1. Safer Care in the ED Dr Susan Robinson East of England CPD Day 24 th April

2. Objectives Definitions Why we need to focus on safety Systems approach 10 steps to improving safety

3. Definitions of Safety The freedom from accidental injury due to medical care or from medical error. The process by which an organisation makes patient care safer. The National Patient Safety Agency (2003) Institute of Medicine 2000

4. Other Definitions You May Have Heard…. zero accidents or serious incidents freedom from hazards, i.e. those factors which cause or are likely to cause harm attitudes of employees towards unsafe acts and conditions error avoidance regulatory compliance ICAO Safety Management Systems Manual

5. Safety The state in which the possibility of harm to persons or of property damage is reduced to, and maintained at or below, an acceptable level through a continuing process of hazard identification and safety risk management. ICAO Safety Management Systems Manual.

6. Why Focus on Safety? Effectiveness of care Efficiency of process Patient experience Staff experience

7. Characteristics of Effective Microsystems Integration of information Measurement Interdependence of the team Supportiveness of the larger system Constancy of purpose Connection to the community Investment in improvement Alignment of role and training Donaldson MS et al. A Technical Report for the Institute of Medicine Committee on the Quality of Health Care in America. Robert Wood Johnson Foundation 2000. http://books.nap.edu/catalog/10096.html

8. Incident Types (ED, MIU, MAU) Reported to NRLS - Oct 2010-Sept 2011 Personal Communication Incident TypeFrequencyPercentRank Access Admission Discharge 732013.62 Clinical assessment 49619.26 Consent, communication, confidentiality 22684.29 Disruptive, aggressive behaviour 4050.7514 Documentation 37256.98 Implementation of care and ongoing monitoring / review 675112.53 Infection Control Incident 7731.412 Infrastructure 39937.47 Medical device / equipment §7063.211 Medication 5355105 Patient abuse 2730.515 Patient accident 765414.41 Self-harming behaviour 5971.113 Treatment, procedure 617311.44 Others 19593.610 Total 53913100 Incident TypeFrequency (%)Rank Access Admission Discharge7320 (13.6)2 Clinical assessment4961 (9.2)6 Consent, communication, confidentiality2268 (4.2)9 Disruptive, aggressive behaviour405 (0.75)14 Documentation3725 (6.9)8 Implementation of care and ongoing review6751 (12.5)3 Infection Control Incident773 (1.4)12 Infrastructure3993 (7.4)7 Medical device / equipment1706 (3.2)11 Medication5355 (10)5 Patient abuse273 (0.5)15 Patient accident7654 (14.4)1 Self-harming behaviour597 (1.1)13 Treatment, procedure6173 (11.4)4 Others1959 (3.6)10 Total53913 (100)15

9. Why do we have a Problem with Safety? Large unlimited volume of patients Large teams which change frequently Inexperienced and locum staff Lack of supervision (out of hours) Diverse and undifferentiated presentations Stressful environment Poorly designed estate Time limited assessment and intervention Interaction with and dependency on a wide range of other services

10. Patient arrives at the ED by ambulance / police Patient arrives at the ED on foot Initial Assessment by PAT nurse Infection Control Presenting Complaint AVPU assessment Decides on placement Initial Assessment by pre-reg nurse Infection Control Presenting Complaint AVPU assessment Decides on placement Secondary Assessment by SAT nurse Presenting complaint Analgesia / ECG / Sometimes x-ray Liaise PA Places Card in Box Patient registered by receptionist at bedside who returns to reception and then brings out front sheet back to nursing staff Patient registered by receptionist at reception. Card then placed by patient in box next to minors Assessment 1 Assessment 2 Resus Blue Chairs Waiting room Secondary Assessment by Minors nurse, pick up card from box Presenting complaint Analgesia / ECG / Sometimes x-ray / sometimes Liaise PA Places card in Box Medical Assessment Arrive at an Inpatient bed SAT Nurse Receptionist PAT Nurse Junior Doctor ENP SpR / Consultant Porter Radiographer X-ray Ultrasound CT Cubicle nurse HCA Ambulance staff Nurse in Charge Ops centre person Minors Receptionist Secondary Assessment by nurse Presenting complaint /VS Analgesia / ECG / Sometimes x-ray Liaise PA Physician’s Assistant Cubicle nurse Secondary Assessment by nurse Presenting complaint /VS Analgesia / ECG / Sometimes x-ray Liaise PA Places Card in Box Secondary Assessment by nurse Presenting complaint /VS Analgesia / ECG / Sometimes x-ray Liaise PA Places Card in Box Ambulance staff Minors nurse Secondary Assessment by Minors nurse, pick up card from box Presenting complaint Analgesia / ECG / Sometimes x-ray / sometimes Liaise PA Minors nurse Cubicle nurse Secondary Assessment by Doctor Physician’s Assistant Physician’s Assistant Physician’s Assistant Bloods/ Urinary Catheter Bloods PA cubicle SpR/ Consultant Porter Medical Assessment SpR / Consultant Junior Doctor SpR / Consultant Medical Assessment Junior Doctor SpR / Consultant Medical Assessment Junior Doctor Porter Nurse Coordinator Update Jonah with x-ray request Paper back-up Co-ordinate transfers to ward and radiology Request bed on phone Co-ordinate treatments Telephone handovers Manage relatives Request specialty Doctors to review SpR / Consultant Nurse in Charge Discharge Nurse Coordinator Update Jonah with x-ray request Paper back-up Co-ordinate transfers to ward and radiology Request bed on phone Co-ordinate treatments Telephone handovers Manage relatives Request specialty Doctors to review In Patient Pharmacy CDU Nurse in Charge Update Jonah with x-ray request Paper back-up Co-ordinate transfers to ward and radiology Request bed on phone and Jonah Co-ordinate treatments Telephone handovers Check Treatments Check Coding Check VTE assessment Check swabs PorterReceptionist HCA / Cubicle nurse Ops centre person Radiographer Minors nurse Treatments Cubicle nurse Treatments Resus nurse Treatments Cubicle nurse Treatments Cubicle nurse Treatments Cubicle nurse Treatments Time Pre-Reg

11. Step 1 Take a systems approach …trying harder will not work. Changing systems of care will. IOM 2001. Crossing the Quality Chasm

12. A Patient Safety Model of Health Care Those who work in health care Those who receive healthcare Infrastructure of systems for therapy Methods for feedback and continuous improvement

13. How Domains and Elements Relate in the Patient Safety Model

14. Step 2 Ensure there is resource and a structure in place to support safety

15. Structure to Support Safety

16. Step 3 Understand how safe your ED is…collect the data…and use it to learn and improve

17. Safety Data (…just some examples) Incidents Complaints Infection control data Levels of mandatory training Deaths within the ED Re-attendance to the ED Morbidity 4hr performance Key sentinel conditions ED crowding Staff sickness Compliance with appraisal Missed diagnoses Risk register Harm events

18. Deaths within the ED No harm events identified and where there are areas for further discussion it is extremely unlikely these had any impact on the eventual outcome. Use DNAR orders appropriately A number of areas require further discussion. – End of life decisions and practice in the resuscitation room – DNAR orders in the community to prevent ED attendance – One case should be reviewed with trainee and trainer re treatment decisions made and documentation

19. Global Trigger Tool

21. Step 4 Understand your risks and manage them

22. Managing risk

23. The hospital is currently investigating why his abnormal CT was not communicated to the patient, the GP or indeed the chest clinic.

24. Root Causes of Incident 1. Time of incident 2. Lack of strategic planning within the Trust No standardised internal process for referral of patients with Cancer MDT alert process not fully implemented Lack of system wide electronic process for communicating with all GPs No system for adding new staff to radiology ALERT system 3. Communication issues Lack of Trust pathway to escalate concerns of risks No agreed system for all GPs to use electronic mail system Role of MDT alert process and handover of responsibilities unclear

25. BUT……4 near misses in last few months

26. FTA – Urgent Cancer Referral GP and Pt. checks 1. Referral form not processed as expected 2. GP did not use the email box used by hospital 3. Results reporting alert system failed 4. The MDT alert email was not reviewed 1 2 4 3

27. Fault Tree Analysis Urgent Cancer Referral from the ED Incident 2 Incident 3 Incident 4 Incident 5 Incident 2 Incident 5

28. Step 5 Focus on your staff

29. Staff Clear goals re expectations Clear communication Align role and training Develop team work Investment Value staff Delegate responsibility to deliver outcomes Consider human factors

30. Staff Experience NHS Staff management & Health Service Quality. West M et al. Sept 2011. Department of Health.

31. Step 6 Work hard to ensure workload matches resource

32. The Tipping Point Kuntz et al. Personal Communication

33. Step 7 Promote a safe environment

34. ED Design Visibility Minimise patient movement Communications Adequate space for important tasks Infection Control Interruption free zones Lighting Noise

35. Effect of Acuity Adaptable, Single Rooms on Medication Errors and Falls

36. Interruption Free Zones The average ED Doc is interrupted 9.7 times an hour spends 2/3 of their time managing 3 or more patients (an office doc less than one minute per hour) has 7 “breaks in task” an hour Acad Emerg Med 2000;7:1239-43 Ann Emerg Med 2001;38:146-51

37. Step 8 Focus on safe processes

38. Effectiveness of Care - Sepsis Use of early goal-directed therapy (EGDT) in the ED results in a 16.5% reduction in mortality 23% reduction in net hospital costs Rivers EP et al. N Engl J Med 2001;345:1368-77. Rivers EP et al. Curr Opin Crit Care 2002;8:600-6.

39. Plunkett PK et al. Eur J Emerg Med 2011;18:192-196

41. Step 9 Develop a true safe culture

42. Safety Culture Shared Values shared throughout the organisation Everyone believes they are responsible for safety Error accepted as normal Standardisation of practice Just Does not blame but holds accountable Ensure processes are workable Deals effectively with unacceptable behaviour Learning Learning seen as a priority Investigates promptly, fully and fairly, feeds back Relentless in regards safety

43. Comprehensive Unit Based Safety Program (CUSP) 1.Assessment of culture of safety 2.Safety education 3.Identification of concerns by staff 4.Senior executives adopt a unit 5.Implementation of improvements to address concerns 6.Analysis of effects 7.Results shared 8.Reassessment of culture Pronovost P et al. J Pat Saf 2005;1:33 - 40

44. Implementing and Validating a Comprehensive Unit Based Safety Program

45. Step 10 Involve patients

46. Involving Patients Those with greatest effect on reducing risk were Feeling well enough to talk to nurses and doctors (0.33, 0.2- 0.53) Ease of finding a nurse or doctor to talk to (0.5, 0.3-0.82) The good and bad things about the treatment options were discussed with the patient (0.6, 0.39-0.94) The patient participates in decisions (0.36,0.2-0.65) Weingart et al. International J for Qual in Health Care 2011. Page 1-9

47. Questions Questions?

48. Step 11 Don’t give up……