Daily Dynamic Discharge (DDD) by Patsy Pattie & Carole Morton

“Daily Dynamic Discharge is to improve the timeliness and quality of patient care by planning and synchronising the day’s activities”.
(The Scottish Government, Edinburgh 2016)

The 6 Essential Actions for improving unscheduled care was launched in 2015. The 6 actions were identified as “being fundamental to improving patient care, safety and experience for the unscheduled pathways”. One of these actions is “Patient Rather Than Bed Management”. This approach requires the multi disciplinary team working together to plan and synchronise tasks required to ensure a safe dynamic discharge process, aligning medical and therapeutic care, discharge earlier in the day and transfer back to the GP in time, reducing the length of stay in hospital.

Why do we need it?
The recent day of Care Audit in September 2016 indicated that 30.5% of patients in hospital beds did not require acute hospital care. These patients should have been transferred to another area for continued care or discharged home.
For some health professionals, too many conflicting demands on time often results in optimising work in such a way that may seem logical to the individual, especially if you are covering across wards, but may not be optimal for patient flow. This mis-synchronisation can cause delays and increase the length of stay for patients. Where there is a clear priority of order of tasks for that day, each individual team member plays their part in ensuring the priority tasks for patients is actioned or completed, which works for the patient, thus reducing delays in discharge or transferring the patient.

Who is doing it?
Ward 10 was nominated as the Exemplar ward for DGRI and implementation commenced in early September 2016. Early indications show that time of day discharges are taking place earlier in the day around mid afternoon. Prior to the introduction of DDD 27% of patients had been discharged by 4pm, in the four weeks since implementation the figure has almost doubled to 49%.

When are we doing it?
Each DDD ward huddle usually takes place at 9am each morning. Some wards have incorporated a DDD catch up meeting into their afternoon handover huddle.

What are the benefits?
The DDD approach promotes proactive patient management for today and preparing for tomorrow’s activities i.e. increase accuracy on our discharge position and increase awareness of the need to create capacity at key points throughout the day.
This is aligned to The Royal College of Physicians acute medical care “The right person, in the right setting – first time” (please see link below).
https://cdn.shopify.com/s/files/1/0924/4392/files/acute_medical_care_final_for_web.pdf?1709961806511712341
A recent quote from Vicki Nicoll, SCN ward 10:
“DDD for us has had such a positive impact on the ward as we are finding patients are being seen by all members of the Multi Disciplinary Team (MDT) in a timelier manner.  The patients are being discussed rather than going from one weekly Multi Disciplinary Team meeting to the next.  Interventions are being done more timely from all members.  We have noticed that length of stay has reduced and patients that you would normally presume would be with us for some time seem to be getting home quicker. We recently had a patient who was a complex discharge and I personally thought the patient would have passed away in the ward, but everybody pulled together and we were able to return the patient home.  Sadly, she passed away at home, where she wanted to be with her family”.

“DDD has taken away the thought that nurses should do everything when in fact it is everyone’s job to work together to ensure that the patient is on the right pathway”.

DDD is currently being rolled out to most of the acute wards in DGRI and a test of change commenced on 21st November in Annan Community Hospital. Implementation at the Galloway Community Hospital is planned for mid December.

We all have our part to play in the planning of a safe discharge for our patients, DDD enhances our current processes, promoting an MDT approach with teams working collaboratively and more robustly.

Patsy Pattie works in the Acute Services Improvement Team and Carole Morton is an Assistant General Manager Acute Services for NHS Dumfries and Galloway

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

 

 

 

Jose by Kirsty Bowie

My name is Kirsty Bowie and in August 2001 my husband and I lost our son Jose.

The following is a shortened personal account of what happened before and after his death. I have chosen to share my story in the hope that it highlights how decisions made in this profession can have devastating consequences for a family like mine.

Jose was born on the 2^nd of August 2001 nine days overdue. My labour started on the 1^st of August early afternoon and continued throughout the night. Despite the pain, I refrained from the pain relief offered, as I wanted to be fully aware of what was going on.

The midwife suggested my waters should be broken as labour progressed. This was done at 7.35am. There was an abundance of meconium. I knew meconium was a sign of foetal distress. It was suggested we do a trace of Jose’s heartbeat. After struggling to locate it, the pattern was irregular, his heartbeat was dipping and wasn’t recovering, at its lowest it dipped to 54 beats per minute. The consultant was called for and it was decided that a foetal scalp ph test would be carried out, this was carried out around 7.45am. I feel it was at this point that things started going wrong.

The consultant had introduced herself, explained the procedure and explained she had a student with her who would be observing and assisting. I felt this was inappropriate given the circumstances. I wanted things to be done swiftly and I feared this may hold things up, which it did. The student dropped, then broke one of the instruments, pulled the steel trolley towards the consultant and a spotlight which was being used flew off the steel table smashing the bulb. My baby was distressed and I remember feeling very agitated at this.

The test was eventually completed and the midwife explained that the results would be with us in a short time. Sure enough only a short time lapsed before the consultant returned. However instead of reassuring me I was now being told “your baby needs to be delivered now”.

Despite this statement of urgency and knowing that Jose was distressed he was delivered by caesarean section an agonising 3 HOURS later. A second consultant had made the decision that I was not a priority.

At 10.35am Jose was delivered with an apgar score of 2. The Paediatrician was called as soon as the resus clock was started. It was claimed it took him 5 minutes to arrive. This is something which I still debate, because he came from Ward 15 which is on the 3^rd floor of the infirmary and travelled by car to the old Cresswell. The journey alone takes longer than 5 minutes and this initially had me wondering whether Jose could have been saved had he got there sooner. I now know that the paediatricians presence made no difference to the outcome. It was concluded the cause of death was meconium aspiration due to a considerable delay from discovery of meconium to delivery.

Craig received the news outside the theatre. He compares that moment to being punched in the stomach, a wave of complete panic at the thought of telling me.

He didn’t have to tell me after all.…..I received the devastating news whilst being wheeled back to the labour room, not face to face, just a voice from behind saying in a very matter of fact way ‘your baby died Kirsty’ I can still recall that voice. I will never forget that voice. Craig was re-united with me in the corridor as I was wheeled back to the labour room. We will never forget that moment or that day.

The consultant and the paediatrician sat at my bedside a short time later to explain what had gone wrong, this for me was too soon however, I do distinctly remember the paediatrician saying he was sorry. He seemed genuine and I appreciated that. I also believe that he had tried his best to revive my son.

Having a baby is supposed to be one of the greatest moments of a persons life. Family, friends, colleagues were all awaiting phone calls. Craig was now dreading delivering the news he was dead. How could a perfectly healthy little boy be let down so badly and denied his life. Family still wanted to see him, he was perfectly formed all ready for life.

 

Jose

In the hours that followed I lay in utter shock. I can only describe the feeling as one of utter desperation and gut wrenching sadness. I had to be persuaded to see him. My biggest fear was letting him go. I still remember how much he weighed in my arms, I kissed his forehead, he was so cold, I unwrapped his blankets and looked down at his little chest, it was one of the lowest points of my life. I felt really scared. I asked Craig to take him away. If I had this time again I would spend more time with him. I regret this so much now as we have no photos of us holding him and this still distresses me.

I just wanted to go home and so made the decision to be discharged that day. Craig requested to see Jose again and dress him in what would have been his coming home clothes and then we left, leaving our beautiful wee boy behind.

The death of a child is one of the worst things that can ever happen to a person. Coming home is really just the beginning……..I lay in his nursery and literally howled. Instead of caring for him we were arranging his funeral and choosing his headstone. We registered his birth and death at the same time. Burying him in the clothes we had bought to bring him home in. It is a life sentence. Jose would have been a teenager this year.

Although we have 2 beautiful girls moving on was exceptionally tough. Grief is exhausting. In the early days we went from being a happy fun loving confident couple to virtual recluses, something I would never have believed. We avoided people, situations and just went through the motions of life, carrying heavy hearts and feeling numb. When you stand at the grave of your child you have reached rock bottom. The death of my son is something I will never get over, and there is never a day goes by that I don’t think about him.

Although I initially felt great anger and bitterness, I have had to learn to accept what happened that day and recover enough to accept that nobody is infallible.

Kirsty Bowie is an Assisstant Practioner in Radiography in DGRI.