Let’s insist on the possible by Valerie Douglas

Many things in life are complicated, require great debate and despite huge resources are not guaranteed to be successful in practice. There are other things which are simple to understand, can easily be implemented and immediately make a difference to improve lives or in some cases save lives. You only have to think of the meaningful campaign to change the care of people with a diagnosis of dementia led by Tommy Whitelaw (Tommy Whitelaw @tommyNTour). It makes sense and it hits you in the heart. As a professional you cannot listen to Tommy talk about caring for his mum and withhold your support for this campaign. His mum is your mum.

Another example is Kate Grainger’s inspirational campaign (#hellomynameis). This focuses right in on the doctor/patient relationship. It goes further than just making us think more about face to face contact with patients who may feel vulnerable, distressed and in alien surroundings. It asks us to look at our practice on a basic level, to say our name aloud, on every contact. At one point this patient was Kate Grainger but the patient could be any one of us.

Last November an important, widely supported campaign for the mandatory teaching of Cardiopulminory Resuscitation (CPR) to schoolchildren was unsuccessful. This Emergency Bill was opposed despite irrefutable evidence that it saves lives. In Norway it has been compulsory for schoolchildren to be taught CPR since 1961 and survival rates are double what they are in the UK. As out-of-hospital cardiac arrest is the commonest life-threatening emergency in the UK so I thought this campaign was bound to be fully supported and unchallenged. You can imagine my disappointment.

I felt at a loss about what to do next, yet felt there had to be a ‘next’. To increase survival rates of cardiac arrest the immediate action of bystanders is crucial. Personally I have carried out CPR three times, twice in a hospital setting and once at a family event. A day of laughter and pleasure turned into tragedy. Event though, as a nurse, I’m aware that the outcome from CPR is variable for a myriad of reasons, I was left affected by this last experience. Then a doctor said to me, “If I had a cardiac arrest I would want someone to have a go.” I am glad I have been taught CPR and am able to ‘have a go’, otherwise the most I could have done that night would have been to phone an ambulance instead of giving a friend a chance of life.

What could I do now? I decided to put together a resolution to RCN Congress 2016 calling on governments to mandate the teaching of CPR to schoolchildren (the remit of the Emergency Bill had been wider, encompassing all kinds of First Aid). The resolution was accepted and I presented this in June this year.

There were wide ranging contributions to the debate. Personal stories were shared about children delivering CPR successfully. A delegate told us about a situation where his 27 year old teammate collapsed during a game of football. 23 players including the referee were there and nobody knew how to do CPR; this man died. He went on to describe a more recent experience when an instructor was brought in to teach CPR to the junior football team. Within 10 minutes they were doing it perfectly.
Some delegates expressed concern about the effect on children if they delivered CPR and it was unsuccessful. Others answered this by saying: remove the fear, teach them young. The evidence is there. Someone else highlighted again that encouraging CPR lessons in schools as an add option is not enough; teaching needs to be a requirement so that there is no national disparity. Kate Ashton made a very acute observation at Congress:
“If we can educate youngsters in schools about sex education and creating life then surely we can educate them about saving lives.”

Every year an estimated 60 000 out of hospital cardiac arrests occur in the UK (BMJ 2013;347:f4800) It could happen to any one of us. What can you do?
Write to your local MP and express your support for the campaign to mandate teaching of CPR.
Become a local First Responder.
Find out if your town/village has a defibrillator and where it is kept.
Ask your school if the teaching of CPR is on the curriculum.
Let’s insist on the possible.

Valerie Douglas is a Staff Nurse in Mental Health at Midpark Hospital, NHS Dumfries and Galloway

Under Pressure…… by @fionacgreen

In November 2013 “Dave” was admitted to hospital following a hip fracture. Dave didn’t always like the food choices and at times found it difficult to drink enough. Several days into his admission his wife noticed a blister on his heel- she mentioned it to the ward team but felt she was dismissed.

By the time of his discharge from hospital Dave had an established ulcer that required regular input from the community nursing team and podiatry.

In June 2014 Dave was admitted to hospital again. The fact that he had already one pressure sore, combined with diabetes meant that he was at high risk of developing further pressure sores and this time he left with a further two pressure sores.

Further prolonged admissions followed to treat deep-seated infection of bone resulting from the presence of pressure sores and ultimately surgical debridement and vascular intervention was required to aid the healing process. With each further admission Dave and his wife became increasingly terrified of what might happen and worried that he may leave with further pressure sores. Last year Dave spent his wife’s birthday, Christmas and New Year in hospital and throughout was visited daily by his wife -it is clear from his story the human impact of developing pressure ulcers

Dave and his wife have given their permission to share their story in the hope that we can begin to learn how important it is that we work together to prevent

pressure ulcers

Lesson one -Prevention is better than cure.

Each year 700,000 people in the UK develop pressure ulcers. Each pressure ulcer adds approximately £ 4000 to the cost of care. It has been suggested that 80-95% of pressure ulcers may be avoidable. Sometimes in healthcare as we concentrate our efforts on the complicated and exciting new developments that come our way we can lose sight of the simple things that can make a huge difference to the outcomes for our patients. By paying attention to early detection of risk, encouraging patients to keep as mobile as possible, addressing incontinence appropriately and by improving hydration and nutrition we can make steps to reduce the risk of pressure ulcers developing.

FG 1

Preventing Pressure Ulcers- the CPR approach

1 Check and identify problems early– this means that socks, TED stockings, and dressings must be removed to allow the pressure areas to be properly visualised

2 Protect – if pressure areas are at risk encourage regular changes in position, consider a pressure relieving mattress and apply REPOSE heel splints or Sundance Z-flex boots to relieve pressure. These are available locally by ordering through the PECOS system.

3 Refer – it is never too early to refer to the podiatry team if you have concerns

Repose Heel protectors and Sundance Z-Flex protectors

FG 2

FG 3FG 4If you want make sure you are skilled in the CPR approach to pressure ulcer prevention you can like me complete a short and practical e-learning module available on the NHS Learnpro site ( you’ll be pleased to see that I passed!)

 

Lesson 2- Improving Patient Experience/reducing harm/ improving financial efficiency

Sadly Dave’s story is one of many but so clearly illustrates that developing a pressure ulcer is an important physical harm that also impacts significantly on the healthcare experience of the patient and their family. Pressure ulcers are not just a huge burden to the patient and their family but also to the NHS and its staff as a consequence of prolonged hospital admissions and ongoing intense community treatment that may be required to heal the pressure ulcer. In Dave’s case listening to his wife’s concerns and making sure that he was eating and drinking well may have helped to prevent the prolonged and costly treatment that followed

Lesson 3 Changing Practice

Over the last few years we have all found ourselves under increasing pressure in the NHS. Some of these pressures relate to our desire to reduce harm, improve our patient’s experience of care, and finally to make financial efficiency savings.

People who come into hospital are also under pressure- they are in a frightening and alien environment and their illness may make it difficult to eat, difficult to maintain hydration and difficult to keep mobile. These factors are all important in the development of pressure ulcers. In Dumfries and Galloway we have begun work to accurately record the numbers of pressure ulcers acquired and we implemented a risk assessment pathway incorporating the elements of the ACTIVE PATIENT CARE bundle, Waterlow score and NATVNS pressure ulcer recording tool on pilot wards. Work is currently ongoing to spread these practices throughout the acute sites and the community

FG 5

21st November 2015 marks worldwide STOP PRESSURE ULCER day- Following on from Dr Bell’s blog last week this is one aspiration that we cannot afford to give up on

Dr Fiona Green is a Consultant Physician and Diabetologist and Clinical Lead for Pressure Ulcer workstream

 

 

Hidden eKIS by @kendonaldson

I took a phone call from a patient’s son some months ago. His Dad, Edward, had recently spent 24 hours in our hospital and whilst all members of staff had been kind and helpful he had a few issues he wished to discuss with me. Edward is 83. He had a heart attack 3 weeks ago and has ongoing chest pains. He has Stage 4 Chronic Kidney Disease (about 20% function) and leukaemia. Sadly this last is not amenable to any treatment.

In short Edward has multiple long term conditions and is dying from his leukaemia. He still has a reasonable quality of life and, with his family, has discussed clearly what his wishes for the future are. His GP has entered all of this into his eKIS or Electronic Key Information Summary which can be accessed by all healthcare professionals though the ECS, Electronic care Summary.

eKIS

So when Edward got sudden onset severe chest pain last week the sequence of events was a surprise to him and his family. Paramedics were called and when they arrived they did an ECG. They then proceeded to fax this to the Golden Jubilee Hospital in Glasgow and discuss his case with the team there. All the time they did this Edward’s son was quietly explaining that this was not necessary, his Dad did not want this level of intervention and that this detail was all available on eKIS. The paramedics had not heard of, and were unsure how to access, eKIS. They apologised for this and took Edward to Dumfries. At least he did not have to go to Glasgow!

On arrival on the Emergency Department the same thing happened. Nobody knew what eKIS was and how to access it. I’m afraid this was replicated in the medical assessment unit. The following day, after Edward had been assessed, he was deemed fit for discharge – a blood transfusion had sorted his anaemia and angina. The first the family knew was when Edward phoned them to tell them. “And” he added “I can now drive!” He was delighted as driving is very important to him.

When Edward’s son arrived, a little surprised and anxious, he discovered that the team, who still had not accessed the eKIS, did not know that Edward had had a heart attack 3 weeks prior and hence couldn’t drive, had not contacted the palliative care team (outlined in eKIS on any admission) and had not really thought through his discharge. “Its not very Holistic” was his understated comment to me. It all got sorted and Edward got home (although a little aggrieved that he couldn’t in fact drive) and neither he nor his family wish to complain but they want to understand why eKIS seems to be a mystery to the Scottish Ambulance Service and most of secondary care.

So what is eKIS? If you click here you will get access to a useful ‘FAQs” about eKIS. You can also read Neil Kellys blog “The KIS of Life”, published on the 14th of February 2014, here. Very simply eKIS is an electronic handover. GPs, in consultation with patients and their families, can enter details about DNACPR, treatment escalation and goals and priorities for the future. The idea is to prevent things like unnecessary trips to Glasgow or, if arriving at the ED in a collapsed state, CTs or endoscopies or trips to theatre. Basically it’s an attempt to communicate a patients wishes to all who care for them. Not much use though if no-one looks at it.

Its important for us all to be aware of eKIS. Not just those of us at the front door. If I review a patient in a clinic or on a ward round and we discuss issues about the future and decisions are made then I should communicate this to the GP and ask for it to be included on their eKIS. I confess I am not very good at this but hope that this story will significantly improve my communication efforts. I must also confess that I did not have a password for ECS when I heard this story but I have remedied that.

It’s almost a daily mantra in my life – “it’s all about communication”. So many small (and not so small!) things go wrong because of poor communication. eKIS is an excellent tool aimed at reducing communication errors. Let’s not be like Peter Pan and keep it hidden, let’s use it.

Postscript: Sadly, since writing this blog, Edward has died. He had a number of admissions to hospital following the one outlined above and had similar problems with communication however died peacefully in the Alexandra Unit.

Ken Donaldson is a Consultant Nephrologist and Associate Medical Director at NHS Dumfries and Galloway

Sepsis 6: Are you on Target? by Sian Finlay

Sian 1One of the things I have always liked about Acute Medicine is that it gives me a chance to make a rapid and noticeable impact on a patient’s outcome. Nowhere is this more marked than in patients with severe sepsis. Every year about 100,000 people in the UK are admitted to hospital with sepsis. About 30,000 of these have severe sepsis or septic shock, which carries a mortality of nearly 40%. It is these people where the stakes are highest. If they are recognised early and get some very simple interventions within the first hour, their chances of getting out of hospital alive are hugely increased. One study found that survival falls by 7% for every hour’s delay in antibiotic treatment!   This is where the ‘Sepsis Six’ comes in. It is a set of 6 simple interventions which should be done within an hour of a patient presenting with severe sepsis:

  1. Oxygen to a target of 94-98% saturation (88-92% if risk of CO2 retention)
  2. Blood cultures (and culture any other likely infection source)
  3. Measure lactate
  4. Intravenous fluids (give a 500ml bolus and reassess)
  5. Intravenous antibiotics
  6. Measure urine output (catheter or accurate fluid chart)

Sian 2All of these steps can easily be delivered by junior doctors and nurses, and yet can make a huge difference. So why don’t we do it all the time? One problem seems to be the difficulty in recognising severe sepsis. Patients often don’t arrive with that label, and indeed may have another tag-line attached to them, such as ‘off legs’ or ‘confusion’.   Sometimes the other label doesn’t sound very serious and no-one else seems overly concerned about the patient. Compared to other emergencies such as acute stroke or MI, sepsis can present with a much broader range of symptoms, so diagnosis can be challenging. The only solution is to be vigilant, and to consider sepsis as a possible cause in every patient with an elevated Early Warning Score (MEWS).  

For the last few years, I have been involved with the Scottish Patient Safety Programme (SPSP) work on improving delivery of the sepsis 6. This group consists of nursing and medical staff from key wards, pharmacy, infection control, and SPSP improvement advisors. Initially we focussed on the Emergency Department and Acute Medical Unit, since most patients come into hospital through these routes. We encouraged staff to use our gold ‘Sepsis ICP’ forms for every patient who might have sepsis. The form takes the user through a list of ‘red flag’ signs, which are designed to identify those with severe sepsis. These are the people who need the sepsis 6, and the time for delivering each component of it is recorded on the form and filed in the patient’s notes. Recently we have spread the message to the Galloway Community Hospital in Stranraer and to the medical HDU. Parallel work is ongoing in Obstetrics. Since the project began, the median time to first antibiotic dose in DGRI has fallen to less than one hour, so we know we are on the right track. However there is still much to be done – when I am collecting the data each month, I still see one or two patients who go unrecognised for several hours or only get part of the sepsis 6.

Sian 3

So what are the next steps?

Firstly we need to raise awareness amongst medical and nursing staff that severe sepsis is a medical emergency. In a world where new doctors can rotate through a department every week, it is often experienced nursing staff who are best placed to take the lead in this, and to flag up the possibility of sepsis to the rest of the team. Next, we need to spread the sepsis work more widely, so we can be confident that a patient will get the same quality of care no matter where or when they become unwell. With this in mind, I would invite anyone who is interested in joining our team or contributing in any way (nursing, medical, or AHP) to get in touch and join our exciting project. And if you don’t have time to do this, but still want to help, just remember that if you encounter a patient with severe sepsis and deliver the sepsis 6 within an hour, you can go home that night knowing you have made a difference. It’s that simple.

If you would like to contribute and join our group please contact the Patient Safety & Improvement Team on dumf-uhb.PatientSafety@nhs.net

Dr Sian Finlay is an Acute Physician and Clinical Director for Medicine at NHS Dumfries and Galloway

 

 

What are you so scared of? by David Christie (@bagheera79)

“Now, what I want you to do is focus on your breathing. Slow big deep breaths, in and out. You’ll think nothing’s happening at first, then you’ll feel the world become a warm, fuzzy place. Maybe imagine yourself somewhere like a hot sunny beach, waves on the shore, warm sun… big deep breaths, in and out…”

I usually say something along these lines as I’m drifting you off to sleep for your operation. The wording and phrasing obviously varies, and to be honest it’s the tone of my voice that’s important. The aim is to create an atmosphere of calm and reassurance. Something to focus on instead of the beeping of the monitor and the plastic smell of the mask, and the thought of what happens next. It sounds daft, but it’s important. People can be terrified, when they come into theatre, truly terrified. 

Some of the reasons for this are obvious – perhaps the reason that you’re having surgery, such as cancer. Or the surgery itself carries risk – such as surgery to major blood vessels, the brain, the heart. But some of the reasons are a little less obvious, I think, and easily forgotten. Imagine you’re coming to theatre. Just getting to that point involves the co-ordinated effort of many, many different teams. Patients need to be referred, seen in clinic and booked for surgery. There’s a need to have pre-operative assessment done for all the medical, nursing, physiotherapy and social needs. A raft of co-ordinated investigations such as blood tests, ECG and more are ordered to make sure that we know enough about you to be able to do it safely. The booking teams need to create lists that need to match with the availability of the surgeon, the waiting time, the urgency of the surgery and the availability of the patient – and possibly that of your carers or relatives. The theatre team needs to know what particular bits of kit are needed and to have it ready for you on the day. Extra members of staff from different departments may also be needed – such as additional surgeons or radiography – the list goes on and on. The whole process is so enormously complicated and intricate that it astonishes me that it works at all. And it needs to have this level of complexity – we humans are not car parts, stamped out in a factory. There are so many different individual problems that need to be overcome, the system needs to be able to cope with them all. And, by and large, we do.

The downside of being able to cope with all of this with a high degree of safety is that the process has become streamlined, smoothed, tick-boxed and protocol-driven. The most widely publicised example of this is the WHO checklist. With a few simple questions this checklist manages two things that seem obvious but used to be done very badly. The first is that it requires all members of the operating team to meet, introduce themselves to each other, and discuss the day’s work ahead before anything happens. In one neat moment, suddenly everyone knows who everyone else is, what the plan for the particular patients that day is, and what problems are anticipated. The second is that, for every patient – before they’re sent off to sleep, is involved in a discussion that is designed to ensure we have the right patient for the right operation, and various safety aspects taken care of – antibiotics, crossmatched blood, prophylaxis against life-threatening blood clots… It’s simple, effective, and has saved many lives all over the world. Unfortunately, all of this can be hugely depersonalising, and worse, unsettling. Having a group of strangers discuss how much blood you’re possibly going to lose just before you fall off to sleep isn’t necessarily reassuring. The whole process of coming in early on the day of surgery – hungry and anxious – to be told to get undressed and meet a sometimes bewildering range of people, including a surgeon that might be different from the one you expected. To be repeatedly asked about yourself, and then to be discussed while you anxiously wait – no wonder people are scared!

So, what can we do? We only have a few minutes with each patient in the morning rush – but that’s enough. To engage with people on a human level, to let them know that we care, to stop them being quite so terrified is not as difficult as it sounds. Simply saying hello and telling people your name goes a long way – it says you care about them enough to let them know who you are! Tell them what’s going to happen and why, what to expect so that they don’t get a fright. Remember that the nonagenarian in front of you may have had an extraordinary life and seen more than you can ever imagine, don’t be patronising.

All of which brings me back to my little spiel at the top, there. Recently I was anaesthetising a man in his eighties for a straightforward urological procedure. He’d been telling us about his life, time in the mountains, his high-flying daughter, an severe accident he’d had racing motorcycles over fifty years ago. I started to inject the medicines to send him off to sleep, and talking about sunshine, warm weather – and he interrupted to say, “Nah, son. I’m gaunnae dream about scoring a penalty fir Liverpool, right in front of the Kop.” I loved that, it made me smile. It made everyone in the room smile, in fact. It reminded me anew, yet again, that our patients are people, with hopes and dreams and complicated lives, and to not lose sight of it. And it reminded me also, that no matter how old we get, boys never grow up.

David Christie is a Consultant Anaesthetist for Dumfries and Galloway Health Board

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?

Vince 1 

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?

Vince 2If 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

Vince 3There 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

 Vince 4

 

Theatre

Once you arrive in theatre a further check is done

Vince 5Following 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.

Vince 6

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

Vince 7

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.

Vince 8 

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.

Vince 9

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.

Vince 9.1

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

Vince 9.2

Thanks to staff for posing as patients in the photos!

Vince Perkins is a Consultant Anaesthetist for NHS Dumfries and Galloway

 

 

 

Communication and Handovers – What’s all the talking about? by Barbara Tamburrini

Barbara T 1After 2 years and 99 posted blogs, addressing 68 different subject areas, I appear to have inherited the slightly daunting task of writing blog number 100 for dghealth. In that very first blog on 19th March 2013, Ken Donaldson encouraged us to open our ears, embrace and not be frightened of communication, interaction and feedback between service providers and service users.

Ken’s vision for the future was to achieve “one blog a week from dghealth for a long time to come” and the evidence that this has been met is clearly demonstrated in the widespread engagement, diverse variety of subjects and immense learning that these blogs have generated.

Despite so many differing categories being listed for these blogs, communication is arguably a subject more frequently visited than most and this topic intertwines into every aspect of our professional practice and service delivery. Communication is an area where the effectiveness of its application has a direct impact on the outcome. We have all had situations, both professional and non-professional where ineffective communication has had a negative impact on our experience and when this involves healthcare provision, the effect can be profound.

One essential aspect of clinical communication involves handover and with the publication of NHS Dumfries and Galloway’s new handover strategy, there is an increasingly important focus on this fundamental area of care provision.

Barbara T 2NHSDG is leading the way nationally in this area with the formation of a dedicated handover group to support, guide and encourage improvement work relating to handovers.

Furthermore, the senior endorsement of handover as a key area within NHSDG and the addition of this to our 9 point of care priorities has demonstrated that handover improvement work has significant support and advocacy at all levels throughout the organization.

But how do we improve the quality of handovers whilst maintaining our focus and energy on all the other priority areas competing for our professional attention? We work in an environment that can sometimes feel like we’re on a hamster wheel without the money to upgrade to first class travel!

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Despite these challenging times, making tangible improvements in our work environment is easier than we might think and this is no less applicable to developing our approaches to handover. Asking 5 simple questions provides the structure required to build a foundation for improvement in handover practice.

 

  1. WHO – who should be involved, who are our essential attenders?
  2. WHEN – when should our handover take place?
  3. WHERE – Where should this handover happen?
  4. HOW – How are we going to structure this handover?
  5. WHAT – What needs to be handed over?

Developing a local protocol for your department based on these 5 standards allows the identification and development of areas of handover whether they relate to shift handovers or transfers of patient care and the effect can be significant.

The protocol clearly identifies fundamental, locally specific details such as which personnel are essential to making the handover fully effective and the appropriate location and time of the handover being addressed. The manner in which the handover will be undertaken is also outlined and the details that need to be included are prioritized. An appendix can then be added to highlight the structure to be applied to the actual handover procedure and this standardizes the process by ensuring transparency and consistency with the way the handover is undertaken on a continual basis.

Over the last 6 months, the Hospital at Night (H@N) ANP team, based in DGRI, have been developing and enhancing their handover process beginning with the handover from dayshift to nightshift at 2145 hours and evaluation of this work is demonstrating impressive results.

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So, how have we achieved this? We initially identified that the handover we wanted to improve was the nighttime meeting at 2145 hours since evidence has indicated that this represented a period of increased significance when care is transferred from dayshift to on-call teams. We then began by formulating a H@N handover protocol based on the 5 handover standards and we identified our target as being 95% compliant as indicated in the NHSDG handover strategy. We then used this local protocol to guide our development of essential elements such as the handover procedure and our improvements measurement.

During this time, we also evaluated our baseline position so we could clearly measure effectiveness and areas for improvement. Once our new handover protocol had been developed and finalized, we set implementation and review dates, publicized the improvement project and undertook team education before implementing and measuring the project.

Although the achievements we have been able to make are clear, we still have challenges in meeting our 95% compliance target in some areas, namely our attendance by essential personnel (WHO) and our punctuality (WHEN). Additionally, this work highlighted that whilst we could measure the handover procedure itself, we had no measurement process for the quality of clinical information handed over and this was felt to be an area of significant concern.

Therefore, the team has developed a quality measuring score for patients handed over using an SBAR-R format which was adapted from an SBAR scoring system implemented within the day surgery unit in DGRI. The aim of this H@N SBAR-R quality score is to measure the quality of clinical communication as well as guiding practice and providing a communication structure. It is also anticipated that this SBAR-R quality measurement can be used to underpin multidisciplinary training and education in relation to clinical communication.

Barbara T 5This has definitely been a work in progress and as happens with all improvement work, successes are achieved whilst challenges are also experienced.

Initial and ongoing engagement has been crucial to delivering the improvements demonstrated and this will also be vital in addressing the challenges which still remain. Nonetheless, the handover improvements the H@N team have implemented and achieved, are easily transferrable across any specialty, discipline and clinical area. This presents the opportunity for shared learning and collaboration to assist and encourage areas who may be considering similar improvement work and practice developments across NHSDG.

The H@N ANPs have some challenges ahead to achieve 95% compliance in all 5 standards whilst also implementing quality measurement for handover communication but this is innovative work that we are proud to be sharing. With support from senior management, the improvement team, the handover group and clinical staff, the H@N team is able to progress these developments and participate in an exciting project that NHSDG is leading the way on nationally. It is hoped that data collection will continue to demonstrate the value of this work and its benefit upon delivering safe, reliable, effective, patient-centered care.

After all, isn’t that what we are all here for?

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 Barbara Tamburrini is an Advanced Nurse Practitioner for NHS Dumfries & Galloway