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SPSP in Primary Care

Scoping Exercise

August 2014

File name: 20140818 Scoping Report Final.docx Version: 0 1 Date: 6-Oct-14

Produced by: Leanne Marshall Page: 2 of 29 Review date: tbc

© Healthcare Improvement Scotland 2014

August 2014

You can copy or reproduce the information in this document for use within NHSScotland and for educational purposes. You must not make a profit using information in this document. Commercial organisations must get our written permission before reproducing this document.

www.healthcareimprovementscotland.org

Scoping Report – August 2014

20140818 Scoping Report Final.docx Version: 0.1 Date: July 2014

Leanne Marshall Page: 3 of 29 Review Date:

Contents

1. Background 4

2. Method 6

3. Overview 8

4. Reducing Avoidable Harm from Medication 9

5. Diagnostic Error 13

6. Results Handling 16

7. System Issues 18

8. Catheter Associated Urinary Tract Infections (CAUTI) 20

9. Pressure Ulcers 22

10. Falls 24

11. Recommendations 26

12. References 27




1. Background

In May 2010, the Scottish Government launched the Healthcare Quality Strategy for

NHSScotland, declaring its intention to put quality at the heart of all that the NHS does for the

people of Scotland. The Delivering Quality in Primary Care National Action Plan set out the

proposals for implementing the Quality Strategy in primary and community care and included

a key commitment to develop and implement a Scottish Patient Safety Programme in

Primary Care (SPSP-PC). For the purposes of this Programme, „Primary Care‟ is defined as

services provided by GP practices, Community Pharmacies, Dental Practices and high street

Optometrists.

While the starting point has been acute care, the Scottish Government has always been

committed to extending this approach to primary care and, through the development of the

Scottish Patient Safety Programme in Primary Care, seeks to improve care and make its

delivery safer throughout the patient‟s journey. A programme of this nature has not been

delivered in primary care before and it should be recognised that the work is significantly

different in that there are very few „off the shelf‟ safety products suitable for implementation in

primary care.

Healthcare Improvement Scotland launched the Scottish Patient Safety Programme in Primary Care (SPSP-PC) in March 2013, and the tools and resources provided were based on the findings from two pilot programmes funded by the Health Foundation (Safety Improvement in Primary Care 1 and 2).

The development, implementation and spread of SPSP-PC has a staged approach (see

table 1.1) with the launch focussing on Stage 1 General Medical Services and specifically GP

practices. While the initial focus is on GP practices, testing is extending into community

pharmacy and nursing. Implementation of the SPSP–Pharmacy in Primary Care

Collaborative, funded by the Health Foundation, has already started. The aim of this

collaborative is to improve patient safety by strengthening the contribution of pharmacists in

primary care, and improving communication within a more integrated primary care team. It is

planned that work in community nursing will be the next area for development.

Table 1: SPSP-PC planned stages

The Scottish Patient Safety Programme in Primary Care comprises 3 work streams to ensure patients receive appropriate and safe care in the primary care setting. The full change packages including a measurement framework for all 3 work streams are available on our website (www.scottishpatientsafetyprogramme.scot.nhs.uk/ ). These three workstreams are as follows.

● Safety Culture: improving patient safety through the use of trigger tools (structured case note reviews) and safety climate surveys.

Stage Area Timeframe

Stage 1 General Medical Services Programme Launch March 2013

Stage 2 Pharmacy and Nursing Prototyping and testing from late 2014

Stage 3 Expanding to other areas, for example, Dentistry and Optometry

Exploratory work late 2014

http://www.scottishpatientsafetyprogramme.scot.nhs.uk/




● Safer Medicines: including the prescribing and monitoring of high risk medications, such as warfarin and disease-modifying anti-rheumatic drugs (DMARDs), and developing reliable systems for medication reconciliation in the community.

● Safety Across the Interface: by focusing on developing reliable systems for handling written and electronic communication and implementing measures to ensure reliable care for patients.

The driver diagrams developed clearly indicate that following the initial year of implementation, new elements of focus would be introduced to the programme. As the driver diagrams were devised in the programme‟s development stages, it was recognised that areas of priority may have changed. It was, therefore, agreed to undertake a scoping exercise to assess the current causes of harm and interventions, to ensure the programme remains focused on the areas of greatest priority and relevance to NHSScotland.

The national team commissioned a scoping exercise between April and July 2014.This report aims to support the delivery group to revise the existing driver diagrams, and agree areas of future focus.

This scoping document excludes harm or interventions within community dentistry and

optometry.




2. Method

To ensure SPSP-PC focuses on the most relevant topics, the scoping exercise involved

gathering and analysing large amounts of evidence-based research using a variety of

methods, as listed below.

● We conducted a literature review. This identified all research published after the 2011 Health

Foundation Evidence Scan: Levels of Harm in Primary Care1.

● We reviewed information from a number of sources. This included medical and defence

unions, clinical risk assessment and claims data, as well as data from primary care

significant event analysis (SEA) and trigger tool review, and

● discussions with experts across the NHS.

This information was then analysed, and prioritised. We also sense-checked our findings with

colleagues in NHS Education for Scotland (NES), the Manchester University Safety Research

Centre, and the University of Dundee. Following the information gathering period, the national

team gathered the views of the wider primary care community to ratify the findings, and explore

any further areas of priority for SPSP-PC to address. This took the form of an online survey,

conducted between 23 June and 11 July 2014. The aim of the survey was to establish which

areas of harm frontline staff considered as priorities. The survey asked participants to rate each

of the high risk areas (noted below) on a scale of 1 to 5 (where 1 was „low‟ and 5 was „high‟).

High risk areas

1. reducing diagnostic error

2. ensuring safe and reliable results handling

3. prevention of catheter acquired urinary tract infections (CAUTI)

4. reducing high risk prescribing

5. ensuring reliability of safety critical processes (for example, availability of in-date

emergency drugs or appropriate storage of vaccines)

6. Prevention of pressure sores

We also asked participants if there was another area, or areas, where they would like

support from the national SPSP-PC team.

The survey was completed by 290 participants, 70% of whom work in general medical

services.

Participants highlighted that the areas of focus identified by the literature review were

important for front line staff. With 91% considering safe results handling as the most

important area of focus for the programme. Prevention of CAUTI by 70% and pressure sores

66% scored lower than the other areas, but this may be due to the fact that there were fewer

respondents from a community nursing setting.




Participants suggested a number of other areas they considered important for the

programme. The most common themes were:

communication between acute and primary care

the integration of IT systems across Scotland

medicines reconciliation and communication between general practice and

community mental health teams

management of patients in their homes, and

more timely integration with other SPSP strands, for example medicines

reconciliation in acute settings, would allow for shared dialogue and more

opportunity to improve processes.




3. Overview

The Health Foundation‟s 2011 Evidence Scan1: highlighted the following sources of harm:

● communication within primary care teams

● the interface between primary and secondary care

● medicines management, and

● diagnostic tests and prescribing.

The current SPSP-PC workstreams are addressing the first three of these areas of harm. Our

recent scoping exercise has reinforced these areas as continuing causes of harm in primary

care and, in addition, highlighted the following.

● High risk prescribing (co-prescribing with other drugs or with co-morbidities causing harm).

● Diagnostic error leading to delayed diagnosis.

● Unreliable systems for handling test results.

● Inadequacies in practice administrative systems.

● Catheter associated urinary tract infections (CAUTI), and

● pressure ulcer prevention.




4. Reducing Avoidable Harm from Medication

4.1 Evidence of harm

The evidence review published by the Health Foundation1 in November 2011 found medicines management as a key area associated with patient harm in primary care.

In 2012, Avery et al2 found prescribing or monitoring errors in 1 in 8 patients and around 1 in 20 of all prescription items. A serious error was found in 1 in 550 prescriptions. Serious errors were often associated with high risk drugs which require monitoring, such as warfarin and methotrexate. There are already SPSP-PC care bundles in place for these.

Previous systematic reviews have shown that 4.9 – 7.7% of admissions are related to

adverse drug events. Deaths from adverse drug events are most often associated with non-

steroidal anti-inflammatory drugs (NSAIDs) and prescribing of anti-platelets3 and a median of

4.3% of admissions are considered to be drug-related and preventable4

When these preventable drug-related admissions were broken down by type of underlying problem, adverse drug reactions and over-treatment were most commonly associated with anti-platelets, diuretics and NSAIDs. Under-treatment problems were more commonly associated with anti-epileptics, whereas patient adherence problems were identified with diuretics, and drugs used to control diabetes and anti-epileptics. 5

A systematic review6 of the drugs that cause preventable admission to hospital estimated that the median percentage of preventable drug-related admissions to hospital was 3.7%. The majority (51%) of preventable, drug-related admissions involved either anti-platelets, diuretics, NSAIDS or anticoagulants. Another 5 classes of drugs accounted for a further 29% of these admissions. These included opioids, BetaBlockers, ace inhibitors, diabetic drugs and steroids. The review concluded that concentrating interventions on these drug groups could reduce the number of preventable drug-related admissions to hospital from primary care.

Polypharmacy has been defined as people taking five or more drugs. In 2010, in Scotland,

almost half of older people (over 75 years of age) were dispensed five or more drugs, with 1

in 5 dispensed 10 or more drugs7. Polypharmacy is associated with increased adverse drug

events and preventable admissions to hospital8

A Scottish study involving 315 practices across groups of vulnerable patients (defined by

age, co-morbidity or co-prescription) found that:

● 13.9% of patients studied had received at least one high risk prescription in the past year

● 19.7% of patients prescribed warfarin had received a high risk prescription, and

● 18.2% of patients with heart failure had been prescribed a drug which was contraindicated or

to be avoided.9

From the evidence it is, therefore, clear that:

● medication continues to cause significant preventable harm

● a number of drugs are particularly associated with harm sufficient to cause admissions

● patients with multiple morbidities and therefore multiple medications are at highest risk, and




● concentrating interventions on these drug groups and patients could reduce appreciably the number of preventable drug-related admissions to hospital from primary care.

4.2 Interventions to reduce medication related harms and inappropriate prescribing

4.2.1 Prescribing Safety Indicators

Prescribing safety indicators have been developed to identify patients who are at risk of

particular harm through drug interactions or interaction between drugs and a patient‟s

medical condition. They are statements that describe prescribing events that can put patients

at risk of harm. GPs use these statements to audit or analyse clinical records, conduct

focused work to make their care safer, thereby reducing the potential for harm in patients.

A Scottish study10 developed a set of assessment criteria for the quality and safety of

medicines commonly used in primary care, with the aim of using them to identify high risk

medication use from electronic medical records. Eleven of these criteria were classified as

high priorities as outlined in the table below. Panelists included pharmacists and GPs.

Table 2: Medication topics identified as high priority for improvement in primary care

Quality criteria Safety criteria

Not using inhaled corticosteroids in patients with uncontrolled asthma

Using MTX without taking precautionary action to prevent patient overdosing

Not using oral anticoagulants in patients with AF and high risk of stroke

Not using gastro-protection in oral NSAIDs/antiplatelets users at high risk of bleeding

Not using ACEIs or ARBs in patients with a history of chronic heart failure

Using oral NSAIDs in patients at increased risk of renal failure

Not using thrombo-embolic prophylaxis in AF patients at low/moderate risk of stroke

Inconsistent monitoring of FBC in patients on DMARDs

Not using ACEIs or ARBs in patients with DM and renal complications

Not using beta blockers in patients with a history of chronic heart failure

Not using metformin as first line antidiabetic in overweight type 2 diabetics

ACEI: Angiotensin converting enzyme inhibitor; AF: Atrial fibrillation; ARB: Angiotensin receptor blocker; DM: Diabetes mellitus; DMARD: Disease modifying antirheumatic drug; FBC: Full blood count; MTX: Methotrexate; NSAID: Non-steroidal anti-inflammatory drug (includes non-selective and COXII selective agents unless stated otherwise)

In 2014, this work was superceded by Spencer et al11 who reviewed the literature relating to

patient safety indicators. From an initial list of over 600, 56 were considered suitable

indicators, with 23 of these, posing either a high or extreme risk of harm. The indicators fall

into 3 categories:

● high risk prescribing with another drug

● high risk prescribing associated with a particular condition, and

● high risk drugs that require monitoring.




A panel of GPs considered six of these posed extreme risk, as indicated in the table below.

Table 3: Prescribing indicators associated with extreme risk of harm

1. Metformin prescribed to a patient with renal impairment where the eGFR is ≤30ml/min

2. Prescription of an NSAID, without co-prescription of an ulcer-healing drug, to a patient with a history of peptic ulceration

3. Prescription of an NSAID in a patient with chronic renal failure with an eGFR <45

4. Concurrent use of warfarin and any antibiotic without monitoring the INR within 5 days

5. Prescription of a penicillin-containing preparation to a patient with a history of allergy to penicillin

6. Prescription of warfarin to a patient without a record of INR having been measured within the previous 12 weeks (excluding patients who self-monitor)

*eGFR: estimated glomular filtration rate; INR International Normalised Ratio; NSAID: Non-steroidal anti-inflammatory drug

4.2.2 How can patient safety indicators be used?

Guthrie et al12 are undertaking a study in Scotland involving six high-risk prescribing

indicators as indicated in table 2.3. Interventions have been designed and are being tested to

reduce high risk prescribing in these areas.

Table 4: High risk prescribing indicators

1. Oral antipsychotic prescription to a patient aged 75 years and over (as a proxy of oral antipsychotic prescribing to older people with dementia).

2. Oral non-steroidal anti-inflammatory drug (NSAID) prescription to a patient aged 65 years and over who is currently prescribed a diuretic and an ACE inhibitor or Angiotensin Receptor Blocker (the ‘triple whammy’).

3. Oral NSAID prescription to a patient aged 75 years and over, but who is not currently prescribed a gastroprotective drug.

4. Oral NSAID prescription to a patient aged 65 years and over who is currently prescribed either aspirin or clopidogrel, but who is not currently prescribed a gastroprotective drug.

5. Oral NSAID prescription to a patient currently prescribed an oral anticoagulant but who is not currently prescribed a gastroprotective drug.

6. Aspirin or clopidogrel prescription to a patient currently prescribed an oral anticoagulant, but who is not currently prescribed a gastroprotective drug.

At least two health boards (NHS Forth Valley and NHS Highland)13 have undertaken work to

look at reducing high risk prescribing. The NHS Forth Valley work involved 55 GP practices,

whereas in NHS Highland, the project involved 16 GP practices and a pharmacist.

NHS Forth Valley Results (after 9 months) ● 31% reduction in the number of patients aged ≥ 65 years on triple whammy combination.

(ACE/ARB + diuretic + NSAID)

● 33% reduction in the number of patients aged ≥ 65 years prescribed an NSAID without gastroprotection

● 55% reduction in the number of anticoagulant users prescribed an NSAID without gastroprotection.

This demonstrates how relatively simple interventions can have a significant impact on high risk prescribing.




4.2.3 Never Events

„Never events‟ are described as a serious, largely preventable patient safety incident that should not occur if the available preventable measures were implemented by healthcare workers14. They are preventable, detectable and measurable. Preventing never events reduces harm, and they have been used successfully in secondary care. In the paper Developing a preliminary „never event‟ list for general practice using consensus-building methods15 the authors identified a number of never events associated with prescribing. However, as plans to test never events as a method of reducing harm in primary care are still

being developed, it is too soon to consider their inclusion in SPSP-PC.

4.3 Conclusions

4.3.1 Prescribing Safety Indicators

It is recommended that Healthcare Improvement Scotland considers the following.

● Using prescribing safety indicators, to focus on high risk prescribing in high risk patients and

to reduce harm to patients. Implementing these PSI approaches would be simple, cheap and

effective.

● Supporting the testing of different indicators and approaches with interested NHS boards.

This work will complement the work of the pharmacy collaborative.

4.3.2 Never Events

It is recommended that Healthcare Improvement Scotland awaits the outcome of the

development of the NHS Education for Scotland interventions to mitigate against these

events, before committing to introduce these to SPSP-PC




5. Diagnostic Error


The overall diagnostic error rate in inpatients admitted to hospital from primary care range from 2-4%16. The majority of errors are caused by incomplete history taking and clinical examination. Diagnostic error is also the most common reason for medico-legal claims against GP‟s17 18. A recent study combining estimates of error from three studies yielded a rate of outpatient diagnostic errors of 5.08%, or approximately 12 million US adults every year. Based upon previous work, the authors estimate that approximately half of these errors could potentially be harmful19. A recent review described five features of diagnostic difficulty. These are:

1. atypical presentations 2. non specific presentations 3. very low prevalence 4. presence of co-morbidity, and 5. perceptual features20 which made diagnostic error more likely.

A US study across two practice sites used trigger tools to identify diagnostic error21. This identified 190 unique instances of diagnostic error22. The most commonly missed diagnoses identified retrospectively were pneumonia, decompensated congestive heart failure, acute renal failure, primary cancer and urinary tract infection (UTI) or pyelonephritis (a serious form of kidney infection). Cough was the chief presenting symptom in 12.1% of cases with diagnostic error, with abdominal pain presenting as the second most common symptom (8.9% of cases.)

In the majority of cases identified, the potential severity of injury associated with the delayed or missed diagnosis was rated as moderate to severe, although the study authors acknowledge this is likely to be influenced by the means of error identification. Documentation of adequate exploration and investigation of the chief presenting symptom was lacking in 48.9% of cases. Within the patient / practitioner encounter there were:

problems associated with failing to order further diagnostic tests (in 57.4% of cases)

error relating to medical history (in 56.3% of cases), and

errors relating to physician examination performance (in 47.4% of cases).

A US study of delays in cancer diagnosis identified 167 cases of colorectal cancer and 92 cases of lung cancer23. Errors (defined as lack of timely action) were identified in 33.5% of colorectal cancer cases and in 32.6% of lung cancer cases.




5.2 Interventions to reduce diagnostic error

Interventions or tools to improve patient safety relating to clinical complexity have mainly focused on prescribing medications and not specifically on preventing misdiagnosis. In addition, tools or systems tend to focus on improving the quality of patient care or reducing harm rather than focusing specifically on reducing misdiagnosis.

According to the Kings Fund22 there is some evidence that a range of improvement techniques can be successful in promoting the quality of diagnosis. These include:

● education and training

● the provision of decision-support tools

● improving access to testing technologies and providing feedback on over-testing

● interventions focusing on individual and practice level reflection, and

● interventions to improve systems and processes of follow-up.

The following tools, processes or systems are aimed at reducing misdiagnosis or improving the

quality of diagnosis.

● Primary care trigger tool - The primary care trigger tool already used in SPSP- PC can

potentially highlight diagnostic error and lead to improvement.

● Significant Event Analysis has been used to identify learning points for individuals within the

practice where they occurred. In one study24) reviewing SEAs in Scotland, 24%related to

missed or delayed diagnosis or disease management

● An enhanced form of SEA has been developed and tested by NES with support from the

Health Foundation. The enhanced SEA takes a human factors system-based approach to

gain a more constructive understanding of how and why events happen. This may prove to

be an improvement on previous approaches to analyse and reduce diagnostic error.

According to the Kings Fund25 GP‟s are more likely to make a misdiagnosis of acute illness

compared to non-acute illness. The most commonly missed diagnoses identified retrospectively

by Singh et al in the aforementioned study22 included three significant infections; pneumonia,

urinary tract infection and pyelonephritis. These can lead to sepsis, a common and potentially

life-threatening condition triggered by an infection. If not treated quickly, sepsis can eventually

lead to multiple organ failure and death.

A review quantifying mortality associated with sepsis in England between 2001 and 2010

concluded that 5.1% of deaths in England were definitely associated with sepsis. Adding those

that may be associated with sepsis increases this figure to 7.7% of all deaths26. Each year in the

UK, it is estimated that more than 100,000 people are admitted to hospital with sepsis and

around 37,000 people will die as a result of the condition27.

Early detection and management of patients with sepsis in hospitals is a priority for

NHSScotland. A workstream within the SPSP acute programme and a range of interventions

and measures have been developed and implemented within hospitals across Scotland.




The Scottish Ambulance Service is testing the use of the systemic inflammatory response

system (SIRS) assessment tool to identify sepsis as a possible cause of illness in patients who

will then require rapid assessment and transport to hospital. The same SIRS tool could

potentially be used in primary care by GPs and Nurse Practitioners in GP practices and out-of-

hours services to identify patients at risk of sepsis to ensure they are transported to hospital as a

matter of urgency and are then given appropriate treatment on admission.

5.3 Conclusions

It is recommended that Healthcare Improvement Scotland:

● promotes the use of the trigger tool to identify and reduce diagnostic error

● promotes the use of the enhanced SEA for the analysis and prevention of diagnostic error,

and

considers testing the SIRS assessment tool to identify patients with sepsis within out-of-

hours services and GP practices.




6. Results Handling

6.1 Evidence of Harm

The World Health Organisation (WHO) identified poor test follow-up as a major cause of

harm to patients. This can result in serious lapses in patient care, delays to treatment, and

litigation28 29 30 1. The reliability of formal tracking systems to oversee the management of

laboratory test ordering and results handling is problematic and a significant source of error

in primary care settings worldwide24. For patients and their relatives this may have multiple

consequences in terms of:

● contributing to avoidable harm and unnecessary distress

● sub-optimal clinical management of illness and delayed treatments

● poor experience of, and dissatisfaction, with care

● miscommunication of tests results by health care staff and

● the inconvenience of return appointments, repeating blood tests or making formal

complaints31 32 33.

One study34 described the types, predictors and outcomes of testing errors reported in US

primary care. Errors occurred in; general administration (18%), ordering tests (13%),

implementing tests (18%), reporting results to clinicians (25%), clinicians responding to

results (7%), notifying patient of results (7%), communication (6%) and other categories

(8%). Charting or filing errors accounted for 15% of errors.

In a review of significant events analysed in general practice, 20% of events related to results

handling systems.24

Medical Protection Society (MPS) claims and practice risk assessments consistently identify

results handling as a key area of risk. In a recent report of Clinical Risk Self Assessments

conducted by the MPS in more than 150 practices throughout the UK and Ireland in 2013,35

over 80% of practices were assessed as having significant risk associated with test results.

6.2 Interventions to reduce harm from unreliable results handling systems

No formal research was identified from the literature review about how care in this area can

be made safer, although SEAs have been used as an improvement method. Initial testing of

a results handling bundle was carried out as part of SIPC2 by NHS Borders. Subsequent

research carried out by NES highlighted further areas for a focused testing of a broader

change package.

Since September 2013, seven practices in NHS Greater Glasgow and Clyde have been

testing tools and approaches that have highlighted areas for improvement and change.




These tools include:

● a process measure bundle

● educational materials for learning sets

● self-assessment questions on practice results systems

● a patient experience questionnaire, and

● resources for patients and clinicians.

6.3 Conclusions

It is recommended that Healthcare Improvement Scotland supports further testing of the

results handling interventions to ensure that:

the change package is suitable for NHS boards using both electronic and paper

based systems

practices reconcile blood tests ordered and received, and

patient experience is used to improve practice systems.




7. System Issues


In the 2011 evidence scan, the Health Foundation identified a number of studies suggesting

that systems or organisational issues are major contributors to harm in primary care1.They

concluded that system failures and process issues which may contribute to patient harm

include:

● inadequate systems for managing test results

● prescribing systems

● poor communication between professionals and patients

● fragmented reporting systems and inadequate systems to share information about errors, which hamper analysis of causes and improvement strategies

● environment and design factors, and

● infrastructure failure.

A separate review mapped out the medication systems in UK primary care. Several stages

of the prescribing process had error rates of 50% or more. This includes repeat prescribing

reviews, interface prescribing and communication, and patient adherence36. Based on

clinical risk self assessments conducted by the Medical Protection Society37, prescribing

continues to be one of the top five risks in general practice. Data from assessments

conducted in 2013 revealed that 95.4% of practices visited had risks relating to the

prescribing system. Common examples include uncollected prescriptions (53%), repeat

prescribing systems (49%), and administrative staff changing medications on the computer

(27%).

In the scoping work for the development of a never event list for general practice15

, NES reviewed the literature to identify key threats to patient in primary care settings with previously comprehensive evidence based summaries. The authors developed a preliminary list of never events some of which related to practice organisation, administration and record keeping. For example:

● a planned referral of a patient prompted by clinical suspicion of cancer is not sent

● a needle stick injury caused by a failure to dispose of sharps in compliance with national guidance and regulations, and

● adrenaline is not available when clinically indicated for a medical emergency in the practice.

A review of SEAs38 from general practice found that:

8% related to administrative issues

7.9% to medical records and confidentiality

6.3% to appointments and surgeries, and

3.7% to equipment failures.




7.2 Interventions to reduce harm from failures in practice systems

The following tools are aimed at identifying, analysing and preventing system issues which

may cause harm to patients

● SPSP-PC already promotes the use of the primary care trigger tool to reduce system issues and lead to improvement.

● The enhanced SEA mentioned in the section on diagnostic error was developed and tested by NES with support from the Health Foundation. The enhanced SEA takes a human factors system-based approach to gain a more constructive understanding of how and why events happen. It may prove to be an improvement on previous approaches to analyse and reduce system failures.

● NES is currently developing a Safety Checklist to ensure safety critical processes and carried out reliably.

● Productive General Practice39 supports practices to review their repeat prescribing systems to make them safer and more reliable. The impact of this approach on safety and harm has not yet been evaluated

7.3 Conclusions


● continues to promote the use of the trigger tool to identify and reduce harm from system failures

● promotes the use of the enhanced SEA to analyse and prevent harm from system issues, and

● learns from the development and testing of the NES safety checklist before considering its inclusion in the SPSP-PC suite of resources.




8. Catheter Associated Urinary Tract Infections (CAUTI)


Long-term urinary catheterisation is used for older people and others, where alternative

treatments for bladder dysfunction are inappropriate or unsuccessful. However,

catheterisation is associated with clear risks, the most common being catheter-associated

urinary tract infection (CAUTI). CAUTIs are widely recognised as a major source of

healthcare-associated infections (HAIs)40 41.The frequency of catheter use produces

substantial overall morbidity for patients and costs to healthcare services42, often including

unnecessary antibiotic therapy, which may then become a major source of antibiotic

resistant pathogens.

Much less is known about the prevalence of CAUTIs and other HAIs in primary and community care settings43 or about the potential for reduction in CAUTI44. Long-term catheterised patients make up around 4% of a district nurse‟s caseload in the UK45. The prevalence of catheterised patients in nursing homes has been estimated to be around 9%46 but may be up to 40% or more in some places47. In one study, the prevalence of CAUTI in community-based, catheterised patients, during October 2004, was 8.5%48. A primary course of antibiotics was prescribed in 54.5% of cases.

During July 2010, as part of Healthcare Associated Infection Long Term Care Facilities (HALT) project, a European HAI prevalence study was carried out across 28 countries in volunteer care homes. Health Protection Scotland (HPS) coordinated the contribution across Scotland. A total of 4870 residents from 83 care homes across Scotland were surveyed. The results indicate that within the surveyed care homes 2.6% of residents had an HAI at the time of survey. The prevalence of HAI by care home ranged from 0% to 13.5%. The most common infection types were urinary tract (52.7%)49.

Following a recent summit, HPS concluded that there was consensus that urinary tract

infections, and CAUTI, in particular, should be the next area of HAI patient safety focus.

8.2 Interventions to reduce harm from CAUTI

The NICE guideline50 on infection prevention and control of healthcare-associated infections in primary and community care provides recommendations on aspects of care associated with long term urinary catheters.

In 2012, HPS and NHS National Services Scotland (NSS) carried out a targeted literature review to identify the key infection prevention and control recommendations to inform a urinary catheter insertion quality improvement tool. It concluded that the key intervention to minimise CAUTI is to avoid inserting a catheter but, if required, then precautions must be taken. This informed the development of care bundles for the insertion and maintenance of catheters to prevent the development of CAUTIs, and have been used in the Acute Adult programme since 2013.




In January 2014, HPS carried out an evidence review of preventing catheter associated infections in community settings and developed guidelines and care bundles for the insertion and maintenance of catheters to prevent CAUTI in a community setting.

From our SPSP-PC site visits, we know that a number of health boards, including NHS Fife, NHS Western Isles and NHS Greater Glasgow and Clyde have begun to undertake pilot work with CAUTI bundles for use in community settings. At this stage it is unclear whether they have adapted the SPSP acute bundles or are using the HPS community setting guidance and bundles.

8.3 Conclusions


● includes the prevention and appropriate treatment of CAUTI in the community in SPSP-PC

● works with key contacts and stakeholders to determine ongoing work in this area, and

● develops change packages to support the implementation of this work in community settings.




9 Pressure Ulcers


Immobility and illness are the key risk factors for developing pressure ulcers. An

observational study conducted in the North of England in 2010 focused on two study sites,

each with an adult population of around 250,00051. Different methods of case finding were

applied to estimate the prevalence of pressure ulcers in adults in the community. Healthcare

settings included patients‟ own home, residential homes, rehabilitation units, palliative care

units and nursing homes. Prevalence at site one (an urban area) was 0.77 patients

assessed as having at least one pressure ulcer per 1,000 of the adult population. At site two

(a mainly rural area) the corresponding figure was 0.40. When nursing home patients were

excluded from the analyses, the prevalence for the two sites was similar at, 0.38 and 0.39

per 1,000 population respectively.

9.2 Interventions to reduce harm from pressure ulcers

The NICE guideline on prevention and management of pressure ulcers examined the clinical

and cost effectiveness of risk assessment tools in the prevention of pressure ulcers

The guideline recommends that healthcare professionals should:

● be aware that all patients are potentially at risk of developing a pressure ulcer

● carry out and document an assessment of pressure ulcer risk for adults if they have a risk factor, using a validated tool

● ensure that adults at high risk of developing a pressure ulcer are assessed by a trained healthcare professional.

● encourage adults at risk of pressure ulcer to reposition themselves (with assistance if required) every four to six hours

● ensure that people assessed as at high risk of developing pressure ulcers have a high specification foam mattresses, and consider a high-specification foam or equivalent pressure redistributing cushion for adults who use a wheelchair or who sit for prolonged periods.

The national tissue viability programme hosted by Healthcare Improvement Scotland

developed a series of tools to help recognise and measure the prevalence of pressure

ulcers. In the second and third phase of the programme the emphasis shifted to prevention

of pressure ulcers with the development and testing of a change package adapted from the

1000 lives campaign in Wales52. Since 2012, the SPSP acute adult programme has been

implementing this change package.

The Leading Better Care programme supported by Scottish Government developed three

key Clinical Quality Indicators (CQI), one of which was pressure ulcers. This recognises that

pressure ulcer reduction is an indicator of care quality in any health or care setting53.




An adapted form of the pressure ulcer change package has been tested by District Nurses in

NHS Greater Glasgow and Clyde. If further testing work is evaluated positively it could

potentially be a useful resource for community nurses taking part in the Leading Better Care

programme, as well as an intervention that could be implemented more broadly in care

homes and by District Nurses.

9.3 Conclusions


● considers further testing of a pressure ulcer prevention change package in community settings. For example, for patients in care homes or being looked after by District Nurses.




10. Falls


Around a third of community dwelling adults aged over 65 will fall each year and around 10% of falls result in a fracture54. Risk factors for falls include; history of prior fall(s), mobility or balance problems, cognitive impairment, continence problems, visual impairment and conditions such as arthritis, cardiovascular disease and dementia. Multifactorial risk assessment is used to determine individual risk based on combining such factors with environmental safety aspects e.g. home hazards. NICE recommends that older people who present for medical attention because of a fall, or report recurrent falls in the past year, or demonstrate abnormalities of gait and/or balance should be offered a multifactorial falls risk assessment. This assessment should be performed by a healthcare professional with appropriate skills and experience, normally in the setting of a specialist falls service. This assessment should be part of an individualised, multifactorial intervention.

10.2 Interventions to reduce harm from falls

A Scottish draft strategy document „The Prevention and Management of Falls in the Community: A Framework for Action for Scotland 2014/2015‟ is under consultation until 16 June 2014 and available at: http://www.scotland.gov.uk/Publications/2014/04/2038

A Cochrane review of randomised controlled trials of interventions for prevention of falls in people aged over 60 living in the community included 159 trials identified up to February 2012.55 Outcomes were rate of falls (e.g. falls per person year), risk of falls (number of fallers in each group) and number of people sustaining a fracture. Single and multi-component interventions were examined. Table 5 summarises results of the meta-analysis.

Group and individual exercise programmes with a variety of exercise goals were effective in reducing rate of falls and risk of falls and also reduced the risk of sustaining a fracture.

Multifactorial interventions reduced the rate of falls but not risk of falling or risk of sustaining a fracture.

Vitamin D supplementation did not reduce the rate of falls or the risk of falling. Subgroup analysis indicated that the intervention may be effective for participants with vitamin D insufficiency.

Home safety interventions reduced rate of falls and risk of falling. In subgroup analysis the interventions were more effective in participants who were at higher risk of falling and in trials where the interventions were delivered by occupational therapists.

In trials of patient education interventions there was no reduction in rate of falls or risk of falling.

In one study, interventions to improve vision in participants aged over 70 increased both the rate of falls and the risk of falling.

http://www.scotland.gov.uk/Publications/2014/04/2038




Table 5: Key findings from Cochrane meta-analysis on falls prevention

Intervention

Rate of falls, rate ratio (95% CI)/number of trials

Relative risk of falling (95% CI) /number of trials

Relative risk of fracture (95% CI) /number of trials

Group exercise interventions focusing on two or more components of physical activity e.g. strength, endurance, flexibility, balance

0.71 ( 0.63-0.82)/16 0.85 ( 0.76- 0.96)/22

0.34 (0.18- 0.63)/6 Individual exercises at home focusing on two or more components of physical activity e.g. strength, endurance, flexibility, balance

0.68 (0.58- 0.80)/7 0.78 (0.64 - 0.94)/6

Mulitfactorial interventions, where participants receive combinations of interventions according to individual assessment of potential risk factors for falling

0.76 (0.67- 0.86)/19 0.93 (0.86-1.02)/34 0.84 (0.67-1.05)/11

Vitamin D supplementation 1.00 (0.90-1.11)/7 0.96 ( 0.89 - 1.03)/13 0.94 (0.82- 1.09)/10

Home safety assessment and modification

0.81 (0.68- 0.97)/6 0.88 ( 0.80, 0.96)/7 1.32 (0.30, 5.87)/1

Patient education 0.33 (0.09- 1.20)/1 0.88 (0.75-1.03)/4

Vision improvement 1.57 ( 1.19-2.06)/1 1.54 ( 1.24- 1.91)/1 1.73 ( 0.96-3.12)/1

Psychotropic medication withdrawal

0.34 (0.16-0.73)/1 0.61 (0.32-1.17)/1

Medication review and modification

1.01 (0.81 - 1.25)/1 0.61 (0.41-0.91)/1

Cognitive behavioural intervention

1.00(0.37-2.72)/1 1.11 (0.80-1.54)/2

Anti-slip shoe for icy conditions

0.42 (0.22-0.78)/1

Balance enhancing insoles 0.56 (0.23-1.38)/1

A systematic review of interventions for falls prevention for older people in long term care facilities such as residential and nursing homes identified 20 trials (to April 2009) with inconsistent results56. Meta-analysis was not undertaken due to the heterogeneity of the interventions and patient populations. Interventions included hip protectors, vitamin D supplementation, medication review, podiatry and vision support. Both this review and a review of studies on implementation of falls prevention interventions in community dwelling older people57 describe barriers to implementation of falls prevention interventions and strategies including; time constraints, lack of knowledge and skills and resource issues.

10.3 Conclusions


● considers further testing of a falls prevention change package in community settings.




11. Recommendations

Decisions about future areas of focus, including prioritisation, should take into account the

following.

Effectively sustaining the current programme by continuing to address topics of value

to frontline staff.

Spread to other primary care settings and professional groups with both the interest

and capacity to work in partnership with Healthcare Improvement Scotland,

Capacity within the Health Boards and the SPSP-PC team in Healthcare

Improvement Scotland to effectively support programme activities

The following interventions were identified as having the potential for success with the

national programme. However, consideration needs to be given to the SPSP-PC team‟s

capacity to support future developments, particularly where further testing may be required.

The table below summarises key areas of harm, interventions and recommendations for

development work required.

Table 6: Areas of harm, interventions and recommendations

Area of harm Interventions Key Recommendations

High Risk Prescribing

Prescribing Safety Indicators

Support testing interventions to ensure reliable safe prescribing.

Test Results Handling

Change package (including measures/ guidance / resources)

Support further focussed testing of the results handling change package.

CAUTI

CAUTI Insertion and maintenance bundles measures and guidance

Support further testing of an appropriate CAUTI change package in community settings. Spread in collaboration with other initiatives.

Pressure Ulcers

Pressure Ulcer bundles, measures and guidance

Support further testing of an appropriate preventing pressure ulcer change package in community settings. Spread in collaboration with other initiatives.

Falls Prevention Falls Prevention Bundle Support further testing of an appropriate prevention change package in community settings. Spread in collaboration with other initiatives.

Diagnostic error

Sepsis SIRS assessment tool Enhanced SEA

Support testing the SIRS assessment tool to identify patients with sepsis within GP Practices and out-of-hours services. Promote the use of the enhanced SEA.

Practice administrative systems

Enhanced SEA Safety Critical Checklist

Promote the use of the enhanced SEA to analysing and prevent harm from system issues. Learn from the development and testing of the Safety Checklist by NES.




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