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St Luke’s General Hospital

Carlow-Kilkenny

Annual Report

2016

Pictured above is the first ambulance arriving at the newly opened Emergency

Department on the morning of the 25th

May 2016.

2 St Luke’s General Hospital Carlow-Kilkenny Annual Report 2016

Foreword

Yet again, 2016 proved to be a very busy year in St Luke’s General Hospital

Carlow-Kilkenny. As an organisation, we cared for 18,773 inpatients, with

an additional 9,527 patients being treated on a day case basis. The number of

people availing of our emergency services reached its highest at 48,105,

whilst we delivered 1,625 babies. We saw a further 45,606 outpatient

attendances.

Between November 2015 and May 2016, we were fortunate to open our €21

million hospital development, which consisted of a new Emergency

Department, an Acute Medical Assessment Unit, an Acute Surgical

Assessment Unit, a Hepatology Department, an Oncology Day Ward, the

Susie Long Day Services Unit (including Endoscopy), the Dr Jim Mahon

Library and Education Centre, our Porter/Security Hub and a new

concourse, complete with Admissions desk, Reception and Switch Board

and a Coffee Shop. 2016 also saw the opening of our first shop on site.

This development has greatly enhanced the way in which we deliver our

services. I wish to thank patients, staff and visitors for their co-operation

during the construction phase.

As you will see from this Annual Report, each department is working to

meet the increasing demands on our services, whilst also providing quality,

patient centred care, which meets the needs of the population we serve.

Anne Slattery

General Manager


List of Contents

Item Page

Foreword 2

Introduction 4

Health and Safety 7

Freedom of Information/Data Protection/Patient Liaison

Office

9

Dr Jim Mahon Library and Education Centre 11

Supplies 14

Pharmacy 15

Dietetics 18

Cardiac Diagnostics 19

Laboratory 21

Physiotherapy 25

New Emergency Department Photos 28

Surgical Directorate 29

New AMAU and Oncology Department Photos 35

Medical Directorate 36

Maternity 38

Respiratory 39

Diabetes Nurse Department 41

Tissue Viability 42

Haemovigilance 43

Oncology Day Ward 45

Hepatology 48

Hygiene Services 49

Arts 54

Clinical Risk Management 55

The Year in Photos 57


Introduction

St. Luke’s General Hospital Carlow-Kilkenny is the Acute General Hospital for Counties

Carlow and Kilkenny. Since January 2015, it is one of the 11 hospitals in the Ireland East

Hospital Group. The population of Kilkenny/Carlow Community Care area is 155,993

(Census 2016) which represents an overall increase of 4% since the 2011 census when

the population was 150,031. Due to its location in the heart of the South East, St. Luke’s

General Hospital in addition to the counties of Carlow and Kilkenny, also provides

services to its bordering counties: Tipperary North and South, Waterford, Wexford,

Kildare and Laois.

In addition to the acute services that are provided on site at St. Luke’s, outreach services

are also provided in Kilcreene, Carlow, Thomastown and Castlecomer. The hospital has

303 beds with a Net Expenditure in 2016 of €64.5 million

The Clinical Directorate model of governance has been in place in St. Luke’s Hospital

since 2003. It previously comprised of a Medical Directorate and a Surgical Directorate.

Since the commencement of the new Consultant Contract (2008), the sole Clinical

Director leads both directorates which consist of Nurse Manager representatives, Health

and Social Care Representatives and the Business Manager. The Quality and Safety

Executive Committee meets monthly and is chaired by Dr. Paul Cotter, Consultant

Geriatrician.

Net Expenditure 2015: St. Lukes General Hospital = €59.924 million

Net Expenditure 2016: St. Luke’s General Hospital = €64.476 million

In Patient Specialty

In Patient Bed Complement

Medical 1

Acute Stroke Unit

Medical 2

CCU

Surgical 1

SMU (Surgical Medical Unit)

Surgical 2

ICU

Surgical 3

22

5

31

6

29

14

31

4

14

Obstetrics 29

Acute Psychiatry 44

Paediatrics 19

SCBU 5

Total 253


Specialty Day Beds

Oncology

10

Surg/Med Day beds 24(16 currently open)

Paediatrics 1

Obstetric Assessment 4

Total 39

Staffing at St. Luke’s (31st

December 2016)

Staff category 31/12/2016

Medical/ Dental 137.15

Nursing 390.37

Health & Social Care Professionals 86.72

Management/ Admin 125.09

General Support Staff 188.15

Other Patient & Client Care 62.13

Total 989.61

Hospital Activity Data 2016 Inpatient discharges 18,773

Day cases 9,527 ED Attendances 48,105 Births 1,625 OPD Attendances 45,606


2015/2016 Developments:

The new ED/AMAU, Susie Long Day Services Unit (Surgical and Medical Day

Unit including colonoscopy etc,) Oncology Unit, Hepatology Unit, Education

Centre and Hospital Concourse

Approval of the MRI scanner (Design Team appointed)

Other recent service developments

Acute Stroke Thrombolysis Service

Early Pregnancy Assessment Unit and Paediatric Assessment Unit

NEWS and IMEWS and PEWS implemented

Purchase of 6 beds for palliative care patients by Susie Long Hospice Group

3000

3500

4000

4500

jan feb mar apr may jun jul aug sep oct nov dec

Emergency Presentations 2016 v 2015 v 2014

2016 2015 2014


Corporate Services- Health and Safety

1. 2016 Objectives:

It is the policy of St Luke’s Hospital Kilkenny to ensure the safety, health and welfare at

work of all employees, so far as is reasonably practicable. The Hospital is also

committed to ensuring that service users, contractors and members of the public are not

exposed to risks to their safety health and welfare.

In the calendar year 2016 the Health and Safety Committee of the hospital which

oversees the Safety Management Programme on behalf of all staff and service users alike

focused on a number of key areas namely:

a) Overseeing the provision of training with particular focus on manual handling

and violence and aggression training.

b) Ongoing analysis and monitoring of trends associated with incident reporting

c) Development of a Health And Safety Risk Register

d) Updating Departmental Risk Assessments

2. Key achievements/activity for 2016

2016 saw continued improved in the safety management culture in the hospital notably:

i. A 21% increase in the number of reportable incidents (145) in

2016 when compared with 2015 (114). 60% increase in lost time

accidents. 213 days lost due to working time accidents in 2016

compared with 85 in 2014

ii. Only 5% of all incidents in 2016 (5) were in reportable to the

Health and Safety Authority compared to 3% (3) in 2015. A

reportable incident is one where an employee is absent from work

for more than three days due to a work related accident.

Greater awareness of the need to report Health And Safety Incidents has as attributed

significantly to this increase mainly due to an increase in the amount of in house Health

and Safety Training that was provided in 2016.

A comprehensive breakdown of incidents reported is included in detailed below.

3. Audit

St Luke’s Hospital Kilkenny is scheduled for a visit by the HSE Audit Team in 2017.

In preparation for this department have undertaken a comprehensive review of the

Risk assessment Process and updated local records to comply with existing HSE

Policies/Guidelines.


4. Work Plan 2017

The Health and Safety Programme in 2017 will continue to focus on addressing the

ongoing training needs of staff. There will be a greater emphasis on establishing the

root cause of accidents /incidents in response to advice offered by the Health and

Safety Inspectorate in 2015. With a likely Health and Safety Audit scheduled for

some time in 2017 the emphasis will be on ensuring that the necessary audit

requirements are met.


Freedom of Information/Data Protection/Patient Liaison Office

HSE Your Service Your Say Compliments and Feedback/Complaints –Comparison 2015 - 2016

Received:

2015

Received:

2016

Compliments/Thanks

38

Compliments/Thanks

55

Complaints 134

complaints 165

Verbal 49 Verbal 43

Over 30 days:

2015: 21 responses took over 30 days to conclude - 13 contained clinical judgement/two were

finance.

2016: 146 responses(s) concluded within the 30 days

23 Feedback/complaint letters (s) took over the 30 days period and 20 of these contained

Clinical Judgment concerns. .

The feedback received in 2016 can be classified as having combinations of the following

categories within the correspondence/feedback received:

Categories of concerns raised in overall feedback:

Access Dignity

and

respect

Communica

tion and

information

Safe

effective

care

Clinical

judgement

Privacy Particip

ation

Finance Improv

ing

health

48 30 75 73 81 18 20 48 2


Categorized Under the HIQA Standards:

1. Person-Centred Care and Support

2. Effective Care and Support

3. Safe Care and Support

4. Communication and Information

5. Leadership, Governance and Management

6. Workforce

7. Use of Resources

8. Use of Information

99 76 42 47 2 2 4 7

Recommendations:

51 recommendations from heads of Departments – 35 implemented

Training in HSE Comments Compliments and Complaints Policy 2017 :

Liam Quirke, Regional Manager Consumer Affairs, provided staff training in

November 2016 and February 2017, and further training will take place in May

2017.

FREEDOM OF INFORMATION/ADMIN ACCESS/MEDICO LEGAL/DATA

PROTECTION

COMPARISON 2015 AND 2016

ST LUKE’S GENERAL HOSPITAL KILKENNY

Requests received 2015 2016

Freedom of Information 90 89

Admin Access 119 125

Medico Legal 236 281

Data Protection 9 23

Total 454 518


Dr. Jim Mahon Library and Education Centre

2016 Objectives:

a. Continuing development of the Dr. Jim Mahon Library and Education

Centre

b. Restructuring regional HSE library services into a consolidated national

structure

c. Continuing provision of core library services and resources to HSE staff

and students on clinical placement

The Library and Education Centre is located on level 3 of the new building and provides

library services and resources to all categories of hospital- and community-based staff.

The remit of our library service is to provide access for all healthcare practitioners to a

comprehensive range of evidence-based, up-to-date knowledge resources for the purposes

of:

research into specific clinical questions, conditions or treatments relevant to the

care of individual patients

keeping up to date with developments in a specific area of the health sciences, or

the professional literature of a given specialty

continuing professional education

Our services are intended to ensure that point-of-care decisions are informed by best

international evidence and that staff engaged in education or research have an available

knowledge resource, and assistance when they need it.

Library services are available to all HSE employees and to students on clinical

placement, and are easily accessible. The library website www.hselibrary.ie/southeast

is home to a comprehensive collection of online resources including e-journals, e-

books, databases, clinical practice guidelines, patient education handouts, and more.

Subject areas include: medicine and surgery; nursing and midwifery; allied health and

social care; health service administration and management. Resources may be accessed

24/7 via any Internet-enabled computer.

Core services available in the new library include:

Clinical Queries: our librarians are expertly trained in locating best quality

health information. We can carry out searches for you, or recommend how

best to find the information yourself. Click on the “Clinical Queries” tab at

www.hselibrary.ie/southeast to submit a question.

Training: we provide training on the use of all resources as well as a range

of printed help sheets and user guides, and online tutorials. Contact us for

assistance in getting the most out of the resources available to you.

Other Services: other services include access to a comprehensive range of

up-to-date and regularly reviewed clinical reference books; document

http://www.hselibrary.ie/southeast


supply from other Irish and international libraries; access to computer

facilities, to purchased electronic resources and the Internet; photocopying

and printing facilities; quiet study areas and research facilities.

The following resources are available:

Journals: 10,000 electronic journals available in HSE South East. Access to

current full-text content for many leading journals.

BioMed Central: Open access publisher of peer-reviewed medical research.

BMJ Journals: Online issues of BMJ and other journals by BMJ Publishing.

BMJ Learning: Short, interactive medical education modules to help build your

CME/CPD portfolio.

BNF and BNF for Children: Continually updated, practical guidance on

prescribing, dispensing and administering medicines.

Catalogue: HSE South East: Details of all books held in each of our libraries.

CINAHL: Core database: nursing, midwifery and 17 health and social care

disciplines.

Clinical Key: A medical e-library by Elsevier Science with all 500 Elsevier

medical journals, 1,000 medical reference books, 9,000 clinical procedure videos

… and more. Includes Lancet.

Cochrane Library: Core resource for evidence-based medicine with systematic

reviews of the effects of healthcare interventions.

eBooks Nursing Collection: 330 nursing ebooks: clinical guides, evidence-based

practice manuals and core reference texts.

Ebsco Discovery Service: A simple search box to search many of our online

resources simultaneously.

JAMA: Online issues of JAMA and other specialist journals by the American

Medical Association.

Lenus.ie: Online repository of Irish health research.

MEDLINE: Core database: medical sciences.

National Guideline Clearinghouse: Clinical practice guidelines from the US

Agency for Healthcare Research and Quality.

NICE: Clinical practice guidelines from the National Institute for Health and Care

Excellence in Britain.

NEJM: Online issues of NEJM.

Nursing Reference Centre: A point-of-care clinical reference tool: nursing and

midwifery.

Royal Marsden Manual: Clinical procedures relating to all aspects of nursing care.

SocINDEX: Core database: social sciences.

UpToDate: A point-of-care clinical reference tool to help answer clinical

questions and improve patient care.

Also available: several other large packages of ejournals, incl.: BioMedical Reference

Collection; Psychology and Behavioural Sciences Collection; and ejournals from Oxford

University Press, Sage, Taylor Francis and Wiley.


Key achievements/activity for 2016

Continuing development of Dr. Jim Mahon Library and Education Centre,

September 2015. Installation of videoconferencing facilities and

infrastructure

Coordination of literature reviews to support the National Cancer Control

Programme’s clinical guidelines in breast cancer, prostate cancer and

gestational trophoblastic disease

Consolidation of all regional library services into the National Health

Library and Knowledge Service

Continuing provision of core library services and resources to HSE staff

and students on clinical placement

Health and Safety

Departmental safety statement and risk assessments completed and continually reviewed.

Service user feedback and links with external agencies/services

Links with other agencies include:

o National Health Library and Knowledge Service

o Library Association of Ireland

o National Cancer Control Programme (NCCP) Guidelines Steering

Group

o HSE Non-Core Task Allocation Steering Group

o Evidence-Based Practice (EBP) Group, South East

o Waterford Institute of Technology (WIT) MSc. Steering Group

5. 2017 Key performance indicators and achievement projections/proposed new

developments

a. Completion of national restructuring of library services (Q3 2017)

b. Design and launch of new service website: www.hselibrary.ie.

c. Procurement and implementation of national library management system.

d. Systematic literature reviews to support new NCCP clinical guidelines in

ovarian cancer, lung cancer and gastrointestinal cancer and other national

programmes.

http://www.hselibrary.ie/


Supplies Department

Key Achievements and Activity for 2016

In 2016 we started the roll out in introducing Kan-Ban & also scanning the store rooms.

The areas that we completed in 2016 were:

ED/AMAU bulk store

Oncology

CCU

DAY SERVICES

SCBU

OPD up & down

Endoscopy theatre

CSSD bulk store

CIVU

All of these areas are now up and running with a two bin system and scanning. Our aim

is that usage over the year should reduce by 10%. Also the fill rate for these areas is over

90%.

A new staff uniform was also introduced which consists of black pants with black polo

shirts with a supplies logo on the shirts.

Plans for 2017

In 2017 the department will be looking at other areas to introduce kan-ban. Under the

national roll our plan funds were received to purchase more kan-ban to roll out and

introduce scanning of the stores. The areas which will be completed between June-Sept

are:

Winter Ward

Maternity

Cardiac Investigation

SMU

SUR 1 & 2

SUR 3

In introducing this, the stores room will be made more efficient and easier for the end

users to locate stock.


Pharmacy Department

The Pharmacy department in St. Luke’s provides a comprehensive pharmacy service to

the HSE hospitals in Carlow and Kilkenny. There are many service developments which

we are currently engaged in. These are outlined below along with our plans for 2017:

Discharge Service/GEMS

The pharmacy discharge service is provided to medical patients. As part of the service,

medication reconciliation is performed on admission, the patient is followed throughout

their stay and a discharge prescription is prepared. Once reviewed by the medical team,

the prescription is sent to the GP and community pharmacy prior to discharge. This

increases patient safety, improves prescribing and enhances communication between all

health care professionals, across all interfaces. In 2017 we aim to extend this service by

combining it with the Geriatric Emergency Medicine Service (GEMS). We will set KPIs

and submit a business case for extra pharmacists to facilitate the extension of this service.

The Geriatric Emergency Medicine Service (GEMS) is being established in early 2017.

Activity data has shown that up to 66% of all patients over 75 attending the hospital are

being referred by the GEMS team for a pharmacy review. This service has been shown to

be very beneficial and as part of the service plan for 2017 the pharmacy dept will look to

merge the discharge project and the GEMS project to consolidate the expanding role of

the pharmacist.

As part of the GEMS project we have already demonstrated the need for pharmacy

resources to be put in place to facilitate pharmacist input into the Comprehensive

Geriatric Assessment, complete the medication reconciliation on admission and prepare

the discharge prescription.

eHealth

As part of the discharge prescription service, the eClincial Suite Medicines

Reconciliation App is used to generate a Meds Rec on admission form and a Discharge

prescription PDF. This discharge form is sent to the patients GP and community

pharmacy, via Health Mail prior to their discharge. The eClinical Software has

completed a full security evaluation by the HSE’s Office of the Chief Information Officer

and fully complies with all HSE Data Protection, Encryption and Password Polices.

Currently Pharmacists have access to laptops for use on wards providing the discharge

service, where they can record information and generate documentation to maximise

efficiencies within the discharge project. As part of the quality assurance process for the

discharge project, prescriptions have been measured against the HIQA standards National

Standards for Safer Better Healthcare (2012), National Standard for Patient Discharge

Summary Information (2013) and Guidance on medicines reconciliation (2014).


Pharmacist generated prescriptions have been seen to be fully compliant with the

standards listed above.

Medication Safety and Quality

In preparation for the announced HIQA hospital pharmacy inspections, a review was

carried out of the medication information service provided by the pharmacy. IV drug

administration guidelines for drugs commonly used on wards were reviewed and updated.

These will be placed on the intranet, for clinical staff to access and will be maintained by

pharmacy. The Pharmacy intranet hub will also contain soft copy of all Pharmacy Memos

circulated to St Luke’s staff. These memos will still be circulated by email. High-risk

medication posters were distributed to all wards for use in treatment rooms. Education

sessions were provided to hospital staff on the use of the new medication Kardex.

Pharmacy will continue to be involved in revisions and updates to the Kardex.

We have identified a need for a Medication Risk Management Pharmacist.

Hep C

The Hepatology service has expanded in 2016 and, in line with icorn targets, aims to treat

70 patients in 2017 with new direct acting antiviral agents.

Oncology

The oncology day ward currently opens four days a week. It is planned to increase

capacity to treat patients five days a week. It will continue to have a clinic day on

Tuesdays when the oncologist sees oncology inpatients and out patients. This increase in

activity may necessitate more pharmacy resources.

The availability of the expanded access programme is significantly increasing with the

introduction of a new agent for the treatment of metastatic breast cancer. An increase in

both the number of patients being treated is anticipated in addition to the use of more

monoclonal antibodies.

The NCCP continue to request detailed reporting on expenditure and details of the agents

we are using. There will be an increase in the number of agents that qualify for

reimbursement under the ODMS system. This involves registering patients and providing

details of each dispensing.

Antimicrobial Governance

Our antimicrobial consumption increased dramatically in 2016. In order to improve

antimicrobial governance and appropriateness a Smartphone APP was introduced in 2016

and made available to HCPs. The antimicrobial guidelines and policies were reviewed

and updated based on evidenced based guidelines and resistance patterns. Education was

provided to staff on antimicrobial guidelines. We participated in the national annual

point prevalence survey. We continue to monitor the consumption of Meropenem in line

with national recommendations.


IEHG Pharmacists Group

As the IEHG becomes more established, we are forging closer working relationships

between the hospital pharmacies and joint quality improvement projects across the

hospital group.

Maternity Medication Governance

We aim to introduce a clinical pharmacy presence into the Maternity unit. We hope to

have adequate pharmacy resources to provide the level of medication governance and

oversight required and to meet the inspection criteria of HIQA and the PSI. This is

required to improve and maintain the required level of medication safety in the maternity

unit.


Dietetic Department


The dietetics department accomodated it’s 1st post graduate students from UCD

FODMAP clinics ongoing – preparing an analysis on the nutritional content of

diet post FODAMP advice in conjunction with UCD

Our dietetic department provides support to the dialysis satellite unit in Kilkenny

City and implemented the Nutrition Care Process (NCP) including nutrition

diagnosis during 2016.

We also support St Patrick’s Centre, which provides disability services in

Kilkenny and during 2016 we established an Enteral Feed Training and Support

Group (EFTSG) and commenced gastrostomy replacement training of nurses in

St Patrick’s centre. Ongoing active involvement in the Support at End of Life

Team. Implementation of NCP including nutrition diagnosis in St Patrick’s

Centre.

Initiated links with community dietetic services to establish existing paediatric

services available in both acute and community settings and to improve

interdepartmental communication to prevent overlap, reduce waiting times for

those under the care paediatric dietetic services

Commenced CHOICE training for children with Type 1 Diabetes

The department received 5,885 inpatient referrals and 2,070 outpatient referrals

during 2016 (both adult and Paediatric)

A dietitian specialising in Paediatric Diabetes began in post during 2016.

All Dietitians now CORU registered.

We developed and submitted abstract to Healthy Ireland re weight management

clinic for staff

Plans for 2017

We aim to commence provision of 5 point Subjective Global Nutritional

Assessment on all renal patients in Satellite dialysis unit once a year and address

acute renal nutritional issues in haemodialysis patients.

Pilot “drop in” dietetic clinic for staff.

Improve compliance with uptake of MUST on ward

Complete an audit of snacks available through catering

Review and improve waiting list times for Paediatric OPD

Second CHOICE facilitator to be trained

More staff to become proficient with insulin pump therapy(the way forward)

Carry out nutritional analysis of paediatric ward menu

Develop closer links with Diabetes Ireland to facilitate relevant courses for

children and adolescents with diabetes (e.g. cookery course)


Cardiac Diagnostics

Key Achievements and Activity for 2016 in our department

1. We continued to provide a range of Cardiac Diagnostics tests and maintain same in a

timely manner. However due to high demands from in-patient activity, resources are

prioritised to this area, and thus seen an increase in our out-patient waiting times.

2. Growth in Cardiac Rhythm Management continues and more complex devices for

follow –up has come on stream and staff continue to up- skill on same

3. Increase in activity for Transoesphageal Service due to the relocation of same to the

new day service unit has seen a 128% increase.

4. Planning of relocation of Cardiac Diagnostics service to a dedicated additional space

Plans for 2017

1. Moving of service to additional larger space

a) Cardiac Diagnostics (old AMAU)

b) Cardiac Echo Labs – Ultrasound (old Cardiac Dept) .

2. Continue monitoring of all activity and waiting list for our service .

3. Clinical Training – Ongoing

Staff attended Echo Course, Pacing updates, Mandatory training continues.

4. Additional Clerical hours to provide support two both locations .

5. Plan to commence new service with the Implant of Loop devices and follow-up

care of same .


Activity Report for Year 2016 Cardiac Diagnostic Department

Diagnostic Total Outpatients Inpatients GP referrals (triaged by

consultant)

12 Lead ECG

303 111 185 6

24 Hour Holter

2342 2083 12 242

24 Hour Blood

Pressure

1273 1226 6 38

Cardiac Event Recorder

44 39 2 3

Exercise Stress Test

1260 700 219 320

ICD Check

137 126 11

Pacemaker Check

500 444 54 1

TOE

48 20 28

TTE (Echocardiogram

2947 1355 1406 174

Grand Total 8,854 6,104 1,923 784


Laboratory

Key Achievements and Activity for 2016 in our department

Quality Improvements set for 2016 Current Status

Quality:

Procure electronic document

management system.

Continue to monitor QMS in BIO with

a view to achieving accreditation once

new analysers installed

Awaiting national tender.

PSR submitted for upgrade with current

supplier pending national tender.

Blood Transfusion:

Preventative action: change process of

authorising Groups

Procure separate interface for IH1000

PA implemented

Interface issue resolved with IH1000

software update – no longer require

separate interface

Haematology:

Ensure IQC schedule is maintained

Resolve errors in coagulation analysers

Validate D Dimer to 24 hrs

IQC audits show 96% compliance with

documenting IQC – the IQC was

performed 100% but not documented on 6

/162 occasions

Coagulation errors resolved-no re

occurrences

D Dimer testing extended to 24 hours

EQUIPMENT:

Replace Issue fridge

Blood Culture tender

Auto validation of results

Issue fridge replaced

Blood Culture tender currently being

evaluated

Auto validation deferred to 2017

Point of Care:

New Blood Gas in ED/AMAU

Implemented & working well

IT:

POC remote access to Blood Gas

Instruments

Commence scanning BT request forms

Remote access in place for BG

Scanning BT forms active since Jan 2017


Improve process for Web Access set up

Leased AC’s working/ No additional users

to be added until installation of new server

in May 2017

Auto validation of results in Blood Science Not complete in 2016 due to staff shortages

& training. Possibility of roll out in BT in

2017 to begin with pending collaboration

with UHW lab.

Plans for 2017


Activity Summary


Test 2015 2016%

change

Total Biochemistry 838794 902726 7.6

Total Haem & Coag 129774 130783 0.8Overall Total No Tests 968568 1033509 6.7

Blood Science workload up 6.7% in 2016 over 2015Review of last 6 years shows a total increase of 32%, primarily driven by Biochemistry workload.The main source of increase in 2016 was SLH up 6.4% and AEH up 12%

0

200000

400000

600000

800000

1000000

1200000

2011 2012 2013 2014 2015 2016

Biochemistry

Haematology

Total


Physiotherapy Department

Key achievements for 2016:

The Physiotherapy achievements for 2016 included many quality improvement objectives

aligned with the National Standards for Safer Better Healthcare (NSSBHC) and included:

Working collaboratively with key stakeholder to develop a Pulmonary

Rehabilitation Programme for those living with Chronic Obstructive Pulmonary

Disease (COPD) across both Carlow and Kilkenny. Referral pathways,

assessment procedures and operational plans were drafted in consultation with

multidisciplinary team members.

Preparatory work to align physiotherapy appointment scheduling and records with

the iPiMS

Pilot participation by a senior physiotherapist in review clinics in ED to provide

early intervention, advice on self management and appropriate onward referral for

MSK conditions

Provision of a weekly ‘drop in’ clinic to provide advice/managment strategies for

staff on work related/work affecting conditions

Development and implementation of a Critical Care Rehabilitaton Pathway

Implementation of a post operative Pulmonary Complication Risk Assessment

and Treatment Algorithm

Full roll out of Bariatric Handling Tool developed in 2015

Continuation of patient satisfaction surveys and actions based on findings

Focus on reflective practice, use of clinical reasoning and goal setting templates

and clinical audit in a drive to continuously improve the quality of care delivered.

Delivery of Bone Health and Falls Education Programmes in collaboration with

Community Services

Development of walking maps within/in close proximity to the hospital to

encourage physical activity amongst hospital staff.

Updating ddepartmental Safety Statement and Risk Aassessments

Development and implementation of CPD Plan for 2016 based on the assessed

needs of individual staff in line with the organisational objectives and service

demands


Key activities during 2016

Key activities during the year included routine physiotherapy delivery Mon to Fri as well

as on-call physiotherapy at weekends and public holidays in the following areas:

Medical, Surgical, Paediatric, Obstetrics and Gynae Wards

ICU and CCU

Outpatient Physiotherapy Department

ED (Sept to Dec only)

Antenatal care for women and their partners

Cardiac Rehabilitaton

Pulmonary Rehabilitation

The following table summarise activity during the year:

Table 1 Summary Physiotherapy Activity 2016

Service Area New Patient

Seen

Carryove

rs from

2014

Total

Patients

Individu

al

Contacts

Group

Contacts

Group

Sessions

Inpatients 3,928 90 4,118 16,497 0 0

On Call 643 0 643 1,046 0 0

Outpatients 1,055 368 1,423 4,894 94 17

ED & Review

Clinics (Sept to Dec

only)

106 0 106 106 0 0

Cardiac

Rehabilitation 399 22 421 448 2,188 42

Pulmonary

Rehabilitation 64 0 64 105 722 119

Ante Natal 237 243 295 0 276 45

2. Plans for 2017

Refine operational guidelines on COPD Pulmonary Rehabilitation Programme in

Carlow Kilkenny and develop GP linkages into the programme

Assist in the setting up of a COPD patient support group in Carlow

Go ‘live’ with iPiMS

Play active role in the roll out of GEMS project in St Luke’s Hospital

Make every contact count (MeCC) by maximising opportunities in interventions

with service users:

o promote physical activity as part of healthy lifestyle

o encourage smoking cesation and direct service users to supports available

locally as required

o promote bone health and falls prevention

Maintain DNA rate at less than 10%

Esure no patient is waiting more than 12 weeks for first physiotherapy

appointment

Maintain/Increase activity with same level of resources


Ccontinue with service user satisfaction surveys

Continue to actively promote best practice and ongoing professional development

in line with service requirements

Continue with reflective practice huddles, clinical audits and PRCs.


Saying ‘Goodbye’ to the old and ‘Hello’ to the

new Emergency Department 25/05/16


Surgical Directorate

Departments include: Emergency Department, Maternity Services, SCBU, Day

Services Unit, Endoscopy, Central Decontamination Unit, Operating Theatres, ICU,

Discharge Lounge, X-ray, Pre Admissions clinic & HCA’s.

2016 Objectives:

The key objectives for 2016 are summarised under the following headings:

Leadership, Governance and Management:

The aim was to provide effective leadership for staff, while managing the Surgical

Directorate Departments productively, through the use of all available resources and

through utilisation of an effective governance framework which was communicated to all

Clinical Nurse Managers in the department.

This was achieved through Department Governance meetings where all our clinical

incidents were discussed and action plans drawn up.

Safe Care and Support:

The Surgical Directorate aim is to provide safe effective care for patients and this was

achieved through working within policies, procedures and guidelines and delivering care

that is evidence based. All staff participates in as many education programmes as is

reasonably practical to ensure that staff are kept up to date with the latest developments in

the service.

Workforce:

Workforce Planning played an important role within the Directorate in 2016 as we

planned to open the new Emergency Department in Q2 2016. This involved extensive

communication with staff/senior management/networking with colleagues and utilising

reports on trying to find the right balance for appropriate staffing. I assessed data and

utilised reports such as NICE guidelines and the Tallaght report to guide staffing levels

going forward. National and local campaigns advertising for staff eventually secured the

appropriate amount of staff required to open the new departments.

Use of resources:

It was envisaged that all available resources would be used in the treatment of patients in

2016. There was a lot of redeployment and training undertaken to ensure efficient use of

resources. Resources were stretched beyond capacity but despite this all patients were

treated with dignity and respect in trying to achieve optimum standards, which is evident

by the limited number of complaints within the Directorate.


Key achievements/activity for 2016

All the Surgical Directorate departments had increased activity in 2016 which is

evidenced in the directorate’s individual reports. All departments are >90% for hand

hygiene and the majority are >90% in hygiene audits. Those that are not are due to infra

structural issues which are being addressed.

Risk Registers in place and live for all departments. One risk escalated to Executive

Management.

Development of Discharge Lounge

Mental health safety initiative in ED (Volunteer Programme)

All departments involved in Audits.

Audit tool developed for the transfer of 4 tasks from NCHD’s

Metrics audits completed

Audit of HCA Qualifications

2016 Department key achievements

Department Key Achievements

Day Services Unit Introduction of a consultant led

hysteroscopy clinic and a GP led Mirena

Clinic.

Day Of Surgery Admission activity

increased

Introduction of Pre Emptive analgesia

under the guidance of Department of

Anaesthesia

Developed general surgery discharge

advice leaflet

Development of an ERCP nursing transfer

letter

Undertook a 4 week Pilot study “Make

every Contact Count”. Qualitative data

obtained and results expected from Health

Promotion team in Q2 2017.

Assisted Mr. Awan in completing his audit

on utilisation & productivity of the day

ward.

ICU 216 admissions – 85 ventilated (39%)

Nursing documentation updated


Care bundles introduced

Aerogun nebuliser system introduced

Closed suction introduced as per SARI

guidelines

Theatre Staff survey

Departmental safety statement

Theatre tables procurement

Monthly Governance meetings

Business case submitted for opening of 3rd

theatre

CDU Quality control measures introduced to

guarantee that the system currently in place

for release of sterile items is robust

Change of wrap and supplier which will

yield significant yearly savings

All staff members of Irish Decontamination

Institute

Endoscopy Commencement of TOE procedures

Enhancement of Bronchoscopy service

All site specific validations and audits

achieved

RANP commenced surveillance clinic with

specific patient cohort

Pre Admissions Clinic Increased activity

Introduction of Anaesthetic clinic

Radiology - X-ray Attendance at departmental radiology

meeting with all stakeholders

Increased activity

Emergency Department Planning works for move to new ED- May

2016

Induction of 7 new staff

Appointment of 7 CNM1’s

Escort policy introduced

Education to all staff re Mental Health

volunteer programme

Minor injury unit commenced

ANP- Minor injuries appointed

Discharge Lounge Establishment of discharge lounge

Meet HSE targets for efficient bed

management

Education all disciplines of staff

Development of KPI’s

Maternity Services Site development for AMP

CMM2 to antenatal clinic service

Completion of patient surveys

Various posts ratified


Guideline Development

Commence implementation of Maternity

Strategy recommendations

SCBU Increased activity

28% increase in CPAP use

Guideline development

Healthcare Assistants All HCA’s at required Level 5 QQI

qualification

Attendance at study days

Improved attendance

Job descriptions for HCA’s in Paeds, ED,

AMAU & Oncology

Planning for 2017

Department Objectives & Aims

Emergency Department Develop Patient Pathways

Meet KPI’s as set out in Emergency

Medicine Programme

Monitor and decrease PET and triage times

Full compliance with PDD

Expansion of roles in ED department in line

with ED Taskforce recommendations.

Develop CNM3 role to include AMAU

2nd

ANP Candidate

Patient Flow

Expand Trauma steering group

Develop CNM1 role in ED

Develop specific role for ED HCA’s

4 staff undertaking 3rd

level programmes

Day Services Unit Introduce nurse led discharge

Scheduling to maximize utilization

Fully open the department

Endoscopy Unit Introduction of new Procedures

Scheduling to maximize utilization

Fully open the unit

Develop nurse led discharge

Conversion of current CLO testing to a

more cost effective & rapid response by Q2

17

RANP liaising with OPD re rescheduling

returns

X-ray Department SOPs all up to date

ERCP – SOP’s etc.

Prepare for MRI scanner installation

-+


Theatre Department TPOT – National Programme for Surgery –

Meet targets

Safe Site Surgery – meet targets

Monitoring out of hours activity

Opening of 3rd

theatre to increase service

provision

CNM2 post

Pre operative Asessment Clinic Adapt our service utilizing the Pre-

assessment model of care document,

More clients due to increased activity in

Day Services Unit.

Review of stats and staffing requirement

Anaesthetic involvement – new clinic

commenced

ICU Critical Care Governance Group quarterly

meetings

Pathway – admitting & discharge policy for

ICU

RANP development

Refurbishment of the department

Roll out of chest drain policy

Develop a policy re 5th

ventilated patient

Central Decontamination Uunit Increased activity

Statistics been monitored for increased staff

Plan for increased traceability of single

items

Plan to decrease costs with regard to

consumables in CDU

Education of ward staff regarding CDU

processed items and accountability for

traceability

Ward chart audits

Complete Contamination policy

Encourage technicians to undertake formal

college training

Discharge Lounge Increase numbers in discharge lounge

Conduct patient experience survey

Introduce QIP on wards for expediting

urgent bloods

To assist senior decision makers in early

discharge to lounge

Maternity Services Implement recommendations from the

National Maternity Strategy

Implement recommendations from System

Analysis Investigation report

Midwife community care pathway


RAMP post

Post Natal Symposium

PROMPT train the trainer programmes

Ultrasonagraphy training for 2 staff

Continue to develop the service and staff as

per bereavement standards, HIQA

standards, BFHI standards and patient

feedback

SCBU Up skilling of NRP train the trainers

Refurbishment of unit

Business case for staffing to meet

Categories of Perinatal Care

recommendations

Healthcare Assistants Increase WTE to introduce a line system for

CNM2’s at ward level to ensure robust

governance of HCA’s.

Approval of more WTE for other areas-

HDU, S3, SMU night duty

Ongoing education

Development of specific role for

ED/AMAU HCA’s as part of the ENIG

Audits Patient Satisfaction Surveys been

completed in 66% of areas.

All departments audits are up to date with

no issues

Metrics for Surgical 2

Strategy Developed induction pack for HCA’s

Completing survey for HCA starters in the

past year


Opening of new Acute Medical Assessment Unit

and Oncology Day Ward April/May 2016


Medical Directorate 2016


Unscheduled Care continued to drive the activity within the Medical Directorate during

2016, with over capacity on inpatient wards and in our emergency departments on a

continuous basis. As part of the ongoing Ireland East Hospital Group Unscheduled Care

Programme, a lot of process improvement work (utilising Lean methodologies) has

commenced and is ongoing. A number of staff have been involved in a number of Rapid

Improvement Events (RIE’s), ranging from an RIE on predicated dates of discharge to

the completion of a value stream analysis (VSA) on Complex Care. Late 2016 saw the

introduction of the daily Navigational Hub in the hospital, which has facilitated a focus

on early discharge’s and an improved PDD application rate for patients. All of these

initatives will assist in reducing our lengths of stay and in improving the quality of patient

care and experiences.

The introduction of the Discharge Lounge at the end of 2016 has also come from the

process improvement plans around Unscheduled Care.

Activity levels in our AMAU continues to rise year on year. On April 11th

2016, the

AMAU transferred to the new facility on the Acute Floor. The Acute Medicine

Programme’s KPI’s continue to be monitored with the aim of reaching National targets

monthly despite the ongoing overcapacity issue.

Admission rate to our CCU increased by 11% in 2016 with it functioning as a HDU (75%

of admissions meeting HDU category) and a business case has been sent to IEHG for

HDU staffing approval.

In line with increased inpatient workload, the demands on our phlebotomy services also

continued to increased. Some additional phlebotomy resources were put in place in the

last quarter of 2016. This coupled with the introduction of the new blood tracking device

has assisted in proving a more efficient service.

A new addition to our outpatient clinics during 2016 has been the introduction of the a

Respiratory ‘Xolair’ clinic under the stewardship of Dr. Brian Canavan.

Three members of our nursing staff from AMAU, commenced their Post Graduate in

Health Science/Acute Medicine.

CCU had 3 staff members under taking 3rd

level courses in the following areas, Higher

Diploma in Cardiovascular nursing, Higher Diploma in Respiratory nursing and

Tracheotomy nurse – Competent in replacement of long term tracheotomy’s.

The Community Infusion and Venesection Unit introduced ‘Biosimilar’ medications


The Hepatology Unit introduced Interferon Free antiviral medications for the treatment of

Hepatitis C

Staff on the Surgical Medical Unit (SMU) continued to participate in the Pressure Ulcer

to Zero collaborative and collected data until November 2016. - A SKIN Bundle was

developed and education is being rolled out by the TVN prior to the introduction of the

SKIN Bundle care plan.

The Medical Directorate had 2 staff trained as Instructors in Break Away Techniques and

Manual Handling who continue to provide training to staff in SLKK.

Nursing Metric’s are monitored monthly and reported to IEHG via the monthly

performance meetings.

Plans for 2017

The provision of services within the Medical Directorate will continue to be driven by the

increasing demand/activity and the relevant key performance indicators.

All ward areas will continue to participate in process improvement plans to meet National

target and facilitate quality initiatives as they arise.

The overall aim will be to

Continue to improve on patient safety.

Continue to improve care bundles.

Continue to improve documentation/assessments.

Be proactive in the introduction of quality. Improvements when opportunity

arises.

Continue to manage staff absenteeism rate through the use of the managing

attendance policy,

100% of all staff trained in identified Mandatory Education.

Facilitation of staff in 3rd

level courses (staff nurse identified to partake in

European Certificate in Essential Palliative care.

100% Staff trained in venipuncture and cannulation.

Roll out of DVT pathway in AMAU. (due April 2017)

Identification of additional pathways for use in AMAU that will improve patient’s

experience. E.g. PE pathway.

Allocation of additional staff WTE to meet HDU need.

Provision of clean clinical treatment room in SMU.

Commence work with Medical 1 and Medical 2 in relation to plans for a sensory

garden for patients with Dementia who attend SLKK.


Maternity Department

Key Achievements and Activity for 2016 in your Department

Continue to build on a culture of quality and safety – by ensuring safe services that are

evidenced based and responsive to the needs of individual women and their babies

Empowering and Supporting women in their choices in relation to antenatal care and

birth experience .

The first National Maternity Strategy ( 2016-2026) and the National Bereavement

Standards following Pregnancy Loss and Perinatal death and HIQA National Standards

for Safer Better Maternity Services ( Dec 2016) were introduced in 2016 . These

standards are key to our strategic direction. Review of relevant standards incorporated

into 2017 service planning. In carrying out the role of safety and quality improvement the

Maternity Patient Safety Statement is published on the HSE and hospital website each

month to provide public assurance that maternity services are delivered in an

environment that promotes open disclosure. Completed Service User Maternity Survey

positive feedback predominantly.

Plans for 2017

To complete a local /Ireland East Maternity gap analysis on the National Maternity

Strategy Implementation plan and set key objectives/ priorities for 2017, in collaboration

with the National Women and Infant Health Programme team . Currently (2017) we are

doing site preparation for Advanced Midwifery Practice to support the delivery of care

pathways based on risk and choice for women, in line with risk categorization and

community care as outlined in the Maternity strategy.


Respiratory


Fully operational Pulmonary Rehab Programme with the appointment of full time

physiotherapist

1 programme run in Carlow winter 2016

COPD support group Formed

Full time Respiratory Physiologist appointed this allows for full range of tests and

services including sleep studies and sleep clinic

Designated Bronchoscopy lists each week

Xolair clinic

Integrated care CNS appointed to service (GP based)

Plans for 2017

Source new equipment to extend the Pulmonary lab to include Cardio/Exercise

testing

Increase research

New specifically targeted treatment clinics for patient groups i.e. Interstitial

Pulmonary Fibrosis

Progress business case for funding for second Respiratory nurse and second

Respiratory Physiologist

Activity for Jan - Dec 2016

Key Achievements and

Activity for 2016

Clinical Focus

Total patients seen by Respiratory CNS in 2016:

815 (all outpatients)

Expansion of Respiratory services in 2016

2016 saw the commencement in post of a Respiratory

Physiologist, Integrated Care Respiratory Physiotherapist &

an Integrated Care Respiratory CNS.

As a result the expansion of respiratory services for patients

now includes a dedicated Sleep Studies clinic, a Pulmonary

Rehabilitation Programme established in both Kilkenny &

Carlow.

Clinics

Nurse led respiratory clinics are provided Monday to

Thursday. This enables the provision of a high standard of

clinical care for patients with respiratory illness and their

families using an evidence based care planning approach

including self-management & health promotion activities.

Patient referrals are accepted from Medical Consultants,

Emergency Department Consultants & their teams/ GP’s/ &


from other healthcare professionals both in the hospital and

community setting, & triaged according to clinical urgency.

At the end of Dec 2016 there were 10 patients receiving

Xolair treatment for brittle asthma which is required to be

given in hospital settings only.

Telephone service

Provision of a telephone service to patient with respiratory

illnesses & their families following discharge/ GP’s/ PHN’s

and other healthcare professionals to offer information/

support & advice on applicable services & resources

available.

Promotion of evidence based practice

Implemented the use of research based respiratory

assessment tools in respiratory nurse led clinics and in the

ROPD clinic for example the COPD Assessment Test (CAT)

& the Asthma Control Test (ACT) to improve respiratory

patient assessment & care.

Presently in the process of developing Safe Administration

of Omalizumab (Xolair) guidelines in collaboration with the

Consultant Respiratory Physician & the Chief Pharmacist.

Plans for 2017

Carry out audit on the administration of Omalizumab

(Xolair), following implementation of the Safe

Administration of Omalizumab( Xolair) guidelines to

measure standards & promote improvement in patient care.

Devise a 16 Week Post-Xolair Assessment form to ensure

the effectiveness of the treatment is evaluated correctly prior

to continuation of patient’s treatment at that point.

Update Guidelines for the Administration of Oxygen

Therapy to Adults.

In collaboration with CCU nursing staff update the NIV

guidelines to promote evidence based practice and improve

patient care.

Facilitate an inhaler workshop for healthcare staff in St

Luke’s in February 2017

In association with CNE in UHW, we plan to assist in

facilitating the Management of Adult Respiratory Patient

study days in 2017


Diabetes Nurse Department


Education of staff (nurses/ doctors) through Medication Management/ Mandatory

training and Grand rounds and Community staff – organised through RCMNE

CHOICE Programme – structured education of kids launched.

Provision of 15 hours of Paediatric nurse specialist each week

New paediatric nurse clinics

Improvements made to Hba1c results with the additional investment into Paeds

services including insulin pumps.

Art therapy to paediatric patients both individually and in groups to address the

psychological needs of the patients

Plans for 2017

Continue to provide education to staff, hospital and community partners

Commencement of Community Diabetes CNS that will run clinics in the

community (GP surgery’s)

Plan to develop CNS Study Day to include diabetes

Pumps initiations for adults and Paediatrics

Develop pump care pathway and policies

Progression of Hypos in clinic and wards – hypo box

Commencement of Nurse Prescribing in clinic

Provision of 5:1 DAFNE education training for DNS and Dietitan.

Implementation of maternity strategy guidelines, in conjunction with consultant

endocrinologist.


Tissue Viability


Clinical focus/ patient care: We received 606 inpatient and outpatient referrals for wound management advice/care.

Consultancy Activities:

Collaboration and representation of patient interests with colleagues within St

Luke’s on patient care, equipment needs, invoicing for rentals/ purchases etc.

Liaison with community care regarding patient funding and discharges on Vac

therapy/ dressing regimes.

Receipt of phone calls from outside agencies for advice on wound management

issues.

Audit and Research:

Ongoing monitoring of hospital acquired pressure ulcer incident reports and

reporting of figures to SMT and Hospital group through SMT.

Opportunistic audits of mattresses within the hospital to determine if meeting

hygiene standards.

Monitoring of rental costs for pressure redistributing mattresses/Negative Therapy

devices.

Updating of documentation/ guidelines/SOPs commenced.

Completed the Pressure Ulcer to Zero Collaborative in the summer.

Education and Training:

Attended an educational conference in Lisbon in late February and the wounds

UK conference in October 2017.

Provided education to surgical colleagues on wound management at surgical

lunchtime meeting.

Provided educational sessions to intern nursing students and opportunity to

shadow TVN for student nurses as requested.

Provided opportunistic education to both staff and student nurses and provided

educational sessions on pressure ulcer prevention documentation and SSKIN

Bundle Care Plan.

Plans for 2017

Complete the updating of documentation/ guidelines/SOPs.

Introduce the SSKIN Bundle Care Plan into all the relevant ward areas with

supportive educational sessions for staff.

Collaborate with surgical colleagues regarding specific availability of Tissue

Viability Nurse hours to enhance OPD service/ patient follow up.

Commence review of incontinent patient skin care regimes within hospital with view

to developing evidence based algorithm/ care plan.


Haemovigiliance Department


Maintained 100% traceability as per EU Directive for all blood component/

products (3008 in total transfused during 2016)

Electronic Blood Track Implementation commenced in February 2016. This is a

national HSE project and will be mandatory for all HSE hospitals. It involves the

use of a handheld PDA to label pre transfusion samples by scanning a barcode on

the patient ID wristband. It is also used to complete pre transfusion checks at the

patient’s bedside to administer RCCs & platelets (by scanning the patient’s

wristband and the barcodes on the blood component). 15 clinical areas have gone

live up to end 2016, with 93% of RCCs transfused using the device in December

2016. Implementation of Phase 3 has been on a phased basis and will continue

during 2017

400 nursing and midwifery staff received the mandatory Haemovigilance training

during the year, incorporating Blood Track Phase 3. Education sessions have been

provided on the Mandatory Training days, IV Medication Management days,

Student Nurse Information days and also informal sessions have been provided on

the clinical areas. Talks have also been given at the NCHD Induction days and the

Medical & Surgical lunchtime meetings.

18 portering staff trained on the procedure for collection of blood from the

laboratory, including new members of staff. All portering staff are in date for 2

yearly training

A total of 21 Haemovigilance non conformances were investigated and closed out

(non conformances which occurred on clinical area in relation to sampling,

collection, or administration of blood). Corrective actions put in place where

appropriate.

Investigation of 13 Serious Adverse Reactions (SARs) and subsequent reporting

to National Haemovigilance Office & close out.

Register maintained for all Maternity blood usage – this register is discussed at

Maternity governance meetings.

Investigation of ABO Incompatible transfusion which occurred in March 2016. .

Full report completed by Haemovigilance & Laboratory Quality Team and report

sent to the CIS by Clinical Risk Manager. Corrective actions put in place.

Haemovigilance Report presented at quarterly Hospital Transfusion Committee

meetings and also at the laboratory Annual Quality Management Review

(AQMR) with the Hospital Manager/ Clinical Director.

Haemovigilance audits completed as per laboratory audit schedule. Audits

completed included (1) Patient Identification wristbands, (2)Management of

Serious Adverse Reactions, (3) Vertical audits in conjunction with laboratory staff

reviewing a blood component from IBTS delivery to transfusion (one in SLGH,

one in KROH and one in Aut Even) and (4) monthly Traceability audits.

Full participation in monthly quality meetings with the Chief Medical Scientist,

Consultant Haematologist and Laboratory Quality Officer.


Irish National Accreditation Board (INAB) inspection took place in September-

all aspects of Haemovigilance documentation including training records and

procedures reviewed by inspectors. Accreditation passed.

Plans for 2017

Continue with Blood Track Phase 3 Implementation during 2017. Maternity &

Paediatrics scheduled for February/ March 2017 (areas remaining include Theatre

SLGH & KROH and DOSA clinic KROH)

Review of all blood transfusion procedures and documentation on clinical areas to

incorporate changes required following introduction of Blood Track Phase 3.

Provide ongoing training sessions for all nursing, midwifery and portering staff.

Maintain 100% traceability for all blood components and blood products

Complete 2017 audits as per laboratory audit schedule, including audits of blood

track implementation.

Continue to monitor and investigate all reported Serious Adverse Reactions &

Serious Adverse Events

Continue to monitor all blood transfusion practices in SLGH & KROH and

investigate non conformances as they arise

Poster presentation of the ABO Incompatible transfusion error has been accepted

for display at the Academy of Clinical Science and Laboratory Medicine

conference in Galway on 31st March. A PowerPoint presentation is also to be

given at the conference by the laboratory Quality Officer, Chief Medical Scientist

and Haemovigilance.


Oncology Day Ward

Introduction

In April 2017 the Oncology day unit moved to its new 10 bedded unit with minimal

disruption to our service, which is a credit to all staff involved, not one chemotherapy

administration day was lost!. Due to staffing issues, only 6 of the 10 beds have been

commissioned to date.

2016 Oncology Activity

A total of 3,080 day patients were treated on the unit in 2016. These figures

include parental and oral chemotherapy, supportive treatments.

There has been an increase in complexity of patients cared for, for e.g. in 2016,

we transferred many of our less complex nursing interventions out to the CIT

team in the community. This enables the day ward team to give more time to

multi drug therapy regimes, which inevitably take longer to administer.

At our oncology outpatient clinic, we saw 149 new patients and 954 return

patients, total (1,095).

CNS Roles:

1) Clinical Focus

1.1 Direct contact with patient while they are on our unit

1.2 Indirect Contact.

We provide point of contact for our clients via phone support to encourage

reporting of symptoms in a timely manner and psychological support for

patients and their families.

2) Patient Advocacy

2.1 Group Advocacy

The CNS on the Day Ward continues to strive to improve the quality of the

service we deliver to our patients and liaise with all staff and management

stakeholders on ways to do this. A Clinical Governance group formed in 2015 and

meetings organised on a 3 monthly basis to discuss developing issues.

2.2 Individual Advocacy.

The CNS attends the outpatient clinic and advocates on behalf of the patient and

their family - any issues they may have difficulty verbalizing. Also we facilitate

scheduling of treatments follow up scanning and other interventions.

2) Education and Training

3.1 CNS Education.


It is imperative we remain up to date on emerging developments and issues in the

area of oncology. We also have a weekly lunchtime journal club in our

department.

Regular updates and education are also provided to the unit, by the various drug

companies/our own pharmacy department, as licensing changes and new drugs

become available.

The CNS staff have been involved in developing new PPGs for circulation

throughout Oncology and the general hospital. This year we have developed a

PPG for treatment of chemotherapy induced Diarrhoea, Mucositis and care of the

CVAD.

3.2 Patient Education

We are responsible for educating our patients before they commence

chemotherapy on any expected side effects; we support this with written material

and reinforce any information at regular intervals during treatment. We tailor our

information based on the comprehension skills and desires of the patient.

3.3 Education of Staff

Education of staff in the hospital continues to be on an informal basis, as we do

not have sufficient resources provide formal education

Audit and Research

Clinical Audit

The CNS in the oncology unit submits Key Performance Indicators (KPIs) to the

NCCP on a monthly basis outlining clinic activity, treatment and delays in

receiving same.

Audit Role

Again, this is an area that we are not able to reach on at present, due to the need

for prioritising current resources for direct patient care

Consultancy

Interdisciplinary:

As a nurse led service, we work and liaise with our Consultant colleagues and

those in other Oncology units on a daily basis via email/telephone and meetings.

We ensure all instructions are carried out, investigations ordered and results

followed through. We meet and discuss shared issues with our colleagues across

the region on a 3 monthly basis.

Interdisciplinary:

We liaise with the entire Medical and surgical teams in the hospital and

channel all new referrals through the nursing staff to ensure timely

appointments and to help identify any urgent cases. This also ensures that

all necessary information is available when patients come to clinic and that

the diagnosis has been given to the patient/family.


We visit inpatients on the ward as required who are admitted although this

has been becoming more difficult as our workload has increased and also

the complexity and duration of treatments. We offer phone advice to the

ward in instances where we cannot review patients.

During 2014 we commenced a weekly MDT in conjunction with the

Palliative care and Home Care teams. This provides a forum to discuss

patient care pathways with the multi disciplinary team members.

We liaise with our colleagues in the emergency department to provide a

timely and quality service to our service users.

Planning for 2017

We hope to extend our service to 5 days per week to facilitate increased

demand.

We hope to introduce the NCCP telephone Triage model.

We hope to introduction scalp cooling for our patients in Q2 2017. 2 scalp

coolers have been purchased at a total cost of €30,000. The Scalp Cooler

drops the patients scalp temperature to minus 22, so many patient comfort

measures need to be in place to help tolerability of device. This will be a

first in the South East and we are very proud to be able to offer this

intervention.

Continue to work to meet all recommendations set out by the NCCP post

the Medication safety audit along with our Medical and Pharmacy

colleagues.

We hope to be secure by additional nursing resources for staff education

within the hospital.


Hepatology Department


We moved to our new department on the second floor of the new building.

All staff attended updating on new DAA treatments

We began providing DAA treatment for Hepatitis C under National Guidelines.

The staff in the department are fortunate to hold the positions of chair and

secretary for Irish Hepatology Nurses Association, and organise bi-annual

meetings in conjunction with the Irish Society for Gastroenterology.

We developed a new Liver Elastography Service, in conjunction with our

Radiologist colleagues.

Plans for 2017

We will treat approximately 70 Hep C patients, as per guidelines from the

National ICORN group

We hope to create new data base for Liver Elastography


Hygiene Services End of Year Report for 2016.

HIQA defines hygiene services as:

“Hygiene is the practice that serves to keep people and environment clean and

prevent infection. It involves the study of preserving ones health, preventing the

spread of disease, and recognizing, evaluating and controlling health hazards”

No. Key Performance Indicator Achieved/Result Comment

1. The hygiene services committee will

have at least meet 8 times in 2016

100% Achieved.( Jan, Feb, March,

April, June, July, Sept, Oct,

Nov & Dec)

Goal achieved

2 100% of Hospital workers will

participate in hand Hygiene training

by the end of the year

74% For 2016 of all hospital

employee.

3 Each Clinical department will

carry out internal hygiene audits on

a two monthly basis.

28 clinical areas

in total were

audited

4 areas completed 6 Audits




1 area completed 2 Audit

2 area completed 1 Audit

(6audits is our target for

clinical areas)

4 Each clinical area will be audited as

per risk category status.

100%+achieved

(Revisits in

some areas)

eCat System introduced.

Goal achieved

5 Each non clinical area will carry out

at least one internal hygiene audit

every six months.

Not achieved Pharmacy Area submitted

only 1

Lab have not submitted any

audit to date

6. All non clinical will be audited at

least once by the end of 2016

100% Goal achieved

7 Cleaning schedules will be reviewed

for all departments

Not achieved IR issues persist in some areas

8 A Patient satisfaction Survey will be

carried out

Completed.

92% of patients

who were asked

to participate

had a very

positive

experience.

Very positive results.

9. The Hygiene Committee will help to

identify, develop and review policies

relating to hygiene

100% Cleaning of Wheelchair

policy,

SLKK Cleaning Manual,

Waste Management Policy,


The Management of Broken

equipment.

Procedure for Improving

Hygiene Standards in

Clinical Areas

10. The Hygiene Committee will

participate in the HIQA Hygiene

Services Assessment Scheme and

progress the Quality Improvement

Plans as necessary.

√

QIPs revisited &

updated on a

regular basis on

hospital website

to reflect

ongoing

progress.

QIPs associated with HIQA

visit on December 15th

2015.

were developed and uploaded

to the hospital website.

11. A Risk Register will be developed

and populated during 2016

Populated at

dept level.

All departments have relevant

hygiene risk highlighted at

ward level & these are

escalated to the hospital risk

register.

Following review of the hygiene audit reports over the year, it has been noted in the

findings areas in need of ongoing intervention and monitoring.

Findings

Technical Services

Completion of the new hospital complex incorporating the new ED, AMAU,

Hepatology, Oncology, Day Services Unit as well as the New Hospital

Library/Education facility

Improvements have been noted in some areas, particularly with the introduction

of the Arantico System traceability is visible and there is evidence of status of

ongoing works.

Painting and floor covering is ongoing depending on Patient Flow and patient

capacity in clinical areas & the main corridors. The admin building has a floor

space inside the main door repaired.

Clutter has worsened along the Stores link corridor. (Broken equipment, empty

cardboard boxes etc)

All Hospital windows were cleaned


Issues that are of ongoing concern each month in the majority of departments

include:

Some WHBs that are non compliant with H.I.Q.A. recommendations.

Loose ceiling tiles, holes in walls, chipped paint on walls, doors and cupboards.

Damaged/ dirty window blinds.

Rust on radiators.

Damaged/worn floor covering/ skirting

Departmental

Some improvements have been noted in clinical practice, eg: hand hygiene. PPE

Sharps bins are mostly in line with best practice with assembly, signature, temporary

closure etc.

Improvement noted in the cleaning of equipment between patient uses.

Problematic Issues

Poor compliance with correct medication management.

Poor compliance with mattress checking

Poor compliance with Laundry segregation policy

Poor compliance with waste Segregation.

Staff training records (Hand Hygiene, Standard precautions, & Sharps) needed

updating in many areas.

Unclear roles & responsibilities in relation to the cleaning of some equipment,

more problematic in some areas than others. Partnership group established to

address change in practices related to these activities. In now an IR Issue.

Housekeeping:

Improvements noted in the cleaning of Sticky tape residue, and Lime scale from taps.

Poor compliance in the cleaning of Gel dispensers and replacement of gel in

public area.

Closure of tasks on eCat

Housekeeping services need to establish records of evidence on cleaning radiators

and window blinds

All Chemicals to remain locked.

Sign off sheets not always up to date.


Achievements.

Rolled out the eCat paperless auditing tool to all areas for audit in St Lukes

General Hospital.

Completion of wheelchair audit and progress made in relation to findings.

Quarterly newsletter

A hygiene awareness week took place in September, very positive feedback and

useful suggestions & comments were received.

Education / training and updates were available for all staff, on the paperless

hygiene audit system eCat early in the year. Ongoing training on request for new

staff.

Information leaflets on hygiene for all staff and patients have been update and

distributed to all departments.

Completion of patient satisfaction survey.(December 2016)

Hospital Cleaning Manual completed and distributed to all areas in the Hospital.

Conclusion:

It is the intention of the Hygiene services Committee to ensure that the best possible

standard of hygiene is achieved through education, audit, review, monitoring and

evaluation of the service in line with the HIQA Hygiene Services Standards and the

National Standards for the Prevention & Control of Healthcare Associated Infection. We

will endeavour to achieve this goal in 2017.


Hygiene Audits 2016


Arts Department


Arts Therapy Student working with Diabetic teenagers and multi disciplinary

team

Oncology art donation

I’d like to tell her project

Exhibitions throughout the year

Music Arts festival during Kilkenny Arts Week (August)

Staff Choir – established in September 2016 and was very successful

Percent for Art installation for the new foyer area was commissioned

Drop-in Wellbeing meditations sessions for staff at lunchtime

Some of our plans for 2017

Percent for art to be completed, installed & launched during 2017

Display of Travellers Art project

Continued participation in Arts festival with own exhibition and performances

Provision of led cultural walking groups to promote arts and wellbeing

Continuation of drop in meditation sessions


SLGH Clinical Risk Management Department

1. Reporting of patient safety events:

The reporting of patient safety events is an important part of the risk management

process and ensuring that the hospital has a positive safety culture. All staff,

regardless of grade are encouraged to report patient safety events. All patient

safety events reported, are reviewed by the Clinical Risk Manager and are logged

onto the National Incident Management System (NIMS) operated by Clinical

Indemnity Scheme (CIS).

The hospital has a good reporting culture and in 2016, 1,259 patient safety events

were logged onto the system pertaining to clinical care related incidents, birth

specific related incidents, medication related incidents, nutrition related incidents

and incidents associated with physical and biological hazards.

Incidents of serious harm (Serious Reportable Events) as per HSE 2015

definitions are reported to the HSE Quality Improvement Division and to IEHG.

Information relating to Maternity incidents are included on the hospital’s

Maternity Safety Statement which is published on the hospital’s intranet site.

2. Review of patient safety events:

All patient safety events reported, are reviewed with the relevant line manager and

patient’s medical team as required. Learning and recommendations from reviews

are brought to the attention of senior management and are implemented through

the relevant governance committees in the hospital.

3. Risk Registers

Risk management is also concerned with the identification of risks and the

implementation of controls to minimise the impact of a risk or to prevent a risk

occurring in the future. A risk register is a database of assessed risks that face any

organisation at any given time. Its purpose is to help Managers prioritise available

resources to minimise risk and target improvements to best effect. All wards /

departments in the hospital are required to maintain a risk register. The overall

hospital risk register is maintained by the Clinical Risk Manager and risks are

escalated to IEHG management team.

4. Education and Quality Improvement

The HSE Quality and Verification Division have recently updated the HSE Risk

Management / Incident Reporting Guidance and Policies and they can be found at

http://hse.ie/eng/about/QAVD/riskmanagement. The Clinical Risk Manager over

the coming months will provide education sessions in relation to these documents.

The Clinical Risk Manager organises education sessions for staff on topics which

in relation to themes identified following review of patient safety events.

The Clinical Risk Manager is a member of governance committees in the hospital

and quality improvement committees in the hospital. The clinical risk manager

http://hse.ie/eng/about/QAVD/riskmanagement


provides data on patient safety events to relevant quality improvement

committees.


The Year in Photos

Eleanor Moore, Business Manager, presenting

the then Minister for Health, Mr Leo

Varadkar TD, with his t-shirt to mark the

launch of the St Luke’s Couch to 5k 2016

Michael Walshe, Housekeeping

Manager, pictured at the Long Puck

Challenge on Jersey Day in 2016.

Prof Garry Courtney, Clinical Director,

pictured with Kilkenny Rose Claire Walsh

and the Rose of Tralee, Elysha Brennan,

during their visit to St Luke’s in 2016

Participants from St Luke’s with IEHG

Service Improvement Leads and Cindy

Walton from Simpler at the Outbrief

from the first Rapid Improvement Event

and Value Stream Analysis in St Luke’s

in 2016

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