SAFETY FIRST – PRINCIPLES

OF SAFE PRACTICE

BMUS – General Medical Ultrasound

Saturday 15th September, 2018C P GRIFFIN

OVERVIEW

Governance

Protocols and Policies

Ergonomics

Health, Safety & Good Practice

Transducer Cleaning

The formal definition:

“A framework through which NHS organisations are

accountable for continuously improving the quality of their services and safeguarding high standards of care by

creating an environment in which excellence can flourish.”

The new NHS: Modern. Dependable 1997

What is Clinical Governance?

Where did it come from?

1989 – White paper ‘Working for Patients’ introduces Medical/Clinical Audit

Reviewing healthcare to ensure best practice is being carried out

Before 1999, NHS Trusts principal statutory responsibilities:

proper financial management ; acceptable level of patient safety; quality of care was responsibility of each clinical group

After 1999, NHS Trusts principal statutory responsibilities include quality of care

Clinical Governance

1990 – Bristol Royal Infirmary – Kennedy report 2001

Concerns raised about high mortality rates raised and ignored over 5 year period

1991 - Beverley Allitt - Clothier Report 1994

Child serial killer convicted of 4 counts of murder and 3 counts of attempted murder

1971 - 1998 - Harold Shipman – Shipman Inquiry 2005

British GP serial killer convicted of 15 counts of murder….suspected > 200!

2005 -2009 - Mid Staffs - Francis Report 2013

Poor care and high mortality rates

High profile cases adding to

Clinical Governance

7 pillars built on 5 foundation

stones

based on patient/carer

partnership

encompasses all staff groups

Very wordy!!!!

Domains of Clinical Governance

Why do we do it? Risk Management

What goes wrong? (litigation cost approx. £2bn per year)

Minimise risk to patients, staff and organisations

Openness & Honesty – Duty of Candour (Francis report)

Honesty with patient and carers when things go wrong

Willingness to learn from mistakes and change processes where necessary

Safe Practice

Feedback and Results

Complaints; PALS (patients see things that we don’t)

CPD and Research

Good quality care should come from evidenced based practice

NICE is responsible for providing national guidance

Knowledge and skills to safely care for patients

Qualified to carry out a role

Approved to carry out a role

Mandatory training – Trust wide

Ever increasing requirements

Mandatory training – Local

Focused to your own department

Non-mandatory training

Focused on your own role

Appropriate - Education & Training

Clinical Governance

Personal and peer-review audit

Images and reports

Images, reports and double scanning (perfect world)

Clinical Audit

Why is it important?

Ensure clinical standards are met (and maintained)

Ensure excellent care is delivered

Ensure systems in place for continuous improvement

Why undertake audit of your

practice?

For the patient

Make sure patients receive the best possible care

Provide patients with confidence in the service you provide

For you

Professional development – identify learning needs

Provide you with the confidence that you are doing a good job

For the organisation

NHSLA (now NHS Resolution) / CQC/ Commissioning/Quality Account requirements

Improve efficiency

Governance The use of ultrasound is becoming more and more widespread

Various professions and professional groups

Ultrasound equipment is cheap and not governed under IRR’99 [EU

law] & IR(ME)R 2000 [UK law]

National Ultrasound Steering Group

Recommendations: Recording of data; equipment evaluation and

procurement; professional clinical standards; audit

A local governance board should be in place

Oversee procurement, maintenance, replacement, maintaining

standards, training and audit

Protocols and Policies

Advanced / Consultant Clinical Practice

4 Tier Structure

The bottom line….

Work within agreed protocols/framework

Have the minimum required initial training…. Followed by continuous CPD

Subject to regular audit and review

Examples of advanced and consultant ultrasound roles

Full independent reporting; interventional procedures; CEUS;

Elastography

Key elements of a protocol

Background and title

Education and training

Scope of practice

Procedure(s) for performing or reporting examinations

Report structure

Clinical audit

CPD requirements

Verification – dates / people / approval process

References

Nightingale J, Developing protocols for advanced and consultant

practice, Radiography 2008: 14, e55-e60

Common errors in protocol design

Type of error Potential consequence

Too long Boring, not read

Too short insufficient guidance

Too prescriptive / restrictive dangerous for experienced practitioners / work outside protocol

Too loose no guidance, dangerous for inexperienced practitioners

Not evidence based / no refs won’t stand up to medico-legal scrutiny

Not properly verified / reviewed / archived

Ditto, and may not have employer cover

Do you have an existing protocol?

YES NO

Is it still relevant and current? Do you have a local hospital

template to follow?

Does it give sufficient guidance to

protect you (and your patients)?

Do you have a similar protocol in

your department that you can

review?

Is it properly verified? Do you have other hospital

protocols that you can review

MUST review and if necessary

update the protocol (with relevant

colleagues) by the end of your

module

MUST create a draft protocol by

end of the module, and have this

fully approved and verified prior to

independent / autonomous

practice

Protocols – Summary

All levels of clinical specialist ultrasound practice requires suitable

protocols and documentation

Allows for non-medical professionals to work within a safe and

effective framework

Regular review and ensuring protocol is fit for purpose

Ergonomics

Occupational injury related to ultrasound practice is increasing due

to greater workloads (more demand and shortages in staffing),

obesity in the general population, poorly designed ultrasound rooms

Repetitive and awkward movements also play a large part

Poor postural alignment during scanning

What can we do?

Ergonomics

Better awareness of scanning positions

Mixed lists

Essential for the teaching of ergonomics from the beginning of

ultrasound training

Break/catch-up slots built into lists

Regular risk assessments

Alexander Technique

Ergonomics

Things you can do

Bed height

Chair height

Patient position

Ultrasound is the most mobile of all radiological modalities

Use it as such!!

Ergonomics – Summary

Be more aware of our scanning techniques

Ensure adequate breaks and suitable lists

Professional bodies should help lead the fight in tackling these issues

Lobby the manufacturers and highlight their responsibility

to the future of the ultrasound profession!!

Health, Safety & Good Practice

Industry standards for the prevention of WRMSKD in sonography

SCoR 2006

Control Measures

Equipment; Administrative & Professional

Equipment (US Systems; Control Panel; Monitor; Transducers; Chair;

Table; Accessories)

Administrative (Education & Training; Workload & Scheduling;

Examination Area)

Professional (Best Practice)

Health, Safety & Good Practice

Chaperones

When conducting an intimate examination, the ultrasound practitioner

should:

act with propriety and in a courteous and professional manner;

communicate sensitively and politely using professional terminology,

use a chaperone when appropriate;

respect the patient’s rights to dignity and privacy,

comply with departmental schemes of work and protocols.

Health, Safety & Good Practice

The examination

Time needs to be allowed for room preparation,

assessing the ultrasound request,

introductions, explanations, obtaining consent and assisting the patient when necessary on to and off the examination couch.

Post- procedure

time is required to discuss the findings with the patient,

write the report,

archive the images and attend to the after-care of the patient, including making arrangements for further appointments and/or further investigations.

Equipment will also need cleaning and disinfecting as required post examination.

Transducer Cleaning

Recommendations

Barrier must be used

Remove the transducer cover

Clean the transducer

Transducer disinfection

High-level disinfection

MHRA alert (fatality due to infection)

Transducer Cleaning

Transducer Cleaning

Health & Saferty Executive Guidance (Ireland) 2017

https://www.hse.ie/eng/about/who/qid/nationalsafetyprogrammes/decontamination/ultrasound-probe-decontamination-guidance-feb-17.pdf

European Society of Radiology 2016

Infection prevention and US probe decontamination practices in Europe (2016) Insights Imaging, 7; 841-847

WFUMB 2017

Guidelines for cleaning endocavity transducers between patients

Abramowicz et al (2017) US in Med & Biol. 43 (5) 1076-1079

Selection of References

Nightingale J (2008) Developing protocols for advanced and consultant practice. Radiography, 14, e55-e60 doi:10.1016/j.radi.2008.04.001

NHS Modernisation agency, NICE. Step by step guide to developing clinical protocols. 2002. Search

at: http://www.institute.nhs.uk

Owen A, Hogg P and Nightingale J (2004), A critical analysis of a locally agreed protocol for clinical practice, Radiography, 10(2):139-144

Paterson AM, Price RC, Thomas A, Nuttall L. Reporting by radiographers: a policy and practice guide.

Radiography 2004;10:205e12.

Gibbs, V & Young, P. (2008) Work related musculoskeletal disorders in sonography and the Alexander

Technique, Ultrasound, 16 (4)

Martin, A Clinical Governance and Advanced Practice – Bolton

Bradshaw, A (2014) Be in balance: A simple introduction to the Alexander Technique.

Any Question?

THANKS FOR LISTENING