The journal vol 1 issue 2 2014 by Surrey and Sussex Healthcare NHS Trust

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MENTAL CAPACITY

Does a person have capacity? By Dr Katy Davies

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END OF LIFE CARE

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A focus on the National End of Life Audit

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PLUS: Written by healthcare professionals for healthcare professionals Vol.1 Issue 2

• Junior doctor poster event P.6/7 • National Emergency Laparotomy Audit P.8 • Acute kidney injury: The Outreach perspective P.11 • Datixweb: Closing the safety action loop P.14 The SAS H NHS logotype white

Summer 2014

Making health and care systems fit for an ageing population-what do we need to do next? By Professor David Oliver

President Elect of the British Geriatrics Society & Visiting Fellow at The Kings Fund

have spent my NHS career as a hospital doctor specialising in geriatric medicine and I have led services within two trusts and taken on national leadership roles. In 2013, I became a Kings Fund Fellow alongside my The NHS I go into SAS work. H NHS logotype full colour many hospitals and health economies to advise on services, or to learn from local innovations. This has given me a great insight into the ‘state of play’ in services for older people and a platform to spread the message about high quality care to those not working The SAS H NHS logotype 2 colour - Black & directly in geriatric medicine. As part of my Kings Fund work, I led the writing of an ‘everything I have learned in one place’ paper ‘Making health and care systems fit for an ageing population’ (www.kingsfund.org.uk/events/ making-health-and-care-services-fitageing-population) which is a practical The SAS H NHS logotype 1 colour - Black resource aimed at those leading frontline services. It was accompanied by the 18th June conference, ‘Delivering innovations in the care of older people’, which allowed organisations from around the UK to speak about their own services and learn from others. The SAS H NHS logotype white

When the NHS was founded, 48% of people died before they reached 65. Now its only 14%, with the fastest growing group in society being those over 80. By 2030, a 65 year old man in England will live on average to 88 and a woman to 91. This represents a victory for society and a success for modern healthcare. We certainly shouldn’t use catastrophic language about the ‘ticking time bomb’ or ‘burden’ or ‘grey tsunami’ of ageing. Most older people self report their health as ‘good’ or ‘very good’ and The SAS H Strapline full colour people in their seventies and eighties report the highest levels of happiness Figure 1 (Sam’s Story) of any group. If anything, older people Copyright The Kings Fund are becoming healthier than those in previous generations. However, ageing people report problems with mobility will alter the very nature of health and and often lose mobility rapidly in the healthcare for good. face of acute illness, creating the need NHS Pantone 300 The SAS H Strapline 2 colour - Black & NHS Pantone 300 for adequate post-acute rehabilitation. There are now more people living Older people are the most likely to not with one, but with multiple long call 999, to be conveyed to hospital term medical conditions, often in and to be admitted. It is also older turn requiring multiple medications. people who are most likely to rely Dementia already affects around on support from carers and who are 800,000 people in the UK and is set most likely to use multiple services to double over the next two decades. The SASand see multiple professionals’ and so H Strapline 1 colour - Black Around 6% of the population over 65 suffer from disjointed and poorly colive with a degree of frailty. There is a ordinated care. Of course, most people growing recognition that people with requiring support at the end of life are frailty have specific needs. They often older, making it essential to give them present to health and care services with fair access to advance planning and falls, confusion, loss of mobility or with palliative care support as well as choice non-specific failure to cope. Many older towards the end of life. The SAS H Strapline white

Continued page 2 TheJournal@sash.nhs.uk

The Journal Summer 2014

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

CQC: NOT FAR FROM OUTSTANDING

ur CQC inspection rated us as good; a rating received by only 30% of hospitals so far, but we were told in the formal feedback that we were not far from outstanding. It is no coincidence we are judged this way when we have had our best ever staff survey and a very encouraging inpatient survey. These two surveys are very dependent on each other; patient experience will always be best when staff feel positive about their work, their role in the organisation and that they are listened to. The Francis enquiry has underlined that we all have a duty to do the right thing and to raise concerns when we see things that are not right. There is no doubt that this can be difficult to do and hard to hear. It is this culture of ‘fixing’ what we can ourselves and escalating what we can’t, that provides the framework for us to be safe and caring. A confidence that problems are identified and dealt with, using structures that enable this, is governance and it is this that will be tested as part of the process to become a foundation trust. I think of governance as the test of “what happens if…” and this is something we all need to think about and be able to answer.

E: des.holden@sash.nhs.uk Consultant Physician Dr Natalie Powell E: natalie.powell@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

We need a radical shift in the way services are provided – focussing on prevention and wellbeing, proactive care, coordination and support based on people, not on a single disease. We also need to ensure that when older people do become acutely ill, we provide rapidly responsive services, high quality acute care and good post discharge support. This in turn means a workforce with the right skills, training and values. The Kings Fund Paper sets out the evidence for how we need to change under nine key headings, from healthy active ageing through to end of life care, with 2

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the 10th “integration” binding the others together. Sam – our model older citizen (see figure 1), sits in the middle.

As an executive team we have not done enough in explaining what happens when people raise concerns and we have more to do in explaining what actions we take when things go wrong. To help with this, we are going to publish some of the patient stories raised through incidents or complaints and I would like you to read them and think about the lessons we take from them. We have been told that we are within touching distance of being an outstanding organisation. What will get us there, is choosing to do the right thing in the moment when the choice matters, be it answering a call bell at the end of a shift, re-writing a drug chart that is unclear, or pointing out a problem no one else has recognised or dealt with. This is what will make us safe, effective and outstanding.

Dr Des Holden Medical Director

the HSJ commission on the care of frail older people, there has never been more momentum around the care of older people.

For each one, we have set out some Whether we look at general practice, overarching goals, an appraisal of the current state of play and then some intermediate care services, acute hospitals or social care, the biggest spend, evidence about ‘what we “The biggest the biggest activity and the know can work’ because you activity and biggest care gaps are in services can’t just parachute a new service or intervention into a for older people. They are now the biggest health system not conducive ‘core customers’. Making care gaps are our our services more age attuned to support it and expect it to deliver. We have also set out key in services and more fit for an ageing references and guidelines and population, will be win/win for older illustrated each section with – better for our older citizens people.” practical examples from current and the only way to deliver efficiencies at a time of great services around the UK. financial pressure. I hope the paper helps The paper has been widely downloaded, those leading local services in Surrey, Sussex and beyond. endorsed by many specialist societies, extensively referred to in the NHS About the author England document ‘Safe Compassionate Professor David Oliver has also previously been the Care’ and is already in use in a number of National Clinical Director for Older people at the places to inform local commissioning and Department of Health Elect. Over the last two years, David has been a great source of help and support in pathway redesign. Coming at the same developing our services for Geriatric medicine here time as other new resources, including at SASH.

The Journal Summer 2014

Under the spotlight…

Does a person have capacity? In the first of a series of articles on consent, we put the issue of mental capacity under the spotlight.

By Dr Katy Davies

Consultant Geriatrician

ental capacity in simple terms, is the ability to make your own decisions, but as we know some people are unable to make decisions for themselves. The Mental Capacity Act 20051’ protects individuals who are unable to make decisions for themselves and applies to all people over the age of 16 in England and Wales. It covers important decisions relating to an individual’s property, financial affairs and health and social care and also applies to everyday decisions, such as personal care, what to wear and what to eat. The five main principles of the Act must be followed by anyone supporting or making decisions on behalf of someone who may lack mental capacity. (For further information visit: http://intranet.sash. nhs.uk/department-directory/clinicalsupport/adult-safeguarding/deprivationof-liberty-safeguards-(dols)/)

Every adult has the right to make decisions for themselves, it must be assumed that they are able to make their own decisions, unless it has been shown otherwise.

2 3 4

Take all practical steps to maximise an individual’s ability to make a decision.

Every adult has the right to make decisions that may appear unwise without lacking capacity.

5 6

If a person lacks capacity, any decisions must be taken in their best interests, informed by seeking information from their next of kin, friends, family, nursing home staff, or an IMCA.

If a person lacks capacity, the least restrictive option to their rights and freedoms should be taken.

‘ Mental capacity’ is situation specific and if a person is deemed not to have capacity with regards to one situation at a given point in time, it does not mean they may necessarily lack capacity in the future.

For a person to have capacity they must be able to: Understand the information that is presented

Retain the information long enough to make the decision

Weigh up the information to make the decision

Communicate their decision by any means possible

Footnote: 1/ Great Britain: Department of Health (2014) Mental Capacity Act (2005) [Online]. Available at: www.legislation.gov.uk (Accessed: 07/07/14)

INFORMED CONSENT: BARRIERS AND HOLISTIC CARE

nformed consent for treatment and its side effects is an ethical imperative and as a healthcare professional, it is important to be perceptive to common psychosocial barriers that may impact a patient’s ability to make an informed decision. There is a risk associated with providing large amounts of information at one point in time, or overloading a patient with information at a point in their treatment trajectory when they may be feeling afraid, confused or overwhelmed1.

We have a professional duty to act as patient advocate and exercise autonomy to ensure that the patient is wellinformed. Barriers in understanding:

language, cultural, health beliefs and behaviours2 and age need to be considered; some elderly patients may be accustomed to the old paternalistic system of ‘doctor knows best’ and may not feel it is appropriate to question. What one clinician may determine ‘best’ in terms of treatment, may not necessarily align with the holistic needs of a patient. Being able to distinguish and anticipate an individual’s holistic needs is paramount. Building a relationship with the patient and getting to know them as an individual, allows us as practitioners to explain how a particular course of treatment may impact on their daily life and psychosocial well-being. The importance

of good communication should not be underestimated; it is fundamental at every stage of the patient pathway and helps empower patients to exercise informed choice. By Maxine May Editor Footnote:

1/ Berry, D. (2007) Health Communication Theory and Practice. Maidstone: Open University Press. 2/ Conner, M. and Norman, P. (1998) ‘Health Behavior’ [sic] Comprehensive Clinical Psychology, 8, pp.1-37 [online]. Available at www.sciencedirect.com (Accessed: 10/08/14).

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The Journal Summer 2014

Patient-centred care

Clinical Patient-centred Update care FOCUS ON END OF LIFE CARE

Care continues even after death By Liz Berry

By Dr Naomi Collins Consultant in Palliative Care

his has been quite a year for end of life care. July 2013 saw the publication of Baroness Neuberger’s independent review of the Liverpool Care Pathway (LCP) for the Department of Health1. Whilst the report acknowledged that the LCP, if used correctly, could contribute to a person achieving a peaceful and dignified death, it also heard of too many instances in which the LCP was used with inadequate communication, approached as a ‘tick box exercise’ or perceived by the public as a conveyor belt to death. It therefore recommended that the LCP be phased out over 6-12 months and replaced by individualised care plans.

end of life. Increased providing quiet rooms “The responsiveness the emphasis on the specific for relatives and having areas to discuss and a named board member of EOLC at SASH document may be with responsibility for has been found to required. A repeat audit end of life care. The latter issue has already At SASH, the LCP was discontinued be ‘outstanding’ by of case notes and the new EOLC plan are underway. been addressed, and the immediately and interim guidance introduction of a six day the CQC” issued. In March 2014 the new End In the meantime, we palliative care service of Life Care (EOLC) Plan, based on are delighted to announce the planned (with a view to moving to a seven day a document from Kingston NHS development of a joint discharge liaison service) is planned for autumn 2014. Foundation Trust, was launched service between SASH and Marie Curie The majority of other hospitals (at least throughout the hospital. The plan aims Cancer Care with the aim of improving 60%) are also currently not achieving to provide prompts for medical and the hospital discharge experience of in these four areas. Of more concern, nursing staff of all the issues that have patients approaching the end of life was the clinical audit based on a review to be addressed in order to provide high (whether they have cancer or not). This of 49 sets of case notes of quality, patient focussed seven day a week service will consist of patients who died in SASH care at the end of life. “The EOLC plan during May 2013. SASH a trained nurse based in the hospital and two nursing assistants who will be performed below the national The 4th National Audit of aims to provide available to provide hands on care at average for the ten aspects Care of the Dying Patient prompts ... the patient’s home. We hope this will examined. This is obviously in Hospitals reported continue to enhance the responsiveness disappointing and requires in May 2014 with a for all the issues 2 of EOLC at SASH, which has been found urgent attention. It is worth mixed picture at SASH . that have been to be ‘outstanding’ by the CQC during remembering the audit is In some aspects of the their inspection earlier this summer. of documentation, and not organisational audit we addressed” necessarily the care given, did well, such as having though everyone in healthcare knows if taken part in a survey of bereaved relatives it is not documented, it is not evidenced within the last two years (achieved by only Footnote: that it is done. Removal of the LCP and 34% of hospitals). The report highlighted 1. Department of Health (2013) More Care Less introduction of the EOLC plan have, of areas to focus on including initiating Pathway A Review of the Liverpool Care Pathway, course, occurred since May last year and a weekend face to face service for England. it remains yet to be seen whether the new palliative care; expanding the education 2. Royal College of Physicians (2014) National care plan leads to an improvement in care at programme for all staff on end of life care; of the dying audit for hospitals, England. 4

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and Lorraine Wells

Operational Manager for Cellular Pathology

hen a patient dies, the responsibility and care for that patient continues until they are transferred into the care of a funeral director. Doctors have a professional responsibility to complete either the medical certificate of cause of death (MCCD), or a coroner’s referral, as soon as possible, especially as a decision from the coroner’s office can take two or three days. The MCCD and the cremation papers are normally prepared by junior doctors on behalf of the consultant who is ultimately responsible. Doctors should be mindful when completing these forms that the Registrar or the Medical Referee at the crematorium, has the power to reject a MCCD or a cremation, causing distress to the next of kin. At this emotional time we need to be mindful of how our actions can be interpreted by the bereaved. The majority of our families

Bereavement Officer

want to finalise the funeral arrangements as soon as possible. However, only when they have received the MCCD from us can the family make an appointment with the registrar’s office to register the death. It is during the appointment with the registrar that the family receives the death certificate and other associated paperwork necessary to complete the funeral arrangements. It can become very frustrating and distressing for the family if they are unable to proceed with confirming funeral arrangements. Bereavement officers often have the difficult task of explaining to the family why their loved one’s certificate is not ready, especially on a Tuesday if they died on Friday – to the family this has been four days. Rightly or wrongly, deaths should be registered in five calendar days which is why the family can become very anxious. From the families perspective, if

“If it takes several days to complete, [a death certificate] it can give the impression that we no longer care.”

PRODUCING A ‘GOOD’ DEATH CERTIFICATE By Ali Alhakim

Consultant Pathologist

hen a patient dies and provided that there is no need for a coroners referral, (eg. accident, suicide, suspicious death, violence, neglect, industrial disease, unknown

it takes several days to complete, it can give the impression that we no longer care. Patient care is continuous and death is no barrier to this care. It is important that we demonstrate dignity, respect and compassion and do all we can to help make what is a very difficult time for family and loved ones, a little easier to bear.

of the patient’s care to ensure that the death is properly certified.

cause of death, during an operation/ iatrogenic deaths) then it is the statutory duty of the doctor who has attended the last illness to issue the MCCD. ‘Attended’ generally meaning a doctor who has cared for the patient during the illness that led to death. It is ultimately the responsibility of the consultant in charge

Doctors are expected to state the cause of death to the best of their knowledge and belief. The MCCD is set out in two parts - the immediate direct cause of death is stated in (1a) and other conditions are stated in sequence in (1b) and (1c) so that 1c leads to 1b. and 1b. leads to 1a. Other conditions that led to death (contributed but not related to 1a, 1b, or 1c) are entered in (II), but in this part, it must not be used to include any past medical history.

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The Journal Summer 2014

C Clinical effectiveness Audit A Research & development R Education & training E

An audit on Basic Life Support skills in Primary Care need for refresher sessions? Dr Amanda Mootoo East Surrey Hospital, Surrey and Sussex NHS Trust Background

• To measure the percentage of Primary Care staff that are competent in BLS skills and resuscitation techniques as per Resuscitation Council (UK) guidelines. • Is the current interval of training sufficient or is there a need for refresher sessions?

Method A prospective audit was conducted to assess the BLS skills of Primary Care staff, (clinical and non-clinical) at a suburban General Practice (Reigate). A selfdesigned, anonymous 12 point questionnaire in a multiple choice format, covering key components of the BLS guidelines was used to assess BLS skills. The questionnaire was completed during a set time frame. Outcome measure: A score out of 12 was calculated for each questionnaire, the percentage was calculated and a mark above 90% was considered as a pass.

• 71% of all Primary Care staff at the General Practice took part in the audit • The average score obtained on the BLS questionnaire was 60% (Fig. 2) • Only 6% of staff scored above the set pass mark of 90% and were deemed competent in BLS. This did not meet the set standard of 90%, whereby 90% of staff were expected to score above the 90% pass mark. • 88% of staff correctly answered questions on emergency equipment

Background Parsonage Turner Syndrome, also known as brachial neuritis or neuralgic amyotrophy was first reported by Parsonage and Turner in the Lancet in 1948¹, following a number of cases reviewed form World war II troops. It is an uncommon condition, with an estimated prevalence of 4-6 per 100,000 people². The classical presentation is acute or subacute onset of unilateral shoulder and arm pain followed by a flaccid paralysis and atrophy of the shoulder girdle and upper arm muscle. Typically the onset of weakness coincides with resolution of pain. Associated sensory disturbance is present in varying degrees. Rarely, other peripheral nerves can be involved, and this case demonstrates an example of bilateral phrenic nerve palsy associated with brachial neuritis. Figure 1 CXR

Case History & Examination A 40yr old previously healthy man presented with increasing shortness of breath, reduced exercise tolerance and orthopnoea. He had noticed these symptoms whilst on holiday in St Lucia which had progressed over the following 3 weeks since his return. He was referred to hospital for CTPA to investigate for Pulmonary Embolism. 3 months prior he had been diagnosed with acute brachial neuritis of the left upper limb. This had presented as severe left shoulder pain occurring after mild trauma and subsequently over the next 2 weeks he developed rapidly progressive left arm weakness with resolution of the pain. On assessment he had marked atrophy of the deltoid, triceps and supraspinatus. Reflexes were diminished and there was significant left arm weakness, mainly shoulder abduction. He had increased respiratory effort with accessory muscle use and abdominal paradox. On chest auscultation there was reduced breath sounds bibasally. No sensory deficit was noted.

Figure 2 Spirometry

Investigations/Management CXR revealed poor inspiratory effort with bilateral raised hemi diaphragm. (figure 1) Spirometry demonstrated a restrictive picture. (Figure 2) There was also a drop in VC from 2.3 (standing) to 0.45 (lying), consistent with diaphragmatic paralysis. EMG showed prominent chronic partial denervation with active changes maximal in C5/C6 innervated muscles significantly worse on the left side, there was also evidence of severe bilateral phrenic nerve lesions. He was treated with 7 days of IV methylprednisolone and then oral steroids, aswell as nocturnal CPAP to aid sleep. His symptoms improved with increase in his vital capacity to 2.3L and he was discharged with nocturnal CPAP enabling him sleep lying flat.

Figure 3 – Brachial Plexus

Result

%Pr

1.34

Fev1 FVC

1.58

PEF

4.22

FEV1/FVC

106

Discussion The presentation of Parsonage Turner syndrome can be complex with variable patterns of nerve involvement. It may affect the nerve roots of the brachial plexus (most commonly) or one or more peripheral nerves. Few cases of bilateral phrenic nerve involvement has been reported. The aetiology is unclear and it can often occur in previously healthy individuals. It is hypothesized that an autoimmune process results in focal demyelination or axonal degeneration. Several associations and risk factors have been suggested including preceding viral illness, immunisation, and postoperative. Due to the complex and varied nature this condition, it can provide diagnostic difficulty and cause delays in diagnosis. Of particular importance in this case, there was a rare neurological cause of this man’s dyspnoea, and highlights how detailed history taking and clinical examination are vital for aiding diagnosis. Management is supportive and recovery can be slow and unpredictable. This man continued physiotherapy and CPAP for over 6 months following discharge, and his left shoulder power and range of movement have increased. His exercise tolerance and sitting/lying VC have improved and he has returned to his full time job.

of how important it is to introduce yourself to patients and carers. Service improvement projects, such as Matthew Sinnott’s work, helps to provide clinical reminders. He identified that increased length of stay prior to ITU admission is linked to poorer outcome of ITU patients. This reinforces the need for early ITU referral and the use of early recognition systems (such as the Early Warning Scores) in identifying deteriorating patients. Judges on the day were Dr Des Holden (Medical Director), Rachel Cooke (Head of Library Services and Knowledge Management) and Dr Sona Biswas (Consultant Radiologist). Winners of the three £100 prizes were:

1. 2. 3.

Parsonage MJ, Turner JWA. The shoulder girdle syndrome. Lancet. 1948;1:973–978 Beghi E, Kurland LT, Mulder DW, Nicolosi A. Brachial plexus neuropathy in the population of Rochester, Minnesota. Ann Neurol. 1985;18:320–323 Figure 3 from Anatomy of the Human Body, 1918. Henry Gray.

Written consent gained from the patient prior to presentation. Please send all correspondence to Dr Caroline Ming, Department of Acute Medicine, Surrey & Sussex Healthcare NHS Trust, Canada Avenue, Redhill, Surrey RH1 5RH

email: caroline.ming@sash.nhs.uk

service improvement as an extension to clinical audit and the range of projects displayed was impressive. Some projects reflected work around our Trust values for example, Dr Andy Allard’s project on the Trust’s support of the #hellomynameis campaign (http:// hellomynameis.org.uk) which serves to remind all staff to introduce themselves to patients. His project has led to increased awareness around the Trust, as well as new easier to read Trust name badges and #hellomynameis lanyards. Feedback from patients has been overwhelmingly positive about their introduction and serves as a reminder

The Journal Summer 2014

Dr Caroline Ming (case presentation): Caroline’s poster highlighted a case of a 40 year old man admitted with breathlessness, who was diagnosed with a rare neurological condition called Parsonage Turner syndrome. It highlights how important a thorough physical examination is in assessing patients. Dr Amanda Mootoo (audit): Amanda’s audit project looked at basic life support skills in primary care and whether there was a need for refresher sessions.

Conclusion There is inadequate knowledge of BLS amongst Primary Care staff. The current frequency of BLS training sessions amongst staff in Primary Care is insufficient. Re-auditing demonstrates significant improvements in BLS knowledge can be achieved through interactive aids and refresher teaching sessions. There is a need for refresher BLS training sessions in between the mandatory 3 yearly or 18 monthly BLS training. Such simple measures will help improve the rate of survival from out-of-hospital cardiac arrests.

Re-audit After 3 months of the initial audit being conducted and all the interventions being implemented, a re-audit was conducted. The same methodology, questionnaire and outcome measure was used. Participants used had taken part in the initial audit and been involved in the implemented changes.

Limitations: Use of a non-practical format to assess BLS knowledge, teaching sessions did not involve use of mannikins and the audit assessed a small sample size compared the entire Primary Care population.

References Resuscitation Council (UK) – Primary Care [homepage online]; Available from: www.resus.org.uk/pages/QSCPR_PrimaryCare.htm‎ Quality and Outcomes Framework guidance [homepage online] Available from: bma.org.uk/-/media/files/pdfs/.../gpqofguidancesummary20132014.pdf‎

Does a surgical post-take ward round checklist improve documentation? Trowbridge S, Patrick T, Chadha K, Conway A, Bruce C, Waheed S Breast Team, East Surrey Hospital, Surrey and Sussex Healthcare NHS Trust

Introduction

Methods

 Despite its fundamental role in patient care, a number of shortcomings

 A trust standardized medical checklist sticker was introduced to PTWR

have been highlighted regarding the surgical post-take ward round (PTWR)1,2.

over a period of 2 weeks.  The use and effectiveness of the stickers was then assessed.

 The positive impact of a checklist on patient safety is already well recog3

nised within surgery, with the WHO surgical safety checklist .

 Feedback was then gathered from surgical teams to establish potential improvements and modifications.

 Ward round checklists have been found to improve documentation, patient safety, and protocol adherence4,5.

 On gaining feedback a new method of PTWR documentation was developed, which was in the form of a A4 proforma.

 This quality improvement project aimed to find a comprehensive, appropriate and easy-to-use surgical PTWR checklist to guard against over-

 Once again PTWR documentation was analysed with the implementation of the new proforma.

sights in documentation and ultimately improve patient care.

Results  70% of junior surgical doctors felt that current documentation was suboptimal (rating it 3 or less out of 5).

the opportunity to look at the checklist and its use in standardising the post take surgical ward round to improve patient safety.

Checklist sticker

 Following the introduction of the standardized medical checklist sticker, 56% of PTWR entries used the checklist sticker  Documentation was improved in 5 of 17 parameters in entries that did not use the checklist sticker.

Looking ahead to next year, we will be running the poster day again in May 2015 and aim to extend the invite for submissions to other disciplines. We will be welcoming contributions from pharmacists, nurses and allied healthcare professionals. Event details will be announced nearer the time. Remember that all audit and quality improvement work must be logged with the audit department.*

 Feedback suggested that the stickers were too time consuming (80%) and comments included that several of the 12 parameters improved by the checklist stickers were perhaps not essential to document in such a time-constrained setting.  Comparatively, the PTWR proforma was used in 70% of PTWR entries.  Documentation was improved in 7 out of 11 parameters compared. to the checklist stickers.

References

There were three poster categories: The first category was for case presentations, where juniors had seen rare or interesting cases that provided valuable learning and reflection. The second category was audit, in which juniors presented audit work that they had been involved with. Audits that stood out included those that had demonstrated completion of the audit cycle such as Dr Soumen Rudra’s work on compliance with the VTE online assessment tool and the benefits of educating juniors in improving its use. The third category was quality and service improvement. Junior doctors are increasingly being encouraged to take part in quality or TheJournal@sash.nhs.uk

Interventions • An interactive, refresher teaching session with an audiovisual presentation on basic life support provided to all staff • The presentation was emailed to all staff so they can recall key steps in BLS in their own time and watch the video uploads of critical manoeuvres e.g. recovery position. • An interactive teaching session was provided on the emergency equipment bag • A poster on a modified BLS algorithm was designed and placed around the Practice as a visual aid.

Checklist sticker vs no checklist sticker Percentage

0 Sticker

100

PTWR Proforma

Date

No Sticker

Checklist sticker vs proforma

Sticker

Proforma

Time Hand cleaning

Percentage 60

Drug chart

Working diagnosis

Differential diagnosis

Investigations reviewed

Obs Fluid balance Lines reviewed Resus status Nutrition Bowels Falls/pressure sores Nursing staff informed EDD Signed/name Management plan

Conclusions

Obs

Fluid balance

Resus status

A surgical PTWR proforma is an effective method of improving documentation and ultimately patient safety in a heavily time-constrained environment.



A PTWR proforma or checklist must be specialty-specific in order to maximize uptake and use.



Feedback is essential to developing an effective and usable adjunct to the PTWR



An on-going cycle of feedback and adjustment would be beneficial to further enhance the PTWR proforma.

2009; 360:491-499 4. Haitham Al-Mahrouqi et al: Post-acute surgical ward round proforma improves documentation, BMJ Qual Improv Report 2013:2. 5. Henry CH Ko et al: Systematic review of safety checklists for use by medical care teams in acute hospital settings limited evidence of effectiveness. BMC Health Services Research 2011, 11:211.

Judges highlighted how the audit had demonstrated change and completion of the audit cycle which could have direct effect on patient care. Dr Komal Chadra, Dr Sam Trowbridge (left), Dr Tanya Patrick & Miss Anna Conway (quality and service improvement). Following on from the Trust’s work rolling out a ward round safety checklist, Sam took

Thousands, if not millions, of prescriptions for medications are written every year in NHS hospitals around the UK. Junior doctors are responsible for the majority of these both in the ward setting and out-of-hours. However, any prescription for medications or intravenous fluid has the potential to cause harm to patients. Indeed, a report from the Audit Commission in 2001, calculated that 1,100 patients had died as a direct consequence of medication errors, while many others faced unnecessarily extended hospital stays. The causes of such errors are multifactorial, originating from genuine mistakes to poor legibility of hand-written drug charts. Over the past year, a new system for electronic prescribing (ePMA) has been designed here at the Trust that promises to increase the safety and delivery of prescriptions to our patients. Using IT to replace the current system of paper drug charts, presents a number of challenges. Lead Pharmacist for the ePMA project Adam Buckler, helped lead an initial systems review with a multidisciplinary team from the Trust evaluating the capability of the system. Since then, there have been 11 workshops, involving senior clinicians and nursing staff, to address challenging areas for this ambitious project.

Nutrition

Signed/name

Management plan



References 1. Kristopher M et al: Ward safety checklist in the acute surgical unit, ANZ Journal of Surgery. 16 December 2013. 2. Fernando KJ, Siriwardena AK: Standards of documentation of the surgeon-patient consultation in current surgical practice, Br J Surg, 2001 Feb;88(2):309-12. 3. Haynes AB, et al: A Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global Population, N Engl J Med

100

Date

Time

Intro team

Documentation parameter

Dr Ming CR, Dr Powell N, D, Dr Zhang L

Documentation criteria

Parsonage Turner Syndrome with Bilateral Phrenic Nerve Involvement

By Dr Oliver Redfern FYI Doctor

Figure 2

Results

Consultant Physician

• The average score obtained on the BLS questionnaire was 79% (Fig. 2) • 42% of staff scored above the set pass mark of 90% and were deemed competent in BLS, compared to 6% in the initial audit. • Although this still does not meet the set standard of 90%, the re-audit shows an improvement in knowledge and skill in BLS amongst the staff following implementation of these interventions.

Aims

By Natalie Powell

Re-audit - results

A vast proportion of deaths from cardiac arrests occur out-of-hospital each year, many of which in the Primary Care setting. Less time to initiate critical steps in cardio-pulmonary resuscitation leads to a higher rate of survival from cardiac arrest. Resuscitation Council (UK) published a set of national guidelines in 2010 stating that ‘all members of the Primary Health Care Team who have contact with patients should be trained in basic life support (BLS) and related resuscitation skills…as a minimum they should be able to provide effective BLS with an airway adjunct such as a pocket mask’. Currently clinical and nonclinical staff gain BLS training every 18 and 36 months respectively, as part of the Quality and Outcomes Framework guidance. But is this sufficient? To improve mortality from cardiac arrests in the pre-hospital setting, we need to optimise the training and skill in BLS amongst all staff of the Primary Care team.

Junior doctor poster event n the 1st May 2014 we held our first junior doctor poster event in the PGMC. Junior doctors from across the Trust were invited to present a poster of work that they had undertaken in audit, quality or service improvement, or an interesting case report. The aim of the event was to encourage juniors in their critical thinking and writing skills and also celebrate their tremendous contribution to audit and clinical governance activities. Over 30 posters were displayed at the event, some of which have also been presented at external international conferences including the Society for Acute Medicine and The National Endocrine Association. The winning posters are still on display in the PGEC.*

Figure 1

ELECTRONIC PRESCRIBING (EPMA)

*The form can be found at:\\Sash01\data\ Clinical_Audit_Medical_Division *The winning posters can also be viewed at www.intranet.sash.nhs.uk/ departments/communications/ publications/The Journal

ePMA is part of the wider scope of the Trust working towards the NHS goal of paperless systems by 2018 and although it is an IT project, it is clinically led. This includes the electronic whiteboard project, where a patient’s journey from admission to discharge is managed through the Cerner system. In theory, this should mean relevant clinical staff are able to see not only a patient’s prescribed medications, but when and why they were changed. Other benefits of the electronic system include: drug calculators (for gentamicin dosing), automatic calculation of infusion rates and alert systems for medical teams to give adequate time for key drugs to be reviewed. Ultimately, all these systems should increase efficiency of drug rounds and reduce the chance of administration errors.

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C Clinical effectiveness Audit A Research & development R Education & training E

National Emergency Laparotomy Audit and Mr Tim Campbell- Smith

By Mr Andrew Day

Senior SpR Surgery

Consultant Surgeon

he National Emergency Laparotomy Audit (NELA) began in December 2012, commissioned by the Healthcare Quality Improvement Partnership and is funded by NHS England. All NHS trusts are required to enter data to the audit. There are approximately 30,000 laparotomies performed per year in England and Wales, typically on patients who are very sick and elderly. The Emergency Laparotomy Network (founded in 2010) has identified that this cohort of patients can have a mortality rate of approximately 15% and in those patients aged over 80 it approaches 25%. The aim of the audit is to drive quality improvement in the care of these patients and hopefully reduce the high rate of mortality and complications associated

with emergency laparotomies. All patients that require an emergency laparotomy must be identified early on in their admission with assessment by a senior surgeon. Prompt resuscitation with intravenous fluids and antibiotic therapy is essential in the peri-operative care pathway. If a risk assessment of predicted mortality identifies a >5% risk of death, then active input from the consultant surgeon and anaesthetist is required. Once surgery is indicated, it should be performed as soon as is practically possible following resuscitation, with direct input from both the consultant surgeon and anaesthetist. Early source control of sepsis, administration of IV antibiotics and intra-operative goaldirected fluid therapy are associated with improved patient outcomes. These patients should be managed in a critical

TRAUMA STUDY DAY: A REFLECTION By Mandy Cox

Trainee Perioperative Practitioner

I recently attended the Trauma Study Day, organised by Trauma and Orthopaedic Senior Sister Naomi Rogerson with talks by Consultant Orthopaedic Surgeon Mr Panose, Junior Sister Leeann Irwin and Orthopaedic Practitioner Lisa Haswell, supported by Depuy Synthes. The various presentations covered the differences between uncemented versus cemented procedures; the anatomy of the hip and the types of hip fractures and surgery.

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Trauma, especially hip fractures, is a complex field of surgery and it can be challenging to know all the special types of sets and instruments that can be used, especially if you do not know your anatomy in this field. As an assistant theatre practitioner, I am unable to ‘scrub’ in this area because it is emergency surgery. I am a circulator in these theatres. However, I can ‘scrub’ for elective orthopaedics. I often feel apprehensive, hoping I can retrieve the correct items requested in an instant. This can be exasperating, not only for me but also the scrubbed team. The workshops helped give me an introduction to a common brand of sets and instruments used in trauma hip surgery. Although the training was not obligatory,

The Journal Summer 2014

IMPROVING IV FLUID MANAGEMENT

care setting during their early postoperative recovery phase. Involvement in the audit will undoubtedly improve the outcome of patients undergoing an emergency laparotomy within the Trust. Interim analysis of the data collected so far at the Trust, has shown an overall mortality for this cohort of patients at 8.6%; well below the national average of 14.6%. It will focus our attention on this high risk group of very sick patients in what has traditionally been seen as the ‘Cinderella’ specialty of surgery. Accurate and timely input of data is critical to this audit, and the bulk of the data can be uploaded live online by the on-call registrars and consultants in surgery and anaesthetics at the time of surgery. Please keep up the good work! Footnote: Saunders, D., Murray, D., Pichel, A., Varley, S and Peden, C. (2012) Variations in mortality after emergency laparotomy: the first report of the UK Emergency Laparotomy Network, British Journal of Anaesthesia, 109 (3), pp. 368-75 [Online]. Available at: www.bja.oxfordjournals.org (Accessed: 11/07/14)

Further reading: NELA (2014) Organisational report of the national emergency laparotomy audit- executive summary [Online]. Available at: www.nela.org.uk/reports (Accessed: 11/07/14) The Royal College of Surgeons of England (2011) The higher risk general surgical patient [Online]. Available at: www.rcseng.ac.uk / (Accessed:11/07/14)

it was an offering of extended training to enable us to be able to increase our knowledge in an informal and relaxed environment. Gaining knowledge about implants and equipment was tremendously beneficial, as was learning about the history of hip replacements and how things have advanced. Study days like this make an enormous difference when working in theatre and if you comprehend the tools and implants, then you understand your role; it also makes it more interesting. I have now reinforced my learning which will help me, not only on a theoretical level but also in practice when allocated to the trauma theatre ‘running’ for the scrubbed team or in elective orthopaedics in the future.

By Dr Harriet Cunningham ‘Innovation in geriatric medicine’ was the theme of the SW Thames Regional BGS meeting for attendees (above).

Regional BGS report

Dr Laura Ferrigan, Consultant Geriatrician

n 22nd May, SASH hosted the SW Thames Regional British Geriatric Society spring meeting. The theme of the afternoon was ‘Innovation in Geriatric medicine’. The programme was introduced by CEO Michael Wilson, who updated attendees on the developments to elderly medicine at SASH. Paul Simpson (Chief Financial Officer), commenced the afternoon programme with a financial introduction to elderly people’s services, demystifying some of the complex financial aspects of the NHS and the pressures facing acute trusts. We were urged as clinicians to engage with our finance teams, local GPs and CCGs, to ensure that the quality agenda had a sound clinical basis.

as clinicians we should recognise that Patient Opinion provides a means for us to respond to this feedback, to ensure patients feel they have been heard. Jeannie Watkins, Physician Associate gave a presentation reviewing the development of the Physician Associate (PA) role in the UK, including their training, regulation and contribution to the medical team. SASH has been increasingly recognised as leading in PA development (articles in BGS newsletter June 2014 and Acute Medicine Journal July 2014).

“Our patients have always talked about us, but ... in the era of social media this is now more transparent and visible”

We were delighted to welcome James Munro, CEO of Patient Opinion, who provided an excellent talk on the use of Patient Opinion for feedback and improving services. We were reminded that our patients have always talked about us, but that in the era of social media this is now more transparent and visible, and

The main programme finished with presentations by Christopher Bell, Darzi fellow and SpR, on the implementation of an Acute Elderly Care team to enhance rapid response and assessment in ED at Croydon University Hospital, and from Samantha Payne, PA, on scoping frailty on the surgical wards. Both demonstrated the increasingly diverse role of the geriatrician in acute trusts and provided the basis for a useful discussion on sharing good practice in service development across the region.

Core Medical Trainee

One of the outcomes of a recent mortality review and indeed a patient complaint, was the incorrect prescription of IV fluids to a patient with renal failure. Anecdotally, we felt that as juniors we had not had much training in the practical management of a patient’s fluid status and this has also been highlighted in audits on acute kidney injury. With recent NICE guidance on IV fluid prescription, we felt it was an opportune time to undertake an audit of current practice and also explore in more detail how confident and skilled junior doctors are in fluid prescription. Over a period of one month, we audited 100 adult inpatients on general medical and surgical wards against the NICE guidelines. This involved looking at the initial assessment of patient’s fluid status, the appropriateness of IV fluid prescriptions, the monitoring and reassessment of patients’ IV fluid status, and whether patients had an IV fluid management plan. We also recorded any instances of fluid mismanagement that contributed to patient harm. Disappointingly, but not necessarily surprisingly, we found that we are not meeting the NICE standards in our prescribing and management of IV fluids for resuscitation and maintenance purposes. Alongside this we have undertaken a junior doctor survey to assess both the confidence of junior doctors in the management of IV fluid therapy, and their knowledge of the most up-to-date IV fluid guidance. This has shown, as we suspected, that the majority of junior doctors are not as confident as they would like in the management of IV fluid therapy, most notably in the assessment of fluid status. Most have had limited, if any formal training in this area. Based on our results, we are seeking to improve the quality of our inpatient IV fluid therapy management. The mainstay of this will be through increasing the training of medical students and junior doctors in IV fluid prescribing and management, starting with incorporating this area into the ward round simulation training for undergraduate medical students, as well as the annual teaching curriculum for FY1 and FY2 doctors. In addition, we are exploring ways to improve the IV fluid prescription chart to aid the appropriateness of IV fluid prescriptions. We are optimistic that through such measures we can lead the way in improving the quality of our IV fluid management.

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The Journal Summer 2014

Clinical case

Collaborative practice The underlying crux of each pathway is the team approach with everyone working symbiotically to ensure our patients receive the best care possible. We have been praised at a recent assessment for our team approach and we aim to continue this high standard to be the best at what we do. Footnote: 1/ NHS Enhancing Quality and Recovery (EQR) (2014). Available at: www. enhancingqualitycollaborative.nhs.uk (Accessed 06/08/14)

As part of a MDT our physiotherapists and occupational therapists (above) play a key role in aiding patient rehabilitation

ENHANCING QUALITY AND RECOVERY PROGRAMME By Sally Dando

and Dr Patrick Morgan

ERP Lead and Professional Lead for Therapies

Clinical lead for ERP and Consultant Anaesthetist

The ERP is a quality improvement collaborative which has been running for five years as part of the Kent, Surrey and Sussex Academic Health Sciences Network. The goal is to provide consistent, high quality care resulting in less complications, saved lives and better patient experience. It supports the clinicians to embed best practice, reduce variation and improve on our multi-disciplinary team performance. Each pathway is based on the latest clinical evidence and is driven through real understanding of meaningful data and what patients say. 117,000 patients in the region have been on EQR pathways1, with a plan for over 400,000 by the end of 2018. Over 750 deaths have been avoided and 25,464 potential bed days have been saved. SASH is one of 14 hospitals across the region which has been part of the programme that originally started by looking at patient pathways for heart failure, community acquired pneumonia, orthopaedic surgery, colorectal surgery, gynaecology surgery and dementia. Additional pathways now include COPD, emergency laparotomy, acute and chronic kidney disease and myocardial ischemia.

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Each of the pathways aims to improve the patient’s quality of care and treatment outcomes by looking at each part of the pathway from pre-assessment to post discharge follow up. Such improvements include better pre-operative information, patient involvement with their pathway, goal setting for each day post-operatively and stringent adherence to planned care. Metrics are agreed by clinicians and audited monthly. Anonymised data from each organisation is collated, assessed and analysed. This data is shared at collaborative learning events involving the other trusts in our region; as it is agreed more can be learned faster together. The Trust has improved on all its targets, and is achieving 100% on most pathways. Improvements have been made on patient information, pre-operative and post-operative care, which has decreased the patient’s length of stay. The Trust has been particular praised of pathway booklets which have been developed by the clinicians involved in each part of pathway. These are now available on the ERP web site.

The Journal Summer 2014

Meacok, R., Rud Kritensen, S and Sutton, M. (2014) The cost-effectiveness of using financial incentives to improve provider quality: A framework and application, Health Economics, 23(1), pp 1-13. Available at: www.onlinelibrary.wiley.com (Accessed 09/07/14)

SASH to become a Schwartz round® centre SASH has recently been successful in bidding to become a Schwartz round® centre. Schwartz rounds originated in the United States and provide a monthly one hour session for staff from all disciplines to discuss difficult emotional and social issues arising from patient care. Developed by the Schwartz Center for Compassionate Healthcare in the US, they were piloted by the Kings Fund in the UK in 2010 with great success and promoted shared experience and learning. The Point of Care Foundation now leads the work in the UK and will be helping SASH by providing training and support as we introduce the rounds. The first round will be on Monday 13th October in the Postgraduate centre at 12.30 for a buffet lunch followed by the round at 11.30-12.30. All clinical staff are invited to attend and participate. Posters will go up nearer the time. Further information about Schwartz rounds can be found at www.theschwartzcenter.org/ By Natalie Powell Consultant Physician

Acute Kidney Injury: The Outreach perspective By Claire Rowley

Lead Nurse Critical Care Outreach Team

An 83 year old lady who had fallen at home had been in hospital following a shoulder replacement. She had a past medical history of asthma, hypertension, hiatus hernia and chronic renal failure which was monitored by her GP. Post-operatively her Early Warning Score (EWS) was 1. She was referred to CCOT three days later when her EWS was 9. We noted that she had been hypotensive for three days, with an EWS of over 5 for at least 36 hours and had had suboptimal hydration. Unsurprisingly, her blood tests revealed acute on chronic kidney injury (urea 30, creatinine 481). Her blood was also acidic as a result. She also had signs of a chest infection and was clinically unwell. Within a few hours she was moved to intensive care for additional monitoring and renal support and made a good recovery. She was moved back to ward care after six days and ultimately discharged home. So what can we learn from this case? Outreach nurse Claire Rowley using the EWS to detect risk of AKI.

• I t is crucial to respond to the EWS in a timely fashion, using the escalation referral pathway on the back of the EWS chart and asking for early specialist review. • We must accurately monitor fluid input and output in patients at risk of acute kidney injury (AKI) e.g. post surgery. • We must ensure adequate hydration (especially in elderly patients and those with impaired kidney function). • We must be aware of a patient’s past medical history that might predict a risk of developing AKI. • If patients are difficult to cannulate and the patient is at risk of AKI, call for help. • Consider catheterisation but only if it aids fluid balance monitoring. Suggested reading: NICE Guidance, CG169 Acute Kidney Injury. August 2013 UK Renal Association, Clinical Practice Guidelines on Acute Kidney Injury. March 2011

ACUTE KIDNEY INJURY: PREDICT, PREVENT AND RECOGNISE EARLY As the case before illustrates, many cases of acute kidney injury (AKI) in hospital are potentially preventable. AKI is seen in 13–18% of all people admitted to hospital. It is important, therefore, for all staff to be aware of its definition; when to predict its occurrence; how it can be prevented and how to manage it effectively:

PREDICT

Measure creatinine and compare with baseline for all admissions if any of the following are likely: Over 65yrs History of renal, heart, liver disease or diabetes Neurological, cognitive problems or disability that might impair intake Hypovolaemia Neprotoxic medications/contrast agents

PREVENT Those that are at risk should have ongoing assessment and early response to change in kidney function or urine output Consider IV fluids for patients needing contrast for radiological investigations if at risk Review medications such as ACE inhibitors, ARBs and metformin in those with impaired renal function and those having contrast agents

RECOGNISE Detect AKI using the AKIN/KDIGO staging Thorough assessment, clinical examination and medication review Clear management action plan including ceiling of care if appropriate Early referral for specialist advice (visiting Renal Consultants, ITU)

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Evidence based practice

Reflective practice

My journey to being a nurse By Karen Archer

First year student nurse Brook ward

am fortunate to have diverse experience from working in mental health, to working at an orphanage in Romania. However, I originally embarked on my journey as a student nurse at East Surrey Hospital 20 years ago. Training was very different back then and perhaps the time was not right for me so I changed direction to work on the front line as an Ambulance Technician; this has been my role for the last 16 years.

Nursing training has changed over the years from conversion courses and state enrolled nursing to Project 2000. Whilst many look back on their training with nostalgia, in this article, student nurse Karen Archer highlights how her degree course will help her meet the demands of modern nursing.

Last year I took the plunge and went back into nursing at the University of Surrey. I am currently a mature student finishing my first clinical placement back where I began my journey at East Surrey Hospital. Before starting I worried that nursing would not be the same due to changes over the years and perhaps I would spend less time with the patients. On my first day I felt excited but anxious. When I saw the paper work needed for each patient, I felt daunted. I thought how would I remember to complete it all and how would this impact on my ability to deliver quality care to my patients? I was lucky to have a supportive ward manager as my mentor and the other nurses made me feel welcome and part of the team. This importantly, has

given me the confidence to develop my clinical skills whilst juggling the daily administrative tasks. Nursing today, I believe, demands strong academic foundations. We learn the importance of critical appraisal and the application of evidence-based practice. We learn the importance of autonomy in also questioning what it best for our patients. Reflection is a useful tool for the nurses, allowing us to ask whether we delivered the best care and how we might do things differently in the future. I am sure my journey will have its frustrations and challenges, but I am already feeling valued for my contribution and know that this time is the right time for me.

REVALIDATION: FEMALE MEDICS LEAD THE WAY By Mr Adam Stacey-Clear Responsible Officer for GMC Revalidation

It is now a legal requirement for all doctors with a license to practice to have an annual appraisal. Indeed, all NHS employees need to have one. The NHS England guidelines stipulate that under exceptional circumstances (e.g. maternity/sick leave or sabbatical) postponement of an annual appraisal must be agreed in advance with the RO. The appraisal process is not designed to catch another Shipman but to promote reflective practice supported by quality healthcare (which is safe by definition). The GMC has outlined the minimum supporting information required and this is neatly set out in sections on the MAG (medical appraisal guide) form found on the Trust intranet*. The revalidation cycle consists of five years of annual appraisals and each appraisal should be an opportunity to be proud of your achievements. The patients have the right to know that their doctor is making every effort to be up-to-date and fit to practice, which is what we would expect of each other. 12

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CRITICAL APPRAISAL A KEY TOOL FOR EVIDENCE BASED PRACTICE

The quality of medical appraisals, as measured by detailed reflection of practice throughout the year and supporting information, ranges from awesome, to frankly completely inadequate. It would be far easier for doctors to populate a copy of the MAG with supporting information each month so that it is not a burden to produce at the end of the year; this needs to be on the radar for everybody a little more. We have achieved the highest appraisal rates in the South East and this was acknowledged by Sir Keith Pearson in February this year (formerly Chairman of The NHS revalidation committee, now NHS England). The Framework for Quality Assurance document has now been published and we all have to comply with it. I have noticed that the ‘best’ appraisal documentation, with only a few exceptions, is invariably produced by the female medical staff who are far more engaged with the process. For those doctors who find the process difficult to grasp then this can be seen as an opportunity to be more organised. Our patients deserve to be seen by doctors who are on board. We must be receptive to the process of getting better. * www.intranet.nhs.uk/forms/medical online appraisal form

By Susan Merner Deputy Head of Library & Knowledge Services

ritical appraisal is a key skill which helps you reach evidence based decisions. Evidence Based Medicine is to Ask, Acquire, Appraise, Apply, Assess. As well as being able to assess articles retrieved from a literature search, it can also be used within journal clubs to discuss recent research and has also appeared as an extra challenge for junior doctors during OSCEs. Critical appraisal enables you to use a standard approach in assessing research – particularly useful when assessing a huge number as you need to avoid adding in your own personal bias. It enables you to focus on key parts of the article and ensures you appraise the statistical data, the methodology used and have a reasoned argument on whether the findings are valid.

which can help save time whilst ensuring a consistent approach. Another useful website we link to is the Centre for Evidence Based Medicine2 which offers a CATmaker (not the feline variety!) which helps you create critically appraised topics (CATs), for the key articles you encounter about therapy, diagnosis, prognosis, aetiology and systematic reviews of therapy. There are also calculators available to help with statistical data.

“Evidence Based Medicine is to Ask, Acquire, Appraise, Apply, Assess.”

Help is available by contacting the library – we can work with individuals and groups to look at how to appraise an article and we run workshops on this topic. Our library website indicates useful resources and links – use Resources – Critical Appraisal to locate this information. The CASP website1 is one of the links and this explains the process of critical appraisal – there are eight different tools available which provide suitable assessment techniques for systematic reviews, meta-analysis, cohort studies etc. All the tools start with two or three screening questions to establish whether it is worth continuing to appraise the article. With practice, this is a technique

If you are feeling bewildered by the mention of metaanalysis or cohort studies there is a useful book to help make sense of this - ‘How to read a paper’3. Copies of the book are available in the library. We also have ‘The doctor’s guide to critical appraisal’ which offers a comprehensive review of the knowledge and skills needed to appraise clinical research papers. Footnote: 1/ Critical Appraisal Skills Programme (CASP) (2013) Available: www.casp-uk.net/ (Accessed: 20/5/2014) 2/ CEBM (2014) Centre for Evidence Based Medicine. Available at: www.cebm.net (Accessed: 20/5/14) 3/ Greenhalgh, T. (2014) How to read a paper (5th ed) Chichester: John Wiley and Sons.

WORKING TOGETHER ON SEVEN DAY STROKE SERVICES By Dr Ben Mearns Clinical Lead for Acute and Elderly Medicine

Our current stroke service at East Surrey Hospital, is based on Chaldon ward and provides acute inter-disciplinary specialist stroke care for up to 700 patients per year. This includes immediate assessment 24 hours a day, 365 days a year by an experienced stroke nurse and the medical team to provide ‘thrombolysis’ and other treatments if necessary to treat a stroke as it is happening. This is known as ‘hyperacute’ stroke care and can reduce the disability caused by stroke when delivered quickly. We provide this service at all times, working with our colleagues across Surrey via a telemedicine network. This means that our Consultants Dr Abousleiman and Dr Zhang can appear on a computer screen in the Emergency Departments of Frimley, Ashford, St. Peter’s, Guildford or Epsom Hospitals to speak directly with patients and staff and see all relevant investigations remotely. The consultants from those hospitals can do the same for us providing joined up care across the whole of Surrey at each local hospital. The next exciting step in our collaboration on stroke care to combine the expertise of consultants at Epsom* and East Surrey Hospitals to enable a specialist stroke consultant to be present on the stroke units of both hospitals every day of the year. The consultants will see every hyperacute stroke patient in person, supervise the TIA (transient ischaemic attack) clinic and review the care of all patients in the stroke units of both hospitals. We are now working together on a plan to deliver this enhanced level of service for our patients by working in synergy and this marks a new step forward for us in collaborating to deliver the highest standard of stroke care for our local population. *Epsom and St Helier University Hospital NHS Trust

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Improving our practice

DATIXWEB: CLOSING THE SAFETY ACTION LOOP By Suzanne Robinson Directorate Risk & Patient Safety Manager

hat is the point of reporting incidents, we never get any feedback? This is a cry heard in hospitals around the world. “They do get feedback, they just don’t recognise it”, is the frustrated reply from the people who operate the incident reporting system1.

Other industries agree that using different methods of feedback is the most effective way of informing staff. The introduction of DatixWeb gives us an opportunity to develop the system so it can supply the information required to feedback on actions taken and the improvements made, as a result of incident reporting, in a way that the organisation can evaluate. Earlier this year, staff completed a valuable survey regarding feedback on Datixweb. Whilst 39% of respondents thought that the feedback section was a useful addition to managing patient safety, 51% felt it was in need of some improvement. Sadly 9% felt it served no useful purpose at all. This is disappointing because we know that there is so much good work and so 14

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A common theme has appeared in our patient feedback and we all need to try our best to improve it. Patients tell us that our wards are very noisy at night and that this can disturb their sleep. This is particularly a problem in assessment areas like the AMU and we need to try to fix it.

Reflecting and learning from our mistakes and sharing this knowledge to make our hospital a safer place

Lesson to learn: At night we need to speak quietly and away from patient areas if possible. We should check the phones on the ward and turn down the ringer volume and think before telephoning a ward at night, as the noise will disturb patients. Please let me know of any other suggestions.

Lessons learned Edited by Dr Ben Mearns

One of the recommendations from the Francis report2, is that a culture of incident reporting by staff is not only encouraged but insisted upon. It recommends that staff should be entitled to feedback on anything they report, together with any information regarding the actions taken or the reasons for not acting. Closing this ‘feedback loop’, which other high risk industries advocate, has remained a challenge within the NHS. What has worked for these industries does not automatically transfer to healthcare, where we have far fewer automated processes and where the result of an error tends to have more immediate consequences.

Shhhhh!

Pitfalls with methotrexate

Clinical Lead for Acute and Elderly Medicine

You say Sepsis, I hear Septicaemia

many improvements happening every day; we just need to refine how we record and share them across the Trust. Feedback on patient safety incidents is not just about information; it is very much about taking action too. Wherever we

For further information of how to obtain feedback please contact suzanne.robinson@sash.nhs.uk. Anyone wishing to report an incident can access Datix via http://datx1/datix/live/ index.php

“Unfortunately 87% of staff had not received any feedback when they reported an incident, even though they had requested it, so it is not surprising that staff feel disillusioned by the process.” work in the hospital we all have a part to play, and the giving of feedback to improve how we all work for the benefit of our patients should be an integral part of patient safety management. The feedback project is still very much a work in progress, as I continue to develop this part of the system for my MSc in Integrated Governance in Healthcare.

The Journal Summer 2014

Footnote: 1/ Hartnell, N., MacKinnon, N., Sketris, I., Fleming, M. (2012). Identifying, understanding and overcoming barriers to medication error reporting in hospitals: a focus group study, BMJ Quality and Safety, 21, pp.361-368 (Accessed: 07/05/14) 2/ Francis, R. (2013) Independent Inquiry into care provided by Mid Staffordshire NHS Foundation Trust January 2005-March 2009. London: Department of Health.

Sometimes the terms that we use can be confusing to patients and their families. We all now use the term ‘sepsis’ to describe a pathophysiological response in the body to infection, that can range from a relatively mild reaction to one that can lead to organ failure and death. However, one family interpreted the term as meaning Septicaemia and based their assumptions of the patient’s care on this diagnosis which led to a complaint. Once the term was explained, the family felt so much better. Lesson to learn: We need to explain medical terms in simple, accessible language to patients and their families and to confirm understanding.

Always check electrolytes when prescribing fluids Most doctors will have been in the position of being handed a drug chart and asked to write up some more fluids. It can feel like a routine job and can be suggested to a doctor in passing. This happened one day on the Acute Medical Unit (AMU) and resulted in a helpful doctor writing up some ‘maintenance’ fluids which included potassium for a patient with high potassium levels and renal failure.

Potassium certainly should not have been prescribed and urgent treatment was necessary to correct the problem. Lesson to learn: Drugs or fluid must only ever be written up for a patient when you know the case and have reviewed all necessary investigations. For fluid prescriptions, we need to always have checked the most recent electrolytes (see page nine for IV fluid audit action plan)

Pause when you prescribe A patient was admitted with a very high INR due to a warfarin overdose. It became apparent that the patient had been taking 3.5mg of warfarin with good effect but at some point this had been reissued and a mistake was made. 5mg tablets were issued in place of the usual 0.5mg giving the patient a total dose of 8mg rather than their usual 3.5mg. This dose was given for several weeks and the INR had not been checked as it was considered to be stable. The patient was admitted with a GI bleed with an INR of over 20 suggesting warfarin overdose. Lesson to learn: We should ensure that when prescribing drugs we stop and look at the prescription once completed to ensure that everything is as it should be. The ward round checklist is a good reminder.

Methotrexate can be a particularly harmful drug and because it is prescribed and administered in a ‘once per week’ way we must ensure that we are vigilant whenever we use it. There have been two times in the last year when an error has occurred and additional doses of methotrexate given and we must all learn from these events to prevent them in future. Lesson to learn: Remember that FY1 doctors should never prescribe methotrexate, even if rewriting the drug chart – get a senior doctor to do it. Remember to always block out the days that the dose should not be given on the drug chart. Remember not to allow boxes of methotrexate to remain in the patient’s own drug supply at the bedside. And please stand back after writing up the drug and check and check again that the prescription is correct. So please when prescribing methotrexate, think and think again.

We want to make The Journal relevant and useful to you. In support of this, we have compiled a suggested reading list to accompany some of the features and topics covered in this issue. Visit The Journal at http://intranet.sash.nhs.uk

TheJournal@sash.nhs.uk

The Journal Summer 2014

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: Lee, S., Ayers, S and Holden, D. (2014) A metasynthesis of risk perception in women with high risk pregnancies, Midwifery, 30(4), pp.403-411. Field, B.C. (2014) Neuroendocrinology of obesity, British Medical Bulletin, 109, pp.73-82. Stockley, S. (2014) Characteristics and practicalities of a new basal insulin, British Journal of Nursing, 23(1), pp.16-20. Bhangu, A., Conway, A., Dent, P and Yacob, D.(2014) Safety of short, in-hospital delays before surgery for acute appendicitis: Multicentre cohort study, systematic review and meta-analysis, Annals of Surgery, 259(1), pp.894-903. Conway, A., Rustom, C., Wills, R., Ball, A., Stacey-Clear, A. and Waheed, S.(2014) Is sentinel node biopsy necessary in patients undergoing mastectomy for DCIS, European Journal of Surgical Oncology, 40(5), p.638. Conway, A. and Waheed, S. (2014) Angelina Jolie’s effect on referrals to a district general hospital Breast Unit, European Journal of Surgical Oncology, 40(5), p.620. Pavlidis, P., Ansari, A., Duley, J., Oancea, I. and Florin, T. (2014) Splitting the normal daily dose of thioguanine may be efficacious treatment for IBD and avoid hepatic toxicity, Journal of Crohn’s and Colitis, 8, S207. Field. B.C.T. (2014) Neuroendocrinology of obesity, British Medical Bulletin, 109(1), pp.73-82. If you have written an article, book or chapter of a book (2014 onwards), then please contact the library team 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.

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

TheJournal@sash.nhs.uk

The Journal Summer 2014

Achievements and Professional Recognition Congratulations to… …Dr Komal Chadra, Dr Sam Trowbridge, Dr Tanya Patrick and Miss Anna Conway (under the supervision of Miss S Waheed) who are presenting their project on the role of open access follow-up for breast cancer patients at East Surrey Hospital at the Congress of the European Society of Surgical Oncology in October and have been shortlisted for a prize.

...Specialist Practitioner in Transfusion, Simon Goodwin, who recently gave a presentation at the Serious Hazards of Transfusion (SHOT) annual Symposium for 2014 on an initiative within our region to improve consent to blood transfusion to be implemented into our Trust from August.

…Editor Maxine May who recently graduated with a first class BSc (Hons) in Therapeutic Radiography from The University of London (St George’s Hospital Medical School) and was awarded the Royal Marsden Smithers prize for academic achievement.

…Consultant Nurse / Dementia and Older People Steve Adams who has been awarded a MSc with merit in Advanced Clinical Practice by St George’s Hospital Medical School.

…Jaidev Mehta and Ada Wong who completed the JPB Diploma in General Pharmacy practice and to Pharmacy Technicians Cathy Roberts, Keir Lavin-Jones and Sheree Mutton who have passed their Checking Accreditation course and exams. …Dr Powell, Dr Mearns, Rachel Forbes-Pyman and Dr Samantha Payne whose article on the role of Physician Associates in geriatric medicine has been published in the worldwide BGS Newsletter for the British Geriatric Society.

…Dr Noman who was awarded joint first place for the Royal Society of Medicine’s Ophthalmology travelling fellowship award. This was for an eye camp Noman planned and ran in rural Bangladesh at the end of April 2014. He recently presented his work at the RSM conference on June 12th. To see a video of the camp in action visit: http://vimeo.com/ user8518763/videos

…Dr Natalie Powell who has been awarded the KSS Specialty School Award for Medicine 2013/14 for her work establishing the innovative ward round simulation training. Also for supporting a large number of CMT trainees and ensuring that quality improvement projects flourished along with dissemination of all of this via presentations and publications for her trainees.

…Samia Babiker who has had the abstract of her MSc project accepted for publication in The Journal of Transfusion Medicine. Samia completed an extensive audit into massive blood loss episodes covering three years from 2011 to 2013. Our Massive Blood Loss policy will be revised later this year in line with Samia’s findings.

…Dr Gaurav Agarwal who was awarded the KSS Specialty School Award for ACCS 2013/14 for his work promoting the education and development of doctors in Kent, Surrey and Sussex.

…Deputy Chief Nurse Sally Brittain who has been awarded a MSc in Clinical Leadership and Health Education by Kingston University.