Claire Gordon, Consultant in acute medicine at Western General Hospital, Edinburgh.Consultant in Acute Medicine at the Western General Hospital Edinburgh.SPSP fellowSpecial interests in recognition and response to the deteriorating patient, communication and patient flow/pathways. Fiona Scott, worked in Paediatrics in Ayrshire for more years than I care to count (25years!!!!)Been ward sister/manager/ senior charge nurse for last 12 years.Initially sister for the medical inpatient ward however after reconfiguration of children’s services in Ayrshire 6 years ago now senior charge nurse (current title) for the children’s inpatient ward at Crosshouse Hospital in Kilmarnock. Which is a mixed medical and surgical ward caring for the children of AyrshireMarried with a 22 year old daughter. Peter Cambell.Joined NHS in 1982. Qualified as a Childrens Nurse in 1989 at Yorkhill in Glasgow. First Charge Nurse post 1992 at Yorkhill. Moved to RHSC Edinburgh in 1998 as Senior Charge Nurse for Acute Recieving Unit. Became Medical Nurse Manager March 1999. Have held several senior nursing post's since then including a period of time as a Project Manager and Acting Service Manager for Childrens Services. Currently Clinical Nurse Manager for Medicine, A&E and Outpatients. Dr Ailsa Howie is an ST6 in Acute Medicine in South East Scotland and a Scottish Patient Safety Fellow. Her area of interest is hospital at night handovers.
Parallel Session 3.7 Applying Best Practice to Develop Innovative and Effective Communication Practices to Improve Patient Outcomes in NHSScotland
Session 3.7 Applying best practice to develop innovative andeffective communication practices to improve patient outcomes inNHS ScotlandDesign, Test and Learn
The Capacity Safety Brief Peter Campbell Clinical Nurse Manager RHSC Edinburgh
Todays Presentation• History• Reason For Change• Format of New Huddle• What has worked well• What hasn‟t worked well• Outcomes• Improvement Clinic• Next steps
History• Morning bed meeting since 1990‟s• Handover from Night Sister• Attended by Senior Nurses• No Medical staff or Service Managers• Could last up to 45 minutes• Complete run down of nurse staffing• Difficult to make decisions• Not clear where the responsibility lay
Reason For Change• H1N1 – new format for bed meeting 2009/10• New Venue• Clinical Director and Service Manager attend• Change in what was being reported on• Further bed meetings as the day progressed• Awareness of national services• Focus on Critical Care & Retrieval Service• Visit to Cincinnati
Format of New Huddle – January 2012• Takes place at 8am prompt in Lecture Theatre• Attended by Charge Nurse or Nurse-in-Charge• Clinical Management Team• Medical leads & CNM‟s plus others• New spread sheet to capture data• Ward report sheet• Outcomes
What Has Worked Well – Key Safety Points• Current Information being reported• Clinical Coordinator spends less time gathering information• Issues are dealt with and responsibilities are clear• Watchers are being identified• Look back, look ahead & follow up• Given plan for the day• Staffing issues are dealt with• Improved team working with Charge Nurses• ER predicted admissions
What hasn’t worked well• Way you are spoken to• Too many private conversations• No clear definition of a „Watcher‟• Don‟t always summarise status & outcomes• Critical Care dominates the discussion• Look back, look ahead & follow up• No medical ARU Consultant• Site issues not discussed• No feedback from Senior Nurse on call• Theatre discussion too brief
Outcomes• Equity of access• Effective prioritisation and triage• Reduction in cancellation of patients• Meeting national targets• Staff attendance at huddle• Briefings take no longer than 10 minutes
Improvement Clinic• Select group from „huddle‟ attendees• Three questions prior to clinic• Collated responses – circulated• Meet for 1 hour – focused discussion• Draw up action plan• Identify who is responsible• Feedback and circulate outcomes
Next Steps• Rebrand – Capacity & Safety Brief• Data recording• Site specific issues• Rota to identify who is chairing & CNM for the week• Plan for safety brief – pre winter 2012• Weekend and PH CBM• Dial in facility for SJH
NHS Ayrshire & Arran Early recognition of thedeteriorating child - ‘Watchers’ Fiona Scott SCN Claire Colvine APNP
BACKGROUNDWithin our children‟s inpatient ward we need a reliablesystem of identifying, monitoring, escalating andcommunicating information about the children in our care tothe right clinicians, at the right time, using the right format.To ensure the early recognition of the deteriorating child or„watchers‟ 24 hours a day, every day (Cincinnati Children‟sHospital).
QUESTIONS WE ASKED OURSELVES• What is our model for improvement? People only want a change if they are going to benefit from it• Where are we now?• Where do we realistically want to be? (What are we trying to accomplish? How will we know change is an improvement?)• How are we going to get there? (What change/s can we make that will result in an improvement)?
IMPROVEMENT AIM Outcome Primary Drivers Secondary Drivers SBAR (reporting system) PAWS (early warning system) Effective written and verbal Safety brief communication Paediatric Global Trigger Tool (PTT) at all times Nursing staff education To have a reliablesystem of identifying Establish Who? and successfully multi-disciplinary Where?managing „watchers‟ handovers in When?100% of the time by ward area at least 3 Why? end Sept 2012 times per day Agreed standard process Effective Education of MDT escalation of Data collection and audit concern process SBAR Visual prompt
SMALL TESTS OF CHANGE - PDSA CYCLES Cycle 4 – Prediction: It continues to work. Plan: nurse in charge, registrars on duty, every 9pm handover in ward area. Results: All team members see benefit of change to the children and themselves. Learn: to maintain high level of communication with all. Action: Monitor continuity of process. Cycle 3 – Prediction: that process will work. Plan: one nurse, one registrar, one 9pm handover in ward area. Results: It worked mainly because of registrar buy- in and same registrar on for next 4 nights. Learn: continuity of key personnel who see a benefit is essential. Action: share the verbal benefits to MDT. Cycle 2 – Prediction: that process would work. Plan: one nurse, one registrar, one 9pm handover in ward area. Results: right people, right place, right format, wrong time. Learn: ensure staff are aware of timing to ensure handover happens as planned and staff get off duty on time. Action: update progress report to discuss at morning MDT handover. Cycle 1 – Prediction: that process would work. Plan: one nurse, one registrar, one 9pm hand over in ward area. Result: right time, right people, right format, wrong venue. Learn: ensure registrar aware of where handover to happen and reasons why. Action: email to all registrars.
How do we know a change is an improvement?• Quantative data collection and analysis (keeping record on safety brief measuring attendance compliance by nurse in charge)• Qualitative anonymous questionnaire given to middle grade medical staff and senior nursing staff for completion
RESULTS Data collected from safety brief noticesEnthusiastic Registrar Monthly Unenthusiastic Locum Registrar Compliance Registrar Cover (mean) 77%
RESULTSData collected from safety brief notices Monthly Compliance (mean) 77% * * 3 day week
Percentage compliance with 9pm handover Feb-May 2012 100 100 98 Registrar stuck in Locum registrar 96 resuscitationunaware of normal practice February March April May
LEARNING AND CHALLENGESLearning• Good quality communication is essential• Buy in from all members of MDT is vital to success• Benefit of change obvious to allChallenges• Keep the process rolling – make it the norm• Regular audit to ensure continuation of change• Staff education (ensuring new medical staff are aware of process and responsibilities)
NEXT STEPS1. Widen to the healthcare team to physio, pharmacist, dietician and others;2. Consideration of medical staff attending huddle at 3pm and 3am;3. Comparison of quality of escalation when lack of compliance with MDT handover.
Applying Best Practice to DevelopInnovative and Effective Communication Practices to Improve Patient Outcomes Medical Handovers Dr Ailsa Howie ST6 Acute Medicine SPSP Fellow
WHAT IS A HANDOVER ?• The transfer of professional responsibility and accountability for some or all aspects of the care of a patient or group of patients to another person or professional group on a temporary or permanent basis
• Relies on a clear and comprehensive system of communication• Transfer of critical information• Ensure seamless continuity of patient care and safety
WHY IS GOOD COMMUNICATION SO IMPORTANT ?• Communication failure leads to • uncertainty in decisions in patient care • inefficient, suboptimal care • patient harm• Communication problems are the most common cause of preventable in hospital disability or death.
LITTLE BIT OF EVIDENCE• 78% of communication breakdowns occurred within a single department – 19% occurred across departments – 2% across institutions.• 92% of the breakdowns were verbal• 64% occurred between a single transmitter and a single receiver.• Cross-disciplinary and intra-disciplinary communication breakdowns occurred with approximately the same frequency. – Most commonly, information was never transmitted (49%) Caprice C Greenberg et al. Patterns of Communication Breakdowns Resulting in Injury to Surgical Patients. J Am Coll Surg
WHY SHOULD WE TRY TO IMPROVEHOSPITAL AT NIGHT HANDOVERS?•Current Handovers • Lack Structure • Not valued by participants • Junior doctors find them stressful • Potential for patient harm
HANDOVER IMPROVEMENTS• Formal Structure • Ensure a set time and place that is free of interruptions, with senior supervision. • A standardised process • Standard proforma• Education • Focus on Foundation Doctors
STANDARDISATION OF THE PROCESS• How should patient‟s be handed over? • Patients who need to be reviewed • Patients “to be aware of” • Patients who need to be admitted • Tasks that require completion
THE PROFORMA• Based on SBAR • Situation • Background • Assessment • Recommendation• Initially paper based• Now on TRAK (In Royal Infirmary Edinburgh)
Addressograph Label WARD SBAR Handover Sheet BASE Requesting HAN ReviewSituationPresenting complaint:(eg: Central chest pain,SOB)Background Relevant PMH Relevant MedicationInclude any recentoperations / proceduresAssessmentProvisional DiagnosisCurrent TreatmentTests undergone andresults Most Recent SEWS Score :Recommendation sTests still needed (eg CTscan)Treatment still needed (e.g.IVI)Results Awaited Mandatory Information ESCALATION CONSULTANT AWARE OF DETERIORATION For escalation to critical care Yes Not for escalation No Ceiling of treatment not decided RESUSCITATION STATUS TIME TILL REVIEW NEEDED For Resuscitation < 1 HOUR DNAR < 4 HOURS Not Discussed OVERNIGHT
HOW DO WE KNOW A CHANGE HAS LEAD TO AN IMPROVEMENT?• Process measures • Percentage of SBAR handover forms completed compared to reviews requested. % of SBAR Forms Completed for Reviews Requested RIE 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Feb March April May June July Aug Sept Oct Nov Dec Jan Feb March Months
Process Measures Number of patients being handed over per month Total Number of Reviews Requested per Month RIE 300 250 200 150 Total Number of Reviews Requested 100 50 0
Outcome Measures• Number of “surprises” per month – A surprise is defined as a patient requiring review overnight who should have been identified at the handover process. Total Number of Surprises per Month RIE908070605040302010 0 Feb March April May June July Aug Sept Oct Nov Dec Jan Feb March Months
WHERE SHOULD WE FOCUS ATTENTION? • Foundation Doctors – Education • Lecture and role play • Doctors on line training module • Difficult Decisions • Identify the patients at risk of deterioration during ward rounds • Make decisions regarding escalation of care
Structured Ward Rounds Claire GordonConsultant in Acute Medicine NHS Lothian SPSP Fellow
Background• Variation: area to area, disciplines, practice and performance• Many functions: decision making, communication, „housekeeping‟?• No „standards‟, no definition• But definitely important?
Person centred, safe and effective care• Clinical diagnosis• Reviewing patients progress against anticipated trajectory• Making decisions about future investigations and treatments• Discharge arrangements• Communicating with pt, interested others and MDT• Active safety checking to mitigate against avoidable harm• Training and development of healthcare professionals
Patient centred care• Patient perspective – of central importance in collectively caring for and communicating with patient• Pt „centre of attention‟, empowered• Need engagement of clinicians, managers and organisations to improve ward round quality• Protect time and resources
Multidisciplinary Team Ward Rounds• Effective multi-disciplinary team-working improves patient outcomes• Pharmacist on the ward round – improves prescribing, med rec, reduces errors• Allows thorough discharge planning• ?board round/ huddles/ run-down
Background – Patient Safety• SPSP fellowship• Daily goals in ICU• Post take ward round checklist• Apply „daily goals‟ to general medical patients• Communication issues between „silos‟• MDT ward round• Boarding
What changes were made• Old model: Doctors go round• Handover to nursing staff at end• New model: attempt to have nurse on WR• Formal MDT huddle at 11.45• Structured WR/ daily goals proforma
Date……………….. Time…………… WR…………………. Review Daily goals:1)………………………………………………… 2)………………………………………………… 3)………………………………………………… 4)………………………………………………… 5)………………………………………………… Nursing: PVC Y/N Needed Y/N Review site Incontinent? Diarrhoea? For LCP? Pharmacy: Antibiotics………………..……………… Thromboprophylaxis Y/N Dosette box Y/N Patient at risk of deterioration Y/N FOR ESCALATION/ NOT FOR ESCALATION/UNDECIDED FOR CPR/ DNACPR/ UNDECIDED Signed………………………….. Bleep………………….
Structured Ward Round Outcomes• LoS: reduced by 0.7• <11am discharge increased to 18%• Transfers to critical care: 3.2% to 0.7%• PVC bundle compliance 52% to 93%• Cardiac arrest calls 2 to 0• Number of outliers 15 to 9.4• Number of 4h breaches 20.8 to 10.8• Antibiotic prescribing 100% from 85%
Structured ward round outcomes• The less measurable… – DNACPR – Palliative care referrals – Complaints/ communication• The not so good: – readmissions 7.8% from 6.3%
Patient Centred Care• Care rounding• „go at the pace of the patient‟• Communication round v business round• Patient communication sheet
Name________________________________ Date__________________Problems: 1) 2) 3) 4) 5)Plan: 1) 2) 3) 4) 5)Consultant: Claire GordonPlease feel free to write any comments or questions on thereverse of this.Patient’s property
Vision• Patient held record• Problem list• Daily goals – MDT and patient• Aid to communication for patients and relatives/ carers