been quite a gap since the last edition you are right, but going forward it is our intention to have three issues a year, Spring/Summer, Autumn and Winter and The Journal will continue with the moto of written by clinicians for clinicians.

3

MRI conditional pacemakers

4

What is the difference...between a Peripherally Inserted Central Catheter (PICC) and midline?

5

Advanced clinical practitioners

6/7

The Danish way of working

8

Potassium blood test

9/10 After action review 11 Publications

In this edition you will find articles on clinical practice, patient safety, technology, and the day to day and hour to hour things people we work with get up to. There are also accounts of care we provided where patients came to harm and these are shared as part of our pledge to learn from incidents.

Schwartz Rounds Schwartz rounds are an opportunity for staff from all disciplines to reflect on the emotional aspects of their work.

The editorial team are grateful to all the authors who took time to contribute on top of busy shifts and hope that this gives the right mix of standard work and human stories, be they staff or patient, but if you think the mix should be different either let us know, or better still write an article yourself. I found all the articles informative and I think I learned something from each one, even the one I wrote.

Everyone is welcome to attend.

The next Schwartz round is: ‘The day I will never forget’ Will take place on: July 14 at 2pm in the PGEC, East Surrey Hospital.

Thank you.

Dr Des Holden Medical director 2

Patient-centred care Hospital to implant MRI-conditional systems, thereby offering the patient the best clinical care. Since January 2016, almost half of all pacemaker implants are MRI-conditional and it is anticipated that this number will increase in the future.

MRI conditional pacemakers In the UK, it is estimated that approximately 46,000 people are implanted with a pacemaker each year and it is thought 75% of those will need a Magnetic Resonance Imaging (MRI) scan during their lifetime.

Pacemakers and Implantable CardioverterDefibrillators (ICDs) have formerly been contraindicated to MRI scanning because of the potential risk of harm to the patient or pacemaker from powerful magnetic and radiofrequency fields generated during imaging, leading to the development of MRI conditional pacemaker and ICDs that will allow patients to undergo MRI scanning safely.

The first MRI conditional pacemaker was approved in the United States in 2011.

Subsequently, the five leading manufacturers have developed MRI-conditional cardiac systems. These devices have hardware modifications to allow for safe MRI scanning; including a reduction in the ferromagnetic content of generators and leads, the replacement with solid state technology and band stop filters in the generator casing or lead to prevent damage to the device circuitry (Lowe, et al,. 2015). Each manufacturer has individual guidance and protocols for the safe scanning of patients with MRI-conditional devices with the proviso that the MRI scanner, as well as patient and device requirements are satisfied. Programming of the pacemakers to safe mode prior to the undertaking of the scan is compulsory and is performed by a cardiac physiologist.

Photo: Gailene Pillay, diagnostic radiographer and Dr Julian Webb, consultant beside the CT scanner in the emergency department

Lowe M , Plummer C, Manisty C, Linker N. Safe use of MRI in people with cardiac implantable electronic devices. Heart 2015;101:1950–1953. doi:10.1136 Santini L, Forleo G, Santini M. Evaluating MRI-Compatible Pacemakers:Patient Data Now Paves the Way to Widespread Clinical Application? Pacing Clin Electrophysiol.

2013;36(3):270-278.

Wilkoff BL, Bello D, Taborsky M, Vymazal J, Kanal E, Heuer H, Hecking K, et al. Magnetic resonance imaging in patients with a pacemaker system designed for the magnetic resonance environment. Heart Rhythm 2011; 8:65–73.

A review by Lowe et al., (2015) at Barts Health NHS Trust, London, demonstrated strong evidence to suggest that MRI scanning in patients with MRI conditional cardiac implantable devices is safe provided appropriate guidance is followed. There is now a wealth of evidence that is growing with further on-going clinical trials. In recognition of the increasing patient need for MRI scans, an active decision has been made at East Surrey

Paula Murrin Highly specialised cardiac physiologist

3

Patient safety the start of treatment.

What is the difference‌ between a Peripherally Inserted Central Catheter (PICC) and a midline?

It is recommended that irritant or vesicant solutions that could cause tissue damage, should be administered centrally as the large volume of blood flowing through the SVC ensures rapid dilution of medications. Phlebitis or an extravasation injury could occur if inappropriate solutions, or medications, were to be infused via a midline.

Another important consideration is the duration of prescribed therapy.

PICCs and midlines are both inserted in the upper arm using ultrasound guidance and a micro-introducer technique. The aftercare and management of both PICCs and midlines is similar but the significant and important difference between these two vascular access devices (VADs) is tip position. The tip of a PICC sits in the lower third of the superior vena cava (SVC) whereas the tip of a midline catheter is located in the upper arm, not in a central vein. PICC tip position must be verified either by chest x-ray or by the use of ECG tip confirmation technology prior to the initiation of infusion therapy. No chest x-ray or ECG tip confirmation technology is required following the insertion of a midline.

Another important consideration is the duration of prescribed therapy. PICCs have a dwell time of months and should be the VAD of choice if treatment is anticipated to last more than four weeks.

At SASH, Power PICCs are inserted, which are reliable for blood sampling and can also be used for pressure injection of CT contrast.

The midlines currently used at SASH are not reliable for either blood sampling or for pressure injection of CT contrast.

The insertion of a PICC or a midline for patients identified as needing intermediate to longterm intravenous access, or who have been assessed as having difficult intravenous access cannot only prevent peripheral veins from being damaged but can also significantly reduce the discomfort, anxiety and pain associated with repeated cannulation attempts.

Jill Clarke Intravenous nurse specialist

The risk of infection and thrombosis are serious complications associated with both devices. However, to select the safest and most appropriate VAD the limitations of a midline should be taken into consideration at 4

Under the spotlight Advanced clinical practitioners.

consultant who ensures rigour and validity of competencies are achieved to the level expected by that of medical colleagues. Further ensuring credibility and safe practice, ACPs are required to be credentialed by the RCEM on completion of the e-portfolio.

An advanced clinical practitioner (ACP) in emergency medicine within the emergency department (ED) is a clinician who is trained to assess and independently manage any patient of any age across the complete acuity spectrum. This broad clinical scope of practice includes patients attending with minor problems, through to those presenting with major injuries and illnesses and on to those requiring life-saving interventions. ACPs are experienced clinicians who come from registered professions including paramedic and nursing backgrounds.

Impact At SASH, the four ACPs in the emergency department have been part of the team since 2015 and are a valuable asset to the multi-professional team. The ACP workforce, which plans to grow, provides stability and sustainability in an ever-decreasing specialty uptake by junior doctors. The success of the role and their presence increases the number of clinical decision-makers on the shop floor, decreasing patient waiting times and improving continuity of care.

Emergency medicine ACPs are autonomous clinicians who perform systematic clinical examinations, make diagnoses and independently prescribe all medicines within their competency. In addition, they can order and interpret radiological investigations including chest, abdo, facial and limb X-rays, and CT imaging of head, neck and CT KUB. ACPs are assessed to be competent in intubation, arterial cannulation, joint reduction and aspiration, lumbar puncture and chest drain insertion as well as ALS and PALS. ACPs hold the final decision to admit or discharge patients but are ultimately supported by consultant-led care, liaising with the multiprofessional team as necessary.

Qualifications Such high level clinical decision-makers are required to hold a 3-year MSc in Advanced Clinical Practice, are affiliate members of the Royal College of Emergency Medicine (RCEM) and are required to complete the 2-year RCEM ACP e-portfolio which is structured on the existing ACCS e-portfolio for emergency medicine specialty registrars in training. ACPs in training have a designated emergency

Katherine Clarke Advanced clinical practitioner in emergency medicine

5

Innovation in practice How do we keep citizens independent?

The Danish way of working Fiona Allsop, chief nurse Dr Des Holden, medical director Four years ago Dr Des Holden and I visited southern Denmark with the NHS Confederation. We saw a stated mission that all citizens wanted to be supported to be independent in their own homes for as long as possible. Around this often repeated aim, health and social care, academia and industry came together to understand and deliver new pathways and supportive technology for the people we call patients to support self-management and independence.

Photo: Fiona meets a member of the Living Lab team

This is a physical space where people involved in care come together to frame problems and try to define solutions. As well as physical space it is a safe space for discussion to happen. It has mocked up rooms where technology can be evaluated by citizens, who may have it in their homes, and by providers of care. Industries who are developing the technology can also gain valuable insight into acceptability, feasibility and reliability before deployment in the home. It’s an environment where the difficult discussions around wicked problems can be had and where failure as a consequence of the need to innovate is accepted as a price of the journey. The team who run the facility are generous with the time they give to visitors recognising the way they have been able to come together is unusual and is delivering significant benefit to their population. They call it a Living Lab.

We also learned two more principles – solutions needed to be co-designed with the people they will support (i.e. not designed in the Board room) and all innovation needs to be robustly evaluated with users to allow broader adoption.

For us the visit was a life-changing experience.

At a time when pilot projects in East Sussex electronically tagged patients with dementia who wandered, so they could be found and returned. In southern Denmark carers were recording short, reassuring video messages which were activated by movement during night-time and asked the potential wanderer to return to bed; 90% of people did, for an investment of less than 200 euros. A similarly different way of thinking was applied to rehabilitation after stroke. The phenomenon of fatigue of rehabilitation exercises was addressed by sensors which detected intention and effort and supported limb movement. This led to people persisting with their exercises longer and regaining more useful function as a result.

...solutions needed to be co-designed with the people they will support

Much of the language of co-design and open innovation that is used has grown from the Health Innovation Centre of Southern Denmark.

6

...all innovation needs to be robustly evaluated with users to allow broader adoption

Returning after four years a great deal of what we had seen in development has been taken forward and is available commercially to support citizens in their homes. The ambition of promoting independence has, if anything, become even more pervasive and even more joined up. Social care believe that only citizens living with dementia will need nursing home support, all people retaining capacity should be supportable in their own homes. They have set themselves the goal of being the first dementia friendly country and the first ever smokefree generation with many businesses and academic departments actively describing their own offering against this agenda. The sports and biomechanics department of University of Southern Denmark has professorial departments on active living and healthy aging, using principles of elite sports science and performance in extended support to ordinary citizens in their homes. Multiple projects are looking at enhanced childhood and workplace activity as a preventative measure for health need in later life. Confidence is high and the new University Hospital is being built with 30% fewer beds.

Denmark faces many of the same problems we face with an increasing elderly population.

They are a higher tax society, spend more on care and their citizens have a greater expectation around support and their own role in that partnership. None of this however is responsible for the concerted effort of thinking differently from a customer or citizen perspective and this is what is so compelling, as is the use of the word citizen rather than patient. In Denmark, citizen is used to convey a flat playing field that is simply what everyone is, with no explicit hierarchy.

Increasingly, I think this is interesting and helpful around a contract of doing our best for people but not holding a magic cure or all the answers. We don’t expect a lawyer or a teacher to do everything for us and guarantee an outcome. The conversation with a citizen in Denmark starts early and builds on what one’s own responsibility is and what can care professionals add.

For me the visit was a life changing experience 7

Patient story Potassium blood test Dr Des Holden, medical director, presented a patient story about Jacob*, a 67 year old man, with shortness of breath brought to ED by ambulance on a Tuesday: Jacob had co-morbidities and reported that he had had diarrhoea. He was nursed in a cubicle in ED and then, even though no diarrhoea was observed, was admitted to the side room of clinical decision unit.

The medical team considered that he had potential cardiac problems and an echo was carried out.

has been discussed with the patient’s family.

Des went on to highlight the pilot and roll out of an electronic system to support the monitoring of early warning score.

Jacob was reviewed by both respiratory and cardiac specialists, clinical ownership was unclear whilst he remained in cubicle in the Emergency Department. During this period an unusual blood test was not acted on and an echo report was not considered by on-call teams as it was not in the notes.

This case will be reviewed by the coroner and has been discussed with the patient’s family.

On Friday evening Jacob was moved to an appropriate medical ward.

Over the weekend his condition worsened.

The patient’s family were raising concerns on the weekend that their father’s condition was worsening which did not prompt a review and he sadly passed away on Sunday. It is unlikely that intervention would have changed the ultimate outcome but the pathway could have been improved for the patient and for his family.

This clinical case was raised and investigated as a serious incident and highlighted key learning. The side room and cubicles in ED are only to be used for short periods, four hours being the expected maximum; the handover of on-call teams needs to be strengthened focusing on ownership of the patient and the on-call bleeps system needs to be regularly reviewed and updated. Echo reports have been made electronically available so they are visible with other investigations.

The Board went on to discuss seven day working, consultant cover and the Trust’s plans.

The non-executive directors drew parallels from other incidents where family views and experience were not listened to and other cases still where determination in early warning score was not, or inadequately responded to. *The patient’s name has been changed.

This case will be reviewed by the coroner and 8

Reflective practice After action review Patient safety - learning and sharing

event incidents of wrong site surgery that occurred in our theatres at SASH in the past 3 - 4 years, along with some of the learning and how we shared this information outside of the organisation for the wider benefit of patient safety in England.

Any process that involves people is inherently risky because it involves people.

Human beings are fallible and in recent years patient safety systems and processes have been designed to recognise and mitigate against this; examining the root causes; changing the process and sharing learning now underpin patient safety.

Sabeena’s story Sabeena is a 36-year-old woman suffering from advanced endometriosis, brought to theatre for a laparoscopic hysterectomy and removal of her left ovary. Sabeena wanted to retain one of her ovaries for endocrine function, which she mentioned to the anaesthetist during the sign-in step.

A never event is an event that safety systems and process should ensure never happens.

The surgeon commenced the procedure and after inserting the ports and camera proceeded to divide the blood supply to Sabeena’s right ovary. He quickly realised his error, paused the procedure and informed the theatre team. After consideration it was decided that due to the extent of her disease Sabeena’s left ovary could not be preserved so she underwent a bilateral oophorectomy.

Sabeena was informed of the error and was naturally upset, especially as she would need to commence hormone replacement therapy, something that she had hoped to avoid.

A never event is an event that safety systems and process should ensure never happens.

There are currently 14 errors designated as a never event, which in the operating theatre includes; wrong site surgery; wrong implant/ prosthesis and retained foreign object. There are also a number of medication never events such as; wrong route administration of medication; overdose of Insulin due to abbreviations or incorrect device; overdose of methotrexate for non-cancer treatment. A misplaced naso or oro-gastric tube is also a never event where the misplacement of the tube is not detected prior to commencement of feeding, flush or medication administration. The full list and definitions is available on the NHS Improvement website.

What went wrong?

An after action review (AAR) was conducted and this involved bringing all members of the theatre team together to discuss the conduct of Sabeena’s operation in detail. It was established that the safety steps had been followed, although the senior surgeon was not present at the briefing and time-out steps.

Other circumstances created a situation where the surgeon lost situational awareness. The AAR established that there was a fairly chaotic start to the operating list when a key item of equipment, the camera stack, failed and had

I would like to explore one of three never 9

for Invasive Procedures (NatSSIPs). With Sabeena’s permission her experience was included as a patient story in the final national standards.

In spite of all this the most recent data (April 2016 – February 2017) records 380 never events having taken place in England, of which wrong site surgery accounted for 156 of the total. Trusts across England, including SASH are actively implementing NatSSIPs by developing the required local safety standards.

Staff being called away during the procedure should be avoided as should the use of abbreviations on operating lists.

to be replaced. Members of the theatre team left or were called away, including the assisting registrar and circulating practitioner. When the operation re-started after the delays the surgeon proceeded to do his ‘normal’ operation which included a bilateral removal of ovaries.

It was also noted that the description on the operating list abbreviated the ovary removal as LSO (left salpingo-oopherectomy).

Learning The importance of the operating surgeon being present for the briefing and time-out cannot be overstated; briefing is designed to ensure that all members of the team have a shared mental model of the planned procedure and are therefore equipped to speak up when there is unplanned deviation. Staff being called away during the procedure should be avoided as should the use of abbreviations on operating lists. These were key findings and an additional time-out was recommended when there has been a significant delay between the initial timeout and the procedure starting.

Conclusion People make mistakes and the reasons we continue to do so despite the multiple systems and processes that we put in place to prevent them are complex and multifactorial. We must continue to learn from our errors and those of others, revising and refining the barriers we erect to prevent them. But while we do so, we have to remember that the result of our error could harm a patient. Our first priority therefore must always be to provide support and ready access to someone who will provide an answer to those questions.

Sabeena was left with many questions and concerns and I was able to establish a direct line of communication (by email) so that she could contact someone whenever she needed support. Sabeena was also debriefed by a senior clinician about the findings and outcome of the investigation.

In 2015 NHS England published a Safety Alert, along with National Safety Standards

Bill Kilvington Associate director - WACH *The patient’s name has been changed.

https://improvement.nhs.uk/resources/never-events-policy-and-framework-review-2016/ https://improvement.nhs.uk/news-alerts/supporting-introduction-national-safety-standards-invasive-procedures/

10

Publications by SASH people The following articles, by SASH staff, have been written and published:

Achievement and professional recognition

Bootstrapping and resampling Samuels T. Anaesthesia 2017; 72(2):271-272.

Effect of admission fascia iliaca compartment blocks on post-operative abbreviated mental test scores in elderly fractured neck of femur patients: a retrospective cohort study.

Odor PM, Chis Ster I, Wilkinson I, Sage F. PM BMC Anesthesiology 2017;17(1):1.

Dr Claire Mearns, consultant anaesthetist, has been presented by the Royal College of Anaesthetists with a RCoA Trainer Award. Claire is currently a training programme director for anaesthetic trainees as well as a college examiner for the primary examination. Voted for by trainees, the award recognises Claire’s dedication and enthusiasm for training and her support of colleagues across SASH.

Effectiveness of semi-permeable dressings to treat radiation-induced skin reactions. A systematic review.

Fernández-Castro M, Martin-Gil B, PenaGarcia I, Lopez-Vallecillo M, Garcia-Puig ME. European Journal of Cancer Care 2017; Apr 18

Tell us:

In vitro comparison of maximum pressure developed by irrigation systems in a kidney model.

Proietti S, Dragos L, Somani BK, Butticè S, Talso M, Emiliani E, Baghdadi M, Giusti G, Traxer O. Journal of Endourology 2017; April e-publication.

If you have written an article, book or chapter of a book then please contact Rachel Cooke 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 Hospital.

Splenomegaly in the returning traveller: a diagnostic workup.

Patel PU, Sastry P, Jawad M. BMJ Case Reports 2017;January :e-publication.

For The Journal Please let communications@sash.nhs.uk know about your professional achievements and recognition.

Use of optical coherence topography for objective assessment of fundus torsion.

Sophocleous S. BMJ Case Reports 2017; February :e-publication.

We also welcome suggestions and submissions of articles for The Journal from all clinical professions across SASH. Please contact Laura Warren, head of communications on x6199 or laura.warren@sash.nhs.uk to discuss.

Visualising odds ratios Samuels T. Anaesthesia 2017;72(1):132-133.

11

Produced by the communications team