1. Care bundle for PVC Insertion and Ongoing Aneurin Bevan Health Board Our story so far…….

2. Background Pre audit Organisation has high incidents of MSSA bacteraemia Link with mortality “Must do” for 1000 lives Engagement at Board level

3. Audit Findings 507 patients surveyed 214 Peripheral Vascular Cannula insitu 142 Peripheral Vascular Cannula in use 96 (44%) Patients had no documentation of when cannula inserted 3 peripheral Vascular Cannula had signs of infection – removed at audit 7.3 PVC infection

4. MSSA data

5. Care Bundle INSERTION ELEMENTS Hand hygiene Personal protective equipment Skin preparation Dressing Documentation ONGOING CARE ELEMENTS Hand hygiene Continuing clinical indication Site inspected Dressing Cannula access Administration set replacement Routine cannula replacement

6. What did we do Develop an organisational policy Developed documentation for the care bundle Identified a pilot area Identified key champions and a start date Staff education Notice boards

7. Example of PDSA Cycle Process mapping of the equipment Changed skin preparation One nurse one patient one cannula Changed the colour of the documentation Reminders placed on drug trolleys

8. Insert name - PDSA Cycle DATA Test 1 Care bundle used by one nurse on one patient on one day (PDSA) Introduction of a bundle ‘ward champion’ A reduction in peripheral cannula related infection rates 95% compliance with bundle on pilot ward then spread using PDSA methodology to whole of Organisation The introduction of a Cannula Care Bundle Test 3 Audit data analysed and staff interviewed for feedback Test 2 Staff on pilot ward educated regarding use of bundle and use of bundle spread to include all patients. Weekly audits commenced. Test 4 Documentation changed slightly following staff feed back. Weekly audits continued showing a steady improvement. Spread to next ward.

9. What we’ve tried Pilot Ward Insertion documentation has had a high compliance rate, and overall staff seem to find the documentation easy and quick to fill in. Ongoing care documentation had a lower compliance rate initially as staff were not used to documenting this aspect of care and would often forget to fill this in. This is now being recorded on a shift Development of a champion absolute key

12. Outcome data for ward 1/2

13. Challenges presented Introduction of another piece of paperwork Reluctance of Clinical staff to embrace Care Bundle “Epic 2 for necklines not I.V.'s” Lack of understanding of change methodology Demands for changes before any PDSA cycles performed

14. Planned PDSA cycles Trial initial document 1 cycle 1 case 1 Anaesthetist 1 Theatre Trial Initial document 1 week in 1 Theatre Trial 1 sticker prototype 1 case 1 Anaesthetist 1 Theatre

15. Initial results Immediate dislike of documentation although process performed Continued dislike of documentation and dislike of care package. Epic 2 guidelines given to all Sticker tolerated and rolled out as initial trial

16. Jade Theatre PVC cannula document- PDSA Cycle DATA Test 1 Bundle documentation tested by one nurse on one patient on one day. All patients arriving on ward from theatre will have appropriate bundle documentation (sticker) 95% compliance with bundle in Jade Theatre Theatre and ward staff involvement in the development of the sticker and education regarding the bundle Test 3 Sticker resized and amended following feed back, trial extended to include more patients and staff. Weekly audit commenced. Test 2 Bundle documentation changed to sticker form as felt may be better suited in theatres. Same approach used as test 1. Test 4 Including sticker as part of the patients prescription chart to see if this will increase compliance. Audit data demonstrates improved compliance rates among theatre staff. Spread to ICU to pilot sticker.

17. Where would it Live ? Needed to be a place where multidisciplinary team would all use Anaesthesia chart rarely read by ward staff Agreed that treatment chart was best place as site checks could be performed on drug rounds Sticker evolved to fit chart

18. Sticker evolution Trial was done on paper reflecting care bundle Stickers produced by Anaesthetists that was printable on addressograph sticker Care bundle reduced to tick box site and type still remained It was decided to go with it as Anaesthetists onside

19. Current position Sticker in use in 1 Theatre constantly Rolling out across orthopaedic Theatres as of March Care bundle documented on ORMIS system to provide record of complience Process mapping to facilitate Care Bundle

20. What we had

21. What we changed to

22. The Response

23. The Compromise

24. What has been learnt in theatre More can be achieved through simple small step Shared ownership has increased adoption Acceptance it is an evolving process Encouraging adopters but keeping foot on the brakes so not to alienate Laggards

25. What have we learnt The same process does not suit all Champions are key Remember to include all key stakeholders Compliance won’t happen over night Feedback of data is essential Ongoing process High investment at first

26. Next Steps Review the sticker to include all aspects of the care bundle Need confirmation from pharmacy colleagues re the use of the sticker on the prescription chart Review the audit tool to include staff knowledge as well as documentation to ensure reliability Continue to spread across the organisation Identify more champions Develop regular PVC group meetings to ensure consistency, spread, enthusiasm and support mechanism for all involved