If I only had the time by John Locke

I have spent a lot of time trying to manage my time over 28 years as a GP and have probably wasted quite a lot of it in the process. The lessons are straightforward around priorities, lists, doing today’s work today, delegation and saying no to tasks which are not my responsibility or that I do not see as important. That would all be easy if I had more time and someone to whom I could delegate work. Our admin staff would probably leave and patients would wonder why I have become so grumpy or obstructive.

                                                                                                                                          

I am often asked by patients if I am busy, sometimes in a slightly sarcastic tone having just spent 30 minutes in a heaving waiting room. My answer depends on that tone. It may be ‘not really’ which makes them think I have been having a snooze or was determined to finish the sudoku puzzle or more often I reply that I start the day with a full timetable then see how many other tasks/patients I can squeeze in.

To prioritise work you can use a matrix of urgent and important boxes.

 

URGENT	NON-URGENT
1. Chest pain Haemorrhage	2. Cellulitis UTI, Patient worried	IMPORTANT
3. Rash Tracheitis	4. Queens score Weather	NON-IMPORTANT

 

Box 1 will be directed to 999 or NHS24.

Box 2 up to 2 weeks

Box 3 a letter to say the request is being considered

Box 4 sometime in the corridor

 

If I worked in an office with a door that shut firmly, fixed appointments daily and access electronically then I could fit all tasks into each box and respond with a timescale mainly determined by me. Medicine is not like that.

Most GP work starts in Box 3 driven by patient perception of urgency but should really be in Box 2. I would like more to move to Box 4 as that may be more important to me on different days such as when Rangers visit Palmerston. Most consultations will really end in Box 4 as there is no diagnosis to be made or it will be self-limiting. Box 1 has been moved to the ambulance service but those symptoms can easily be moved to any other box depending on the underlying cause. A 1 week old rash from a new perfume may be urgent due to patient concern but will heal whatever I do, so over to Box 4.   A reported rash which turns out to be a nasty cellulitis with rigors should be Box 1.

The problem is that to make these decisions I have already spoken or seen the person so the time has already gone. Our appointment systems cope with same-day demand to manage Box 3 when Box 2 could really be the starting point. The e-mail attachment has already been opened or the letter read before I can decide on the box. So I wondered how I could metaphorically shut the door without becoming totally unavailable and I realised that everyone else except me had worked it out years ago

– A PERSONAL REFERRAL TEMPLATE!

This would have the usual pre-amble about national guidelines, urgency, exclusions, links to other (more appropriate) services and a telephone ‘hot-line’ with 8 different pre-recorded messages, all spoken quite quickly so you would have to press 9 to repeat them.

As an aside, when I was a GP trainee the other GPs wondered why one partner had quieter nights than them. Then they listened to the message he left on the telephone and knew why.

The referral page would include examples of urgency and several mandatory boxes to complete, including, of course, some of which you would never have thought of asking such as weight, exercise tolerance and smoking status which are irrelevant to most requests but help me update QOF figures.

Exclusions would include tasks which should have been done by another clinician, prescription requests by in-patients or for the deceased (not kidding), urgent requests for medication needed for a holiday booked 2 months ago or anyone asking for a house visit having just flown back from Florida that day or specifying which time they will be in.. Similarly any replacement of sedatives or opiates even when the police have been informed.  These will all need a covering letter.

Important but non-urgent requests such as ongoing symptoms, medical reports, HGV exams, meeting requests and replacement certificates will be put on a waiting list. This will be within 4 weeks for sore knees and shoulders and 8 weeks for all other problems.

Ideally, of course, a period of consultation, staff communication and public awareness of this new system will be vital to its success. I will write a strategic document with an implementation timescale and financial projections which will be circulated but unfortunately I have been unable to assess any impact on other parts of the service…

 

……I don’t have the time.

John Locke is a General Practitioner

 

 

VTE? Vital Team Effort! by Vince Perkins

I was asked a while back to be involved with our Boards attempt at reducing the rate of venous thromboembolism ,VTE. This is the development of a clot in a vein which might lead to a significant health problem such as deep venous thrombosis ( DVT) and Pulmonary Embolism, (PE )

Both can lead to chronic morbidity and death

I have been fortunate to work with a great VTE team. This multi-disciplinary advisory group includes nurses, doctors  pharmacists, and local patient safety advisors. We receive valuable assistance from IT and coding staff. Regular Data collection from wards has been an important aspect of the teams work

I hope to give a brief overview of what we in the VTE group have been doing and suggest areas where we could continue to improve.

Why is VTE an issue?

The Scottish Patient Safety Initiative views VTE reduction as one of its priority points of care. A 2005 study showed that in the UK 25, 000 avoidable deaths occurred every year from hospital acquired VTE. A more recent study from 2011 puts the figure now at 1000 deaths a week.

But it’s not just deaths that are a concern. It’s all the other problems that may develop from a clot such as long term limb swelling, chronic ulceration and of course the potential dangers of requiring long term treatment with blood thinning drugs such as warfarin.

What figures do we have locally?

 

Deaths recorded for these patients

                                DVT       PE

2010/11                2              24

2011/12                4              12

2012/13                6              24

2013/14                6              20

Emergency department figures

92 patients discharged home from ED with diagnosis of DVT 2013/14

Demands on Radiology July 2013-14

1115 examinations undertaken for Lower limb Ultrasound and CT pulmonary angiograms 

A recent statement from The Medical Royal colleges, College of Midwives, College of Nursing and Royal Pharmaceutical Society included

“There is significant evidence to support the view that hospital-acquired VTE can be prevented through a combination of two simple, safe and effective steps “

These are

Risk assessment AND administration of preventative treatment

Guidelines to assist us have been produced including SIGN 122 (Scottish Intercollegiate guidelines network)   and NICE CG92  (Google them for their quick reference guides)

So ask yourself :if you are coming in to our hospital to have surgery or you are being admitted to an inpatient ward for medical treatment what are we all doing as a team to reduce the risk of you developing a preventable complication which may lead to long term morbidity or even death?

Risk Assessment

Measures to consider putting in place for your admission

You should be risk assessed preferably using a formalised risk assessment chart. These include taking into account issues such as anticipated prolonged immobility, type of surgery, obesity, and medical comorbidity such as heart failure which all increase the risk of a clot developing .Part of the risk assessment also looks at relative contraindications to interventions so that an appropriate risk/benefit decision can be made. Depending on that assessment appropriate advice should be given to you and specific measures put into place.

Preventative Treatment

This might include:

Advising early mobilisation and good hydration,

Considering means to improve blood flow in lower limbs such as TED stockings or pneumatic pumps   “mechanical prophylaxis”

Considering prescribing of drugs such as enoxaparin  (clexane) to help thin the blood   “chemical or pharmacological prophylaxis”

Whether you are medical or surgical the same principles should apply. Assessment followed by REGULAR further reassessment

What happens in our Trust and what have the VTE team been doing to improve things?

If you are coming in for elective surgery you will be preassessed by a member of the preassessment team in DGRI or Galloway Community Hospital. This includes a VTE risk assessment using a standardised form designed by our group.

You will also be given information verbally and in leaflet form to take home to read to allow you to be better informed on VTE risk

Day of admission surgery

There may be a gap of several weeks from your initial preassessment to the actual day of surgery and so you should be reassessed on admission to check there have been no significant changes since the preassessment. An example to think of with the summer coming up is that following preassessment you went on a holiday which involved a long haul flight. This will increase your risk of VTE and thus modify the initial assessment. Or perhaps you have since started an oestrogen containing oral contraceptive which again may modify your risk

Ward Assessment

 

 

Theatre

Once you arrive in theatre a further check is done

Following input from the VTE team, Theatre staff have now incorporated specific questions concerning VTE prophylaxis into the WHO safety checklist .This now acts as another prompt to attempt to ensure that TEDs, if indicated have been applied and clexane if indicated, has actually been prescribed .

 

Recovery

When you arrive in recovery after your operation the formalised SBAR handover allows another opportunity to ensure VTE prevention measures have been implemented.

Medical admissions Ward

An assessment is undertaken on all patients as part of the acute admission clerking and recommendations made

Obstetrics

A formalised chart based risk assessment is done

Paper systems

How is the VTE team trying to improve our Trust’s current paper based assessment and prescription system?

One initial modification introduced by the VTE working group was a change in how the current kardex is presented

The first “box” in our kardex has “thromboprophylaxis?” written as a prompt. This idea came   from our ICU drug kardex where it had been shown to be a useful reminder for staff

A second significant issue concerns our current paper based approach

In surgical patients the risk assessment is a separate piece of documentation, either filled in at preassessment or as part of the acute admission paperwork. In medicine there is an area for assessment included in the medical clerking document. Crucially in both current systems the assessment is divorced from the actual prescription in the kardex, creating a latent risk. To try to reduce this risk The VTE team are piloting having the assessment   being incorporated into the kardex This has been undertaken in the surgical assessment unit.

 

Why? Because in our current paper based system   the assessment is yet another piece of paper that can get “lost” in the notes. The assessment may not be acted on e.g. advice to prescribe prophylaxis might not be seen. This similar risk can occur in the current medical admissions format; the admitting consultant may document that you need clexane but this is not carried through to actually prescribing. Having assessment and kardex as one document is surely better for patient safety. This concept has been successfully introduced in other hospital in Lothian and Borders.

Electronic Prescribing

Ultimately our Trust will be moving away from paper onto the electronic casenote. Therefore our group were keen to influence the proposed electronic prescription system; HEPMA .This is being piloted in ward 18 with subsequent rollout to all wards .We advised that it should include a mandatory electronic VTE assessment tool.

(A major study from John Hopkins Hospital, Baltimore demonstrated significantly higher compliance when a computerised clinical decision support tool was implemented.)Lessons from the John Hopkins Multi-Disciplinary VTE Prevention Collaborative BMJ 2012

Incorporating the risk assessment and subsequent reassessment into an electronic mandatory system will also promote the concept of a standardised approach to VTE assessment and management. Currently our medical and surgical wards have different approaches to the same problem .Surely a uniform system practised across the hospital would be better? The team would welcome your views

Subsequent reassessment

A vital part of assessment is further reassessment during the hospital stay; ideally every 48-72hours. Why? Because circumstances change and clinical conditions alter.

Let me give you some examples

You may have come in for what was meant to be day surgery but then due to unanticipated surgical difficulties you end up having a prolonged admission.

But the clexane   is never written up so you end up with a DVT…..

Or perhaps you have been admitted with pneumonia and correctly prescribed clexane on admission but subsequently your kidney function worsens. The dose should be reduced but isn’t

You then have a significant bleed due to the enhanced effect of the drug……

Or maybe you came in with what was thought to be (incorrectly) a lower g/i bleed but in fact turns out to be a colonic cancer.

You were initially assessed as an increased bleeding risk so were not prescribed clexane. Despite a significant change in diagnosis you are not reassessed. You don’t get prescribed prophylaxis and subsequently develop a PE…….

Or perhaps you come in having vomited blood and so are not prescribed clexane. Mechanical prophylaxis such as TEDs is not considered and some days later you develop a DVT……

Unlikely scenarios? Perhaps you have come across similar examples yourself? 

Nationally we have evidence that no hospitals are particularly good at documenting the reassessment of VTE risk during a patient’s stay. Our patient safety team‘s local data confirms this.

In an attempt to improve reassessment rates the VTE group are grateful to Ward 6 for currently piloting a more formalised, nurse led approach to reassessment. How about your ward area? The more we all become involved the safer the patient environment will become. Again the team would value your thoughts.

Discharge

Increasing evidence is available to suggest that prolonged injectable prophylaxis post discharge is beneficial in reducing VTE rates in certain specific situations.

For some time now elective knee and hip replacement patients being discharged from ward 16 have been going home having been taught by the nurses to give themselves their own clexane. If unable, then plans are put in place so that a family member or district nurse can assist. Post Hip patients continue clexane for 28 days and post knee patients continue for 14 days.

Post Caesarean section patients (depending on risk factors )may also go home from Cresswell Maternity Unit self administering injections in some cases up to six weeks post discharge .

Other groups that may benefit from prolonged administration may include other types of major surgery such as colorectal surgery patients. Any new developments must include discussion with our Primary Care colleagues.

Feedback: Closing the loop

Post hospital discharge a team may not necessarily know or be made aware that their patient has developed a VTE. This could lead to an assumption that “it never happens to one of our patients”.)

In  an initial effort to improve feedback the VTE group has suggested that if a patient develops a VTE following a recent surgical procedure then that surgeon should receive a copy of the medical discharge letter. This type of feedback would also be very useful for patients seen and treated for DVT in the Emergency Department and indeed for any team with recent involvement in that patient’s care.

Conclusion

VTE prevention involves all of us

If you come in as a patient you would want a proper thorough assessment

You would want appropriate safeguards put into place to minimise the risk of a clot developing.

You would also want a regular reassessment to make sure that interventions are modified appropriately.

You would want to go home safe in the knowledge that you have been given appropriate discharge advice. Above all you want to feel that all the team are doing their utmost to minimise harm.

VTE?   Vital Team Effort!

If you would like to contribute and join our group then contact me on vincent.perkins@nhs.net

Special thanks to Emma McGauchie, Staff nurse day surgery/Improvement Advisor and Becky Henderson, Project Officer, Patient Safety

Thanks to staff for posing as patients in the photos!

Vince Perkins is a Consultant Anaesthetist for NHS Dumfries and Galloway

 

 

 

Dementia Champions in Dumfries and Galloway by @gbhaining

Who are we?

Across Dumfries and Galloway there are currently 116 dementia champions on our register. We come from a variety of professions and backgrounds including:-

• Nurses
• Allied Healthcare Professionals
• Social Work
• Care at Home
• Chief Executive Offices
• GP Medical Centres
• Community Nursing
• General Hospital
• Mental Health Hospital
• Community Hospitals

How do we become a dementia champion?

As dementia champions we have attended training either locally or nationally. The training provides us with knowledge of dementia, some of the complications and the impact a physical illness can have on a person living with dementia. Listed below are some of the topics included in the training:-

• Understanding dementia
• Communication
• Environment
• Promoting person and family centred care
• Community connections
• Working with families and friends
• Promoting health and well being
• Stress and distress
• Sexuality
• End of life care
• Supporting and protecting people’s rights

We are keen to stress that this training does not make us “experts” but gives us a greater understanding of dementia.

Our Charter.

As dementia champions we have developed and agreed a charter which outlines how we plan to promote our role and support people with dementia and their carers when we are delivering care.

How can you (our colleagues and teams) help us to help you?

If a person living with dementia or cognitive impairment is admitted to hospital or being seen by services check whether they have a copy of “This is Me”. This document can provide us all with very important information and can assist us to make sure we are supporting each person in the best way possible.

Effective use of “This is Me”

• If the person doesn’t have a copy of “This is Me” offer them one to complete along with their family and friends.
• “This is Me” can contain information which is not always readily available at first point of contact.
• Encourage all those working with the person to read “This is Me” and talk to them and their family about the person’s preferences.
• “This is Me” should be easily accessible and ideally left with the person to allow them to share with staff working with them.
• Sign the document after reading as this allows families and carers to see who is involved in the delivery of care.
• You must also make sure that “This is Me” goes back home on discharge as this document is very important to the person it belongs to.

You will see from our charter that we are striving to introduce ourselves to people with dementia, their families and carers during episodes of care. The ward or department may not always have a dementia champion on duty but you can assist us by making sure that everyone in the area knows who the dementia champions are and how to contact them.

We all wear badges as a means of identification so make sure you know who we are!

We will do our best to help, support and answer any queries you may have, however, as we’ve previously said, we are not experts! If we can’t advise you we know who to go to find out.

Development and Training.

We keep ourselves up to date by attending at least one of four development sessions organised for us each year. Our charter states we have to attend a minimum of one development session annually but we are encouraged to attend as many as possible.

These sessions cover a variety of topics but all help us to understand how we can best support people with dementia, their relatives and carers. The sessions are facilitated by Gladys Haining our Alzheimer Dementia Nurse Consultant and Alice Wilson Deputy Nurse Director. As dementia champions we are involved in decision making around specific topics we want to further our knowledge about. These sessions also give us an opportunity to discuss our role, share examples of good practice and discuss some of the challenges we face as dementia champions.

We rely on you as our colleagues and managers to facilitate out attendance at these sessions and your support is greatly appreciated.

To summarise:

• We, given the opportunity, can support and advise you on aspects of dementia and how to support people with dementia during episodes of care.
• We may not always be around, but, please make sure your department has up to date information about the dementia champions, who we are, when we’re on duty and how we can assist both staff and people with dementia.
• If we can’t assist you or answer queries we will seek help and support from some-one who can.
• We want to be able to help and support you as much as we can, so make sure you utilise the skills and knowledge we bring to the team.

If you require more information about dementia champions please contact:

Gladys Haining
Alzheimer Scotland Dementia Nurse Consultant

Tel: 01387 246981 Email: – ghaining@nhs.net Twitter @gbhaining

Never, ever too posh to wash! by @AliceWilson771

When I was a student nurse the ward Sister reigned supreme, not just over the nursing staff but with everyone who set foot in her ward. I say “her” because even when I was a student, there were very few males in nursing and the only man I ever knew who had been in charge of a ward was my own dad. In his day, my dad had to train in London with 4 other men because there were very few places that allowed men to train as nurses and certainly not in a group with women – not so much equity of access then; mind you those were also the days when women had to leave nursing and other jobs if they got married.

We have, of course, moved on but the role of the Senior Charge Nurse is fundamentally the same; to ensure the standards of care in their areas and develop and support staff – sounds simple but is done in the context of a very complex and demanding environment

Back in the day student nurses were employed by Health Boards and had a stronger sense of belonging to the organisation. Everyone had a vested interest in you from the very first day you set (a very shaky) foot into your first ward. The ward Sister took a real (and scary!) interest in first year students, working with us and teaching us things we never forgot. Over the years I have adapted much of that teaching as things move on and because there are ways I feel suit me better but there is one thing that never changes and, if I walked into a room now, I would do exactly as I had been taught; here’s why: In my first ward and on my third shift the ward Sister announced that I was going to learn “properly” about bed bathing and that she and I would bed bath “Mary”

Before we even got into the room we had discussed what we would notice immediately and over the course of the process of bathing; I didn’t understand the importance of that at that point. On entering the room, I was expected to introduce myself to Mary and explain I was a student and was learning and that the Sister would involve me in lots of discussion and questions. Mary didn’t look terribly impressed…and then, remembering what Sister had said about noticing, I realised it was cold in the room and that the window was open – that tiny prompt was the start for me about what a bed bath really means. It meant that I asked Mary if she was cold and allowed her to make the decision to close the window and realised that a bed bath wasn’t just about cleanliness and comfort, it is a unique opportunity to make a connection with another human being who is in a vulnerable situation, afraid, maybe in pain or discomfort or worrying, not about their illness but about their family, home, or often, their pets!

It is a fantastic opportunity to assess the physical and emotional state of an individual; by simply coming into a room, talking and listening and laying hands on a person you can assess so many things and offer reassurance and explanation. It is often suggested that nurses have moved in their focus to a more technical role and away from “menial” tasks such as personal hygiene,

I find this an interesting consideration and would offer that in more than 31 years of nursing I have never considered washing another human being as a menial task for the reasons I have just laid out. It is a privileged position we hold and I firmly believe that any nurse who is “too posh to wash” has perhaps lost sight of that unique chance to notice the individual