mortality and harm reduction in aneurin bevan health board...aneurin bevan health board 10th june...

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Mortality and Harm Reduction in

Aneurin Bevan Health Board

10th June 2011

ABHB Vision

The vision statement for the Aneurin Bevan Health Board is:

• Working with you for a healthier community

• Caring for you when you need us

• Aiming for excellence in all we do

ABHB PrioritiesOur priorities for Quality and Patient Safety are:

• Patients and service users experience high quality care

We will care for patients equally with compassion, dignity and respect to ensure that fundamental standards of care are always provided.

• Safe care

We will provide the safest healthcare possible in a clean, orderly environment, and we will prevent needless deaths, pain or suffering.

• Efficient evidence – based services

We will use our resources carefully and according to best scientific evidence to ensure that we provide the best value to patients.

• Making the most of our staff

We will ensure our staff are trained and educated to improve the way we provide services. We will share learning openly and celebrate success.

• Promoting health

We will work actively with the community, our workforce and individuals to promote healthy lifestyles and prevent illness.

• Integrated care

We will work across professional and organisational boundaries to help people with chronic conditions, and to look after people when they become unwell.

ABHB Aims – Reducing

Mortality and Harm

• Aim: To have a RAMI in line with top performing UK organisations and eliminate seasonal and weekly variation in RAMI by June 2013.

• Aim: To establish the Global Trigger Tool as a measure of patient harm and reduce adverse events per 1000 patient days to 10 by June 2013.

ABHB Risk Adjusted Mortality

Index (2010 base)

ABHB Risk Adjusted Mortality Index (RAMI) 2010 Base

108.6

82.9

139.3

104.5

77.9

61.3

40

60

80

100

120

140

160

Apr-08

May-08

Jun-08

Jul-0

8

Aug-08

Sep-08

Oct-08

Nov-08

Dec-08

Jan-09

Feb-09

Mar-09

Apr-09

May-09

Jun-09

Jul-0

9

Aug-09

Sep-09

Oct-09

Nov-09

Dec-09

Jan-10

Feb-10

Mar-10

Apr-10

May-10

Jun-10

Jul-1

0

Aug-10

Sep-10

Oct-10

Nov-10

UCL Mean LCL

Adverse Events per 1000

Patient days (from the GTT)

Royal Gwent

Hospital

Nevill Hall

Hospital

High Level Actions for

Reducing Mortality• Mortality and Harm Group reviews Mortality and Harm data and

triangulates with other data to identify further ways to reduce mortality

• Mortality Audit undertaken and regular reports circulated to clinicians,weekly at NHH and monthly at RGH.

• Currently reviewing variation in daily mortality over the week in line withhigh level aim, in order to identify whether day of admission has an impacton mortality.

• Also working to review 30 day mortalities for specific conditions, in line withthe AQF, but are currently looking at impact on the measure of usingdifferent operational definitions

• Identify new priorities for action to reduce mortality

Taking Forward the

Driver Diagram• The 1000 Lives Steering Group has been set up, with

representation from all the Divisions and Localities, to embed the priorities for reducing mortality and harm in the Divisions and Localities.

• In particular, the Group receives presentations from each of the mini-collaborative areas, embeds the spread of interventions in the Divisions and Localities, and addresses the requirements of a measurement system for all the interventions, ABHB-wide.

• Taking new priorities/drivers to reduce mortality/harm and developing the interventions to make further change

Mortality Reduction Driver

Diagram

ABHB Harm reduction Driver

Diagram

Leadership Walkrounds

Walkarounds take place

across Aneurin Bevan

Health Board in Acute,

Community and Mental

Health Hospitals

Number of Walkarounds per month

0

1

2

3

4

5

6

7

8

Oct-0

7

Dec-

07

Feb-0

8

Apr

-08

Jun-

08

Aug

-08

Oct-0

8

Dec-

08

Feb-0

9

Apr

-09

Jun-

09

Aug

-09

Oct-0

9

Dec-

09

Feb-1

0

Apr

-10

Jun-

10

Aug

-10

Oct-1

0

Dec-

10

Feb-1

1

Apr

-11

Number of Walkarounds cumulative

0

20

40

60

80

100

120

Oct-0

7

Dec-

07

Feb-0

8

Apr

-08

Jun-

08

Aug

-08

Oct-0

8

Dec-

08

Feb-0

9

Apr

-09

Jun-

09

Aug

-09

Oct-0

9

Dec-

09

Feb-1

0

Apr

-10

Jun-

10

Aug

-10

Oct-1

0

Dec-

10

Feb-1

1

Apr

-11

Leadership Walkrounds

Achievements

• Ongoing programme of walkrounds reviewed and now undertake 2 in an afternoon to make the process more efficient (hence no walkarounds in Jan and Feb 2011 while the programme was reset)

• Reviewed process and Action Plans from each walkround now agreed at the end of the walkaround

• Now revisiting wards and departments seen previously

Challenges

• Follow up of agreed actions

Next Steps

• Quarterly paper to Executive Team on Walkarounds to agree completion of follow-up actions

• Walkarounds in primary care planned

Progress in Mini-Collaboratives

Critical Care

Critical CareAchievements• Central Line Infections >300 days between

• MDT rounds & daily goals

• Hand Hygiene

• Patient diaries tested at RGH now being used at NHH

• Implementing SKIN Bundle

• Taking forward PVC bundle

Challenges• Couple of instances of VAP in long stay patients or patients with

spinal injury – explored this via Safer Patients Network, now using gel for oral hygiene to reduce incidence of VAP

Next Steps• Central Line Maintenance Bundle being spread to Neonatal unit

• Ongoing involvement in RRAILS use on wards

Deteriorating Patients

Achievements• Deteriorating Patients Steering Group

• Updated Observation Policy circulated to organisation

• MEWS audit highlighted areas to concentrate training

• Completed NCEPOD Crash Call study

• Looking at use of tool in Mental Health

• Piloting NEWS tool

• Plans regarding change from MEWS to NEWS tool on specific day to avoid confusion with differing scoring systems

Next Steps• Implement revised NEWS Observation Sheet

Rapid Response to Acute

Illness (RRAILS)Achievements• Bundles implemented on Surgical Assessment Unit (RGH) and 4/3 (NHH)

• PSAG board re: MEWS established on both sites

• Spreading to CCU, D3W, 3/4 and 3/3 wards

• Training given and sepsis bundles

• RRAILS discussed with Medicine Directorate

Challenges• Implementation on wards currently without Outreach Support

• Waiting for revised Observation / NEWS charts to be printed

Next Steps• Sepsis bundles to commence on spread wards in May at NHH and June at RGH

• Policy for deteriorating patients will have to be changed in light of NEWS chart

• Jump call chart

HCAI – Central Lines (CVC)

• Nevill Hall Hospital • Royal Gwent Hospital

HCAI – Central Lines (CVC)

Achievements• 95% reliable process for insertion and maintenance bundles at RGH

and NHH intensive care units

• >300 days since central line infection (>600 days for RGH)

• Use of bundles in theatres

• Bundle spread to Neonatal Unit

Challenges• Spreading Maintenance bundles to other areas

• Measurement in other areas

Next Steps• Spread of Maintenance Bundles to Ward areas, proforma being

devised for use

HCAI – Catheter Associated

Urinary Tract Infection (CAUTI)% compliance with maintenance bundle by week

D3W

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

09/0

1/11

16/0

1/11

23/0

1/11

30/0

1/11

06/0

2/11

13/0

2/11

20/0

2/11

27/0

2/11

06/0

3/11

13/0

3/11

20/0

3/11

27/0

3/11

03/0

4/11

10/0

4/11

17/0

4/11

24/0

4/11

% c

om

pli

an

ce

% compliance w ith maintenance bundle

% compliance with maintenance bundle by week

RGH - CCU

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

19/1

2/10

26/1

2/10

02/0

1/11

09/0

1/11

16/0

1/11

23/0

1/11

30/0

1/11

06/0

2/11

13/0

2/11

20/0

2/11

27/0

2/11

06/0

3/11

13/0

3/11

20/0

3/11

27/0

3/11

03/0

4/11

10/0

4/11

17/0

4/11

24/0

4/11

% c

om

pli

an

ce



Ward C5East & C7E

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

05/0

9/10

12/0

9/10

19/0

9/10

26/0

9/10

03/1

0/10

10/1

0/10

17/1

0/10

24/1

0/10

31/1

0/10

07/1

1/10

14/1

1/10

21/1

1/10

28/1

1/10

05/1

2/10

12/1

2/10

19/1

2/10

26/1

2/10

02/0

1/11

09/0

1/11

16/0

1/11

23/0

1/11

30/0

1/11

06/0

2/11

13/0

2/11

20/0

2/11

27/0

2/11

06/0

3/11

13/0

3/11

20/0

3/11

27/0

3/11

03/0

4/11

10/0

4/11

17/0

4/11

24/0

4/11

% c

om

pli

an

ce

% compliance with maintenance bundle


ward 4/1

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

01/0

8/10

08/0

8/10

15/0

8/10

22/0

8/10

29/0

8/10

05/0

9/10

12/0

9/10

19/0

9/10

26/0

9/10

03/1

0/10

10/1

0/10

17/1

0/10

24/1

0/10

31/1

0/10

07/1

1/10

14/1

1/10

21/1

1/10

28/1

1/10

05/1

2/10

12/1

2/10

19/1

2/10

26/1

2/10

02/0

1/11

09/0

1/11

16/0

1/11

23/0

1/11

30/0

1/11

06/0

2/11

13/0

2/11

20/0

2/11

27/0

2/11

06/0

3/11

13/0

3/11

20/0

3/11

27/0

3/11

03/0

4/11

10/0

4/11

17/0

4/11

24/0

4/11

01/0

5/11

08/0

5/11

15/0

5/11

% c

om

pli

an

ce



ward 4/4

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

17/0

4/11

24/0

4/11

01/0

5/11

% c

om

pli

an

ce



ward 4 -2

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

08/0

8/10

15/0

8/10

22/0

8/10

29/0

8/10

05/0

9/10

12/0

9/10

19/0

9/10

26/0

9/10

03/1

0/10

10/1

0/10

17/1

0/10

24/1

0/10

31/1

0/10

07/1

1/10

14/1

1/10

21/1

1/10

28/1

1/10

05/1

2/10

12/1

2/10

19/1

2/10

26/1

2/10

02/0

1/11

09/0

1/11

16/0

1/11

23/0

1/11

30/0

1/11

06/0

2/11

13/0

2/11

20/0

2/11

27/0

2/11

06/0

3/11

13/0

3/11

20/0

3/11

27/0

3/11

03/0

4/11

10/0

4/11

17/0

4/11

24/0

4/11

01/0

5/11

08/0

5/11

15/0

5/11

% c

om

pli

an

ce


RGH

wards

NHH

wards


Urinary Tract Infection (CAUTI)

Achievements• Spread maintenance bundle to 7 wards across ABHB

• Now collecting insertion and removal baseline numbers

• Spreading this data collection to 6 wards

• Driver diagram pulled together for maintenance bundle

• Working with nursing home to implement maintenance bundle

Challenges• To collect data on ecoli bacteraemia linked to catheter care

• Keeping staff motivated when leads change roles

• Spread bundle to other locality leads, training planned

• Formulate insertion bundle

Next Steps• Meeting with continence services to review catheter documentation across ABHB

• Reviewing the use of the Data Collection Spreadsheet


Urinary Tract Infection (CAUTI)

HCAI – Peripheral Vascular Cannulae


D7E Ortho

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

08/1

1/10

15/1

1/10

22/1

1/10

29/1

1/10

06/1

2/10

13/1

2/10

20/1

2/10

27/1

2/10

03/0

1/11

10/0

1/11

17/0

1/11

24/0

1/11

31/0

1/11

07/0

2/11

14/0

2/11

21/0

2/11

28/0

2/11

07/0

3/11

14/0

3/11

21/0

3/11

% c

om

pli

an

ce


NHH

CCU

Insertion Bundle Maintenance Bundle

NHH

CCU

NHH

1/2

NHH

1/2

D7E


D7E Ortho

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

08/1

1/10

15/1

1/10

22/1

1/10

29/1

1/10

06/1

2/10

13/1

2/10

20/1

2/10

27/1

2/10

03/0

1/11

10/0

1/11

17/0

1/11

24/0

1/11

31/0

1/11

07/0

2/11

14/0

2/11

21/0

2/11

28/0

2/11

07/0

3/11

14/0

3/11

21/0

3/11

28/0

3/11

04/0

4/11

11/0

4/11

18/0

4/11

25/0

4/11

02/0

5/11

09/0

5/11

16/0

5/11

% c

om

pli

an

ce


D7E

HCAI – Peripheral Vascular

Cannulae (PVC)

Achievements• Working well on CCU, 1/2 and D7E

• Taking part in SPN „Pass it On‟ programme working with Tayside in Scotland to test, implement and spread PVC bundle

• Ongoing measurement in place

• Successful PDSA testing of PVC sticker in orthopaedic theatres

• Spreading PVC bundle to corresponding ward 3/1

• Cannula Poster being used to boost usage of sticker

• Being measured via ORMIS theatre system

• Plan in place to promote use of sticker in theatres

Challenges• Coordination of implementation of bundles across wards, community starting with

CAUTI before PVC

Next Steps• Reviewing data collection tool using generic 1000 Lives spreadsheet

Hand Hygiene

Hand HygieneAchievements• Reaching High Compliance across ABHB

• Hand Hygiene Audits across all acute wards (weekly audits)

• Hand Hygiene Audits spread to community hospitals and departments

• Over 4000 hand hygiene opportunities audited each month

• Measurement and feedback system in place

• Graphs displayed on each ward

• „Bare below the elbow‟ incorporated into „Hand Hygiene Policy‟ and audited

• „Point of Care‟ tool being tested including hand hygiene

Challenges• Reliability of audit data – IPACT team carrying out validation audits to confirm hand

hygiene compliance

Next Steps• Spreading use of Point of Care tool to audit hand hygiene

Infection Rates –

MRSA / C Difficile

Nevill Hall Royal Gwent

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

70.00%

80.00%

90.00%

100.00%

Jan-10 -

3/3 3/4

4/3 4/1

4/2 3/2

1/2

Feb-10 -

4/3 4/4

4/2 3/2

3/1 2/4

2/3

Mar-10 -

3/3 3/4

4/3 4/1

3/2

SCBU

2/1 4/4

Apri-10 -

3/3 3/4

4/3 1/2

2/4 4/1

2/3 4/2

May-10 -

3/3 3/4

4/3 4/4

CCU ICU

Jun-10

3/3 3/4

4/3 1/2

2/4 3/1

3/2 4/1

SCBU

Jul-10

3/3 3/4

4/3 CCU

4/4

Aug-10

3/3 3/4

4/3 3/1

2/1

Sep-10

SCBU

1/2 3/2

Oct-10

3/3 3/4

4/3 CCU

4/1 4/2

2/3 4/4

Nov-10

3/3 3/4

4/3 2/4

2/1 3/1

3/2

Dec-10

3/3 3/4

4/3 1/2

2/3 2/4

4/1 4/2

ICU

Q3a Is the antibiotic

consistent w ith trust

guideline?Target 95%

CDifficile – Antibiotic

Stewardship

Is the Antibiotic used consistent with ABHB guidelines?

NHH Hosp

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

70.00%

80.00%

90.00%

100.00%

Nov-09

- D4E

Dec-09

- C4E

Jan-10

- B6

C5W

D2W

C4E D4E

Feb-10 -

C4E D4E

B3

Mar-10 -

C4E C6E

D4E

C6W

Apr-10 -

C4E D4E

C6E

C6W

May-10

- C6E

C4E D4E

D3E

C4W

D4W B3

Jun-10

C6E C4E

D4E

D2W

C5E

Jul-10

C6E C4E

D4E

Aug-10

C6E C4E

D4E B3

B6 C7W

Sep-10

C4E D4E

D2W

C5E

C5W

D3E

Oct-10

C6E C4E

D4E B3

C4W

Nov-10

C6E C4E

D4E

Dec-10

C6E C4E

D4E

Q3a Is the antibiotic

consistent w ith trust

guideline?Target 95%

RGH Hosp

CDifficile – Antibiotic

Stewardship

Achievements• Monthly Audit of Antibiotic usage

• Antibiotic Pharmacist and Consultant Microbiologist carry out audit and speak to medical/nursing staff re: antibiotics each month

• Antibiotic Medication Stop Policy Updated

• Audit data feedback to nursing and medical staff

• Antibiotic Automatic Stop Policy approved at Clinical Forum

• Data showing improved compliance with antibiotic policy

Transforming TheatresAchievements• Both theatres fully engaged with Transforming Theatres Programme

• Knowing How We are Doing Boards up and running with information and measurement displayed

• WHO Checklist and pain score audits, patient satisfaction surveys, being carried out

• Daily glitches being recorded and presented on board

• Jade Theatre have – standardised anaesthetic rooms,

– organised anaesthetic drug cupbourds and line and block trolleys,

– also safety attitudes questionnaire and transfer from ward to theatre audits being carried out,

– also Operational Status at a Glance board up and runnning

• Urology theatre well underway – with 5S organised theatre achieving higher infection control mark as a result,

– planning to start anaesthetic room standardisation,

– also roll out of patient walkdowns to theatre

Surgical ComplicationsAchievements• 95% reliability reached in most areas

• Hand hygiene audits being carried out in theatres

• Anaesthetists administering prophylactic antibiotics

• Measurement via ORMIS system at RGH, NHH, CDMH & St Woolos

• WHO Checklist implemented in all surgical units and being audited

• WHO checklist and SSI drivers included in new Caesarean Section Pathway document

Challenges• Outcome measurement of SSI difficult

• WHO Checklist process reliability

Next Steps• Consultant lead reviewing WHO checklist

• Measurement for Obstetric Patients being initiated

Surgical Complications

Process Measures

Surgical Complications – SSI joint

replacement - outcome measures

Enhanced Recovery After Surgery

Achievements• ERAS used Colo-rectal Surgery at RGH since 2008

• MDT led by Surgeon & Anaesthetist,inc.nursing/physio/dietetics

• 15/17 elements implemented

• LOS reduced from 9 to 6/7 days

• Carbohydrate Loading on ABHB Formulary

• First ERAS Steering Group Meeting taken place

• Advanced Nurse Practitioner employed to lead ERAS

• ANP in discussions with key stakeholders, eg. MDT team, GPs

• Retrospective measurement Initiated

Challenges• Ongoing Measurement

Next Steps• Implementation/clinical hub group to be set up

• Process for ongoing measurement

• ERAS documentation

• Spread to T&O

Enhanced Recovery After SurgeryLength of stay - In Hospital

Aneurin Bevan Health Board - Nevill Hall Hospital

from Feb 2010 to Mar 2011

0

10

20

30

40

50

60

70

80

90

100

Feb

2010

Mar

2010

Apr

2010

May

2010

Jun

2010

Jul

2010

Aug

2010

Sep

2010

Oct

2010

Nov

2010

Dec

2010

Jan

2011

Feb

2011

Mar

2011

Months

Days

(B3) % of pts admitted on day of surgery



0

10

20

30

40

50

60

70

80

90

100

Feb

2010

Mar

2010

Apr

2010

May

2010

Jun

2010

Jul

2010

Aug

2010

Sep

2010

Oct

2010

Nov

2010

Dec

2010

Jan

2011

Feb

2011

Mar

2011

Months

% p

atie

nts

(B3) % of pts where Carbohydrate drinks given 12 hours per-op



0

10

20

30

40

50

60

70

80

90

100

Feb

2010

Mar

2010

Apr

2010

May

2010

Jun

2010

Jul

2010

Aug

2010

Sep

2010

Oct

2010

Nov

2010

Dec

2010

Jan

2011

Feb

2011

Mar

2011

Months

% p

ati

en

ts

Length

of Stay

Day of

Surgery

Admission

Carbohydrate

Drinks 12 hrs

pre-op

(B4) % of pts sat out in chair 6 hours post-operative on day 0 of surgery



0

10

20

30

40

50

60

70

80

90

100

Feb

2010

Mar

2010

Apr

2010

May

2010

Jun

2010

Jul

2010

Aug

2010

Sep

2010

Oct

2010

Nov

2010

Dec

2010

Jan

2011

Feb

2011

Mar

2011

Months

% p

ati

en

ts

Sitting out

6 hrs post-

op

(B4) % of pts achieved 4 x 60 metre walks daily after surgery ( or adapted as

appropriate)



0

10

20

30

40

50

60

70

80

90

100

Feb

2010

Mar

2010

Apr

2010

May

2010

Jun

2010

Jul

2010

Aug

2010

Sep

2010

Oct

2010

Nov

2010

Dec

2010

Jan

2011

Feb

2011

Mar

2011

Months

% p

ati

en

ts

4 x 60m

walks

daily

(B5) % of pts contacted within 48 hours post discharge to check progress at

home



0

10

20

30

40

50

60

70

80

90

100

Feb

2010

Mar

2010

Apr

2010

May

2010

Jun

2010

Jul

2010

Aug

2010

Sep

2010

Oct

2010

Nov

2010

Dec

2010

Jan

2011

Feb

2011

Mar

2011

Months

% p

ati

en

tsPatients

contacted 48

hrs post-

discharge

Hospital Acquired

Thrombosis

RGH Surgical Thromboprophylaxis

Hospital Acquired Thrombosis

Achievements• Risk assessment tool being tested in Pre-assessment Clinic in General Surgery,

orthopaedics and general medicine

• Risk Assessment Tool slightly altered following PDSAs

• Education regarding the Risk Assessment Form

• Anticoagulation nurses measured DVT incidence

• Consultant Surgeon annual Audit of Post-Operative VTE

• HAT steering group in place reporting to Thrombosis Committee

• Agreement to implement tool initially in general surgery

• Incidence of HAT within 30 days of admission is being derived based on Betsi Cadwaladr Methodology

• Measurement for Risk assessment in surgery initiated using ORMIS

Challenges• Different Prescribing Practices

Next Steps• Initiate risk assessment in orthopaedics

• Revisit plans for implementation and spread of tool

Transforming CareAchievements

• Phase 1 adaptor wards coming to end of foundation

modules

• Direct care averaging 40-45%

• Phase 2 in progress – 17 wards May-Sept to carry

out activity follows, visioning and ward reviews

• Roll out plan devised

• Wards engaging in Transforming Care away days

• Graphs agreed to be displayed on ward areas, eg.

infection rates, pressure ulcers

Transforming CareChallenges• Time to do the work

• Staff learning tools and techniques

Next Steps• Roll out gantt chart to be completed

• Phase 3 will start Sept 11 – Jan 12

• Phase 4 will start Jan 12 – April 12


Skin BundleAchievements• Monthly pressure damage prevalence data collection

• Safety Calendars being used to record pressure damage

• All adult wards using SKIN Bundle

• Focussed attention on introducing bundle to assessment areas, A&E, MAU, SAU

• Tests for Incidence reporting instead of prevalence in Caerphilly

• Paediatric ward piloting pressure ulcer risk assessment tool for children

Challenges• Incidence reporting instead of prevalence reporting

Next Steps• Target Theatres as indicated in AQF

• Developing action plans as a result of Annual Community Pressure Ulcer

Prevalence Audit, Locality Action Plans to inform Corporate Plan

• Group looking at adapting SKIN bundle for Community Application

Chronic Heart FailureThis is Nevill Hall Data taken from the National CHF Audit Database. Originally auditing

only those patients referred to the Heart Failure Service, from Dec 09 a representative

sample of ALL patients with CHF were included

Chronic Heart FailureAchievements• Heart Failure Service achieving high compliance rates for drivers

• Specialist Nurses and Audit Dept working together for National CHF Audit at NHH

• Spread audit data collection to patients not referred to Heart Failure Service, despite initial dip in compliance, this is now being improved

• MDT steering group set up including consultants, GP, pharmacy, specialist nurses, 1000 Lives

• Active pharmacy involvement, presentation to pharmacy forum

• Successful testing of sticker on general and cardiac wards

• Specialist nurses concentrating on frequent flyers

• Feedback of progress to ABHB1000 Lives Steering Group

• 1000 Lives spreadsheets being used

Challenges• Ongoing Measurement - primary and secondary care

Next Steps• Spread and measurement in Primary Care

• Spread of drivers to patients not referred to Heart Failure Service

• Initiate data collection for National Audit in RGH

Acute

Stroke Care

RGH Acute Stroke Data

% compliance with First Hours bundle

Stroke patients

from Apr 2010 to Jan 2011

0

10

20

30

40

50

60

70

80

90

100

26/04/201026/05/201026/06/201026/07/201026/08/201026/09/201026/10/201026/11/201026/12/2010

Weeks

% c

ompl

ianc

e

% compliance with First 3 Days bundle

Stroke patients


0

10

20

30

40

50

60

70

80

90

100

26/04/201026/05/201026/06/201026/07/201026/08/201026/09/201026/10/201026/11/201026/12/2010

Weeks

% c

ompl

ianc

e

% compliance with First Days bundle

Stroke patients


0

10

20

30

40

50

60

70

80

90

100

26/04/201026/05/201026/06/201026/07/201026/08/201026/09/201026/10/201026/11/201026/12/2010

Weeks

% c

ompl

ianc

e


Stroke patients


0

10

20

30

40

50

60

70

80

90

100

26/04/201026/05/201026/06/201026/07/201026/08/201026/09/201026/10/201026/11/2010

Weeks

% c

ompl

ianc

e

% compliance with First Hours bundle

Stroke patients

from May 2010 to May 2011

0

10

20

30

40

50

60

70

80

90

100

04/05/201004/06/201004/07/201004/08/201004/09/201004/10/201004/11/201004/12/201004/01/201104/02/201104/03/201104/04/201104/05/2011

Weeks

% c

om

pli

an

ce

% compliance with First Days bundle

Stroke patients


0

10

20

30

40

50

60

70

80

90

100

04/05/201004/06/201004/07/201004/08/201004/09/201004/10/201004/11/201004/12/201004/01/201104/02/201104/03/201104/04/201104/05/2011

Weeks

% c

om

pli

an

ce


Stroke patients


0

10

20

30

40

50

60

70

80

90

100

04/05/201004/06/201004/07/201004/08/201004/09/201004/10/201004/11/201004/12/201004/01/201104/02/201104/03/201104/04/201104/05/2011

Weeks

% c

om

pli

an

ce


Stroke patients


0

10

20

30

40

50

60

70

80

90

100

04/05/201004/06/201004/07/201004/08/201004/09/201004/10/201004/11/201004/12/201004/01/201104/02/201104/03/201104/04/201104/05/2011

Weeks

% c

om

pli

an

ce

NHH Acute Stroke Data

First Hours Bundle

First Days Bundle

First 3 Days Bundle

First 7 Days Bundle

Acute Stroke Care

Achievements• Executive Support for process

• Root Causes

• Patients to Stroke Unit quickly

• Training

• Bundles Checklist

• Visual Board on Ward

• Operational Policy

• CT scanning protocol for Out of Hours pts

• Weekly review of data

• Work presented to National Safer Patients Network Conference in Manchester

Challenges• Sustaining compliance.

Next Steps• Multidisciplinary Stroke

Documentation- Wales wide.

• Direct admission policy.

• 7 Day Physio working

Stroke Care - TIAAchievements• RGH & NHH have 5 day rapid access TIA clinics

• Referral Pack/Patient leaflet/GP Information

• ABCD2 Scores being used by GPs to identify appropriate referral pathway

• Clinic sees 100% of lower risk patients

• Measurement system in place

• Engagement of medical staff who take part collecting data

• Monthly meetings to feedback data and problem solve

Challenges• Weekends/bank holiday clinic cover

Next Steps• Ongoing work to engage GPs

Stroke Care - Rehabilitation

Achievements• Stroke Rehabilitation Wards across five localities: Glyn Mynach,

Ruperra, Cedar, Caerwent, Ysbytty Aneurin Bevan

• 4 Teams starting to collect data

• Established leads in each area

• All five management boards have received an update on the early rehab bundles

• Rehabilitation subgroup set up

Challenges• Engaging medical and nursing staff

Next Steps• To start regular fortnightly meetings with Nursing Director

Reducing Harm from Falls

Achievements• Good attendance from ABHB at Mini-Collaboratives

• Half-day training event that both provided an opportunity for discussion about falls within the Frailty Programme, and provided training on the IHI Model for Improvement, measurement and using PDSA cycles to introduce the driver diagram

• Some Teams collecting data and using it successfully to support change

Challenges• Introducing the Falls Driver Diagram at the same time as service

changes in connection with Frailty Programme

• Collecting data centrally in ABHB

Next Steps• Revisit set up of pilot sites, now that the Frailty Programme is in

place

Falls Data

% patients who receive the full Trigger Bundle

Falls

from Jan 2011 to Feb 2011

0

20

40

60

80

100

120

05/01/2011 05/02/2011

Weeks

% p

atie

nts

% patients who complete the initial screening using an

agreed tool

Falls

from Jan 2011 to Feb 2011

0

20

40

60

80

100

120

05/01/2011 05/02/2011

Weeks

% p

atie

nts

Mental Health – Improving Care

for People with Dementia in

General Hospitals

Achievements• Pilots of General Hospital care

agreed on C7E (trauma ward,RGH) and Ystrad Mynach Hospital,with focus initially on identifyingpatients with dementia or delirium

• Memory Clinics also piloting manyaspects of the driver diagram

Challenges• Low levels of liaison psychiatry in

place

Next Steps• Audit of patients identified with

dementia and delirium currently on the General Wards

• Putting in place the measurement across the different drivers

Intelligent Targets for Dementia

ABHB – To Improve Memory

Assessment Services

ACHIEVEMENTS

• 3 Pilot sites

• Pre diagnostic counselling checklist developed

• Use of ACE-R + complimentary functional assessment agreed as standard when appropriate

• Development of assessment guidance achieved and introduced in pilot sites

NEXT STEPS

• Post diagnosis interventions. Promoting adjustment, checklist being developed, lead by OT.

ACHIEVEMENTS• Pilot sites identified at Royal Gwent

C7E and Y Bannau at Brecon Hospital.

• Audit of identification of dementia on admission underway.

• Developing dementia friendly environments where possible in other wards in ABHB. Dementia friendly refurbishment completed at Rowan Ward, County Hospital, Pontypool.

NEXT STEPS• Initial awareness training being

arranged with OAMH Liaison Nurse.


ABHB – To Improve Care on

General Hospital Wards


ABHB – To Improve Community

CareACHIEVEMENTS

• Audits of prescribing in care homes

undertaken in Newport, Caerphilly and

Torfaen.

• Medicines management department

undertaking care home medication audit

in South Powys

• Guidance sheet on anti-psychotic has

been developed

NEXT STEPS

• Guidelines on “Managing behaviour that

Challenges” and alternative

interventions being revised.

• Audit tool adjusted to include MCA and

alternative interventions. Will now use

revised tool to audit Care Home in

Rhymney.

• Audit of carers views of the service to be undertaken in Blaenau Gwent

• Review of a care pathway produced by a carer in Monmouthshire

• To facilitate UK Carers survey in all Boroughs

• To review the pilot on Direct Payments in Blaenau Gwent. Integrate option on CPA

• Roll out Psychological Therapies for carers currently run in Blaenau Gwent and Caerphilly. Monmouthshire next.

• Respite to be taken as an issue to SPG


ABHB – To Increase Support

for Care Givers


ABHB – To Improve Quality of Care

in NHS In-patient Dementia Units

ACHIEVEMENTS

• Pilot sites in Chepstow, Newport and Ebbw Vale

• Life history books being used in pilot areas

• Therapeutic activities CST and POG groups being used on Cedar Parc Ward at Ebbw Vale.

NEXT STEPS

• Developing dementia care pathway

• Carers satisfaction survey being revised and will be used on the three pilot wards

• Sycamore Ward in Newport will have DCM observation audit

• Protocol for anti psychotic prescribing to be introduced on Llanfair Ward, Chepstow.

Early Intervention Services

for First Episode Psychosis

Achievements

• Early Intervention Service has been established for 2 1/2 years. The only comprehensive EI Service in Wales.

• There is a team in each of the 5 boroughs of Gwent.

• In accordance with the FEP Guidelines we work with the clients for 3 years. This is the “critical period” following the recognition of a psychosis.

• Service already has 140 clients which, for the duration that the service has been running, is in accordance with national and international predictions

• Number and length of admissions of 140 clients has been significantly reduced


Early intervention Services

for First Episode PsychosisAchievements Continued

• Also have representation from CAMHs and established pathways and joint working practice with CAMHs

• With CAMHs established multiagency project in Caerphilly area, targeting child and youth services to educate staff around psychosis and promote early detection

• First year‟s 2010/11 FEP Intelligents Targets concentrated on establishing the Duration of Untreated Psychosis (DUP) (length of time someone is psychotic before receiving treatment). As we the only established service in Wales we able to provide fairly comprehensive data on the DUP. Mean DUP = 26 mths; Median DUP = 6mths. This is similar to the findings of other first world countries prior to the long term establishment of an Early Intervention Service


for First Episode Psychosis

Achievements Continued

• Further to the 2010/11 FEP ITs, we piloted an array of future targets for NLIAH including measures of QOL, functioning, engagement, therapies, satisfaction, admissions, suicide attempts etc.

• With NLIAH developed a database to record this information which can be used to track the progress of client and service.

• Have begun FEP scoping and development exercise in South Powys



in First Episode Psychosis Challenges

• The devolving of the service to local borough secondary services

• The demand of secondary services and management to widen the entrance criteria for FEP

• The shortage of staffing, resources and training to meet the demands of working with all FEP clients over a 3 year critical period

Next Steps

• To secure a team structure and identity so as to maintain fidelity to the Early Intervention model

• To roll out the multi-agency work in Caerphilly across the rest of the ABHB

• To use our unique position of having an Early Intervention FEP service, to promote such work across Wales.

• To develop EI FEP services in South Powys

Mental Health Intelligent Target –

Identifying Depression in

Hospital Settings

Achievements• The Clinical Lead has been established, with additional clinical support

• Clinical engagement from the teams for the chronic conditions where co- morbiddepression can lead to poorer outcomes has been attained, and it has been decidedto focus the pilots in the outpatient setting.

• The Clinical Lead has visited all the outpatient clinics identified to pilot the driverdiagram to understand what is already in place related to depression

• Developed process in respiratory to implement drivers, and process beingdeveloped in the other areas

Challenges• Low level of liaison psychiatry service in place, although this is being addressed in

Newport

Next Steps

• Implement processes that have been developed, includingmeasurement

Medicines Management -

AntipsychoticsAchievements• MDT team being set up including Consultant Psychiatrist, MH Pharmacist, Locality

Pharmacy advisor, EMI care home advisor working with pilot GP practices and Care homes

• Review visits taken place this year in three EMI care homes

• Across 2 homes 45% reduced, stopped or switched drugs

• Extensive work already in place in Caerphilly

• Pilot EMI home and GP practice

• MDT meeting held at GP practice where way forward for pilot area agreed

• Antipsychotics included in GP medication review

• Agreement for GPs and Consultant Psychiatrist to do alternative 6 monthly reviews

• Patient/family leaflet devised and on intranet

Challenges• Communication

• Measurement

Next Steps• Devising guidance for GPs to help them with medication reviews

• To set up measurement process

• Sign up of other practices, perhaps those with enhanced services for care homes

Meds Management – High

Risk Meds – Warfarin/Insulin

Achievements• Patients with high INR visited daily to

optmise treatment

• All Wales Warfarin chart in place

• Insulin prescribing chart on all wards at NHH and some at RGH

Maternity ServicesAchievements• MEOWS patient observation system in place

• DVT prophylaxis policy in place

• Updated Caesarean Section pathway to include measurement processes

• Initial measurement being tested

• Sepsis work being tested

• MDT team set up and building on previous work

Challenges• Measurement

Next Steps• Reviewing process for ongoing measurement using run-chart spreadsheets

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