network event : patient pathways 19 december 2018 · the report of the culturepublic inquiry into...

Network Event : Patient pathways

19 December 2018

Presentations: slide pack

December 2019 Network Event : NWL Critical Care Network

1

Professor Tim Evans DSc. FRCP. FRCA. FMedSci

Memorial Service 24th January at 3.15pm,

St Luke’s Church Sydney Street

with a reception afterwards at the Royal Brompton Hospital

Invitation from his family and the Trust to colleagues and friends in the NWL CC Network

Introduction and Aims & Objectives for the day 19 December 2018

Network Event 2018 NWL CC Network 1

Network Event 2018Introduction and Objectives

•The NWLCC Network•Achievements so far 2018‐19•Objectives for today

North West London Critical Care Network North West London Critical Care Network

North West London

www.londonccn.nhs.uk

Critical Care Network North West London

Critical Care Network NWLMembership

Who are we?

8 CCGs in NWLBrent, Harrow, Hillingdon, Central London, West London, Hammersmith & Fulham, Hounslow, Ealing

8 CCGs in NWLBrent, Harrow, Hillingdon, Central London, West London, Hammersmith & Fulham, Hounslow, Ealing

Ambulance serviceL AS

Rapid implementation Rapid implementation of clinical policy &

initiativesSenate, Nat CRGs

Close local collaboration with CCGs, SpCom, EPRR, Senate, Nat CRGs

Quality measures

Acute trust reviews

Stakeholder events

Network organisation1WTE Director + Project Lead

&delivery from clinical staff employed by others

Transfer training & vol faculty

Task & finish groups

NWL‐wide MDT & user events

Clinical forum & board

Critically ill and at‐risk patients in North West London

Patient‐facing clinicians(medical, nursing, AHP) across all NWL acute hospital sitesComprehensive local

clinical engagement and inter‐site networking

Co‐ordinated events and workstreams delivering local, London‐wide, and national goals (e.g. clinical standards, patient pathways flu response, AKI, NEWS implementation, bus.cont)

Supported by lean organisational structure responsive to local clinical and commissioning needs

Local, clinical and patient‐driven agenda

Transfer audit and research

Web‐based training

North West London Critical Care NetworkA local & operational delivery network

Introduction and Aims & Objectives for the day 19 December 2018


NWLCC Network Achievements in 2018 examples 1

• Transfer Faculty Network Event learning and development for faculty and the workstream: July 2018

• Maintained patient transfer audits across all sites, departments for level 2 & 3 patients ; 700+ patient transfers used to inform Activity, capacity, local trust delivery meetings, CCG quality schedule, as well as provide intelligence for local actions in transfer training for greater patient safety

• Maintained incident rate at approx 4% (down from 16% originally ) • Trained c500 staff (MDT) in patient transfer skills and pathways delivered in 19

courses using multi disciplinary faculties and process :Feedback scores 98% rating and 100% participants say it will improve safety of their transfers , hundreds of “patient safety pledges” from front line staff FREE to members

• Developed the Paediatric Transfer Bag with CATs, LAS and adult/paeds /outreach services … … now available ! Its yellow

• Spot audit for renal patient transfers – reported to CCGs, Trusts and NHSE and informing on‐going work with all hospital sites

• Completed update to STrAPP ‐ the NWL Network Transfer APP

North West London Critical Care Network

NWLCC Network Achievements in 2018 (examples 2)

• Strategic Outline Case developed for Digital transfer documentation ‐ to develop prototype documentation for “One London” and the “Technical Design Authority” for the London Healthcare Records Exemplars : targeting funding sources

• Submission to ICS conference SOA 2018 – Clinical Applied Skills Passport (stage 1) E poster presentation

• National audit of types of reviews undertaken by CC networks ( with Mid Trent) to develop national core for some reviews E.G Peer Reviews

• EPRR –mass casualty ‐ designed and led two Workshops for NHS England EPRR on critical care escalation and transfers

• EPRR ‐ led design process for local, regional and national design of action cards for critical care escalation and for secondary transfer teams in mass casualty situations

• Decant support ‐ for two major moves • Daily operational business


Aim & ObjectivesNetwork Event : 19 December 2018

Bring together 70+ MDT clinical staff from across NWL organisations to inform ourselves and our work and consider how we use our collective Network resources for 2019 : Patient safety • Understand a new development for the NHS in patient safety and how it

may influence our work at network and hospital levels Patient pathways • Identify actions we can take at sector, hospital and network level to

improve our patients’ pathways and experience in the NHS and also identify any issues for escalation to others (where potential influence or/and responsibility sits elsewhere)

Adult/Children critical care• Understand the national and local changes planned in Childrens’ services

and share good practice and learning for the benefit of patientsResilience • Look after ourselves to better look after our patients


And today is a mix of ……

• Presentations• Panels /discussion• Workshop• Short /snappy updates• SLIDO questions • Coffee/tea /lunch upstairs • Exhibition ‐ thank you to the exhibitors


Capital Nurse & NWL CC Network Critical Care IV competency passport

19 December 2018


CapitalNurse is jointly sponsored by Health Education England, NHS England and NHS Improvement

IV competency passport for critical care in London

Gezz Van Zwanenberg, Chris Caldwell and Jacqueline Robinson-Rouse

Sustainable nursing workforce for London1. more to study nursing

2. continue nursing career in London

Consistent high standard of nursing care

reduce unwarranted variation

Promote importance of nursing

and opportunities that are available to nurses

We want to support nursing in LondonEvery London nurse is a CapitalNurse

For more information and to get involved

https://hee.nhs.uk/our-work/capitalnurse

[email protected]

@Capital_Nurse #Capital_Nurse

Please see the next slide for a list of all CapitalNurse work

CapitalNurse workRoutes into Nursing Retention Other pan London

workSTP work

• DoN talent pipeline • Community nursing

& midwifery parking• Cost of living

analysis

• Nursing work experience

• Understanding impact of bursary removal

• Employment offer • Student nurse

ambassadors

• Preceptorship phase 2 • Rotations • Career clinics• Experienced nursesQualification in specialisms:• Older people’s nurses• CAMHS • Theatre • Neonatal • Critical Care QIS • Children’s SACT• Perinatal mental health• IV therapy

SEL – Abi Masterson• scopingSWL - Sean Farran• Care home

leadership• Older nurses• Children’s palliative

care• Staff engagementNEL – TBCNWL – TBC• Foundation rotation

programme

NCL – Claire Johnston• Career clinics/

transfer schemes• Rotational schemes• Older nurses• Passport into

leadership (care homes) cohort 2

• GPN forum• Overseas nursing• Health and care role

shadowing• Employment offer• Return to practice• Preceptorship

network• Flexible working

Completed/ embedding/ evaluating: • Ella and Abi film • GPN leadership

Completed/ embedding/ evaluating: • Clarifying routes into

nursing • Nursing degree

apprenticeship• SN@P (numeracy

testing)Completed/ embedding/ evaluating: • Career framework • Preceptorship framework• SACT (chemotherapy)

QIS• Urgent and emergency

care QIS• Nurse educator

Completed/ embedding/ evaluating: NCL:• Passport into leadership

cohort 1• Leading across a system• Nurse lead for social care


19 December 2018


Our vision is to ‘get nursing right for London’

- - Online resource- - Nursing degree apprenticeship

- Career development support - Nearly 1,000 users

- 100% Trusts engaged- Improved NQN retention

- London wide standards, 30% savings- 102 emergency nurses trained for 18/19 winter pressures

- Career clinics- Flexible careers

What is CapitalNurse doing?Why is London different? What difference is it making?

1/3 nurses from

overseas

50% NQNs leave London

within 5yrs

Shortage of 900+ primary care nurses

Holds 20% of England’s

nursing vacancies

Nurse friendly employment practices

Qualifications in specialisms

Career framework

Preceptorship framework

Clarifying and supporting routes into nursing

System leadershipImproved STP system leadership

& collective action

Eng

age,

invo

lve

and

colla

bora

te

The IV Administration Project

Aim:

One common approach to IV administration training and assessment across London

Project Lead: Susie Scott

Objectives:

• Reduce variation

• Reduce the duplication of effort & resource utilisation

• Accepted standard of training & assessment

• Excellence in practice


19 December 2018


The Concept of a ‘Skills’ Passport

A document or record of a person’s training, education, knowledge and skills assessment which enables their records to move with them between organisations.

The employer can check easily on a future or new employees achievements

An IV Administration Passport would enable a professional’s training and assessment to be achieved once, recorded and then maintained as an accessible record.

Systemic Anti‐Cancer TherapySACT

Critical care work

Engagement: So far……

Next Steps:

• Write up and share views from stakeholder events

• Begin work with ‘working group’ • Agree and create…• Pre implementation data collection• Pilot at pilot sites

Accident investigation in healthcare: Dave Fassam, HSIB National Investigator

19 December 2018


Accident investigation in healthcareNWL CC Network Event

Dave FassamNational Investigator

@hsib_org

Investigating clinical incidents

“In this paper we suggest that [learning] would be most effectively achieved by the creation of a small, permanent independent agency, charged with coordinating major inquiries and safety investigations in the NHS.”

Independent inquiries• Each start afresh and determine own unique approach• Teams are short-lived and dissolved once the report is

complete• No capacity to review progress against recommendations• Rare, costly, conducted years after the events occurred, no

capacity to drive organisational change

Investigations in other industries1915 1912 Brooklands Flanders monoplane crash (2)

2005 1999 Paddington rail crash (31/520)

1989 1987 Herald of Free Enterprise (193)

Healthcare?

Drivers for HSIB’s establishment• Five public inquiries between 2010 and 2015

• All identified fundamental issues compromising safety, public accountability, professional culture in the health service, and the rights of patients

• Significant cost


19 December 2018


Public Inquiries into NHS Hospital Care

The Report of the Public Inquiry into

children’s heart surgery at the Bristol Royal Infirmary (2001)

Mid Staffordshire NHS Trust

Public Inquiry (2013)

Review into the quality of care and treatment provided by 14 hospital trusts in England:

overview report (2013)

Freedom to Speak Up (2015)

Morecambe Bay

Investigation ( 2015)

Findings of Public Inquiries

“appalling lack of care, compassion and leadership”, “ a culture of denial, collusion and incompetence”

Excess mortality rates

Failure to respond to staff concerns

and patient complaints

System wide failings

Investigation Specific Findings

Culture of fear and

intimidation, staff afraid to speak up

Families stories disregarded,

lack of involvement in investigations

Investigations lacked

independence

Trusts lacked investigation capability and

capacity

PHSO investigation into Sam Morrish2016• Sam was 3 years old and died from Sepsis in December

2010.

• 2014 investigation found that had Sam received appropriate care he would have survived

• BUT the investigation failed to explain why he died

• PHSO found the investigation not fit for purpose in that it failed to identify extensive series of errors

• Didn’t focus on learning or span organisational and hierarchical barriers

• Investigation excluded the family and many staff


19 December 2018


Erosion of public trust in the NHS

A Global First Health Accident Investigation Branch is Born

HSIB team (national)• Functionally independent

• 12 investigators: clinical, air accident, military accident, human factors

• 3 Principal National Investigators

• Up to 30 investigations per year • 1.8m+ reports on NRLS• 24,000+ serious incident reports

• Improving the standard of investigations across the NHS

Expanded remit• In November 2017, the Secretary of State for Health and Social Care

announced a new maternity safety strategy detailing plans for HSIB to undertake ~1000 independent safety investigations

• The investigation element is part of an overall strategy to improve maternity safety

• A maternity implementation team was set up to develop the approach, methodology, and recruit investigation teams

• Programme roll out began in April 2018, with full national coverage by April 2019


19 December 2018


HSIB Principles• Objectivity

Recommendations are for learning and improvement not to attribute blame or liability

• Transparency

Reflecting a model of openness through genuine engagement

• Independent in action, thought and judgement

Operating without fear or favour and exercising independence when investigating any area of patient safety

• Expertise

Staffed by investigation experts with a range of backgrounds

• Learning for improvement

Use findings to deliver practical solutions, address causes and contributory factors and provide support to increase the capability within local NHS systems

Challenges• What should we investigate?

• How do we involve families?

• How do we engage with NHS organisations?

• How do we engage with other statutory bodies?

Researching potential risks

Health system risks

Review and analyse data to

determine systemic issues

Create library of systemic risks

Data gathering

Evaluate against HSIB criteria

Scoping

HSIB criteria

Outcome Impact

Systemic Risk

Learning Potential

• People: physical, psychological, loss of trust• Service: quality and reliability, capacity and capability• Public: confidence, political attention, media profile

• Systemic safety deficiency: range of care settings; geographic/specialist spread; scale through system structures; complexity of interactions

• Dormancy period: time taken to identify risk; route of discovery• Persistence and expansion: Permanence; potential for escalation and spread

• Potential for increased knowledge: new knowledge; gap in current knowledge; • Potential for systemic improvement: opportunity to positively influence system,

practices, safety culture• Practicality of action: feasibility of conducting effective investigation; practicality of

issuing influential recommendations• Value of intervention: adequacy and scope of safety actions by others; potential to

develop HSIB capacity and capability


19 December 2018


What should we investigate?• Consistent challenge to measure the scale of patient safety in healthcare.

• In UK 10% patients suffered harm when receiving hospital care (Vincent et al 2001).

• 3.6% rate of preventability of mortality (Hogan et al 2015)

• Approx 230,000 hospital deaths = 8,280

Is it all about death?• Most hospital deaths do not involve error AND

• Most errors do not result in death but can result in significant harm, suffering and distress

• Incident reporting – 2 national incident reporting systems, significant overlap

• National Reporting and Learning System (NRLS) 1.3 million per year (Woodward 2017),

• Only 5% of incidents captured in either of reporting systems (Woodward 2017)

Investigation principles• System wide safety issues• Systems, not individuals• Insights from human factors science• A Just Culture approach• Safe Space principles• Learning from near misses as well as serious

harm

HSIB Investigation selection• Individual incidents are the basis of our investigations

• Safety Awareness Notice open to all, public professionals, NHS organisations, external organisations such as Police

• Intelligence Unit review incident reporting systems identify potential investigations

• Identification of themes of national importance and then identifying incidents to initiate an investigation


19 December 2018


HSIB investigationsJuly 2017 Cardiac and vascular pathwaysOct 2017 Recognising and responding to critically unwell patientsNov 2017 Wrong route administration of an oral drug into a veinJan 2018 Safe delivery of oxygenJune 2018 The primary management of acute onset testicular painAug 2018 Button battery ingestionSept 2018 Communication and follow up of unexpected significant radiological

findingsOct 2018 ePrescribing systems and safe dischargeOct 2018 Management of chronic health conditions in a prisonerOct 2018 The diagnosis and management of ectopic pregnancy

5 more investigations launched and being scoped

Sept 2017

Wrong site interventionsProvision of mental health services in the ED

Oct 2017 Transitions from CAHMS to AMHSNov 2017 Implantation of the wrong prosthesis

Insertion of an incorrect intraocular lens

Investigation themes

Equipment Design / Use

Diagnostic Medication

Coordination of work

National Guidance

Transfer Communications

Procurement

Cognitive Biases

RecommendationsInvestigation into the implantation of wrong prostheses during joint replacement surgery

Investigation into administering a wrong site nerve block

Observations


19 December 2018


How do we involve families?• Critically important for HSIB, given the history of NHS investigations

• What level of involvement?

• How do we maintain our independence?

• Head of Family Engagement

• Now ensuring that family engagement is considered at the earliest stages of each investigation

• Model of engagement will develop over time

Engagement with NHS organisations• Mixed response so far

• Some NHS Trusts are wary of us; are we another regulator?

• Investigation teams understand that these relationships are critical for future success

• No powers so far but ensures investigation teams take a collaborative approach

• Independence!

Essential investigation ingredients

Independence

Family engagement

Trust engagement

Engagement with statutory bodies• NHS regulators, CQC, NHSI

• Coroner

• HSE

• Police


19 December 2018


Findings so far• System based errors,

• Referral between agencies and departments

• Work arounds,

• Work as done, not imagined

• Assumptions being made about competencies

• Families/patients ignored during the investigation process

• Compromised investigation capability and capacity

• Revert to who did or didn’t do it

• Cultural limitations regarding understanding errors

Next five years• Embryonic organisation

• Experience

• Legislative change – HSSIB Bill

• Establishment on statutory basis with powers

• Review impact of HSSIB

Patient pathway workshop: renal access and maj trauma repatration 19 December 2018

Network Event 2018: NWL CC Network 1

Renal Workshop Background reminders • Pathways for known CKD patients ‐ into their local hospital ED

• In‐patient access to satellite dialysis AKI and CKD patients• Haemofiltration in ICU /recovery‐ in/out

• 13:1 units to renal centre – (national average 4/5)• Feedback from units, audit in 2018 and Transfer audit

– Referral process – Clarity of inter‐hospital referrals – Patient status – are they on the list? When might they move?– Communication ‐ multiple email routes, calls, clinical and non clinical– Transfer – Handovers – status WORKSHOP – SOP, transparency of list of patients waiting


Renal Workshop

Renal Question 1:

Getting the patient referred

What items do you expect to be in a standard operating procedure (SOP) for the referral of a patient in ICU to the renal services at Hammersmith Hospital ?

Think: referral, acceptance, review, feedback, escalation, safe transfer

Renal Question 2. Knowing the status of your patient (that you think has been referred):

The Renal waitlist spread‐sheet is to be shared with each hospital/Trust site operational management on a daily basis by the renal service:

What essential items about your patient(s) do you expect to see on the excel spread‐sheet?

Think: Trust, Hospital site, ward, Pt Initials, gender, age , diagnosis, referral date, acceptance on list date, anticipated date of move?

Renal Question 3. E‐ referral systems

What are the key features of an E referral system that you would like to see?

Think: any you rate highly or dislike intensely? App based, web based, same for different specialties, clinical “views”, operational “views”, time saving features?

Patient pathway workshop: renal access and maj trauma repatration 19 December 2018

Network Event 2018: NWL CC Network 2

Major Trauma Repatriation workshop

Content of a SOP :

• critical care to critical care • Structure and format of handovers


Major Trauma Question 1. Getting the patient repatriated to a critical care unit locally

What items do you expect to be in a standard operating procedure (SOP) for the repatriation of a patient in the major trauma centre ICU to a local ICU?

Think: Pre‐warning – do you know they are there? , advance notification, specialist input, home team notification, MDT, clinician discussions, hospital support (management/services), patient expectations, family/relatives, equipment, skills , onward destination…. Longer term requirements, timeframe, showstoppers?

Major Trauma Question 2. Handover tool

What are the essential elements or key features of a standardised handover tool from one ICU to the other?

Think: SBAR? A.M.P.L.E. digital? barriers, challenges, opportunities, existing discharge documentation, family /relatives?

Cardiac patient pathways in NWL: Donna Hall 19 December 2018


NW London Cardiac Patient Pathways – overview

Dr. Donna HallClinical Lead Harefield ICUMedical Lead NWLCCN

NWLCCN – 3 cardiac centres

• Hammersmith Hospital• Aortic dissection• Primary PCI

• Royal Brompton Hospital• Aortic dissection• SARF (VV ECMO)

• Harefield Hospital• Aortic dissection• Primary PCI• Transplantation

Identification and treatment of aortic dissection in patients presenting with chest pain

Aortic dissection – how to access pathway?



Minor impact on critical careHammersmith – cardiac ICU post‐op

Harefield – ITU

Spend reasonable length of time in theatre

Short post‐op length of stay

Primary Percutaneous Coronary Intervention (Primary PCI)

• First PPCI at Harefield April 2003 – taxi driver• 2006 DOH – Mending Hearts and Brains – made clinical case for change and 24/7 PPCI service

• Following 2008 publication of NIAP report (National Infarct Angioplasty Project) coordinated rollout of PPCI services in England

• Reduced mortality and improved outcome cf. fibrinolysis• Reduced in‐hospital mortality• Lowest mortality if bypass A+E• More patients suitable for PPCI than fibrinolysis

• Commissioned service 2013/14

Percutaneous coronary intervention in the UK: recommendations for good practice 2015 (BCIS)

• Minimum centre volume is 400 cases/year.• Minimum of three interventional cardiologists per centre.• PPCI centres should have at least two catheter laboratories and 24/7 provision of service for STEMI.

• PPCI centres should perform an absolute minimum of 100 STEMI/PPCI cases/year.

• BCIS fully supports the provision of PCI in appropriately selected patients in centres without on‐site cardiac surgery.

• 0.05% required emergency transfer for surgical revascularisation in 2012



Impact on Critical Care

• Immediate involvement by critical care team• Never close to PPCI• Harefield – one critical care unit – overflow into Recovery area

• % of admission (2017‐18)• 1% PPCI only• 7% OOHCA + PPCI• 1% other

• Hammersmith – general critical care – overflow into cardiac ICU and theatre

Access to PPCI via ambulance service

• Paramedics/ED call ahead for Primary activation• Ambulance met at entrance to hospital by revascularisation team• Patient taken straight to cath lab to reduce door to balloon time• Critical care contacted if patient intubated

Non PPCI referrals

• Cardiology Reg on call via switchboard• Now using referapatient.org web‐based referral and documentation• All referrals discussed with cardiology consultant• If critical care required – cardiology consultant to ICU consultant• Expectation to have ICU – ICU consultant discussion if accepted for cardiology procedure

• Hammersmith ICU will encourage cardiologists to visit patient if in neighbouring ICU especially if capacity issues

Heart transplantation (+ mechanical support)

• For inpatient referral call Transplant physician Fellow bleep via switchboard• Receive a referral form – fully completed



Criteria for urgent listing Cardiogenic shock pathway

• A place for it• Developing a coherent and organised pathway – cardiology, transplant cardiology, critical care and transplant surgeons

• Very high mortality, complex and huge resource (especially critical care)• External referrals or via the PPCI programme

Salvage VA ECMO – 21 patients from 15 centresClinical Commissioning Policy:Extra corporeal membrane oxygenation (ECMO) service for adults with cardiac failure - July 16

• 1. Following heart surgery• 2. Acute heart failure• 3. Augmented CPR• uncertainty about which patients are likely to benefit from this procedure, and the evidence on safety shows a high incidence of serious complications – NICE 2014

• NHS England has concluded that there is not sufficient evidence to support a proposal for the routine commissioning of extra corporeal membrane oxygenation (ECMO) for adults with acute cardiac failure.

Organ Donation update: Lucy Dames 19 December 2018


Organ Donation in the UKLucy Dames Team Manager –London Organ Donation Services Team

@Lucy_Dames

• UK-wide organ donation organisation

• Legal and ethical issues• Clarified roles

• Acute hospital Trusts• Departments of Health/NHS

• Monitoring and reporting• Review of donor co-ordination

& organ retrieval• Training• Public promotion and donor

recognition

Falling donor numbers in UK led toOrgan Donation Expert Working Group

14 recommendations aimed to increase organ donors by 50% over 5 years

DBD Donors

Regional SNOD Teams

Each Region will have:

• 1 Regional Manager

• Regional Clinical Lead

• 2-4 Team Managers

• Approx. 12-20 SNODS per region

• 24/7 coverage

• Hospital Based

SNOD =Specialist Nurse Organ Donation

50% increase in donors achieved

Since 2007/8:

17% fall in total waiting list

57% increase in transplants (all organs)

75% increase in deceased organ donors

UK deceased donors, transplants and transplant waiting list

809 899 959 1010 1088 1212 1320 1282 1364 1413

23842559 2655 2706

29163118

35083339

35283710

6469

69437026

781478877658 7645

7335

6388

0

1000

2000

3000

4000

5000

6000

7000

8000

2007-08 2008-09 2009-10 2010-11 2011-12 2012-13 2013-14 2014-15 2015-16 2016-17N

umbe

r

DonorsTransplantsTransplant list


Network EVent 2018 NWL CC Network 2

609 611 624 637 652 705 780 772 785 829

200288 335 373 436

507540 510

579584

0

100200

300400

500

600700

800900

1000

11001200

13001400

1500

2007-08 2008-09 2009-10 2010-11 2011-12 2012-13 2013-14 2014-15 2015-16 2016-17

Num

ber

Donors after brain death (DBD) Donors after circulatory death (DCD)

Increase in number of deceased donors in UK

DBD DCD

87

44

73

30

80

36

82

50

106

59

90

47

100

45

95

45148

46

68

34

136

68

Num

ber

0

100

200

300

Year

09/10

10/11

11/12

12/13

13/14

14/15

15/16

16/17

17/18

18/19

Apr-Sep 18/19

projected

Actual deceased donors - London team

1 October 2009 to 31 September 2018, data as at 8 October 2018

Age of deceased donors

8 5 7 4 4 4 3 4 4 4 4

5348 50

46 42 38 37 37 39 36 36

2226 24

2424

25 26 22 25 25 24

13 17 1518 20 23 22 22

22 23 22

3 3 5 8 10 11 12 16 11 13 14

0

10

20

30

40

50

60

70

80

90

100

2006/07 2007/08 2008/09 2009/10 2010/11 2011/12 2012/13 2013/14 2014/15 2015/16 2016/17

70+60‐6950‐5918‐490‐17

% o

f don

ors

Devastating Brain Injury Pathway

GOAL =For ALL Acute Hospital Trusts in the UK to Implement this pathway



Technological Improvements

• ‘DonorPath’ is an award winning tablet based app created by APADMI and NHS Blood and Transplant

• 766 duplicated nurse hours saved

• 18,373 app form submissions per year

• 132,000 A4 sheets saved per year

• “(The app) had enabled out Specialist Nurses to work in a truly mobile way –it’s transformed the way they work” –John Richardson, Head of Health Informatics –Organ Donation and Transplantation

DCD Donor Assessment Pathway

• In the UK DCD donation accounts for 40% of all organ donors

• 75% of all referrals for organ donation are potential DCD donors.

• In 2014-15,

– 3064 Specialist Nurse –Organ Donation attendances at potential DCD donors

– 520 (17%) proceeded to donate organs. • The rate of non-proceeding DCD donations has a negative impact on

the families involved, morale, staffing resources within NHSBT and the appetite of healthcare colleagues to make donor referrals.

• Requirement to increase donor referrals to reach strategic target of increasing transplant number

• The DCD Donor Assessment Form, devised from assessment of historical outcome data, allows SNODs to quickly assess the suitability of a potential DCD donor at the point of referral which has multi-factorial benefits –if any exclusions are identified then the referral is considered a non potential donor

• If an exclusion to DCD donation is not identified then further clinical information is taken at point of referral and this can then be used to make screening calls to local and national transplant centres



• Once a referral is complete these forms are collected electronically and the data is reviewed regularly to ensure the tool remains up to date and that exclusions are regularly assessed.

• There is a similar assessment form for all Neonatal and Infant Donor assessment (under 5kgs or <2 months old)

Current initiatives to increase activity

1 Focus on ‘missed opportunities’Reports of individual missed referrals, family consents, organ transplants

2 Review of length of donation process 3 Organ Utilisation Strategy

DBD donation

The success:

• Organ Donation Expert Working Group established by Government in 2006 in response to falling donor numbers in UK

• Changes in infrastructure and increasing use of Maastricht 3 DCD donors led to sustained increases

• UK deceased donor (DD) rate now 21 pmp – record high• 57% more DD transplants than 10 years ago• Kidney waiting list and waiting times falling• Focus on ‘missed opportunities’, reducing

the length of the process and organ utilisation

809 899 959 1010 1088 1212 1320 1282 1364 1413

23842559 2655 2706

29163118

35083339

35283710

6469

69437026

781478877658 7645

7335

6388

0

1000

2000

3000

4000

5000

6000

7000

8000

2007-08 2008-09 2009-10 2010-11 2011-12 2012-13 2013-14 2014-15 2015-16 2016-17

Num

ber

DonorsTransplantsTransplant list

Taking organs and transplant into 2020

Should any of these groups fail to respond the strategy will not be achieved



The Behaviour Change StrategyPublic Organ Donation Promotion

• What are you waiting for ?• Hothouses – If you could save a life, would you?• Sign for Life • Paid social• In hospital materials pilot – Lift wraps, wall mounts, family information

booklet

The Behaviour Change Strategy

• End of transaction prompts - now feature across 25 high traffic Government sites& engaged a number of Health Insurance companies to secure new prompts.

The Behaviour Change Strategy Opt-Out – ‘Max and Keira’s Law’



Engagement

Publ

ic

Faith

Don

or

fam

ilies

Patie

nts

NH

S

Gov

t.

Vol.

Sect

or

On-line survey X X X X X X XMeeting X XExisting forums X XFocus groups X X

Decision to legislate

Decision to legislate

PreparationPreparation

DevelopmentDevelopment

Parliamentary stages

Parliamentary stages

Royal AssentRoyal Assent

ImplementationImplementation

Parliamentary Process

This means the Bill is on track to get Royal Assent (meaning, if passed, will become an act of Parliament) in the Spring of next year, 2019. There would be a year to prepare for implementation of the Bill and to run a public information campaign, notifying people to the change. All being well, the opt out system would come into effect in April 2020

The Private Members Bill, which would introduce an opt out system of organ donation, has now been considered by a committee of MPs in the House of Commons and successfully moved to the Report Stage and is now for consideration in the House of Lords.

Evidence?Study Setting Impact of presumed consent

Abadie and Gay, 2006

22 countries,1993‐2002 25‐30% higher organ donation rates.

Neto et al, 2007 34 countries over a five year period 21‐26% increase in organ donation rates

Healy et al, 2005 17 countries, 1990‐2002

organ donation rates higher by were greater by 2.7 donors per million population (PMP)

Gimbel et al, 2003 28 countries, 1995‐1999 Extra 6.14 donors PMP

Bilgel, 2012 24 countries, 1993‐2006

13‐18% higher organ donation

rates than countries with informed consent legislation.

Transplant units, H&I laboratory and other hospital staff and Specialist Nurses for Organ Donation in the UK for

provision of data to the UK Transplant Registry.Andrew Broderick NHSBT

APADMIAll our donors and their families

Acknowledgements

@Lucy_Dames

Paediatric Critical Care Network in NWL: Ruchi Sinha & Michelle Pash 19 December 2018


NORTH WEST LONDON PAEDIATRIC CRITICAL CARE

NETWORK DR RUCHI SINHA

MICHELLE PASH

SERVICE SPEC

• Paediatric Critical Care (PCC) services look after children and young people whose conditions are life‐threatening and need constant close monitoring and support from equipment and medication to restore and/or maintain normal body functions.

• The definitions of the full range of Paediatric Critical Care (PCC) are as follows:

• Level 1 paediatric Critical Care Units (PCCUs) will be located in all hospitals providing inpatient care to children and willdeliver level 1 PCC care. (Provided in all District General Hospitals which have in‐patient facilities. This level of activity is not specialised and is not commissioned directly by NHS England and is the responsibility of CCG’s.

• Level 2 PCCUs may be specialist or non‐specialist and are provided in tertiary hospitals and a limited number of DGHsand will deliver level 1 & 2 care. These were formerly classified as HDUs. (Commissioned by NHS England)

• Level 3 PCCUs (PICUs) are usually located in tertiary centres or specialist hospitals and can provide all 3 levels of PCC.(Commissioned by NHS England)

• In England 1.4 children per 100,000 population are admitted to a PCC Level 3 unit.

• Children up to the age of 16 are normally cared for in a Paediatric Critical Care environment, although the National Service Framework for Children states the age range for inclusion within paediatric care is 0‐18 years (up to but not including the 19th birthday).

• PCC services shall be available to all critically ill children from the point of discharge from maternity or a neonatal unit until their 16th birthday.

• In addition, on rare occasions a PCC unit may be deemed to be the most clinically appropriate place to provide critical care to young adults between the ages of 16‐24 years (up to but not including the 24th birthday) – for instance as part of a long‐term pathway of care managed by a paediatric team or because of their stage of physical or emotional development. Young people who have not completed transition to adult services will usually be cared for in a PICU unless they, or their carers, express a different preference.

Therefore, any patient between the ages of 0‐24 years cared for in a designated level 3 PCC or transferred to or from a level 3 PCC unit by a commissioned paediatric critical care transport service, will be considered to be accessing paediatric critical care

Paediatric Critical Care Network in NWL Ruchi 19 December 2018


THE NEED FOR CHANGE• Demand Vs capacity in PICUs

• Length of stay/complexity

• Technology dependence

• Long distant from home

• Variations in

- HDC bed days across regions

- Retrieval

- Repatriation

HIGH DEPENDENCY CARE FOR CHILDREN - TIME TO MOVE ON A SET OF RECOMMENDATIONS TO IMPROVE THE CARE OF THE CRITICALLY ILL CHILD BEYOND THE PAEDIATRIC INTENSIVE CARE UNIT

• Classification of Paediatric Critical Care and Paediatric Critical Care Units (PCCUs)

• Clinical Pathways and progression between critical care levels

• Transportation

• Workforce considerations - Nursing staff considerations

- Medical staff considerations

- Maintaining competence and skills / Continuing Professional Development (CPD)

• Setting standards and defining quality

• Measurement of activity and outcomes

• Audit and governance arrangements

• Commissioning arrangements and designation of critical care units

RCPCH 2008 TIME TO MOVE ON

• Interventions performed in all

hospitals admitting children

• Level 1 (basic critical care) interventions.

• Can be performed in a Level 1 unit

designated to undertake Level 1 interventions

• Level 2 (intermediate critical care)

• interventions. Can only be delivered in a Level 2 unit

• designated to undertake Level 2

• interventions

• PICU – able to deliver Level 3

• (advanced critical care) interventions

• Currently only performed at specialist



• Paediatric Critical Care and Specialised Surgery in Children Review• NHS England launched a national review into paediatric critical care and specialised surgery in

children in October 2016.

• The review is considering paediatric critical care, specialised surgery in children, paediatric critical care transport and extracorporeal membrane oxygenation (ECMO). Though there are distinct issues to address, there are also some common challenges and areas of overlap between the elements of the review.

• The key drivers for the review are increasing pressure on services and variation in the care currently provided.

• The review aims to assure sustainable services that are fit for the future and reduce the variations of care that some children currently experience.

• NHS England will continue engaging on a vision for paediatric critical care and specialised surgery in children during 2017. The review terms of reference are available.

ISSUES TO ADDRESS

• Increased surgery in specialist centres• Increased length of stay• Increased disability and more LTV patients• Workforce pressures under considerable strain, esp in winter

LEVEL 1 PAEDIATRIC CRITICAL CARE UNIT -INTERVENTIONS

• Oxygen therapy + pulse oximetry + Electrocardiogram (ECG) monitoring (includes ‘high flow’ nasal oxygen therapy/Optiflow)

• Arrhythmia requiring IV anti-arrhythmic

• Diabetic Ketoacidosis requiring continuous infusion of insulin

• Severe Asthma requiring IV bronchodilator therapy

• Reduced conscious level (Glasgow Coma Score (GCS) 12 or below) AND hourly (or more frequent) GCS monitoring

• Upper airway obstruction requiring nebulised adrenaline

• Child with apnoea's

LEVEL 2 PAEDIATRIC CRITICAL CARE UNIT -INTERVENTIONS

• Status epilepticus requiring treatment with continuous intravenous (IV) infusion

• Nasopharyngeal airway

• Long term ventilation via a tracheostomy or mask

• Arterial line / Central venous pressure monitoring

• Epidural

• Care of tracheostomy (first 7 days of admission)

• Acute non-invasive ventilation, including Continuous Positive Airway Pressure (CPAP)

• >80 mls/kg fluid bolus in 24 hours

• Inotropic / vasopressor treatment



TIME TO MOVE ON

• Level 1 PCCU (DGH) interventions• AIRWAY: • Care of child with airway pathology until local anaesthetist provides support.• Intubation and ventilation of child or baby in an emergency (including all relevant equipment and training) until retrieval

team arrives.• Management of the unventilated child with tracheostomy (>7 days post procedure) • Care for child with established naso‐pharyngeal airway.

• BREATHING: • Deliver intravenous bronchodilators, or continuous nebuliser for severe asthma in a fully monitored environment until

retrieval team arrives or child stabilises.• Deliver CPAP (<1 years) and ± Nasal humidified high flow oxygen (Optiflow or equivalent system) for the support of child

with respiratory disease (<2 years).• Chest physiotherapy for child with respiratory

• Level 2 PCCU (DGH) interventions• A Level 2 PCCU (DGH) must be able to provide all Level 1 PCCU interventions. • Where there is a failure to respond to treatment as expected and/or the requirement for intervention persists

for >24 hours in a Level 1 PCCU setting the child should be transferred to Level 3 PCCU (after discussion with PCCN lead centre).

• LTV patients at home or in the community who become unwell will be asked to present at their designated Level 2 PCCU (DGH) rather their nearest Level 1 PCCU (DGH). It is therefore not anticipated that there will be transfers from Level 1 PCCU (DGH) to Level 2 PCCU (DGH). This mirrors the bypass pathways for major trauma. In the event of unexpected presentation at a Level 1 PCCU (DGH) of a LTV patient or patient with a tracheostomy, the child will be assessed, treated and transferred to a Level 2 or Level 3 PCCU as appropriate. The transfer of this child should be discussed with the children’s acute transport services.

• LTV patients will typically step down from Level 3 PCCU to Level 2 PCCU (DGH) and then home. • The following levels of care would constitute Level 2 (DGH) interventions. • BREATHING: • Acute non‐invasive ventilation (BiPAP) and CPAP for CYP (≥1 year).• Management of long term ventilated child (by mask or tracheostomy) as per LTV standards (‘Paediatric Long

Term Ventilation Service Specification’ (NHS England) and ‘From hospital to home: Guidance on discharge management and community support for children using long‐term ventilation’

NETWORK CONFIGURATION

Level 3

• St Mary’s (Imperial)

• Royal Brompton

Level 2

• Chelsea & Westminster

Level 1 (2)DGHs

• Hillingdon•Watford• Northwick Park •West Middlesex



GEOGRAPHICAL COVERAGE OF NETWORK

● Watford

Northwick Park Hospital: PCC Level 1 and 2 summary

National Standards Data ‐ November 2017

Patients Bed days

PCC Level 1 7 18

PCC Level 2 26 116

TOTAL 33 134

4.3 patients per day requiring critical care interventions

Hillingdon Hospital paediatric critical care ‐ bed days

Level (derived) Data

Level 1Level 2

Total Total Pts

Total Bed days

YearsDischarge Date Total Pts

Bed days

Total Pts

Bed days

2017 Aug 8 25 8 25

Sep 15 47 15 47

Oct 20 280 3 11 23 290

Nov 30 105 2 3 32 107

Dec 23 81 2 9 25 90

Grand Total 96 536 7 23 103 559

Watford General Hospital ‐ 2016 HDU overview

Admitted from L1 L2Grand Total

ED/AE23 21 44

Theatres2 2

Grand Total25 21 46

DATA/ACTIVITY CATS DATA – AUGUST TO DECEMBER 2017CATS summary: August to December 2017

Count of CATS ID Month

Referring Unit Outcome Aug‐17 Sep‐17 Oct‐17 Nov‐17 Dec‐17 Grand Total

Northwick Park Hospital‐(RV820) Accepted for transport 2 1 2 13 14 32

Advice only 1 1 1 5 5 13

Refused 1 1 2

Total 4 2 4 18 19 47

The Hillingdon Hospital‐(NPV02) Accepted for transport 3 2 3 6 3 17


Refused 1 1 1 1 2 6

Total 10 6 13 11 9 49

Watford General Hospital‐(RWG02) Accepted for transport 1 4 8 4 17


Total 1 2 6 9 8 26

Grand Total 15 10 23 38 36 122



NETWORK MATURITY

• Established beginning of 2018

• Developmental, evolving in response to CQUIN

• Not a formal ODN

• ? Plan for North London ODN

AFFILIATED NETWORKS

• CATS• North East London PCCN

• South London and South England PCCN

• North West London Critical Care Network (Adults)

• North West London Trauma Network

• North West London Paediatric Surgical Network

• LTV – evolving network for PAN‐London

CURRENT NETWORK PRIORITIES1) Nursing Education & Passport

2) Patient Journey between PCC units/levels including standardised infection control guidance and uniform discharge communication

3) LTV Pathway

• Collaboration with Retrieval Team

• Simulation Training

• Workshop Teaching

• Work Placement (medical/nursing/other HCP)

• Data Collection

• Support in Commissioning Proposals

NETWORK WEBSITE



ONLINE TOOLS

GREATEST CHALLENGES

• Funding for DGHs• Funding for Network after CQUIN• Transport for level 1 and 2 patients

• Repatriation challenges – infection control and transport• Capacity

• ENT under 2 years• Paediatric Surgery• LTV • Time frame to achieve objectives



VISIONS FOR THE FUTURE• Collaboration with our adult network

• Education and training

• Cooperation and engagement at both ends of the spectrum ‐ big kid / small adult with comorbidities

• Flexible movement of nursing workforce to meet demands

• Passport

• Training

• Governance

• More robust LTV pathway

• Just one example of clinical pathways to improve patient flow

THANK YOU FOR LISTENING

Any Questions?

Critical Care patient perspective: Mike Dean 19 December 2018


Royal Overseas League, London, 19th December 2018




https://www.ambulancewishfoundation.org.uk/

Nutrition survey in NWL Critical care Units ‐results & areas for improvement: Ella Terblanche

19 December 2018


Nutrition Survey in NW London Critical Care units:

results and areas for improvement

Ella Terblanche Nutrition Lead RBHT

[email protected]

Last year Results from national survey into fasting practices on ICU • 176 units• Only 20% had a fasting guideline• Fasting times are varied, inconsistent leading to underfeeding & frustratedstaff

• When guidelines present, fasting was significantly shorter for surgery & radiology

Implementation of volume based feeding (VBF) at NWP• % calories delivered increased from 51% to 82% of target• % protein delivered increased from 40% to 73% of target

GPICS V2Nutrition Support

Gezz

Nutrition survey in NWL Critical care Units ‐results & areas for improvement : Ella Terblanche

19 December 2018


Survey of current nutrition practices

Network dietitians completed it for their units

15 responses 13 NHS hospitals2 Private hospitals

Must have a ICU specific nutrition support guideline

Yes‐ in one document

53%[CATEGORY NAME]

[PERCENTAGE]

[CATEGORY NAME]

[PERCENTAGE]

Does your unit stipulating time to initiate nutrition?

Yes 60%

No40%

4 units‐within 48 hours

4 units within 24 hours

1 unit‐ 4‐6hours

Factors included in guidelinesFactor Number of

units Prokinetics 13GRV’s 13Re‐feeding 11NJT criteria 9Fasting times 5VBF 3

Nutrition survey in NWL Critical care Units ‐results & areas for improvement: Ella Terblanche

19 December 2018


NGT type & confirmation must comply with NHS England Guidance

Number of units

Had guidance 15

pH first, CXR 2nd 9

Only using CXR 5

pH & Cortrack 1

Using Rylestubes for feeding

5

If the dietitian could change one thing…….

4 4 4

1 1 1

Improved compliancewith guidelines

Fasting guidelines Catch up feeding Nutritional screening& referal

Ryles tubes forfeeding

High proteinfeeds/supplements

Improvements

All units need to have 1 easily

identifiable nutrition feeding guideline

Need to define time to initiate feeding

Avoiding feeding via ryles tubes

Develop fasting guidelines

Network wide auditing of GPICS V2

compliance

For units that capacity for new

initiatives – consider VBF / catch up

Discharge from ICU Jane‐Marie Hamill 19 December 2018


Discharge From ICU

What makes us frustrated ?

• Poor Wi-Fi connection

• Nobody moving down in a bus when there is room

• Plastic packaging

• Forgetting someone’s name

• Loud people

• When someone doesn’t know the words to a song but sings itanyway

• No parking spaces ……………………………………………………

***CONFIDENTIAL***

Poor Parking?

Timely discharge from ICU

***CONFIDENTIAL***



Discharge within 4 hours Why is it important?

• Risk of cross infection

• Delays overall hospital stay

• Stress from ICU environment they no longer need to be in (noise,light etc)

• Delay to incoming patients

• Avoidable risk of late night discharges

• Patient experience – lack of handover etc

***CONFIDENTIAL***

Discharge from ICU Jane‐Marie Hamil 19 December 2018


Quality Measurements

Number of patients discharged with 4 hours

Number of patients discharged between 4 and 24 hours

Number patients who wait greater than 24 hours

• Number of patients transferred out between 22.00-07.00

CW- 2017/18

Delay (hrs) APR MAY JUN JUL AUG SEP OCT NOV DEC JAN FEB MAR Total % of total< 4 10 11 12 6 22 11 5 7 14 12 13 7 130 27%4 to 24 13 21 19 16 19 16 23 19 22 17 20 23 228 48%24 + 10 12 5 6 13 15 18 16 7 1 5 7 115 24%Total 33 44 36 28 54 42 46 42 43 30 38 37 473

Discharge times/delays & reason

WM-2017/18

Delay (hrs) APR MAY JUN JUL AUG SEP OCT NOV DEC JAN FEB MAR Total % of total< 4 25 21 27 6 14 3 2 15 20 17 6 22 178 37%4 to 24 15 27 20 22 17 17 22 19 29 20 23 16 247 51%24 + 3 4 0 5 2 10 6 12 7 0 4 4 57 12%Total 43 52 47 33 33 30 30 46 56 37 33 42 482

Discharge times/delays & reason

Discharges -22.00-07.00

14 5

3 35 4

1 2 31 1

33

13 4

13 2 2 2 2 3 2

4

29

Discharges in Icu Between 22.00‐07.00 2017/18

CW West Mid



Reason

Reason APR MAY JUN JUL AUG SEP OCT NOV DEC JAN FEB MAR TotalNo beds 21 26 22 17 24 25 35 29 23 15 20 25 282No sideroom 2 5 0 2 2 3 4 3 1 2 4 3 31No level 1 beds 0 0 2 3 5 2 1 1 5 1 0 1 21Transport problems 0 0 0 0 0 0 0 0 0 0 0 0 0MDT/Outreach review 0 0 0 0 1 0 0 1 0 0 1 0 3Ward delay 0 2 0 0 0 0 1 1 0 0 0 1 5Total 23 33 24 22 32 30 41 35 29 18 25 30 342

Other Reasons

Ward Reasons Flow /speciality Unit Reasons

• Waiting for cleaning bed area

• Lack of equipment• Lack of mattress• Waiting on side room

• Awaiting ambulance transfer

• No speciality or receiving consultant yet to accept patient care on the ward

• Patient ICU discharge documentation not ready

• LINES (arterial ,CVP lines in )

***CONFIDENTIAL***

What have we done

Senior consistent presence at the clinical site bed meetings

The nurse in charge had been attending previously but this could have been multiple staff in a week. Currently the lead nurse/ deputy attend every day to facilitate continuity regarding discharges and establishing robust plans with site team

Increased awareness by site team

The site team are more aware of the importance of stepping down critical ill patients this is supported by senior executive team. All step downs are recorded on the white board in the site office so that there is a visible trail of what is happening to them.

***CONFIDENTIAL***

Discharge from ICU Jane‐Marie Hamil 19 December 2018


When the clock starts

***CONFIDENTIAL***

Discharge from ICU is a Clinical not managerial decision

Clocks Starts ………When patient is deemed medically fit for discharge

Clock Stops………..When patient leaves the unit

Clock Stops………..If patient deteriorates after decision made but the patient hasn’t left the clock stops

***CONFIDENTIAL***

Escalation Process

***CONFIDENTIAL***

What have we done

• MDT meeting discussing complicated patients

• Development of Patient pathways

Elective /Emergency

• Escalation – vocal presence at Bed Meeting

• Data Capture

• Actively reducing Number of patients we transfer out before 07.00by keeping patient on the ward bed until that time

***CONFIDENTIAL***



Has it worked

…….reduction to 19% of patients waiting more than 24 hours compared to last year

….. 50% less patients transferred out between 22.00-07.00

***CONFIDENTIAL***

However

Timely Discharge from ICU has always been a challenge. The specialised commissioning datasets have made this more visible externally.

The patient flow in a hospital is affected by multifactorial issues. Discharges from ICU are one part on a list of priorities. When demand is high if a patient is unplaced in the emergency department and therefore not in a place of safety, priority for that bed may go to this patient rather than the patient discharging from ICU.

However by communicating, planning and escalating appropriately we can make small changes to discharge patients safely in a more timely way.

***CONFIDENTIAL***

Finally …..

***CONFIDENTIAL***

Pooling ICNARC data and opportunities: Jacek Borkowski 19 December 2018


J A C E K B O R K O W S K I

L N W U H N H S T R U S T

“Pooling” ICNARC data in NW London

Source of information

What do we get? ICNARC REPORT 2017

11 parameters



How much information was used

113592780 data points collected

8745 used by ICNARC

113584035 unused

First conclusion

What can I do with this

Opening session ESICM Lives 2018 in Paris was about AI in Critical Care SOA 2018 – 1 session dedicated to AI And….

One of the biggest AI engine in the world

I asked Google translator to translate into Polish, Spanish and back to English (on my mobile):

Result:



Other options

Do it yourself

What about other more common bacteria?

Results

1635 positive tests 849 excluded: fungal infection, anaerobes,

Mycobacterium/TB, one appearance only 786 test analysed (as per Abx resistance) 356 positive episodes: multiple appearance

in more than one patient within 2 weeks before and after sample date

What happened next Second conclusion



Scale of processed data

p1=3.00768E-08 p2=0.672371079

N=158

p1=0.049334405 p2=0.24693624

N=20

Third Conclusion

The Lister Hospital

Conclusions

Rehabilitation after critical illness 19 December 2018


Source - Rehabilitation after critical illness in adultsQuality standard [QS158] Published date: September 2017

Adults at risk of morbidity have a formal handover of care, including their agreed individualised structured rehabilitation programme, when they transfer from critical care to a general ward.

Rationale - Continuity of rehabilitation is very important because any breaks or gaps can set back or slow down recovery. A formal documented handover of care which includes the individualised, structured rehabilitation programme ensures that the general ward team understands the person's specific physical and non-physical rehabilitation needs, the goals they are working towards and how best to support them. This should ensure continuity of care and improve the person's experience of transfer from critical care to a general ward.

Patient transfer triage tool for North West London 19 December 2018


Royal Overseas League, London, 19th December 2018


Staff resilience in critical care: Kate Jenkins, Clinical Psychologist for Intensive Care at Salisbury Hospital

19 December 2018


STAFF RESILIENCE IN CRITICAL CARE

Dr Kate Jenkins

Clinical Psychologist for Intensive Care at Salisbury

District Hospital

RESILIENCE

“ Resilience is the process of positive adaptation in the face of adversity, trauma or other sources of stress such as family and relationship problems, serious health problems or workplace and financial stressors “

(American Psychological Association, APA)

RESILIENCE

“ Being resilient does not mean that a person does not experience difficulty or distress. Emotional pain and sadness are common in people who have suffered major adversity or trauma in their life (APA)


19 December 2018


RESILIENCE

“ Resilience is not a trait that people either have or do not have. It involves behaviours, thoughts and actions that can be learned and developed “ (APA)

RESILIENCE

“ People who are resilient have developed an ability to self regulate their emotional states when challenged or threatened. This is the result of a combination of cognitive and affective state management “

(British Psychological Society, BPS)

RESILIENCE

“ Resilience can help protect you from various mental health conditions, such as anxiety and depression as well as factors that increase the risk of mental health conditions, which occur as a result of workplace stress or bullying” (The Mayo Clinic, USA)

EXPECTATION VS REALITY

• Things are changing

• As medicine advances, we are supposed to advance with it!

• Complex interventions

• Patients survival improving

• Rehabilitation expectations

• It’s not what it used to be!


19 December 2018


THE IMPORTANCE OF EMPATHY

• We are all humans, fighting our own battles and living our

own lives, thrown together into a team and expected to

work together and “unite against the common enemy” (in

the case of a hospital, the stressful environment, the

financial pressures)

• When your brain is preparing for war, it’s harder to

engage in empathic behaviour

• What is empathy?

BUILDING EMPATHY

• Get to know each other

• Socialise

• Don’t talk about work stuff on breaks

• Acknowledge help

• Ask people if they’re ok

• Validate each other

• HALT exercise

RANDOM ACTS OF KINDNESS

• Can you think of a time when someone did something kind for

you out of the blue?

• How did that make you feel?

• Can you think of a time when you did it for someone else?

• How did that make you feel?

THREE GOOD THINGS

• What are three good things about working here?

• Each evening, write down three good things that happened that day and why they happened

• They don’t have to be huge – it could be that your sandwich was particularly nice, because you took the time to make it the night before rather than rushing in the morning, or your colleague made you a lovely cup of tea, because you’d asked them how their child was who’d been poorly

• Get into the habit of noticing the glimmers of light, even when the rest of the day may have felt quite bleak

• Little things, added together, can become more significant

• 3@3


19 December 2018


EXPECTATION REALITY

EXPECTATION REALITY


19 December 2018


EXPECTATION REALITY

BUILDING RESILIENCE IN THE FACE OF A MAJOR INCIDENT

• Communication

• Access to information?

• Access to support – but how? Staff can’t leave their patients

• Bite sized

• Acknowledgment from higher echelons

• Don’t exclude people

Thank you to all our exhibitors today!!

network event : patient pathways 19 december 2018 · the report of the culturepublic inquiry into...

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