ED Safety Checklist Masterclass Presentation

1. ED Safety Checklist Masterclass Monday 25th April 2016

2. Welcome & Introduction Deborah Evans, Managing Director, West of England AHSN

3. The West of England Academic Health Science Network We are delivering positive healthcare outcomes by • driving the development and adoption of innovation • supporting the adoption and spread of evidence-informed practice • and making a meaningful contribution to the economy.

4. The West of England Academic Health Science Network

5. Academic Health Science Networks As the only bodies that connect NHS and academic organisations, the third sector and industry, we are catalysts that create the right conditions to facilitate change across whole health and social care economies, with a clear focus on improving outcomes for citizens.

6. Academic Health Science Networks

9. The ED Safety Checklist The Why! Dr Emma Redfern, ED Consultant University Hospitals Bristol

10. The Problem Patient safety in the urgent care environment, particularly at handover and during crowding Delays in recognition and treatment of severe illness and deterioration A staffing crisis and reliance on agency staff. Human factors in urgent care

12. Where’s Wally?

13. Safer Transfers of Care

14. There’s Wally!

15. The ED Safety Checklist The What! Alex Hastie & Caroline Clark ED Safety Checklist Project Nurses University Hospitals Bristol

16. PDSA Cycles The PDSA cycle is shorthand for testing a change by developing a plan to test the change (Plan), carrying out the test (Do), observing and learning from the consequences (Study), and determining what modifications should be made to the test (Act).

17. • A comprehensive list of essential components of care, prioritised according to required completion time • Incorporating elements to improve not only safety but patient experience through their ED journey. • A multidisciplinary tool to provide safe, timely emergency care What is the ED Safety Checklist?

18. • Feedback from ED Team • Review of Clinical Incidents • Review of complaints • Inclusion of information from nursing indicators How was it conceived?

19. • Focused on hourly themes Vital signs, NEWS, pain scoring • Frontloading of investigations • Promotion of care pathways • Early identification of required referrals onto specialist teams What does it comprise of?

20. • Checklist pilot trial • Checklist roll out • Reformation of ED Safety Checklist Team • Collection of multi-sourced feedback How was it implemented?

21. • Fluctuating enthusiasm from a large team • Timing • Correlation between checklist uptake and department acuity • Varying attitudes from different staff groups • Data collection What problems did we face?

22. • Length of Stay • Outliers • ED Targets – 4 hour breaches, nurse indicators • Mortality • Clinical Incidents • Patient Experience How did we measure our success?

23. • Introduction of CQuin • Staff group specific, multi source feedback • Shop floor champions • Senior support • SWAS involvement • Continued indicator audit • Shift from monthly to daily uptake auditing How did we maintain our results?

24. Within the Department Business as normal Continued auditing Shop floor champion Outside the Department Collaboration between other trusts National dissemination What next for the project?

25. • Structured introduction • Designated team • Specific staff group engagement • Multidisciplinary involvement • Shopfloor champions • Daily and monthly auditing • Set targets What have we learnt?

26. The ED Safety Checklist The How! Ellie Wetz, Patient Safety Improvement Lead West of England AHSN

27. The ED Safety Checklist Toolkit • Developed to support the implementation of the ED Safety Checklist at adopting trusts. • Guidance not mandate!

28. The ED Safety Checklist Toolkit Toolkit Structure: 1. About the ED Safety Checklist 2. Form your team 3. Organise your ED 4. Agree your measures Appendixes

29. The ED Safety Checklist Toolkit 1. About the ED Safety Checklist • Local Fields • Baseline Data • Comprehensive review of ED clinical incidents • ‘Best Practice’ Fields • Vital signs taken and NEWScore calculated regularly • Front loading of investigations i.e. imaging, bloods

30. The ED Safety Checklist Toolkit • PDSA • Helps teams plan • Test on small scale • Review • What works? What doesn’t? • QI Toolkit http://www.weahsn.net/ what-we-do/skills-knowledge- development/improvement-resources-and-tools/the- improvement-journey/

31. The ED Safety Checklist Toolkit Project Logic Model • Inputs • Activities • Outputs • Outcomes • Impact

32. The ED Safety Checklist Toolkit 2. Form your team • Local Implementation Team (LIT) • Existing ED Staff • Lead Nurse • Lead Consultant • Audit Coordination Nurse/Data Analyst • Other key stakeholders

33. The ED Safety Checklist Toolkit • LIT fortnightly meetings • Agenda • Project documentation • Risk & Issue Log

34. The ED Safety Checklist Toolkit 3. Organise your ED • How will you print, store and restock the ED Safety Checklist? • ED Safety Checklist Training • Real-time feedback • NEWS Training

35. The ED Safety Checklist Toolkit 4. Agree your measures • How do we know a patient safety intervention has a positive impact? We measure it! • Baselining • KPI’s & Dashboards • Life System Platform • Evaluation

36. The ED Safety Checklist Toolkit Appendixes • ED Safety Checklist http://www.weahsn.net/what-we-do/enhancing-patient-safety/ • SHINE 2014 Final Report • QI Resources http://www.weashn.net/what-we-do/skills-knowledge- development/improvement-resources-and-tools/the-improvement- journey/ • Research Papers

37. Q & A General Discussion Chaired by Deborah Evans, Managing Director, West of England AHSN

38. Refreshments & Networking

39. The Interface with the Ambulance Trust Phil Cowburn Acute Care Medical Director South Western Ambulance Service NHS Foundation Trust Consultant in Emergency Medicine University Hospital Bristol

40. NEWS?

41. Emergency Department • Increased demand • “Winter Pressures” • Lack of discharges • Poor flow • Exit block • Crowding

42. Effects on Ambulance Service • Crews tied up • Hours lost • Poor performance • Delayed response times • Undifferentiated risk in community

43. Who’s Caring for Patients in the Queue?

44. Care of Queue ED at Bristol Royal Infirmary – University Hospitals Bristol NHS Foundation Trust – Adult only ED 2012 Retrospective review of ED notes and PCF 100 consecutive queuing patients over 2 week period

45. Care of Queue Patient care responsibility of ambulance Trust Clinical SOP requiring minimum 15 minute observations Increased frequency if clinically indicated

46. Care of Queue

47. Care of Queue

48. Care of Queue Number of Sets of Observations Compared to Time Queuing 0 5 10 15 20 25 30 <30 30-59 60-89 90-119 >=120 Time in Queue (minutes) NumberPatients 0 1 2 3 >=4

49. What was really happening in the Queue

50. Queue Events 6 CVE – Average age 76 – All queued > 75 minutes – No CT < 60 minutes 4 # NoF – Average age 87 – All queued > 90 minutes – No X-Ray < 60 minutes

51. Queue Events 4 Serious Incidents Missed MI – Deteriorated in queue, moved to resus, arrest, RIP OD self discharged – No capacity assessment or mental health matrix # dislocation ankle with critical skin – Queued 3 hours, reduction >6 hours post injury – Plastics referral

52. Who Owns this Risk?

53. Late Night Chat Acute Gold • We’re full • We’re not performing • Stop bringing patients • I need nurses and beds • We’re unsafe • We want a divert • We’re un-safer than you • We might close Just shut the doors and don’t let ‘em in Ambulance Gold • Everyone is full • We’re not performing • Start taking the patients • I need crews • We’re unsafe • No-one will take a divert • We’re un-safer than you • You can’t close Push ‘em through the doors and go

54. Risk Reduction Improve quality care Get basics right Work together Grassroots

55. ED & Queue Which patients are sick? Which patients are deteriorating? Which patients have time critical conditions ?

56. Birth of The ED Safety Checklist

57. Better NEWS

58. NEWS

59. How NEWS might help? Potential for ambulance service to – Prioritise HCPC calls – Assist on decision making to discharge – Define & communicate pre-alerts

60. Transforming Urgent and Emergency Care Service in England Safer, Faster, Better: Good Practice in delivering urgent and emergency care NHS England August 2015 “All adult patients should have a NEWS established at time of admission.” “Where patients experience long waits, their NEWS should be recorded, pain assessed and managed and essential care given.”

61. Ambulance Service Electronic Care System & ePCR

62. WEAHSN supported Roll out & incorporation of NEWS into ePCR Auto calculates ED can see all information Including NEWS Part of executive summary Aim to incorporate SHINE Checklist

63. Working Together Adoption and spread -safer transfers of care

64. Measuring the Impact of the ED Safety Checklist Kevin Hunter, Patient Safety Programme Manager, West of England AHSN

65. Baseline Data • Understanding your current standards of care • Case note review • Suggested 20 notes per month • 1 year of data • Performance against Key Performance Indicators • Data input sheet provided in Toolkit • Serious Incident Review • Common themes Inform local checklist & PDSA

66. Key Performance Indicators

67. Key Performance Indicators • Suggested 5% ED Safety Checklist audited per month (at UHB: 200 per month) • <50% complete – not valid • Basic clinical care • Pathways • Patient experience • Local KPIs to reflect local checklists

68. Key Performance Indicators

69. Key Performance Indicators 1. Red: <49% 2. Amber: 50% - 79% 3. Green: >80% 40.00% 50.00% 60.00% 70.00% 80.00% 90.00% 100.00% Pain scoring at triage and analgesia given Nov 13 - May 15 Pain - Pain score & triage Pain - Analgesia IntroductionofEDSafety Checklist

70. What is the ‘Life’ System? • A web based platform designed to assist front line staff running Quality and Safety improvement projects • It has been developed as part of the PSC in partnership by SeeData and South West AHSN • Regional subscription model – Free for our members to use • Supports team working and collaboration – an open and transparent culture • Ability to view projects on the system from across the country • Able to seek assistance and support from other users • Gives a regional overview of improvement activity

71. The Principles Life has been build by SeeData and South West AHSN on a set of principles that are designed to support continuous improvement: • All users agree that the information they add to the system can be viewed (with limitations able to be set) • The system is not designed to collect detailed information on users, organisations or patients • The system will make minimal use of mandatory fields to encourage flexible use • The information collected is only to support improvement and is never to be used for performance management

72. Login Page

73. Front Page – My Projects

74. My Organisations Projects

75. All Projects

76. Project General Info Tab

77. Project Driver Diagram Tab

78. Project Measures Tab

79. Project Change Ideas Tab

80. Project PDSA Tab

81. Project SPC Chart Tab

82. Project Documents Tab

83. Connect Module - Discussions

84. Resources Module

85. Organisations List

86. Users List

87. Aggregate Chart Development

91. Participating AHSN’s in ‘Life’: • West of England • South West • Wessex • Kent, Surrey and Sussex • UCLPartners • Oxford • West Midlands • East Midlands • Eastern • North West Coast.

92. Any questions then please see Kevin Hunter throughout the day or email kevin.hunter@weahsn.net To sign up for a user account: https://life.seedata.co.uk/login/ Further Information

93. The West of England ED Collaborative Dr Emma Redfern, ED Consultant University Hospitals Bristol

94. Participating Trusts • Weston Area Health Trust • North Bristol NHS Trust • Gloucestershire Hospitals NHS Foundation Trust • Great Western Hospital NHS Foundation Trust • Royal United Hospitals Bath NHS Foundation Trust • University Hospitals Bristol NHS Foundation Trust • South Western Ambulance Service NHS Foundation Trust

95. West of England AHSN Support • Implementation Toolkit • Financial Award • Band 7 Lead Nurse • 2 days per week for 6 months • 1 day per week for 12 months • Band 4 Data Manager • 1 day per week for 18 months • Conditional on: • Attendance at ED Collaborative Meetings • Submission of KPI Data

96. Lesson’s Learnt • Cultural ‘Buy In’ • Executive Teams • ED Medical & Nursing Leads • Local ‘ownership’ of the ED Safety Checklist is important • EDs are structured and staffed in different ways • Success is more likely if adopting Trusts plan their own implementation model

97. Interactive Session Chaired by Deborah Evans, Managing Director, West of England AHSN

98. Discussion: • Barriers • Challenges • The role of Patient Safety Collaboratives • What other support is needed?

99. Next Steps Dr Emma Redfern, ED Consultant University Hospitals Bristol

100. • Pledges • Can we form a nation-wide collaborative? • How shall we structure ourselves? • The role of Patient Safety Collaboratives • KPI Data • Life System

101. Summary & Close Deborah Evans, Managing Director, West of England AHSN

102. @weahsn Connect with us

ED Safety Checklist Masterclass Presentation

ED Safety Checklist Masterclass Presentation

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