Velindre NHS Trust June 10th 2011 Presenter: Professor Peter Barrett-Lee, Medical Director

Mortality Mortality Key Drivers Measurement Communication Weekly review of all inpatient deaths at VCC Further investigation of specific cases - learning opportunities maximised Survival data captured by site specific teams Measurement Weekly mortality feedback email to Consultant and key professionals. (Case by case basis) Medical completion of incident reports Communication Medical involvement in investigations Mortality Key Drivers Individual cases presented at open education sessions Trust Quality and Safety committee Reporting structures SBAR communication measured at handover Review of pilot area Rapid response to acutely unwell patients Audit of patient transfers to ITU Allocation of appropriate resources Compliance with Care bundles (2 minute safety briefing) Spread plan Introduction of National early warning score

Progress So far since August 2010 when commencing our mortality review to May 2011we have had: 52 in-patient deaths so far (average 1 - 2 deaths per week) All were considered to be “expected” and they were not receiving radical treatment. 100% had an NFR (Not For Resuscitation) status in place 84% were placed on Integrated Care Pathway “Care in the Last Days of Life” General Areas of Concern that have been taken forward and addressed are: Management of Heart Failure in a palliative care setting Poor Fluid Balance chart monitoring Lack of evidence to demonstrate that individual patients have had a Thromboprophylaxis risk assessment completed. Examples of Good Practice identified are: Evidence of patients being actively involved in end of life choices and decisions. Excellent documentation of communication and support to both patients and their families by Pall Care Team as well as nursing teams. DNR decisions being made at appropriate time involving pt’s consultants. Evidence of timely referrals to MDT members Improved nursing documentation covering all Activities of Daily Living.

Mortality case study: Management of heart failure Situation: Acutely unwell patient with neutropenic sepsis Background: 63 yr old breast cancer patient, palliative, 12 days post weekly abraxane chemotherapy Identified through the mortality review Assessment: Initial acute sepsis managed well according to RRAILS care bundle approach Concerns regarding the management of subsequent heart failure-Inadequate fluid balance charts/ unclear IV GTN prescription Recommendation: Review the management of post sepsis heart failure

Oncology Global Trigger Tool Data

Harm: case study Reducing HCAI CAUTI care bundle Hand hygiene audits all wards Hand Hygiene Reducing HCAI Monitor compliance with care bundle Review of antimicrobial prescribing guidelines Antimicrobial spot audits (indications and review date) Development of bowel care bundle Care bundle introduced across all wards in Feb 2011 Patients have been asked to talk about events of harm and 4 digital stories have been developed for patient safety training. Hospital acquired UTI was identified as one of VCC’s top harm events using the OGTT Hospital acquired UTI was identified as one of VCC’s top harm events using the OGTT during 2 year 1000 Lives Campaign

1000 Lives Plus and Intelligent Targets Next steps – focus on: Transforming care – including Reducing Hospital Acquired Pressure Ulcers Rapid Response to Acute Illness (RRAILLS) Reducing Healthcare Associated Infections Depression Dementia