1. Neuraxial Connector Surveillance Training
Clinical Instrument Surveillance Programme
Public Health Wales
Neuraxial Connector Surveillance

2. Background
2009 patient safety alert requiring neuraxial procedures to use non-Luer connectors
Spinal, epidural and regional infusions and bolus doses and lumbar punctures
Wales Neuraxial Connector Reference Group set up by Welsh Government to oversee this
Concerns over unexpected clinical consequences, eg. wholesale change in tonsillectomy instruments
Neuraxial Connector Surveillance

3. Nrfit (non-Luer) Connectors
Delays due to dissatisfaction with proprietary connectors
An initiative of an international standard
ISO standard connector (Nrfit) will be implemented in January 2017 in California
To be introduced in April 2017 in Wales
Neuraxial Connector Surveillance

4. Excluded: facet joints Regional nerve blocks?
Background continued
WNCRG subgroup have agreed all neuraxial procedures using neuraxial equipment will be covered
Excluded: facet joints
Regional nerve blocks?
Neuraxial Connector Surveillance

5. Clinical Instrument Surveillance Programme (CISP)
Our aim is to improve patient safety through surveillance
Experience in surveillance of changeover from reusable to single-use tonsillectomy instruments
Detected instrument problems at the time of surgery and patient complications
Benefits of surveillance:
Identify problems quickly and efficiently so they can be addressed
Provide reassurance to clinicians of devices use
Improve patient safety
Neuraxial Connector Surveillance

6. Neuraxial project - CISP
Agreed by WNCRG subgroup
To monitor the safety of the introduction of non-luer connectors in Wales by detecting changes in complication rates and device problems on introduction
Device usage, device problems, procedure complications, patient complications
Reports of these outcomes and alerts of potential problems issued to health boards and Welsh Government. Clinicians can get their data on request
Surveillance includes: All health boards, all specialities and independent hospitals
Neuraxial Connector Surveillance

7. Neuraxial project – CISP
Agreed by WNCRG sub group
Data set and web form agreed
Training
Train the trainer
Baseline data collection
Now until change over
Continuous surveillance essential
Data collection post change-over
April 2017
Minimum 6 months (funding dependant)
Neuraxial Connector Surveillance

8. How are procedures reported?
Web form
Accessed from any computer/device with health board intranet access at:
Shortcuts exist on health board computers:
Can be accessed via Wales Clinical Portal from all HBs??
ABMU (IE favourites under Clinical Systems)
Aneurin Bevan (desktop shortcut to intranet Apps Page)
Hywel Dda (shortcut in start menu)
Training material at:
Neuraxial Connector Surveillance

9. Device types for procedures
Epidural
Epidural kit
Administration set
Epidural (Tuohy) needle
Epidural catheter/connector
LOR syringe
Syringe (slip)
Syringe (lock)
Drawing up needle
Drawing up disc filter
Spinal/epidural filter
Spinal
Spinal needle
Introducer needle
Procedures
Device type
CSE
CSE kit
Administration set
Epidural (Tuohy) needle
Spinal needle
Introducer needle
Epidural catheter/connector
LOR syringe
Syringe (slip)
Syringe (lock)
Drawing up needle
Drawing up disc filter
Spinal/epidural filter
Spinal catheter
Spinal catheter/connector
Lumbar puncture
Manometer
2/3 way tap
C-section wound care management training

10. 2. Procedure complications
1. Device problems
2. Procedure complications
3. Patient complications
Neuraxial Connector Surveillance

11. Patient and procedure details
Neuraxial Connector Surveillance

12. Devices used and any problems with devices
Neuraxial Connector Surveillance

13. Procedure complications
Neuraxial Connector Surveillance

14. Patient complications within 28 days
Neuraxial Connector Surveillance