Open and Honest Care in your Local Hospital

Report for:

September 2015

Open and Honest Care in your Local Hospital

The Newcastle upon Tyne

Hospitals NHS Foundation

Trust

The Open and Honest Care: Driving Improvement

programme aims to support organisations to become

more transparent and consistent in publishing safety,

experience and improvement data; with the overall aim

of improving care, practice and culture.

1. SAFETY

NHS Safety thermometer

95.6%

97.3%

Overall 96.0%

For more information, including a breakdown by category, please visit:

http://www.safetythermometer.nhs.uk/

Health care associated infections (HCAIs)

Patients in hospital setting MRSA This month 2 Annual Improvement Target to date 0

Actual to date 5* * 7 successful appeals for C.Diff

For more information please visit:

http://www.newcastle-hospitals.org.uk/patient-guides/keeping-hospitals-clean.aspx

Further information about HCAIs and C.difficile appeals is on pages 5 and 6.

* 1 MRSA third party assignment agreed with CCG

39 33*

Open and Honest Care at The Newcastle upon Tyne Hospitals NHS Foundation Trust : September

2015

This report is based on information from September 2015. The information is presented in three key categories: safety, experience and improvement. This report will also signpost you towards additional information about The Newcastle upon Tyne Hospitals NHS Foundation Trust's performance.

On one day each month we check to see how many of our patients suffered certain types of harm whilst in our care. We call this the safety thermometer. The safety thermometer looks at four harms: pressure ulcers, falls, blood clots, and urine infections for those patients who have a urinary catheter in place. This helps us to understand where we need to make improvements. The score below shows the percentage of patients who did not experience any harms.

HCAIs are infections acquired as a result of healthcare interventions. Clostridium difficile (C.difficile) and methicillin-resistant staphylococcus aureus (MRSA) bacteremia are the most common. C.difficile is a type of bacterial infection that can affect the digestive system, causing diarrhoea, fever and painful abdominal cramps - and sometimes more serious complications. The bacteria does not normally affect healthy people, but because some antibiotics remove the 'good bacteria' in the gut that protect against C.difficile, people on these antibiotics are at greater risk.

The MRSA bacteria is often carried on the skin and inside the nose and throat. It is a particular problem in hospitals because if it gets into a break in the skin it can cause serious infections and blood poisoning. It is also more difficult to treat than other bacterial infections as it is resistant to a number of widely-used antibiotics.

C.difficile

7

We have a zero tolerance policy to infections and are working towards eradicating them and have already made great progress; part of this process is to set improvement targets. If the number of actual cases is greater than the target then we have not improved enough. The table below shows the number of infections we have had this month, plus the improvement target and results for the year to date.

Pressure ulcers

This month 52 Category 2 - Category 4 validated pressure ulcers were acquired during Acute hospital stay and 0 in the community.

Severity Number of Pressure Ulcers in our Newcastle Community setting Category 2 0 Category 3 0 Category 4 0

The pressure ulcers reported include all pressure ulcers that occurred from zero hours after admission

Rate per 1,000 bed days: 1.46 Hospital Setting

Rate per 10,000 Population: 0.00 Newcastle

Further information about our work to reduce harms is on pages 4 and 5.

Falls

This month we reported 10 fall(s) that caused at least 'moderate' harm.

Severity

Moderate Severe Death

Rate per 1,000 bed days: 0.28

Further information about our work to reduce harms is on pages 4 and 5.

Number of Pressure Ulcers in our Acute Hospital setting

48 4

4

This measure includes all falls in the hospital that resulted in injury, categorised as moderate, severe or death, regardless of cause. This includes avoidable and

unavoidable falls sustained at any time during the hospital admission. Falls within the community setting are not included in this report.

In the community setting we also calculate an average called 'rate per 10,000 Clinical Commisioning Group population'. This allows us to compare our improvement over time, but cannot be used to compare us with other community services as staff may report pressure ulcers in different ways, and patients may be more or less vulnerable to developing pressure ulcers than our patients. For example, our community may have younger or older patient populations, who are more or less mobile, or are undergoing treatment for different illnesses.

Pressure ulcers are localised injuries to the skin and/or underlying tissue as a result of pressure. They are sometimes known as bedsores. They can be classified into four categories, with one being the least severe and four being the most severe. The pressure ulcers reported include all avoidable/unavoidable

pressure ulcers that were obtained at any time during a hospital admission that were not present on initial assessment.

In the hospital setting, so we know if we are improving even if the number of patients we are caring for goes up or down, we calculate an average called 'rate per 1,000 occupied bed days'. This allows us to compare our improvement over time, but cannot be used to compare us with other hospitals, as their staff may report pressure ulcers in different ways, and their patients may be more or less vulnerable to developing pressure ulcers than our patients. For example, other hospitals may have younger or older patient populations, who are more or less mobile, or are undergoing treatment for different illnesses.

0

So we can know if we are improving even if the number of patients we are caring for goes up or down, we also calculate an average called 'rate per 1,000 occupied bed days'. This allows us to compare our improvement over time, but cannot be used to compare us with other hospitals, as their staff may report falls in different ways, and their patients may be more or less vulnerable to falling than our patients. For example, other hospitals may have younger or older patient populations, who are more or less mobile, or are undergoing treatment for different illnesses.

Number of falls

4 2

2. EXPERIENCE

Patient experience

The Friends and Family Test

In-patient FFT score

₉₈

₉₀

100

We asked 63 patients in September 15 the following questions about their care in the hospital:

Yes Always/Most of Time or Excellent/Good

Do you feel able to ask any questions about your treatment or condition? 100%

Are you involved as much as you want to be in decisions about your care and treatment? 98%

If you have needed to use your nurse call button, has this been responded to in a timely manner? 100%

Overall do you feel safe, secure and supported in this hospital? 98%

How likely are you to recommend this ward to your family/friend if they needed similar care or Treatment? 98%

A patient's story

Staff experience

In the first quarter of 2015/16 we carried out a survey on a sample of our staff, we asked 995 staff in the hospital the following questions:

Extremely Likely/Likely

How likely are you to recommend the Trust to friends and family if they needed care or treatment? 95%

How likely are you to recommend the Trust to friends and family as a place to work? 73%

See supporting information for more detail on the Staff Survey

The Friends and Family Test requires all patients, after discharge from hospital, to be asked: How likely are you to recommend our ward to friends and family if

they needed similar care or treatment? We ask this question to patients who have been an in-patient and/or attended Acccident & Emergency (A&E). Both scores (if applicable) are below:

To measure patient and staff experience we ask a number of

questions.The idea is simple: if you like using a certain product or doing business with a particular company you like to share this experience with others.

The answers given are used to give a score which is the percentage of patients who responded that they would recommend our service to their friends and family.

Mr M was admitted to Freeman for a planned operation on his pancreas. He had insulin dependent diabetes for which he used two different types of insulin. His insulin regimen had been documented when he attended the preoperative assessment clinic a few weeks earlier, although no doses were recorded. When he was admitted for his operation it was documented that there had been no change to his medication, that he had type 1 diabetes and that he was independent in managing his own insulin injections.

When Mr M returned from theatre he was on an insulin drip which is normal after having surgery. This was stopped on the ward but his usual insulin injections were not immediately prescribed. Mr M took two doses of his quick acting insulin but did not take his long acting insulin, which he really needed. As a consequence of not getting the appropriate insulin he became very unwell with a diabetes crisis (diabetic ketoacidosis) and needed to be transferred to the critical care unit where he recovered. When he returned to the ward there were further occasions when insulin was not prescribed or given which could affect his health.

In 2013 the National Diabetes Inpatient Audit showed that in many hospitals in the UK management of insulin prescriptions is complex and that within Newcastle Hospitals mistakes were present within insulin prescriptions. The mistakes using the paper insulin prescription chart included: not having the insulin prescribed, having the incorrect type of insulin prescribed and having the incorrect time recorded for the insulin prescription (often it wasn’t prescribed for the times before meals as it should be). The same problem is occurring in hospitals throughout the UK. The result of insulin errors can be very serious.

Improvement story: we are listening to our patients and making changes

Supporting information

3. IMPROVEMENT

In response to the frequent insulin errors that were occurring, in July 2015 the Trust moved the insulin prescribing away from paper charts to the electronic prescribing system. This means that doctors do not have to prescribe insulin on a handwritten chart or on a daily basis and the prescription for insulin can be done at the same time as the other medications the patient is taking. The doses can be easily reviewed and modified as needed. The blood glucose tests that the nursing staff undertake at the patients’ bedside also automatically download to the electronic system. This means that the doctors can easily review trends in blood glucose levels each day along with the insulin doses that the patients receive.

The system allows the patients to be able to administer their own insulin within the Trust’s self-administration of medications policy if they are able to do so. In this scenario the system allows for the doctor to prescribe a dose range of insulin for the patient to choose between. The nurses are still able to document exactly what insulin dose the patient has taken. It is now clear to the doctors and pharmacists reviewing the electronic system when insulin has been omitted and the reasons given for this. The ward pharmacists also get a list of all patients taking insulin on their ward so that they can provide a safety check to ensure insulin is not omitted inappropriately.

With the introduction of this electronic blood glucose and insulin prescribing system the proportion of insulin errors has fallen in the first six weeks. The electronic system allows us to understand better where errors are still occurring and take early action.

The Trust regularly reports a low rate of harm from the Safety Thermometer. This is demonstrated on the graph below which shows that the Trust (blue line) has reported a low rate of harm maintaining 95.81% or above harm free care and a 12 month average of 96.63%, which are both above the national average of 94.0%.

In order to achieve and maintain this position the Trust has done significant work to minimise Falls, Infections and Pressure Ulcers. This report is an opportunity for us to share with you some of our learning and what we have done to reduce harm.

Falls Prevention

Prevention of patient falls, particularly those which may cause patients ‘harm’, is a key priority for the Trust. There has been a lot of work done to make sure all staff working in our hospitals take responsibility for preventing falls.

This has included:

-A new falls assessment for all adult in-patients (some hospitals only do a falls assessment on patients who are aged 65 and over)

-A falls prevention campaign called ‘No Falls On My Patch’. This includes posters being displayed in all wards and departments to highlight falls prevention. -‘Call Don’t Fall’ posters are displayed at patient bed spaces and in toilets and bathrooms to prompt patients to press their call bell when they need assistance. -We have over 100 beds that lower to the floor for the highest risk patients who may fall out of a standard bed. These beds reduce the risk of injury for our patients. -For patients who do not bring in footwear or don’t have appropriate footwear for their stay in hospital, we can provide well-fitting slippers and also non-slip slipper socks so that all patients have access to safe footwear.

-All patients who are assessed as being at risk of falling whilst in hospital have regular comfort and safety checks using the FOCUS Chart. These checks include making sure the patient has everything they need close by, including a drink and the call bell. Also, staff can offer assistance with activities such as going to the toilet for those patients who are not safe enough to do this on their own.

-We have a specialist Falls Prevention Coordinator who reviews all falls incidents and carries out an investigation if a patient suffers serious injury following a fall e.g. a broken hip. 92 93 94 95 96 97 98

Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15

%

Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Harm Free 96.72 97.35 96.73 97.7 96.18 96.32 96.2 95.81 96.89 97.01 96.65 96.66 96.08 NUTH Mean 96.63 96.63 96.63 96.63 96.63 96.63 96.63 96.63 96.63 96.63 96.63 96.63 96.63 UK Mean 94.00 94.00 94.00 94.00 94.00 94.00 94.00 94.00 94.00 94.00 94.00 94.00 94.00

hip.

Lessons learnt from looking at data about when and why falls have occurred and Root Cause Analysis are shared with clinical staff through briefings at professional forums, link nurse meetings and formal falls prevention education.

We are committed to reducing harm and review the circumstances when patients have fallen to identify learning we also review the clinical evidence and network with other care providers to see what we can learn.

Pressure Ulcers

The Trust is committed to reducing the incidence of Trust acquired pressure damage to an absolute minimum. At times, pressure ulcers develop and this is inevitable, for example when patients have to be nursed flat on a mattress and cannot be turned because they are too medically unstable to do this; or when they spend long times in theatre (some patients can be on a theatre table for 12-14 hours for very long life-saving operations). Nevertheless, the majority of pressure damage can be prevented with frequent and regular repositioning regime.

We have been working very closely with all our wards to embed turning regimes in every ward routine; we have invested in a selection of excellent mattresses that redistribute pressure to minimise risks and improve comfort; we have invested in renewing all the pillows so that patients can be repositioned from side to back to

side with comfort and efficacy; we have invested in a Time2Turn campaign where care plans, documentation and turning discs assist nurses and all other health

professionals to turn patients. Finally we have designed a patient leaflet to remind patients and carers that we are partners in the fight against pressure damage and that they can help and support us achieve our very ambitious.

Safety Thermometer - Funnel plot for Falls with Harm (Newcastle is the selected trust) and demonstrates the Trust's positive position when compared with others.

Pressure Damage Numbers by Category, Category II and Moisture Lesions being our highest numbers of damage

The above line graph demonstrates a steady reduction over time from April 13 to April 15. In December 14 we saw a sudden increase; this was disappointing but not unexpected as the Trust saw a marked increase in emergency admissions with increased numbers of very sick patients and staff working very hard to meet the needs of patients. However this recovered the following month and overall, Pressure Ulcer figures continued their downward trend.

Every instance of harm is formally reviewed using a Root Cause Analysis tool to ensure that lessons to learn are identified; These lessons are then shared across the organisation and used to inform education for staff as well as develop practice improvements such as those identified in our improvement story this month. Whilst number of pressure ulcers have shown variation, the overall trend is down and staff are encouraged to report even very small skin breaks as this ensures all damage is identified and treated appropriately.

Infection Prevention and Control

Preventing healthcare-acquired infection (HCAI) is a top priority for the Trust and the infection prevention and control team work very closely with clinical staff to help them reduce risks and deliver safe care. These are some of the ways we try and achieve this

We talk and listen to each other

If there is a case of C. difficile or MRSA blood infection, we take this very seriously. We want to know what has happened and why, so we meet with the doctors and nurses caring for the patient to review the care given; the most senior nurse and doctor in the Trust are also involved in this. We look at what went well;

identifying areas of good practice but also talk about what we could have been done better. We share this with all other departments in the Trust so that everyone learns. We also regularly meet with the infection prevention and control experts from other local Trusts to share ideas and experiences. We also benchmark with other similar Trusts to share best practice and learning.

We remind staff what is best practice

Hand hygiene is the most effective action staff can take to prevent the spread of infection. We have eye-catching posters, designed specifically for the Trust, to remind staff, patients and visitors how and when to clean their hands. We also use soaps, hand gels and moisturisers which are kind to the skin.

We run regular campaigns to raise awareness on how to reduce HCAI. Over the summer we will be running a new campaign to raise awareness about Clostridium difficile. This will be targeted at all groups of clinical staff in both the hospital and the community.

We deliver care in a safe, clean environment

We work with Hotel Services and Estates to ensure our wards and departments are clean and well-maintained. In addition to our routine cleaning staff, we have

‘Rapid Response Cleaning Teams’ who are not based on one ward or department, but are ready and available to go to any area that requires additional cleaning. We have also increased the frequency of routine of cleaning that occurs throughout the wards.

How do we know what we think happens, does happen?

We undertake a whole range of observations of practice and audits so that we can be assured we are delivering safe care and reducing harm. Examples of these include assessment of staff knowledge, practice and cleanliness.

C.difficile Appeals

There is an appeal process in place in relation to C.difficile cases as it is recognised that not all cases are avoidable. Last year the Trust successfully appealed 24 of the 89 cases recorded, which demonstrates that all care was appropriate and well documented.

Staff Family & Friends Test (FFT)

Staff Family & Friends Test (FFT) is completed by staff across the year via an online survey. It is a chance for our employees to anonymously feedback views on our organisation, with each Directorate getting invited to take part in one of the quarters.

Within the region we are the best performing Trust for recommending us as a place for care and in 2nd _{place for being recommended as a place to work. When compared to a}

National Benchmarking Group we are again the best performing Trust for recommending us as a place for care and within the top 3 Trust’s recommended as a place to work.