The journal vol 1 issue 3 2014 by Surrey and Sussex Healthcare NHS Trust

DNACPR AND DNAR

SEPSIS SIX AWARE

The solutions? By Dr Fiona Lamb

Surviving sepsis By Dr Shuaib Quraishi

P.3

P.4

PLUS: Written by healthcare professionals for healthcare professionals

• Frailty: A geriatrician’s perspective P.5 • Delivering on R&D recruitment targets P.6 • Improving communication with SBAR P.9 • Case study from the Board P.10

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Clinicians, incident reporting and analysis: learning for improvements in patient safety such industries. We need to anticipate the sources of system insufficiencies and human errors and eliminate or modulate them. We must rely on frontline staff, the experts in providing healthcare, to pick up the gauntlet for safety improvements. This begins with clinicians reporting patient safety incidents or risky situations so that we can take corrective action before harm occurs.

By Dr Dan Cohen International Medical Director, Datix Ltd

f we are to be successful in providing safe healthcare, we must be able to admit our own liabilities. Benevolent intentions do not always translate to safe outcomes. Our systems of healthcare and our processes for providing care are complicated by inefficiencies. Our personal strengths and effectiveness, even our compassion, can be limited or impaired by innumerable human factors. The processes of diagnosis are encumbered, often unknowingly, by human biases that direct us away from asking important questions or obtaining relevant additional data and our interventions, whether diagnostic or therapeutic, may be potentially hazardous.

and we may not appreciate the risks in our workplace or acknowledge our contribution to those risks.

Doctoring and nursing are “When a Just A quintessential element revered professions. Some Culture is in improving patient in these professions see safety is the necessity themselves as very special lacking, then to learn from instances people but my view is incident reporting where things go wrong; that we are ordinary when someone is people, albeit people with and patient safety harmed, and equally enormously special, even when harm is avoided will certainly sacred, responsibilities. by timely recognition of suffer” We have much to be circumstances that can grateful for when things lead to harm. Healthcare go right and much to learn from when is striving to become a high-reliability things go wrong. Sadly, complacency industry, and we need to replicate some abounds where caution is warranted, of the successful processes used by

Doctors seem to be the group of professionals least likely to report patient safety incidents, and yet they have much to add to our understanding the contributing factors that lead to incidents. Common reasons that doctors give for not reporting incidents include fear, guilt, loss of professional respect, daily workload pressures, lack of support and even threats of recrimination from managers and administrators. Therefore, it is important for institutional leaders to develop and sustain a management framework that embodies a Just Culture where mistakes are acknowledged for their learning value and where personnel actions taken, if any, are measured and appropriate, taking into account all contributing factors. When a Just Culture is lacking, incident reporting and patient safety will certainly suffer. Reporting incidents and ensuring their thorough analysis is part of our professional and ethical obligation; part of our responsibility to our patients to make healthcare safer. Continued page 2

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Comment

WELCOME TO THE JOURNAL The Journal is a clinically-led publication produced quarterly by Surrey and Sussex Healthcare NHS Trust (SASH). It is written and edited by healthcare professionals for healthcare professionals. It aims to improve interprofessional engagement, collaborative practice and knowledge-sharing across the Trust, whilst helping to embed a culture of continual learning and quality improvement. Editorial Board Editor Maxine May Tel: 01737 768511 x 2633 E: maxine.may@sash.nhs.uk Medical Director Dr Des Holden E: des.holden@sash.nhs.uk

A CULTURE OF IMPROVEMENT

e have now had our Board-toBoard with the Trust Development Authority (TDA), the second of three steps on the journey to Foundation Trust status. The TDA and Monitor are very interested in how boards oversee and impact quality (as well as finances). This third edition of The Journal carries the first of a series of clinical cases which have been presented to Trust Board and used as an honest reflection on the care we provide and to drive quality improvement. The Board uses patient stories, presentations from clinical teams, scorecards and benchmarking, its assurance subcommittees (Safety and Quality, Audit and Assurance, Finance and Workforce committees) and its NED ward walks, as well as its key strategies (quality, clinical, IT, work force) to ensure that all the decisions it takes are grounded in, and relevant to, the delivery of high quality care.

Dr Heidi Fahy

GP, Programme Director, GP tutor East Surrey and Crawley GP member, ESCCG

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

Clinicians have two full time jobs. Every day we must work hard to be the best that we can be; the risks are paramount and the responsibilities daunting. The other equally important full time job is to work to be even better at our profession the next day and the one after that. Shared learning from our experiences is key and we must be open and candid. Our patients deserve nothing less than everything we have to give! It may not be the Duty of Candor but it is closely aligned… Further commentaries on patient safety from Dr Cohen are available at www.datix.co.uk TheJournal@sash.nhs.uk

Please read The Journal and take as many lessons from its lead feature, its articles and stories as you can. Dr Des Holden Medical Director

FACING CHANGE TOGETHER

Consultant Physician Dr Natalie Powell

Since the last edition we have begun our SASH Plus culture champions work. Our culture champions have been identified by their managers as daily exemplars of our values and this initiative is to present positive role models throughout all areas of the Trust in parallel with the introduction of achievement reviews and talent mapping which are being introduced by the more traditional top down route. This organisational development work is again to enable our quality of care to be at the heart of all we do.

ednesday is a very special day of the week for a few very privileged GPs like me. On Wednesdays, I am a Program Director (PD) and work in the education department at SASH. I remember reflecting on what the role of a PD would entail when I had to give a five-minute presentation in my interview at the KSS (Kent, Surrey, and Sussex) Deanery (now HEKSS) back in 2006, and I likened the role to that of a conductor of an orchestra. Every Wednesday, I have the pleasure of working with a number of talented, highly qualified young doctors who have made a decision to take up General Practice as their chosen career. Over three years, we get to facilitate the transition of around 20 doctors into GPs who are fit for the future and we orchestrate their training to make sure by the end that we have produced GPs who we would be proud to recommend to friends and family. Since 2007, becoming a GP is quite a process, with the introduction of the new membership set of assessments by the Royal College of GPs (RCGP). In our roles as educators, we have had to adapt, change and evolve to make sure our training here at East Surrey and Crawley Vocational Training Scheme (CRESH VTS) is better and beyond ‘fit for purpose’. I expect we

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are not alone in feeling that the speed of our professions’ evolvement has been at a pace and sometimes, it feels like a race in which you just can’t run fast enough. Having said that, as doctors, we are generally pretty resilient, and not only do we keep up, but we aim to win! Another reason for being lucky is because me and the other PDs get to work with other educationalists in other specialties. One of the highlights of the role is meeting hospital clinicians who are involved in the teaching of our GPs, be it in the corridor, in an organized teaching session, the queue for lunch in the canteen, or paying for a quick snack in Boots. It takes the interface between primary and secondary care to a level, which I wish could be available for all doctors. This brings me to one of the other hats I wear – a GP member on the East Surrey Clinical Commissioning Board (ESCCG). Since April 2013, GPs have a central role, working with directors and managers in the NHS, to use their knowledge of their patients to enable high quality, safe and up to date health care. The best development for me has been the greater involvement of NHS clients - our patients - who are involved increasingly in commissioning and decision-making. The GP world for doctors coming to the end of their training is very different to the one I joined many decades ago, but change is inevitable, and not to embrace change would be foolish. According to Winston Churchill: “To improve is to change; to be perfect is to change often.” I would add “and lets do it together.”

Under the spotlight…

DNACPR and DNAR - the solutions? By Dr Fiona Lamb

Consultant Anaesthetist and Intensivist

his week, I overheard these three comments: “I never complete a DNAR*;” “She had a community DNAR, but I didn’t look at it;” “This patient should have had a DNAR.”

The new guidance for CPR (CardioPulmonary Resuscitation) decisions emphasises communication and agreement1. This communication needs to be sensitive, appropriate and involve the patient, the people important to them and their healthcare teams. The challenge in an acute hospital is to tailor this process for either slowly, or rapidly, deteriorating patients. DNACPR* refers to the therapy of CPR with hard and fast chest compressions investigated in-hospital cardiac arrests this as an Advanced which temporarily distort the Decision Refusing Treatment with CPR and found poor results for chest by 5-6 cm, equivalent patients with chronic diseases and/or (living will). Other patients to an applied weight of cancer2. Few of these patients survived are unable to contemplate approximately 50 kg, repeated “The new and a significant number had disabilities this, or are too unwell to 100 to 120 times a minute. guidance for and were unable to return to their homes. think coherently about this These forces may harm ribs CPR decisions CPR in these situations emotive topic and internal organs and the may postpone death briefly. to allow them ‘rescue’ cardiac output may emphasises to understand be insufficient to preserve communication To the staff I overheard and the difference “People may have vital organ function. The to you, I recommend reading between CPR clear ideas about indication for this therapy is and agreement” the new guidance and 2012 and all other a comatosed person, without how they wish NCEPOD Time to Intervene therapies and normal breathing, having study as these will help you treatments, no signs of life and no palpable pulse. to be treated and with CPR decision making. cardiac arrest and dying There are numerous causes for this state processes. In these situations, may have had including death and the dying process. By Footnote: questions linking CPR with default, everyone on the Trust’s premises time to discuss 1/ Resuscitation Council death may force a choice will receive CPR if they fall into this state (UK) (2014). Decisions this with people in favour of CPR which is making this a unique therapy. CPR should relating to Cardiopulmonary unlikely to be of benefit and not be performed if the person declines important to Resuscitation (3rd edition) may result in harm. Similarly, it and/or the multidisciplinary team has Guidance from the British them. Few will it is difficult to discuss this made a decision, with their knowledge and Medical Association, the with upset relatives. expertise, that CPR would be inappropriate have formalised Resuscitation Council (UK), and for the patient and this has been agreed the Royal College of Nursing. this” The public receives Available at: https://www. by all concerned. These wishes and/ information regarding resus.org.uk/pages (Accessed: or instructions are communicated by a CPR from the media, 30/11/14) completed and immediately available red which portrays the young having cardiac bordered DNACPR form. 2/ NCEPOD (No date). Time to Intervene? A arrests with exaggerated survival rates. review of patients who underwent cardiopulmonary Ideally, discussions about CPR and DNACPR In addition, news stories, including that resuscitation as a result of an in-hospital of the professional footballer Fabrice need to occur with the public before they cardiorespiratory arrest. Available at: http://www. Muamba who survived with 78 minutes become patients and as people approach the ncepod.org.uk/2012report1/downloads/CAP_ of CPR, fuel the public’s perception of end of life - as part of a wider discussion of summary.pdf (Accessed: 2/12/14). healthcare plans. People may have clear ideas CPR as a miraculous therapy and lead them to believe it is applicable for all about how they wish to be treated and may *DNAR - Do not attempt resuscitation people which, of course, it is not. The *DNACPR - Do not attempt cardiopulmonary have had time to discuss this with people 2012 NCEPOD study Time to Intervene resuscitation important to them. Few will have formalised TheJournal@sash.nhs.uk

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Clinical case

Are you Sepsis Six aware? • Take blood cultures. • Take serum lactate and full blood count measurement. • Take accurate urine output measurement. • Give high-flow oxygen. • Give intravenous fluids. • Give empirical intravenous antibiotics.

By Miss Bernadette Pereira Surgical Registrar

epsis is one of the few conditions which affect the under developed and the developed world with equal ferocity. In the developed world, the incidence of sepsis has risen between 8-13% over the last decade and claims more lives than bowel and breast cancer combined. In the UK, it is estimated that more than 100,000 people are admitted to hospital with sepsis and around 37,000 people will die as a result of the condition1.

The recognition of sepsis is a problem for healthcare workers worldwide, including the UK and US. Research shows that simple interventions - such as giving IV antibiotics and fluids in the first hour - can reduce the risk of death by over one-third, yet international guidelines representing these interventions are delivered to fewer than one in eight patients in the NHS2. Adoption of the Sepsis Six has shown to decrease mortality, the length of stay in hospital and use of intensive care bed days3. It is a clinical tool designed for use in patients with severe sepsis and is

an easily accessible, and comprehensible pathway that can contribute to the delivery of simple, yet lifesaving interventions. Many hospitals in the UK and beyond have developed combined recognition/intervention tools aimed at rapid delivery of the Sepsis Six to patients with severe sepsis including here at SASH1. The Sepsis Six consists of three diagnostic and three therapeutic steps (can be remembered as ‘take three things’ and ‘give three things’). Most importantly, these steps have to be instituted within one hour of the initial diagnosis of sepsis:

SURVIVING SEPSIS By Dr Shuaib Quraishi Specialty Registrar in Acute Medicine

he medical division has conducted a trustwide audit to assess our adherence to the Sepsis Six bundle and has now implemented changes to improve care and mortality. A retrospective audit assessed adherence to Sepsis Six bundle on patients that had positive blood cultures and met severe sepsis criteria. Performance overall with the sepsis bundle showed there was much room for improvement. An extensive trustwide education program was rolled out for doctors and nurses where teaching in ED, AMU and grand rounds took place to increase awareness. Sepsis Six 4

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protocols were made available on the Trust intranet and posters were placed in clinical areas. Simulation - based training on sepsis for doctors - was initiated. A prospective audit was then carried out which assessed patients suspected of having severe sepsis to assess whether there was an improvement in adherence to Sepsis Six. The 30-day mortality rate was compared to assess if there was any impact on mortality. Results revealed the following percentage adherence (retrospective % vs prospective %) of each of the Sepsis Six targets: 1. 2. 3. 4. 5. 6.

Blood cultures (38% vs 55.5%) Lactate/haemoglobin (33% vs 55.5%) Urinary catheter (14% vs 20.4%) Oxygen administration (52% vs 90.7%) Fluids (58% vs 81.5%) Antibiotic administration (52% vs 62.9%)

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Achieving these six simple steps in the first hour can double the chance of a patient surviving. It can be delivered by any junior healthcare professional working as part of a team. For the delivery of the Sepsis Six in a septic patient, all you need is a qualified prescriber, basic healthcare equipment and the will to make it happen. Together we can make that change. Footnote: 1/ The UK Sepsis Trust (no date) Raising Awareness of Sepsis. Available at: www.sepsistrust.org 2/ Dellinger, R.P, Levy, M.M, Carlet, J.M, et al. (2008) ‘Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock’, Intensive Care Medicine, 34 (1), pp. 17–60. 3/ Daniels et al. (2011) ‘The sepsis six and the severe sepsis resuscitation bundle: a prospective observational cohort study’, Emergency Medicine Journal, 28 (6) pp. 507-12.

7. Accepting that the methodology was different in the two audits and allowing for confounding factors, such as patient demographics, we demonstrated a reduction in mortality at 30 days of 50.3% (38%.vs 18.9%). Education and training helped promote early recognition and better management of patients with severe sepsis, resulting in a 50.3% relative risk reduction in mortality without added healthcare costs. The audit has now been presented at both the regional research and development conference (IMRAD, September 2014) and the Society for Acute Medicine international conference (October 2014). *The protocol for sepsis bundle can be accessed via the intranet by searching departments/ clinical/acute medicine/medical guidelines/ sepsis

Patient-centred care

FRAILTY – A GERIATRICIAN’S PERSPECTIVE

SCOPING FRAILTY IN HOSPITAL ADMISSIONS TO DELIVER PATIENT CENTRED CARE By Sam Payne

Physician Associate in Geriatric Medicine

By Dr Iain Wilkinson Consultant Orthogeriatrician

any of the patients in and out of hospital are elderly and some, but not all of them will be ‘frail’ – but I suspect what we all mean by ‘frail’ or ‘frailty’ may differ. Historically, frailty was tied to age. Over recent years there has been large-scale academic interest in the concept of frailty and what it means. Fried1 suggests that a frail person has three or more of the characteristics identified in table 1. Those with one or two were termed as ‘pre frail’. Across all studies, patients identified as frail have higher mortality and the older you are the more likely you are to be frail2

In Canada, Professor Rockwood’s group has taken this a stage further and developed a frailty index3. They identified a number of age related ‘deficits’ that are recorded in comprehensive geriatric assessments. Looking at the number of deficits recorded for each patient (i.e. x) and comparing it to the maximum possible (i.e. y) allows the creation of an index score for frailty (=x/y). This is very comprehensive but not really practical in the standard clinical setting. It does however confirm the idea that frailty really is the manifestation of an accumulation of deficits. As patients become progressively frail they are less and less able to tolerate conditions that stress the homeostasis of their system. With each illness / physiological insult, the ability to maintain that homeostasis gets worse and worse – i.e. their level of frailty escalates. This explains why frail

patients may come into hospital with one condition but have a number of different problems during their stay. One key aspect in all this is the condition of sarcopenia – where there is change in muscle architecture and function. Less function leads to less activity (you get more tired so do less). As patients develop a sarcopenia they become relatively nutritionally (and hence ATP) deficient which drives further muscle changes and hence further frailty development. A frailty cycle1 has been suggested as management of frailty is complex and there is no wonder drug to use. The key is a comprehensive geriatric assessment looking at each aspect on the frailty cycle. Nutritional intake is a cornerstone. On the wards we need to get used to being holistic, look at food charts and try to maximise intake and maintain mobility from day one. Footnote: 1/ Clegg, A. and Young, J. (2011) ‘The Frailty Syndrome’, Clinical Medicine, 11(1), pp. 72-75. 2/ Theou, O. et al. (2014) ‘Identifiying Common Characteristics of Frailty, Across Seven Scales’, J Am Geriatr Soc, 62, pp. 901-906. 3/ Searle, S. et al. (2008) ‘A standard procedure for creating a frailty index’, BMC Geriatrics, 8(24). 4/ Fried, L. et al. (2001) ‘Frailty in older adults: evidence for a phenotype’, J Gerentol A Biol Sci Med Sci, 3(56), pp. 146-56.

Frailty characteristic definition Weight loss Weakness Poor endurance / slowness Low levels of activity Table 1 – from Fried4

>4.5kg loss from baseline over last year Reduced hand grip strength – lowest 20% of population Reduced gait speed – lowest 20% of population (around 1 m/s) Reduced energy usage – lowest 20% of population

lder people constitute around 60% of medical in-patients at SASH, which is similar to national statistics. The Royal College of Physicians Acute Care toolkit1 highlights the need for early specialist input. We need a means, therefore, of identifying those in need in order that they receive the best and most appropriate care. Frailty scores or indices may help to achieve this2. We conducted a scoping exercise to determine the level of frailty amongst medical and surgical older admissions and used the Dalhousie Clinical Frailty Score3 to retrospectively allocate a frailty score to patient based on records in the medical, nursing and therapies’ notes. The aim was to determine if the frailty score might be a useful means of identifying patients to target for early geriatric specialist input when admitted to hospital. Fifty surgical and fifty medical patients were studied. The median frailty scores were 3 in surgical elders and 6 in medical elderly admissions. Of the surgical patients, 21 had at least one Activity of Daily Living (ADL) impairment on admission and six additional patients developed impairment during admission (and this correlated with a higher baseline frailty score). Of the medical patients, 36 had at least one ADL impairment and the average number of impairments was 6 (which correlates with the higher average frailty score) but only 3 patients acquired additional ADL impairment during admission. Within the surgical cohort, the length of stay for those with frailty scores ≥5 had an average LOS of 20.08 days compared to 6.02 days for those with scores of ≤4.6. What the scoping exercise demonstrates is that frailty is common and if present on admission, it is likely to impact a patients’ clinical course and their stay in hospital. The ability to recognise frailty early may help to identify those that need early specialist input and also to identify person-specific needs that we as healthcare providers should be meeting. Footnote: 1/ Royal College of Physicians (2014) Toolkit Toolkit.. Available at: http://www.rcplondon.ac.uk (Accessed: 26/07/14) 2/ Partridge, Harari and Dhesi. (2012) Age and Ageing, Ageing, (41), pp. 142-147. (Accessed: 28/07/14) 3/ Dalhousie University Frailty Score. Geriatric Medicine Research, Dalhousie University, Halifax, Canada. 2007-2009 version.

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

Delivering on recruitment targets By Dr Sandeep Cliff Consultant Dermatologist

ndertaking clinical research trials is no mean feat. Assuming that all relevant approvals are in place, the next obstacle is recruiting patients on time and to target. However, it is essential that we select studies that are a good fit for our patients and our processes. Meeting targets is not solely the responsibility of the principal investigator but is shared by the co-investigators, clinical nurse specialist and our dedicated research nurse. Our GPWSIs*, associate specialists and secretaries are also involved in supporting research activity; it is a team effort. Research is discussed as part of our weekly team meetings and this provides an opportunity to set realistic targets and

and Louise Nimako

Senior Research Nurse Manager

discuss strategies for identifying suitable patients. Some of our strategies include informing GPs of impending studies, asking our secretaries to be vigilant in looking for suitable patients and informing our colleagues at the trust. For the past two years, we have also been running a dedicated monthly biologic clinic for patients with psoriasis; our most active research area. Patients attending this clinic benefit from a streamlined assessment and review process where the opportunities to participate in research are integrated into their care pathway. Currently, we are the top recruiter for an Actinic Keratosis clinical trial, having achieved the target of ten recruited patients well ahead of the other UK sites.

We had recruited to time and target on an earlier phase of this clinical trial so were approached directly by the sponsor to be involved again. The department is currently running four commercial studies, three of which are clinical trials and four non-interventional studies. As our research activity grows, we will develop our experience with new products, undertake valuable additional training/ education and have the opportunity to offer patients treatments that would not normally be available to them. Patients who we approach are fully informed that participating in a study is not obligatory but the vast majority are keen to participate to help either themselves, or others in the future. It is this altruistic attitude that inspires and motivates us to undertake more studies, supported by an enthusiastic patient population and dedicated team (pictured above). * General Practitioners with special interest

PHARMACY CLINICAL TRIALS: HOW WE HELP WITH RESEARCH By Yasmin Begum

Lead Pharmacist - Research & Development

linical trials drive innovation, generate income and give rise to more cost-effective treatments. It is imperative that we allow our patients access to cutting-edge therapy. In pharmacy, we play a crucial role in undertaking clinical trials with Investigational Medicinal Products (IMP). In the past 12 months we have been involved with over 25 studies. Our aim is to safeguard patients, healthcare professionals and the Trust by ensuring IMP are appropriate for use 6

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and are procured, handled, stored and used safely and correctly. We also ensure that IMP are managed and dispensed to patients in accordance with the protocol and ensure that all pharmacy clinical trial procedures comply with relevant guidelines and regulations An IMP is a pharmaceutical form of an active ingredient, or placebo, being tested or used as a reference in a clinical trial. This includes a product with a marketing authorisation when used or assembled (formulated or packaged) in a way different from the approved form, used for an unapproved indication, or used to gain further information about an approved use.

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The pharmacy feasibility process is a challenging aspect, ensuring that we can deliver on the protocol and most importantly, that this trial will be of benefit to patients. We need to focus on the detail of the study and how this integrates with the specialties involved. We will look into clinical risk issues and how to address these in cases where the use of an IMP may force changes to normal routine practice. Increasing the awareness and encouraging clinical trial activity is always a challenge, however, our aim is to do more outreach work with clinicians interested in conducting research.

Quality improvement

QIPS - IMPROVING PATIENT CARE

MODEL FOR IMPROVEMENT – IHI APPROACH

By Dr Andy Allard Junior Doctor

e all aim to practice and provide patient-centred medicine and make information easily accessible to the patient to facilitate their decision making process. This is key in preserving their autonomy. It is important the patient is able to trust the healthcare professional and in order to achieve this, the patient must know who their care givers are and what their roles are.

By Rachel Cooke

Head of Library Services and Improvement Fellow, NHS Institute for Innovation and Improvement

he Model for Improvement promoted by The Institute for Healthcare Improvement (IHI)1 asks three questions: • What are we trying to achieve? • How will we know a change is an improvement? • What changes can we make that will result in improvement? Seemingly simple questions, but when you apply this to a quality improvement project/initiative they can be quite hard to answer. However, if you do not answer them then it is very difficult to know and even harder to demonstrate to anyone else what you have done; whether the changes you have made have resulted in an improvement and that the improvement will be sustainable. What are we trying to achieve? If you don’t have a clear idea of what you are trying to achieve it is difficult to articulate to others what it is you are trying to do and to be sure that all those involved in the improvement understand what you are trying to achieve. Without a clear and achievable aim, it is easy for a project to become sidetracked. How will we know a change is an improvement? Identifying measures for an improvement can be challenging. However without measurement it is difficult to see whether the changes you are making have made any difference, to know when you have reached your target and to demonstrate to others Include a wide range of conditions in the sequence of tests ce den Evi

Theories, hunches, & best practices

A P S D

Study Study

Previous data from a patient survey of 100 medical in-patients had suggested that 20% of patients did not recall their doctor introducing themselves on the ward round and 70% did not introduce the other members of the team looking after them.

the impact of the changes that you have made.

We designed a quality improvement project (QIP) that took on the principles behind Dr Kate Granger’s #hellomynameis campaign in order to try to improve staffpatient communication within the Trust. As part of the project, we have made a number of changes in consultation with our patients with particular focus on patients who might have cognitive or visual impairment. We have redesigned staff name badges to make them easier to read and encouraged the use of #hellomynameis lanyards to make staff IDs more visible.

For some improvements there will be existing baseline data, however for others there won’t be. Once you have baseline data it is possible to identify realistic outcome measures and what processes needed to be measured to reach the agreed outcomes. What changes can we make that will result in improvement? To bring about sustainable change you need to take small steps and study what happens at each stage. The Model for Improvement uses a process called PDSA cycles (Plan, Do, Study, Act). (Figure 1) PDSA cycles: always testing ideas before implementing By carrying out PDSA cycles it is possible to build your knowledge and understanding of what is happening, whilst it is happening, so that you can make changes and adaptations whilst testing out the improvements instead of waiting until after the implementation of the change.

A P S D

A P S D ent

ng rni

Lea

Plan Plan

Figure 1 Plan = Change or test Do = Carry out the plan Study = Summarise what was learnt Act = Determine what changes are to be made

ata &D

A P S D

Act Act

and

Breakthrough results

Implement a change

em Test new conditions rov p m

Test a change

Develop a change

We ran a very successful elderly care update evening for GPs and members of the public recently and the project was presented at the Society for Acute Medicine (SAM) International meeting in Brighton last month. I was particularly pleased with the positive reaction received at SAM as evidenced by the subsequent coverage it received on Twitter! QIPs are a vital part of improving our services and it is great as a junior doctor to see how far this project has gone to help improve patient care. Footnote: 1/ Institute for Healthcare Improvement (2014). Model for improvement. Available at www.IHI.org

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

Figure 2. Using PDSA cycles to sequentially build knowledge and understanding TheJournal@sash.nhs.uk

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Reflective practice

So much more than milk? was expecting a girl and the excitement her baby on effortlessly. We all watched grew. She committed to pumping every on as this mother and baby found their By Alexis Ozmen three hours in order to try way together; what a Infant Feeding Coordinator and induce lactation. As a privilege. It dawned on mother myself, I wondered me how easy this was for “I feel so proud her and how comfortable am part of the infant feeding team what it must feel like to responsible for implementing the anticipate meeting your new to have been she was with it. She was Unicef Baby Friendly Initiative within baby, yet not experience any part of an event emotionally drained but not our Trust and providing specialist care to of the physical closeness that physically - she wasn’t in mothers and babies. comes with being pregnant. which took any post-birth discomfort, I could only imagine it must care of so many she was just all consumed Recently, I met a mother in waiting feel overwhelming and I felt by her desire to feed her peoples’ needs Natalie. Her baby was being carried by a it was crucial that she was baby and she did. Weeks on gestational surrogate and she and emotions” supported in and her baby continues to had been referred to me by her choice to breastfeed with the aid of a her community midwife as breast feed her supplementer. “I felt it was she was keen to breastfeed baby. her baby and was looking for crucial that she As I reflect on that moment - their support. was supported The date for the C-section wonderful surrogate drifting in and out of arrived and as I sat outside sleep with her own partner stroking her in her choice to She shared her story with the theatre doors, I was hand, with this mother’s husband making breastfeed her me; she spoke of multiple nervous and excited for calls to family and friends, and then over fertility procedures and how baby” the them. Then she cried, in the chair, a mother, gazing at her baby she sadly lost her precious a huge relief for everyone. and feeding her so contentedly - I feel so twin boys at 23.5 weeks. As The doors would swing proud to have been part of an event which I listened, it occurred to me open now and then and took care of so many people’s needs and that her desire to breast feed was about Natalie and I would exchange a look - I emotions. much more than breast milk. She spoke was willing this to work for her. She had of longing to meet her baby and explained her baby, skin to skin, at last. And that, for me, is what breastfeeding so eloquently, how important it was to her meant for this woman – it struck at her to be able to put her baby to her breast. In recovery, I held the nursing very core as a mother and it will nurture supplementer which contained a small her baby’s soul. It is more, much more, We stayed in touch; her scan revealed she amount of infant formula as she latched than just milk.

SOUTH OF ENGLAND FALLS MEETING: A REFLECTION By Amanda Trease Back Care and Manual Handling Trainer

uring August this year, East Surrey Hospital hosted a meeting for the South of England Falls Group. There were 16 representatives from hospitals across the south of England, including doctors, nurses, dementia specialists, physiotherapists and occupational therapists. We had the opportunity to demonstrate some of the falls prevention equipment 8

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that we commonly use at our hospital. We also learned about new developments in falls prevention as two specialist companies showcased new equipment to the group; equipment suitable for hospital and home care, orientated towards specific patient needs. The appropriate use of ultra-low beds was insightful and made for an interesting discussion with the group. We reviewed the criteria and assessment that should be made to ensure these beds were being used appropriately, following individual patient assessments.

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During our multidisciplinary discussions, it was identified that simple solutions, such as activity aprons for patients with dementia, may be a useful idea to provide stimulation and distraction thus reducing the risk of wandering and falls. This event provided an ideal opportunity to come together to share best practice and to learn from other professions and trusts. It was good to learn what systems other hospitals had put into place and to share processes and thoughts on all aspects of falls prevention.

Collaborative practice S

- Situation

- Background

A - Assessment R

- Recommendation

IMPROVING COMMUNICATION WITH SBAR By Claire Rowley

Lead Nurse Critical Care Outreach Team

“Hello, I’m calling from Nightingale ward. Was it you that saw the patient in bed three earlier? I can’t remember what her name is. Anyway, she doesn’t look well and I need you to come and see her. I don’t have the EWS chart with me. Hang on. I’ll go and get it……….” Sound familiar? If so, remember to use SBAR (Situation, Background, Assessment and Recommendation), a communication tool designed to convey a great deal of information in a succinct and brief manner. Why do we need it? We all communicate differently, according to profession, culture and gender. Have you ever had the feeling that the person you are talking to is not listening and not receiving your message? By using the SBAR tool of communication you can help people to listen better, understand each other and work better to help look after our patients. It also helps the person taking the referral to prioritise their work. Who should use it and when should it be used? This is a tool we should all be using when exchanging information as part of a multidisciplinary team to ensure safe, effective handovers or whenever you have a request from a physician, or fellow medical team member. This can include referrals, face-to-face, or over the phone escalation due to an elevated Early warning Score (EWS) and handover at a MET* call.

How to use SBAR State the Situation: For example, “Hello my name is staff nurse Claire and I am calling from Nightingale ward about a patient called Doris Spiggy. I have just done a set of observations and her EWS has climbed from 3 to 6.” State the Background: For example “Mrs Spiggy is 74 yrs old and was admitted two days ago with a chest infection. She is on antibiotics. She had a CXR on admission. She has a past medical history of COPD and Dementia.” State your Assessment: For example, “She is not looking good. Her respiratory rate is now 28, her saturation has dropped to 88% from 93%. She is not on any oxygen. Her heart rate is 89 and her blood pressure is 145/75. Her temperature is 37.4. She says her breathing feels worse. I have helped her to sit upright, but I am concerned about her.” State your Recommendation: For example, “I need you to come and see this patient as soon as possible please. How long will you be? Is there any thing you would like me to do in the meantime (e.g. start O2).” Be succinct in your communication. You will get your point across, be better understood and people will be find it easier to understand what you are saying. If you don’t already use the SBAR communication tool, try it. It can be found on the back of all EWS charts and will soon be available at desks (next to the telephones) on all wards.

MENTORING WITHIN MEDICINE Dr Sarah Denny

Junior Clinical Fellow in Medicine

entoring is common within medicine and can be formal and informal. Educational and clinical supervisors have a mentoring role but also mentoring often takes the form of a doctor taking another, often more junior, under their wing when they show an interest in a particular specialty. But what is mentoring all about? It is often seen as a process by which a more senior individual helps a junior to progress in their career, but mentoring also involves assisting the development of an individual into what they aspire to be, within their career or otherwise. Mentoring is not as one-sided as it might first appear; both mentees and mentors stand to gain considerable benefits from the experience. For mentors, they are given the opportunity to pass on their knowledge and experience, whilst being made aware of any learning gaps they might have themselves. Furthermore, they are given the opportunity to develop their leadership, organisation and communication skills, thus enhancing their own development. The benefits may seem more obvious for the mentee, but these include the development of new and existing skills, as well as encouragement of ongoing learning and also preparation for periods of transition. An example of this would be the transition from medical student to F1, or senior house officer equivalent to specialty registrar grade. Who better to provide the support and guidance required at these stages than the peers who have already experienced this? Here at East Surrey Hospital we are working with the foundation directors to look for willing volunteers from each specialty to be available once every four months to answer questions that the foundation doctors might have surrounding particular specialties. For example: “What is it like to work within a particular specialty?”, “Who can I get in touch with about taster sessions?” and “What can I do to improve my CV for specialty training?” If mentoring is something that interests you then please get in touch at sarah.denny@nhs.net.

*medical emergency team TheJournal@sash.nhs.uk

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Case study from the Board

Clinical stories no.1

A case study about how the treatment of one patient in her 80s led to changes in the way we deliver care. system. On average we record 550 Datix 2/ No one requested the patient’s medical safety incidents per month, although records when she was admitted. Although By Dr Des Holden the vast majority of these are incidents notes can always be requested and are Medical Director which cause no harm or minor harm. We kept on site at East Surrey Hospital for grade all incidents as minor, moderate two years after an admission before they The Trust Board at SASH has been or severe harm. The total numbers of SI’s go to remote storage. It is not our culture commended for its prioritising of and are presented every month at the Trust’s to request notes out of hours. This lady’s focus on safety and quality of care, yet Executive Committee for quality and risk, notes were in the hospital but were not it is apparent many staff have no sight and at the Trust Board. Where an incident used during her first three days of care. of the role, or interest in clinical matters results in significant harm which the board has. Through The or death, or where it is 3/ The patient was Journal we will publish a series of cases particularly newsworthy, admitted through the ED “As from 1 presented at the Trust Board that have the incident is declared as and registered on their led to change. Serious. All such Serious electronic system and December the Incidents are entered on to then re-registered onto the Trust has set a Case 1 a national database and in Cerner PAS system when target for 80% addition to being discussed she was admitted. Both woman in her 80s was brought to within the hospital, a root these systems contain an of notes to be the ED by ambulance complaining cause analysis is performed ability to create electronic available within warning flags for issues of abdominal pain and feeling and this is shared with our unwell. As part of her care a urine dip test commissioners (the CCGs). one hour, 24/7” such as MRSA status, was performed which tested positive for We have to declare a SI vulnerability, or drug blood. The admitting doctors diagnosed within two days of being allergy, but it is not our a urine infection and prescribed her a made aware and put any immediate steps culture to use these systems in this way. common antibiotic. She was admitted to in place to protect other patients (or staff) Had her allergy status been flagged a ward for her ongoing care, but within and we have to complete the investigation electronically on a previous admission, 24 hours had developed a skin rash. Her within 45 days of declaring the SI. this information would have been care was reviewed and the antibiotic was available when she presented in ED. As it stopped. She subsequently The root cause analysis was, all of the clinicians who treated her developed pneumonia and for the incident described took her word for it when she stated she sadly died. above was performed by had no drug allergies. “ Serious an external team as, due incidents are She was admitted on a to sickness, we didn’t have 1 Action taken Friday and her medical enough people in the risk entered on The Trust Board (in public) heard records were not requested team to meet the time scales. this case presented and asked for our to a national until the Monday. Although The results suggested the plan to address the issues database, a root Trust could improve in three management the patient had told the identified. They heard that the ePMA ambulance crew, the areas: project would help by blocking the cause analysis prescription of drugs identified as triaging nurse and the is performed having a contra-indication by allergy. medical staff that she had no 1/ Many older people have They also requested medical notes to and this is allergies, her medical notes low grade colonisation of be available in real time to inform the indicated she was severely their urine with bacteria shared with our case. As from 1 December the Trust allergic to the antibiotic she the diagnosis of this is setting a target for 80% of notes to commissioners” and had been given. being infection, rather than be available within one hour, 24/7. colonisation (which might This will be communicated widely to This lady’s case was raised not have needed treating clinical teams and audited and will be as a Serious Incident (SI) by the team at all), was not certain in that there was maintained until the introduction of looking after her. The easiest way this disagreement between the clinicians electronic patient records. This target will subsequently increase to 100%. can be done is by using the Trust’s Datix treating the patient.

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Improving our practice

Lessons learned

Setting the right expectations

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

Edited by Dr Ben Mearns

Clinical Lead for Acute and Elderly Medicine

Patient perception One of our patients wrote to me and was upset that they had not seen a specialist for three days following admission. The patient also felt that they were being kept in the hospital unnecessarily awaiting a more specialist review and taking up a bed that they did not need. On review, it was clear that in fact a specialist did see the patient shortly after arrival as you would expect and the plan had been set appropriately at the very start. Admission was for treatment, observation and investigations that all happened within timescales that we would accept as being fairly fast. Lesson to learn: We may perform well and give good care but the patient may be left with a very different view. We need to try harder to check understanding and continue to check this at every stage throughout their treatment.

Reducing the risk of blood clots A patient with abdominal cancer was admitted to the hospital. Their risk of venous thromboembolism was welldocumented in the electronic system and the correct preventative treatment was started. However, because the patient developed a bleeding ulcer in their bowel, the heparin treatment was appropriately stopped. The patient subsequently died and a contributing factor was a pulmonary

embolism. Unfortunately, stockings were not prescribed alongside the heparin despite the risk assessment suggesting that they should be used. This may have significantly reduced the likelihood of a blood clot forming. It is clear from this case that good decisions were taken regarding the heparin, but that we should have also prescribed stockings. Lesson to learn: Please do remember to prescribe both stockings and heparin if the risk assessment indicates that they are needed. Please also reassess patients for venous thromboembolism prevention during their stay and in particular when their condition changes. If there are clear reasons not to use stockings then this must be clearly documented during the risk assessment.

Acting on an abnormal EWS We are generally very good at reacting to the Early Warning Score (EWS) for our patients and getting appropriate help when required. Some investigations have identified that on occasion the EWS can be measured, but the appropriate action may not be taken. Lesson to learn: Please do follow the guidance on the observation charts and call for help as needed.

One of our medical team was being very helpful and told a patient that they could go home later that day if a blood test showed improvement. However, they failed to understand that the pharmacy would only be able to respond to the discharge prescription once the blood test was known and therefore, a delay was inevitable. We gave the patient an expectation that could never be met and they became very upset. Lesson to learn: It would be helpful if ward staff liaised with pharmacists ahead of time, to order the patient’s drugs to the ward to be “discharge ready”. Ward staff should ensure that they are able to use the pharmacy tracking system and contact the pharmacist directly for urgent requests. Medication can be collected from pharmacy once indicated on the system and pharmacists will keep it up to date. Please also remember that pharmacy will prepare medications in two hours from receipt of the prescription and this should be communicated to patients. The simple message is: all of us need to understand the systems that our colleagues use and to put a realistic expectation in the mind of our patients and relatives.

When we hear hooves it might be a Zebra A patient was admitted with a known history of cancer and had lost power in his legs. The medical team correctly wanted to rule out a secondary deposit from the cancer leading to compression of the spinal cord and arranged the necessary tests to find this out. The tests came back negative and it later became apparent that there were no pulses in both legs. Whilst we do not know when the circulation to the legs was lost, it may well have been the cause of the initial weakness and it was felt that there was a significant delay to arranging further treatment. Lesson to learn: Whilst these diagnoses will always be difficult, it is very important that medical staff keep an open mind throughout a patient’s stay and ensure that we document clearly what examinations have been done. These diagnoses will always be difficult and we will not get it right every time. Our guidance has been changed to encourage clinicians to check for circulatory causes of weakness with a view to spotting these diagnoses earlier.

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Publications authored by SASH staff A literature search carried out by the library team identified the following articles that have been written by SASH staff: Payne S, Davies K, Powell N. (2014) 22 Frailty scores to target at risk acute surgical admissions. Age & Ageing. 43 October /suppl2 Ziahosseini K, Ali S, Simo R, Malhotra R. (2014) Uvulitis following general anaesthesia. BMJ Case Reports Perera S, Ali H (2014) Spontaneously resolved exudative retinal detachment caused by orbital cellulitis in an immune compromised adult. Eye. 28(9) p.1144 Hadjipavlou M, Tharakan T, Khan SA, Swinn M (2014) Spontaneous bladder rupture of a urinary bladder with non-muscle invasive bladder cancer, BMJ Case Reports Dowsing T, Chellamuthu P, Powell N, Forbes-Pyman R. (2014) Can someone call my PA? Acute Medicine. 13(2) pp.78-81 Khan SA, Chang RT, Ahmed K, Knoll T, van Velthoven R, Challacombe B, Dasgupta P, Rane A. (2014) Live surgical education: a perspective from the surgeons who perform it. BJU International. 114(1) pp.151-8 J. Greenhill, J McKinley, A Holland, S. Ranjan, P Morgan (2014). Reduced mortality in patients with haematological malignancy receiving invasive ventilation in ICU, Intensive Care Medicine, 40 supp 1, 22 J. Greenhill, J McKinley, A Holland, S. Ranjan, P Morgan (2014). Improved mortaility rates for patients with haematological malignancy admitted to ICU: a 10 year retrospective review, Intensive Care Medicine, 40 supp 1, 22 ME Sinnott, N Lucas, P Morgan (2014). Hospital length of stay prior to ICU admission: Effect on mortality and length of stay, Intensive Care Medicine, 40 supp 1, 78 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

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Achievements and professional recognition Congratulations to… …the Acute Medicine team who have once again been prolific in their poster and oral presentations at the recent Society for Acute Medicine conference in October in Brighton. The Junior doctors and physician associates had a total of 10 posters and contributors were Andy Allard, Shuaib Quraishi, Andy Kermode, Amal Hassan, Lorri Williams and Samantha Payne. Dr Martin Dachsel also presented his work looking at thrombolysis for pulmonary embolism and Rachel Forbes-Pyman ran a symposium on the role of PAs in AMU. The past immediate president of the society thanked the Trust team personally for their significant contribution to the very successful conference. …Dr Martin Peter, Dr Dioszeghy Csaba, Dr Sercl David, Dr Munazah Akhtar, Dr Julian Webb (all from ED) and to Ceccherini Andrew and Ahmed Riaz (from Radiology), who recently presented posters at the European Society of Emergency Medicine. …Clinical Lead Ben Mearns and Chief Divisional Nurse Nicola Shopland for hosting our first Schwartz round in November and to Dr Sarah Rafferty, Dr Hanadi Asalieh, Amanda Becker and Elizabeth Choate for sharing their stories.

…Claire Butler, Team Lead SLT (Acute Inpatients) and Clinical Lead SLT (Adult Dysphagia) who has just been revalidated until 2016 by the Royal College of Speech & Language Therapists as a national adviser in adult dysphagia. …Directorate Risk and Patient Safety Manager, Suzanne Robinson who has been awarded a MSc with merit in Integrated Governance in Health and Social Care by the University of Westminster. …Dr Cliff (right), Dr Man, Dr Patel, Dr Slater, Nwando Onugha and Louise Nimako have recently had an article accepted for publication in the first edition of a new national research network magazine INSIGHT. The article was accepted under the theme of progress in treatments or services as a result of research and focuses on a change in service delivery for psoriasis patients which has had a positive impact both on patient care and research delivery.

DENTAL TRAUMA SEMINAR October saw the inaugural use of the dental skills laboratory with a lecture and hands-on seminar on dental trauma. Dr Peter Day, Associate Professor and Consultant in Paediatric Dentistry at the Leeds Dental Institute and a leading expert on the management of Paediatric Dental Trauma was speaker for the day. The audience comprised general dentists, paediatric dental StRs, dental SHOs, dental nurses and staff from our emergency department. The lecture, A traumatic day for all–an update in managing acute paediatric dental trauma, was followed by a hands-on

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demonstration of various dental splinting techniques, ranging from basic splints to the use of state-of the-art titanium trauma splints. Consultant Paediatric Dentist Mr Thayalan Kandiah (above right) cohosted the event and was on-hand to offer practical demonstration and advice. Feedback from the delegates was very positive and more courses are planned for the future.