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

2. 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 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

3. Progress
So far since August 2010 when commencing our mortality review to May 2011we have had:
52 in-patient deaths so far (average 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.

4. 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

5. Oncology Global Trigger Tool Data

6. 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

7. 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