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Paper 6

NHS Board Meeting Monday 9 October 2017

Scottish Patient Safety Programme – Maternity & Children Quality Improvement Collaborative Author(s): Angela Cunningham, Associate Nurse Director – Women and Children’s Services Jackie Welsh, Improvement Advisor

Sponsoring Director: Professor Hazel Borland, Nurse Director

Date: 11 September 2017

Recommendation The NHS Board is asked to receive this report and discuss:

ongoing work of clinical improvement in the Maternity, Neonatal and Paediatric services.

work undertaken in and across the services to improve Culture and Team Work.

that the collaborative has completed its initial three year programme and has moved to a new phase

Summary

The MCQIC programme was formally launched in March 2013. The collaborative covers the areas of Maternity, Neonatal and Paediatric safety work. The work for this initial three year period of the collaborative is now complete, and we moved into the next phase in April 2016. There is a mixture of existing and continuing work as well as new work commencing in each area.

All three workstreams continue to have funded National Clinical Leads on a sessional basis. Until recently, one of these leads was NHS Ayrshire & Arran (NHSA&A) based which was very helpful in taking work forward in our Board. This paper provides assurance that work is progressing in line with the national requirements.

The overall aim of the programme is to improve outcomes and reduce inequalities in outcomes by providing a safe, high quality care experience for all women, babies, children and families across all care settings in Scotland.

A selection of measures being undertaken within the MCQIC programme is presented from the Maternity, Neonatal and Paediatric workstreams.

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Key Messages:

The MCQIC programme is well embedded into practice in Women & Children’s; the teams are working towards implementing all the measures, moving to spread those with sustained improvement in the pilot areas, as per the improvement methodology. The methodology is used to test changes outwith the National programme, and remains “how we do things”.

In areas of sustained improvement we have introduced a step down approach to reporting. Each of the workstreams has multidisciplinary meetings on a regular basis to discuss/monitor progress against the programme aims.

All three workstreams have individual reporting toolkits for collecting data when national measures have been spread beyond pilot reporting sites. Clinical areas have created shared drives to collect data but technical support is required for the creation and annotation of run charts. The Directorate has also commenced the move toward recording data on the Quality Improvement Portal. Staff receive ongoing training where required and QI support with activation of each measure. There have been some differences noted in the way data is recorded between the QI Portal and the national toolkit. This is currently under discussion.

Moving forward the Directorate is recruiting a Risk & Quality Improvement Team. The post of Clinical Risk Co-ordinator interviewed on 21 August 2017. A preferred candidate has been identified and will be appointed pending references. An Improvement Advisor post has been advertised with interviews scheduled for 26 September. Plans are also in place to recruit a Practice Development Midwife, which has gone to advert and admin support for the team which is awaiting advert. The medical element of this team is currently being agreed and developed by the Medical Director and Clinical Directors. This team will provide expert risk / improvement knowledge at Directorate level

The Gynaecology in-patient ward (previously Ward 6) is now established in its new location within the Ayrshire Maternity Unit.

Glossary of Terms AMU CO CTG CVC ENT EWS HIE HIS MCQIC MDT NNAP NNU PDSA PICU PVC QI SBAR SPSP UHC W&C

Ayrshire Maternity Unit Carbon Monoxide Cardiotocography Central Venous Catheter Ear, Nose and Throat Early Warning Score Hypoxic Ischaemic Encephalopathy Healthcare Improvement Scotland Maternity & Children Quality Improvement Collaborative Multi-disciplinary Team The National Neonatal Audit Programme Neo Natal Unit Plan Do Study Act Paediatric Intensive Care Unit Peripheral Vascular Cannula Quality Improvement Situation, Background, Assessment, Recommendation Scottish Patient Safety Programme University Hospital Crosshouse Women & Children’s

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1. Maternity Workstream 1.1 Situation

The Maternity Workstream continues to report nationally on agreed measures within the Maternity Care Measurement matrix. We have introduced step down measures for Carbon Monoxide monitoring at booking as there is sustained improvement in this measure. Work continues locally and nationally on the referral process to smoking cessation services and uptake of this. We continue to test the undernoted measure related to smoking and this is detailed later in the report:

The percentage of women who continue to smoke and who are provided with a tailored package of care.

1.2 Background

The Maternity Care Scottish Patient Safety Programme strand aims to support clinical teams in Scotland to improve the quality and safety of maternity healthcare. The overall aims of the Maternity Care strand remain to:

increase the percentage of women satisfied with their experience of maternity care to >95% and

reduce the incidence of avoidable harm in women and babies by 30%

MCQIC was launched in March 2013 and is a programme of QI that ran in its current format until March 2016. The national discussions as to how work will be progressed have been agreed with Scottish Government Health Directorate, Early Years Collaborative, Raising Attainment For All and Healthcare Improvement Scotland. This is subject to ongoing changes as the iHub is developed. The MCQIC Midwifery Champion previously funded 15 hours per week via the national programme is currently supported 7.5 hours per week by the service. Moving forward the Directorate is in the initial stages of recruiting a QI and Risk Team. There are also identified Obstetric Consultant Leads and Consultant Anaesthetic Leads. 1.3 Assessment 1.3.1 Stillbirth Rate As seen at Figure 1 the NHS Ayrshire & Arran stillbirth rate continues to show sustained improvement. There are not enough data points yet to analyse the increase in May and July 2017, particularly as June and August 2017 were back to the reduced rate.

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Figure 1. Rate of stillbirth

1.3.2 Neonatal Mortality Rate Use of neonatal cots is co-ordinated nationally to maintain resilience and availability across Scotland. Sometimes local women require to be transferred to other health board areas to deliver their babies. The data below represents all babies, including these who were transferred to other Units and therefore, is not completely representative of what is happening locally. Figure 2. Neonatal Mortality Rate

Education fetal movement 1GP practice, 1MW 1

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Fetal movement education spread to all community areas

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1.3.3 Rate of severe post-partum haemorrhage Demonstrating improvements in this measure continues to be a challenge nationally. Local data shows that severe Post Partum Haemorrhage is mainly associated with delivery by Emergency Caesarean Section. Commencement of a prophylactic oxytocin infusion post delivery for all Category 1, 2 and 3 caesarean sections commenced on 1 August 2017 as an improvement intervention. Figure 3. Rate of severe post-partum haemorrhage

1.3.4 CO monitoring at booking CO monitoring at booking is at 100% and remains on target Figure 4. Women offered CO monitoring at booking.

June Testing scribe sheet and PPH trolley

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1.3.4.1 Referral to Fresh Air-shire There are still challenges in the referral process to Fresh Air-shire. Work is underway to test a direct referral letter from the midwife to Fresh Air-shire which will be tested in North Ayrshire. The current process of referral via the medical secretary obtaining information from the Electronic Patient Record is not reliable. It would be advantageous to have a direct referral facility to all other agencies within the Electronic Patient Record system (eClipse). Figure 5. Pregnant women with a CO level >4ppm (or who say they are current or recent no smokers) that are referred to smoking cessation services.

1.3.4.2 Compliance with attendance at first appointment Percent of pregnant women referred to smoking cessation services that attend first appointment is a new national MCQIC measure. This data is being reported by Fresh Air-shire via the QI Portal. This is calculated from the number of referrals received by Fresh Air-shire and the number of those women who attend the first appointment. Currently there are too few data points for a chart.

1.3.5 Cardiotocography

CTG or electronic fetal monitoring records changes in the fetal heart rate and their temporal relationship to uterine contractions. The aim is to identify babies who are becoming short of oxygen (hypoxic) so that appropriate escalation can be undertaken. CTG is the best method currently available to monitor a fetus during a high risk labour. Intermittent fetal auscultation should be considered after careful risk assessment. The use of the CTG measures is built on the assumption that the following infrastructure is in place at unit level: 1. Locally agreed documentation for CTG monitoring 2. Local level escalation protocol in place for concerns raised from CTG monitoring and

interpretation

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3. All staff who care for women undergoing CTG monitoring are appropriately trained incorporating: Completion of a recognised accredited fetal heart monitoring training package Completion of a local competency based assessment A timetable for training updates is agreed and local governance is in place

Ayrshire is one of only five Boards across Scotland reporting on this measure. As a result of being proactive in data collection, Ayrshire has initiated national discussion around this measure. Locally it has been identified that the yes/no question in relation to the percentage of hourly reviews undertaken does not reflect how often the CTG is actually reviewed. For example, a woman could have a labour lasting 12 hours. If the CTG has been assessed hourly on 11 out of 12 occasions then the response to the question of whether the CTG has been assessed hourly must be no and mean this element of the bundle is recorded as non-compliant.

As a result of feedback from Ayrshire to the national team in relation to the calculation of the number of CTG interpretations viewed hourly, a modified toolkit has been provided to capture data differently to reflect the total number of CTG interpretations meeting the hourly criteria. This data collection commenced in May 2017 and will inform the national overview.

Figure 6 presents the number of interpretations that were recorded hourly. The CTG must have been assessed within 10 minutes of the hour to comply. There is not yet an agreed national operational definition in relation to how close to the hour the assessment must be to comply. Discussions are ongoing nationally.

Figure 6. CTG assessments that are documented hourly

This data reveals that 81%-99% of interpretations locally have been undertaken hourly.

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Figure 7. Interpretations with buddy (fresh eyes) review

Figure 7 above shows improvement within intrapartum care. The CTG measure has been incorporated into the local QI Portal and measurement is expected to commence shortly for antenatal CTGs in Maternity Day care, Maternity Assessment, Inpatient award and Labour Suite. A combined antenatal/intrapartum CTG assessment sticker has been developed and tested using improvement methodology. The final version of the CTG assessment sticker was implemented on 1 August 2017. Up until this date there had been separate antenatal and intrapartum assessment tools which resulted in variation of approach. The ‘fresh eyes’ approach has now been adopted for both antenatal and intrapartum CTG assessment in all clinical areas using CTG assessment. Figure 8. Percent of interpretations which are correct

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Figure 9. Interpretations which are suspicious and pathological that are actioned appropriately

It is yet to be demonstrated whether we will see a correlation with CTG assessment and the number of babies admitted to the neonatal unit with HIE (Hypoxic Ischaemic Encephalopathy). Currently the rate of HIE national data is awaited. Data is collected by the Neonatal Team via the electronic Badgernet system however it requires to be reviewed and audited prior to release nationally. It is expected to be available late summer/early autumn. The CTG measures have initiated peer discussion and learning within the labour suite as midwives have been involved in data collection where possible. Mandatory CTG learning sessions for midwives who interpret CTGs in the antenatal and intrapartum settings are established. These sessions will be multidisciplinary when possible. Different dates and times of sessions are currently being tested to facilitate maximum attendance. 1.3.6 Sepsis Six In previous national enquiries into Maternal Death, Sepsis has been found to be a leading cause. Accurate and effective management of Sepsis which includes delivery of the elements of the Sepsis Six bundle within one hour of suspicion of Sepsis is known to reduce mortality and morbidity. The measure for this is an “all or nothing‟ measure, all six elements of the bundle must be met to attain compliance. The data involves small numbers and there may be no women presenting with Sepsis in each reporting month (see May 2017). This measure has been spread to all five clinical areas within the AMU (as shown in the below graph). Compliance against this measure will continue to be monitored.

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Figure 10. Compliance with Sepsis Six Bundle

1.4 Future Developments As part of the overarching W&C QI priorities the items below were also noted as priority areas of work for 2017/2018 within Maternity Services:

Debriefs - Woman to Staff following delivery / experience within the inpatient ward.

Incident Debriefs in Labour ward 2. Neonatal Workstream 2.1 Situation The National Neonatal Programme is continuing in 2017 with the structure measuring four data points. It has been noted that any unit wishing to continue service improvements locally should continue to do so using the SPSP methodology. 2.2 Background The key objective of the Neonatal Care strand is to achieve a 30% reduction in avoidable harm in Neonatal Services by seeking to reduce:

harm from mechanical ventilation

harm from invasive lines

high risk medicines

harm from transitions of care and undetected deterioration and also to:

increase natural feeding,

ensure service user engagement

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Figure 11. Peripheral Vascular Cannula (PVC) Insertion Bundle Compliance

The Neonatal Quality Improvement Group formed in March 2014 and continues to meet on a regular basis as a multidisciplinary team. The MCQIC Champion and a representative from the Paediatric QI Team have a standing invitation to attend. Given the benefits of these meetings, our aim is to try and sustain the momentum in driving forward patient safety and improvement work within Neonatal Services. 2.3 Assessment 2.3.1 PVC Bundle Given the improvements in overall compliance the data collection for this element has now been stepped down to three monthly. This commenced from October 2016 and has remained at 100%. 2.3.2 Gentamicin Bundle Gentamicin is a high risk medicine which can cause harm. There are four elements within the Gentamicin bundle which is an all or nothing bundle so all elements must be achieved to be overall compliant. Compliance with the bundle was not initially sustained and the team drilled down into the specific elements to identify the components causing difficulty in achieving and seek solutions against these components. The importance of achieving 100% compliance of this bundle was shared at safety briefs with the result that 100% compliance in all four elements was achieved in July 2016. This was not sustained with administration within 1 hour being the component that was not achieving 100% compliance. This was again highlighted at staff safety briefs given the effectiveness of this action in the past, which again has demonstrated improvement.

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Figure 12. Compliance with Gentamicin Bundle

2.3.3 CVC Bundles We had maintained 100% compliance in both the Insertion and Maintenance Bundles until July 2017 when we observed only 90% compliance in the maintenance bundle. The toolkit was changed nationally and the data archived, however we are able to show data from April 2017. Figure 13. CVC Maintenance Bundle

In addition to these bundles - following review of a previous Datix a central line insertion checklist was compiled and tested using Plan, Do, Study, Act (PDSA) methodology. Part of this bundle confirms correct line placement, confirmation of same by two senior clinicians and the significance of the length of time inserted in relation to acquired sepsis during line placement.

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2.3.4 Vancomycin prompt The vancomycin prompt is a step by step guide to ensure the safe administration and monitoring of vancomycin which is a high risk antibiotic. The prompt has been introduced within the Neo Natal Unit (NNU). In addition, following an action agreed at the neonatal quality improvement group meeting in order to maximise the Vancomycin dosage, we now obtain an additional sample timously, to ensure a more accurate analysis of the neonate’s renal function which could impact on achieving the therapeutic dose. Data collection for therapeutic levels has proven to be challenging and we therefore had to consider how to optimise collection of this data. A data collection tool has now been developed with the view to medical staff supporting the collection of this information. Figure 14. Vancomycin Bundle Compliance

2.3.5 Increase Natural Feeding Currently all staff within Neonatal Services comply with the ‘Infant Feeding Policy for Maternity Services’ to support new mothers and their partners to feed and care for baby in ways which optimise health and wellbeing. We have recently ratified an Infant Feeding policy for the NNU. There are now ‘Unicef UK Baby Friendly Initiative Standards for Neonatal Units’. NHS Ayrshire & Arran Neonatal Services have been assessed and passed Stage 1 and 2 of these Standards and preparatory work is underway to be assessed for Stage 3. This has been fully supported by the Maternal and Infant Feeding Team. There has been a slight decrease observed in the number of infants discharged from the NNU receiving breast milk, however we are in the process of implementing the nutrition bundle.

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Figure 15. Newborn Infants discharged on breast milk

2.4 Data Points Restructure

NHS Ayrshire & Arran has launched a new QI Portal, a system that would allow us to capture the SPSP measures as per the Boards requirements. We are currently liaising with the QI Team with a view to have the appropriate measures added. Currently the NNU only record the rolling programme of Infection Control measure to this Portal. It would be beneficial to have the SPSP Neonatal Measurement Plan and add the appropriate measures to the QI Portal and discussions are in progress with HIS to allow the measures collected on our local portal to be sent directly to them instead of having to complete their tool and duplicate effort. The National Neonatal Audit Programme has received additional funding from the Royal College of Paediatrics and Child Health to continue with data collection obtained through Badgernet. Since some of the data collected for NNAP are mirrored with SPSP Neonatal measures, we believe this will assist in providing more accurate and meaningful information. This will also broaden the team of staff participating in data collection. 2.5 Interpretation and Feedback of Data We identified a gap in how we feedback data analysis to staff and explored opportunities on how we could improve this. Staff also identified a need to increase the handover time from 15 minutes to 30 minutes. This feedback resulted in a test of change utilising the whiteboard for a six week rota period where handover time was increased to 30 minutes to feed back the information required. This has now been implemented as routine practice within NNU; the below image shows the board in use. We utilise the additional time to feedback on interpretation of the monthly data collection, highlighting what we do well and what we could do better. Since using this method of feedback we have noted improvements in documentation audits. Badgernet completion compliance has also improved and we have optimum support in the shared learning from Datix, peer review and QI work within the Unit.

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Image 1. Staff feedback Board in NNU

2.6 Staff Performance Collaboration with parents highlighted the need to make our staff performance board more meaningful to parents and visitors. Using their constructive feedback we have re-designed our performance board and have changed the title to ‘Our performance ...Your safety. How are we doing?’ Image 2. Performance Feedback Board

2.7 What Matters to You Day AMU participated in ‘What Matters to You Day’ on 6 June 2017. To mark this in the NNU we held a cake and coffee afternoon and invited staff and parents also to have a chat and get an understanding of what matters to each other. This was so successful, that we now hold a monthly tea, inviting parents, staff and a graduate along to give each the opportunity to just sit and get to know each other and chat about ‘what matters to them’.

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2.8 Future Developments As part of the overarching W&C QI priorities the items below were noted as priority areas of work for 2017/2018 within Neonatal Services:

Inter-professional Perinatal Care Collaborative for Extreme preterms"

Unplanned Removal of Invasive lines to reduce harm

Reduction in hypothermia to reduce harm

Reduction in Infection to reduce harm

Reduction is hypothermia to reduce harm is also being addressed within the ‘Inter-professional Perinatal Care Collaborative for Extreme preterms’, and will call for collaborative working with Labour Ward / Theatre colleagues.

3. Paediatric Workstream

3.1 Situation

The Paediatric workstream continues to report measures in relation to the nationally agreed Serious Harm Index. NHS Ayrshire & Arran is collecting data on four measures having added Central Venous Catheter bloodstream infections to Serious Safety Events, Unplanned admission to Paediatric Intensive Care Unit, and Medicines Harm. Currently around 15 hours per month are used to complete audits as it is essential that the National Data toolkit is completed as well as many of the same audits on our NHS Ayrshire & Arran QI Portal. 3.2 Background

The key objective of the first phase of Paediatric Care strand was to reduce avoidable harm by 30% by December 2015. Subsequently this measure was recognised nationally as undeliverable; however, the work towards reducing avoidable harm is ongoing. These are six nationally recognised Paediatric core measures that each NHS Board reports on each month:

Serious Safety Events

Ventilator associated pneumonia

CVC related blood stream infections

Unplanned admission to Paediatric Intensive Care Unit (PICU)

Medicines Harm

Child Protection Harm 3.3 Assessment 3.3.1 Serious Safety Events There have been two serious safety events, including crash calls in this six month reporting period. Of the two events, one was recorded on Datix and one was not. This has been used as a Learning Point for dissemination throughout the department to emphasise the importance of ensuring all incidents are recorded on Datix

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The first event was a post Ear, Nose and Throat procedure bleed that the ENT medical team will review within their own case review systems and any changes in procedures or processes will be communicated to the Paediatric team.

The second was a teenager with acute exacerbation of asthma who had a respiratory arrest with successful resuscitation with no long lasting effects. This teenage was on holiday in Ayrshire from Glasgow and will be follow-up at Royal Hospital for Children in Glasgow.

Figure 16. Serious safety events

3.3.2 Ventilator associated pneumonia

Ventilator associated pneumonia is not applicable to the paediatric wards in University Hospital Crosshouse as we do not nurse children within our service with acute invasive ventilation needs. 3.3.3 Central venous catheter related blood stream infections

CVC infections are reported direct to HIS via microbiology although we have had two confirmed in this six month reporting period. One hospital acquired and one community acquired. 3.3.4 Unplanned admission to PICU

We have had twelve unplanned emergency transfers to PICU since February 2017, with

the peak being three in July.

Post ENT surgery bleed (PESB) PESB

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Total power failure

sub therapeutic aminophylline dose

Post ENT surgery bleed

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respiratory arrest

tonsil bleed

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Serious Safety Events NHS A&A Children's Unit, 1A & 1B

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Figure 17. Unplanned admissions to PICU from Ward 1B

3.3.5 Medicines Harm There have been no reported episodes of medicines harm requiring intervention over the past six months reporting period. However there has been a slight increase in the amount of reported medicine errors via DATIX. These all relate to electronic charting on the JAC system of Medicines ePrescribing. Significant work has been done in the ward area with all staff to eliminate this user issue and this now features on the Ward Daily Safety Brief (example of safety brief below).

3.3.6 Child Protection Harm

Child protection harm is an area still to be agreed nationally.

3.3.7 National Paediatric Data Toolkit 3.3.7.1 Medicines reconciliation This measure is both a quantitative and qualitative study that is carried out on a Friday morning after the Multi-disciplinary Team handover. Each child admitted acutely to the Children’s Assessment Unit or Inpatient Ward should have medicines reconciliation done as part of the medical admission process. A completed form should include patient identifiers, two individual sources of information regarding drugs, list of drugs in current use, doctor’s name, date and page number.

Increase in bronchiolitis patients

intusseception, Nec fac, Bronch

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Unplanned admission to Paediatric Intensive Care Unit (PICU) NHS A&A Children's Unit, 1A & 1B

Ward 1B Safety Brief 8am 4pm 8pm 3am

Staffing : medical/nursing (absence & study leave)

Number of patients in ward including ‘on pass’

Have all name bands been checked and in place?

Are all medicines charted appropriately on JAC?

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Reliability has not yet been achieved with recognised peaks and troughs in data being clearly identified. However, in June 2017 a ward round bundle which includes admission medicines reconciliation was introduced via PDSA methodology and already a significant increase in compliance has been demonstrated.

Figure 18. Medicine reconciliation within 24 hours of admission

3.3.7.2 PVC maintenance bundle. The PVC Maintenance bundle is a record of the condition, patency, hand hygiene and assessment of use that should be completed once in each 24 hour period. This is predominantly completed by nursing staff. Currently compliance is improving and an active action plan has been developed to assist in our improvement of this focus area. Figure 19 Compliance with PVC Maintenance Bundle

3.3.7.3 Use of SBAR communication There is re-assessment and training underway in use of the Situation, Background, Assessment, Recommendation communication tool throughout the Children’s Unit. Use of this tool encourages accurate and relevant sharing of information between all medical and nursing staff including at nursing staff handovers and at MDT meetings.

Combined 1A & 1B

change of doctors medical teaching

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PVC Maintenance Bundle Compliance

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A project had been undertaken in ward 1B predominantly focussing on nursing handovers to increase efficiency, accuracy and reduce unnecessary interruptions. We have noted a slight improvement and we will continue to promote high quality SBAR exchanges. Figure 20. Exchanges where high quality SBAR is used.

3.4 Future Developments

As part of the overarching W&C QI priorities the items below were noted as priority areas of work for 2017/2018 within Paediatric Services:

Implementation of the National Paediatric Early Warning Score

PVC Compliance 4. Gynaecology Workstream

4.1 Situation

The Gynaecology ward has relocated from the old ward 6 within the main building at UHC and is now situated in the AMU; whilst not coming under the auspice of the MCQIC, it does however, report on the measures outlined in the Adult SPSP programme. Any testing or implementing of new work programmes is done so using QI methodology.

4.2 Background Since its launch in 2008, the Acute Adult programme has contributed to a significant reduction in harm and mortality to acute adult inpatients In 2012, the Cabinet Secretary for Health & Wellbeing announced stretching new aims for the Acute Adult programme:

To further reduce mortality in Scotland’s acute hospitals

To further reduce harm experienced by patients in Scotland’s acute hospitals

New nursing staff ward busy + reduced staff

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% of exchanges that use a high quality SBAR Children's Unit, 1A & 1B

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The Senior Charge Nurse has disseminated elements of the SPSP measurements to all staff (Band 2 and above) for data collection. This has since resulted in a collaborative approach within the ward. Staff are now able to devote more time to complying with the SPSP measurements and embrace QI methodology 4.3. Assessment

4.3.1 Food, Fluid and Nutrition Measurement Tool for adult in-patient wards

Historically, Food Fluid and Nutrition was collected on four measures. A more robust tool was added to the QI Portal on 1 March 2017. The tool ensures risk assessments are completed appropriately to look at a more holistic patient journey. The introduction of this new measure is part of a suite of activity and supports for improved nutritional care.

Figure 21 Compliance with the Food Fluid and Nutrition Tool

The measures are discussed on the safety brief daily, to ensure good practice is sustained.

4.3.2 Falls

The organisation is committed to reduce the number of falls in all in-patient wards in NHS Ayrshire & Arran. The number of falls within the gynaecology ward is generally low with no fall having sustained harm.

Figure 22. No of falls in the Gynaecology Ward

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The increase in falls in July was further investigated at ward level. Both falls were attributed to the patients being reluctant to take nurse advice. 4.3.3 PVC Compliance PVCs account for 1.9% of all healthcare associated infections in the UK. PVC insertion sites should be inspected regularly. The catheter should be removed as soon as it is no longer required. They should be re-sited only when clinically indicated. The below graph demonstrates compliance with the PVC Bundle. Where data is shown as ’zero’ no data was recorded for that month.

Figure 23. Compliance with the Adult Peripheral Vascular Catheter Care Bundle

4.3.4 Compliance with Early Warning Score (EWS) EWS Tools can help with the recognition of deteriorating patients. The Early Warning Scoring system changed from the historic Modified scoring system to the National Early Warning System in July 2017 within the acute hospital setting. Figure 24. Compliance with the use of the Early Warning score tool

The measure changed in March and therefore the data was collected, but on a different chart. Compliance from January to March was 95%, 65% and 93% respectively.

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4.3.5 Pressure Ulcers

As part of the Adult SPSP programme, there is an aim to reduce pressure ulcers in hospitals and care homes by 50% by December 2017. The Gynaecology ward collects information each month on the number of Pressure Ulcers developed within the ward. No incidences of pressure ulcer development have been recorded within in the Gynaecology Ward.

4.4 Future Developments

As part of the overarching W&C QI priorities the items below were noted as priority areas of work for 2017/2018 within Gynaecology Services:

PVC Compliance

EWS Compliance

Discussions are currently taking place with the ward manager to ascertain other areas of priority

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Monitoring Form

Policy/Strategy Implications

This initiative links to the Board’s SPSP / Quality Strategy

Workforce Implications

This workstream has implications for workforce moving forward to maintain progress across all three workstreams

Financial Implications

There may be financial implications identified as new National Standards of care are identified. This will be discussed as the programme progresses.

Consultation (including Professional Committees)

There is no requirement to involve professional committees as this work forms part of the SPSP process.

Service users are informed of progress via user links established in the services and notice boards in clinical areas.

Risk Assessment

Delivery of the programme is aimed at reducing harm within the Maternity & Children’s services. Non delivery of the programme could impact on the provision of a safe service and reputation of the organisation if timely effective implementation does not happen.

Best Value - Vision and leadership - Effective partnerships - Governance and

accountability - Use of resources - Performance management

This programme encompasses all of the best value standards. The delivery of the elements contained within the MCQIC programme and the SPSP programme will support the Boards commitment to safe, effective and person centred care.

Compliance with Corporate Objectives

Create compassionate partnerships between patients, their families and those delivering health and care services which respect individual needs and values; and result in the people using our services having a positive experience of care to get the outcome they expect.

Protect and improve the health and wellbeing of the population and reduce inequalities, including through advocacy, prevention and anticipatory care.

Single Outcome Agreement (SOA)

Not required

Impact Assessment Impact assessment is not required as this is an internal document