ED Safety Checklist Masterclass
Monday 25th April 2016
Welcome & IntroductionDeborah Evans, Managing Director,
West of England AHSN
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The ED Safety ChecklistThe Why!
Dr Emma Redfern, ED ConsultantUniversity Hospitals Bristol
The Problem
Patient safety in the urgent care environment, particularly at handover and during crowdingDelays in recognition and treatment of severe illness and deteriorationA staffing crisis and reliance on agency staff.Human factors in urgent care
Where’s Wally?
Safer Transfers of Care
There’s Wally!
The ED Safety ChecklistThe What!
Alex Hastie & Caroline ClarkED Safety Checklist Project Nurses
University Hospitals Bristol
PDSA Cycles
The PDSA cycle is shorthand for testing a change by developing a plan to test the change (Plan), carrying out the test (Do), observing and learning from the consequences (Study), and determining what modifications should be made to the test (Act).
• A comprehensive list of essential components of care, prioritised according to required completion time
• Incorporating elements to improve not only safety but patient experience through their ED journey.
• A multidisciplinary tool to provide safe, timely emergency care
What is the ED Safety Checklist?
• Feedback from ED Team
• Review of Clinical Incidents
• Review of complaints
• Inclusion of information from nursing indicators
How was it conceived?
• Focused on hourly themesVital signs, NEWS, pain scoring
• Frontloading of investigations• Promotion of care pathways• Early identification of required referrals onto
specialist teams
What does it comprise of?
• Checklist pilot trial• Checklist roll out• Reformation of ED Safety Checklist Team• Collection of multi-sourced feedback
How was it implemented?
• Fluctuating enthusiasm from a large team• Timing• Correlation between checklist uptake and
department acuity• Varying attitudes from different staff groups• Data collection
What problems did we face?
• Length of Stay• Outliers• ED Targets – 4 hour breaches, nurse indicators • Mortality• Clinical Incidents• Patient Experience
How did we measure our success?
• Introduction of CQuin• Staff group specific, multi source feedback• Shop floor champions• Senior support• SWAS involvement• Continued indicator audit• Shift from monthly to daily uptake auditing
How did we maintain our results?
Within the DepartmentBusiness as normalContinued auditingShop floor champion
Outside the DepartmentCollaboration between other trustsNational dissemination
What next for the project?
• Structured introduction• Designated team• Specific staff group engagement• Multidisciplinary involvement• Shopfloor champions• Daily and monthly auditing• Set targets
What have we learnt?
The ED Safety ChecklistThe How!
Ellie Wetz, Patient Safety Improvement LeadWest of England AHSN
The ED Safety Checklist Toolkit
• Developed to support the implementation of the ED Safety Checklist at adopting trusts.
• Guidance not mandate!
The ED Safety Checklist Toolkit
Toolkit Structure:1. About the ED Safety Checklist2. Form your team3. Organise your ED4. Agree your measuresAppendixes
The ED Safety Checklist Toolkit
1. About the ED Safety Checklist• Local Fields
• Baseline Data• Comprehensive review of ED clinical incidents
• ‘Best Practice’ Fields• Vital signs taken and NEWScore calculated regularly• Front loading of investigations i.e. imaging, bloods
The ED Safety Checklist Toolkit
• PDSA• Helps teams plan• Test on small scale• Review• What works? What
doesn’t?• QI Toolkithttp://www.weahsn.net/ what-we-do/skills-knowledge-development/improvement-resources-and-tools/the-improvement-journey/
The ED Safety Checklist Toolkit
Project Logic Model• Inputs• Activities• Outputs• Outcomes• Impact
The ED Safety Checklist Toolkit
2. Form your team• Local Implementation Team (LIT)
• Existing ED Staff• Lead Nurse• Lead Consultant• Audit Coordination Nurse/Data Analyst• Other key stakeholders
The ED Safety Checklist Toolkit
• LIT fortnightly meetings• Agenda
• Project documentation• Risk & Issue Log
The ED Safety Checklist Toolkit
3. Organise your ED• How will you print, store and restock the ED Safety
Checklist?• ED Safety Checklist Training• Real-time feedback• NEWS Training
The ED Safety Checklist Toolkit
4. Agree your measures• How do we know a patient safety intervention has a
positive impact? We measure it!• Baselining• KPI’s & Dashboards• Life System Platform• Evaluation
The ED Safety Checklist Toolkit
Appendixes• ED Safety Checklist
http://www.weahsn.net/what-we-do/enhancing-patient-safety/• SHINE 2014 Final Report• QI Resources
http://www.weashn.net/what-we-do/skills-knowledge-development/improvement-resources-and-tools/the-improvement-journey/
• Research Papers
Q & AGeneral Discussion
Chaired by Deborah Evans, Managing Director,West of England AHSN
Refreshments & Networking
The Interface with the Ambulance Trust
Phil Cowburn Acute Care Medical Director
South Western Ambulance Service NHS Foundation TrustConsultant in Emergency Medicine
University Hospital Bristol
NEWS?
Emergency Department
• Increased demand• “Winter Pressures”• Lack of discharges• Poor flow
• Exit block• Crowding
Effects on Ambulance Service
• Crews tied up• Hours lost• Poor performance• Delayed response
times• Undifferentiated risk
in community
Who’s Caring for Patients in the Queue?
Care of Queue
ED at Bristol Royal Infirmary– University Hospitals Bristol NHS Foundation Trust– Adult only ED
2012 Retrospective review of ED notes and PCF100 consecutive queuing patients over 2 week period
Care of Queue
Patient care responsibility of ambulance TrustClinical SOP requiring minimum 15 minute observationsIncreased frequency if clinically indicated
Care of Queue
Care of Queue
Care of QueueNumber of Sets of Observations Compared to Time Queuing
0
5
10
15
20
25
30
<30 30-59 60-89 90-119 >=120Time in Queue (minutes)
Num
ber P
atie
nts
0 1 2 3 >=4
What was really happening in the Queue
Queue Events
6 CVE– Average age 76– All queued > 75 minutes– No CT < 60 minutes
4 # NoF– Average age 87– All queued > 90 minutes– No X-Ray < 60 minutes
Queue Events4 Serious Incidents
Missed MI– Deteriorated in queue, moved to resus, arrest, RIP
OD self discharged– No capacity assessment or mental health matrix
# dislocation ankle with critical skin– Queued 3 hours, reduction >6 hours post injury– Plastics referral
Who Owns this Risk?
Late Night ChatAcute Gold
• We’re full• We’re not performing• Stop bringing patients• I need nurses and beds• We’re unsafe• We want a divert• We’re un-safer than you• We might closeJust shut the doors and don’t
let ‘em in
Ambulance Gold• Everyone is full• We’re not performing• Start taking the patients• I need crews• We’re unsafe• No-one will take a divert• We’re un-safer than you• You can’t close
Push ‘em through the doors and go
Risk ReductionImprove quality care
Get basics right Work together
Grassroots
ED & Queue
Which patients are sick?Which patients are deteriorating? Which patients have time critical conditions ?
Birth of The ED Safety Checklist
Better NEWS
NEWS
How NEWS might help?
Potential for ambulance service to – Prioritise HCPC calls – Assist on decision making to discharge– Define & communicate pre-alerts
Transforming Urgent and Emergency Care Service in
England Safer, Faster, Better: Good Practice in delivering urgent
and emergency care NHS England August 2015
“All adult patients should have a NEWS established at
time of admission.”“Where patients experience
long waits, their NEWS should be recorded, pain
assessed and managed and essential care given.”
Ambulance ServiceElectronic Care System & ePCR
WEAHSN supported Roll out & incorporation of NEWS into ePCR
Auto calculatesED can see all information
Including NEWSPart of executive summary
Aim to incorporate SHINE Checklist
Working Together
Adoption and spread-safer transfers of care
Measuring the Impact of the ED Safety Checklist
Kevin Hunter, Patient Safety Programme Manager, West of England AHSN
Baseline Data
• Understanding your current standards of care• Case note review
• Suggested 20 notes per month• 1 year of data• Performance against Key Performance Indicators• Data input sheet provided in Toolkit
• Serious Incident Review• Common themes Inform local checklist & PDSA
Key Performance Indicators
Key Performance Indicators
• Suggested 5% ED Safety Checklist audited per month (at UHB: 200 per month)
• <50% complete – not valid• Basic clinical care• Pathways• Patient experience• Local KPIs to reflect local checklists
Key Performance Indicators
Key Performance Indicators
1. Red: <49%2. Amber: 50% -
79%3. Green: >80%
Nov-13
Jan-14
Mar-14
May-14
Jul-14
Sep-14
Nov-14
Jan-15
Mar-15
May-15
40.00%
50.00%
60.00%
70.00%
80.00%
90.00%
100.00%
Pain scoring at triage and analgesia given Nov 13 - May 15
Pain - Pain score & triage Pain - Analgesia
Intro
duct
ion
of E
D S
afet
y
Che
cklis
t
What is the ‘Life’ System?• A web based platform designed to assist front line staff running
Quality and Safety improvement projects
• It has been developed as part of the PSC in partnership by SeeData and South West AHSN
• Regional subscription model – Free for our members to use
• Supports team working and collaboration – an open and transparent culture
• Ability to view projects on the system from across the country
• Able to seek assistance and support from other users
• Gives a regional overview of improvement activity
The PrinciplesLife has been build by SeeData and South West AHSN on a set of principles that are designed to support continuous improvement:
• All users agree that the information they add to the system can be viewed (with limitations able to be set)
• The system is not designed to collect detailed information on users, organisations or patients
• The system will make minimal use of mandatory fields to encourage flexible use
• The information collected is only to support improvement and is never to be used for performance management
Login Page
Front Page – My Projects
My Organisations Projects
All Projects
Project General Info Tab
Project Driver Diagram Tab
Project Measures Tab
Project Change Ideas Tab
Project PDSA Tab
Project SPC Chart Tab
Project Documents Tab
Connect Module - Discussions
Resources Module
Organisations List
Users List
Aggregate Chart Development
Aggregate Chart Development
Aggregate Chart Development
Aggregate Chart Development
Participating AHSN’s in ‘Life’:• West of England• South West• Wessex• Kent, Surrey and Sussex• UCLPartners• Oxford• West Midlands• East Midlands• Eastern• North West Coast.
Any questions then please see Kevin Hunter throughout the day or email [email protected]
To sign up for a user account:https://life.seedata.co.uk/login/
Further Information
The West of England ED Collaborative
Dr Emma Redfern, ED ConsultantUniversity Hospitals Bristol
Participating Trusts
• Weston Area Health Trust• North Bristol NHS Trust• Gloucestershire Hospitals NHS Foundation Trust• Great Western Hospital NHS Foundation Trust• Royal United Hospitals Bath NHS Foundation Trust• University Hospitals Bristol NHS Foundation Trust• South Western Ambulance Service NHS Foundation
Trust
West of England AHSN Support
• Implementation Toolkit• Financial Award
• Band 7 Lead Nurse• 2 days per week for 6 months• 1 day per week for 12 months
• Band 4 Data Manager• 1 day per week for 18 months
• Conditional on:• Attendance at ED Collaborative Meetings• Submission of KPI Data
Lesson’s Learnt
• Cultural ‘Buy In’• Executive Teams• ED Medical & Nursing Leads
• Local ‘ownership’ of the ED Safety Checklist is important
• EDs are structured and staffed in different ways • Success is more likely if adopting Trusts plan
their own implementation model
Interactive SessionChaired by Deborah Evans, Managing Director,
West of England AHSN
Discussion:
• Barriers
• Challenges
• The role of Patient Safety Collaboratives
• What other support is needed?
Next StepsDr Emma Redfern, ED Consultant
University Hospitals Bristol
• Pledges• Can we form a nation-wide collaborative?• How shall we structure ourselves?• The role of Patient Safety Collaboratives• KPI Data• Life System
Summary & CloseDeborah Evans, Managing Director,
West of England AHSN
@weahsn
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