Patient_Safety_Learning

This case study focuses on a North Staffordshire Combined NHS Trust project. The lead consultant for the service was concerned that the clinical pathways were not optimised and bottlenecks were delaying access, assessment and diagnosis of patients. As a result there were delays to initiating treatment. In addition to potential harm to patients this was resulting in inefficient and wasteful use of resources.

Following pathway changes, value and efficiency impact was noted in the following areas:

• Because head CT scans are provided by a neighbouring acute trust, reducing the number of  patients referred had a direct impact on service cost as well as releasing capacity in the wider system. Comparing baseline activity with the review period showed a 30% reduction in CT  scan referrals and a £7,800 direct cost saving.
•  The number of patients not attending appointments reduced from 572 in the baseline period  to 379 after implementing pathway changes. While not a cash releasing saving this improved  overall efficiency and productivity for the service and contributed to a reduction in overall unit  price per attendance.
• At the start of the project, the average unit price for patients attending the memory service  was £280.93. Through a combination of direct cost savings and efficiency and productivity  gains arising from the revised pathway, this figure had reduced to £205.12 in the review  period.

Do you have a cost-saving or efficiency case study to share? What were the patient safety implications? Do you have resources or knowledge to share that can help others make positive changes?

Comment below (sign in or register here for free first), or get in touch with us at content@pslhub.org to tell your story. 

"One of the best examples I saw involved a case in which a worker was about to move a vehicle and trailer. The keys were in the ignition, but before starting the vehicle, he decided to perform a walkaround and discovered a mechanic was working underneath the trailer. Together, they agreed to take the keys out of the ignition and established a tagging system to ensure nobody else would inadvertently move the equipment while it was being worked on."[1]

According to this article by Safety Management Group, just like near-miss reporting, a formal good catch program promotes reporting and learning while providing important metrics that can be tracked and trended over time. It turns an organisation's safety philosophy into a clear reality.

Do you use a 'good catch' reporting system in your health and social care setting? Has it made a difference to safety culture or behaviour? How easy was it to implement? Do you recognise and/or celebrate staff for reporting incidents? 

Or perhaps this is something you'd like to implement. What would you like to ask others who have tried it? 

Share your experiences and questions in the comments below. You'll need to register for free first. 

Related reading:

• Near-Miss and Good-Catch Reporting
• Promote a culture of safety with good catch reports
• Using good catches to increase worker ownership of safety
• 5 Examples of good catches in healthcare and how to implement a near miss campaign

[1] SMB. Using good catches to increase worker ownership of safety. Accessed online 9/08/23. 

Hi @Lorraine 2 Many thanks for sharing your positive experience of undergoing a hysteroscopy procedure.

I am very pleased to hear that you felt supported, informed and that the pain was manageable. Sharing good practice examples is vital, as you say, for improving the quality of care more broadly in this area. Routine collection of pain scores is also important, as you have also highlighted, if we are to understand the prevalence of high levels of pain. 

If you have not already seen this, the calls to action at the end of this blog may be of interest to you:

Thank you again for sharing your experience

Thank you for sharing your experience.

I am so sorry you went through such pain. It is interesting to hear that the medication you were given to relax the cervix and uterus helped to some extent, I am unsure how often this is offered.

At Patient Safety Learning we continue to call for more research and training in this area, and for all pain management options to be consistently offered to, and discussed with, women undergoing IUD procedures.

Most importantly we are calling for women to be listened to and their experiences routinely captured by health services so the extent of these experiences can be fully understood. Thank you again for sharing yours.

The following account has been shared with Patient Safety Learning by Jen*:

"My first coil insertion and later removal were both done at different GP surgeries and were both agonising. I have broken bones and torn ligaments before, yet nothing compared to the pain I experienced in and after those procedures. For my second coil insertion, I felt I was prepared as I was going to a health centre where I would receive a local anaesthetic and numbing gel, and the procedure would be done by expert nurses. I also took paracetamol beforehand. Still, the pain was so agonising that I screamed. When it came to getting up, they told me I was white as a sheet and then I fainted. There were two nurses there and they had no idea what to do with me. I couldn't stand without my legs collapsing under me. They offered me ibuprofen and visibly panicked when I reminded them I am allergic to it; it was like they had run out of options. Eventually they told me they needed to close so sent me on my way. I had no one with me and drove myself home - I convinced myself I was being very silly and weak because if it was that bad, they'd have called for an ambulance or at least advised me to call a friend, instead of allowing - in fact encouraging me - to drive myself home. I screamed and sobbed in pain all the way home, where I managed get myself a hot water bottle and to drag myself upstairs to bed. I found leftover tramadol from when I broke my ankle, and it didn't touch the pain. I eventually passed out again. The pain lasted for days, and I didn't feel able to tell anyone what was wrong - I had been told by many doctors for many years that I had a low pain threshold and thought that my experience was a reflection of that. I felt a bit pathetic and weak, to be honest. 

"During all of my coil appointments, I was told I had a tilted uterus which they said was very common, and why the insertions had been so 'tricky'. I was later diagnosed with endometriosis and adenomyosis and was told they were common causes for a tilted uterus! There was no mention of those conditions as a possible cause when previously discussed, it was just explained as being one of those things - which would suggest to me that there is a gap in education for healthcare providers. 

"To this day, that second coil fitting is of the most traumatic experiences I have ever had."

*The patients name has been changed

Hi @Flávia

Thank you for responding. Your collaborative project sounds very interesting, we would love to hear more. Please do get in touch via content@pslhub.org. 

• Perhaps you have ideas around how safety can be improved in your field of work - whether that's in a hospice, hospital, charity or care setting. 
• Or you might have been part of a project that has improved safety and would like to share that with others.

Infiltration is when fluid or intravenous drugs are administered to a patient (which are given to patients into a vein through a cannula or other device) inadvertently leak into the tissue surrounding a vein by mistake. Extravasation is when infiltration occurs but  the  drugs involved are called vesicants which  can damage the tissue and cause serious harm to the patient.

The National Infusion and Vascular Access Society (NIVAS) are leading a campaign, to improve awareness of infiltration and extravasation and reduce avoidable harm. 

• Do you have insights to share on this topic?
• Perhaps you are a patient who has had an extravasation injury?
• Or a healthcare professional who has insights to share around making improvements?

Share your thoughts below (you'll need to register for free here first).

Hi @perbinder thank you for posting. @Claire Cox might be able to help share your request among relevant networks.

Hi @Sophie Osullivan

It might be worth contacting @Kirsty Wood who has done a lot of work in this area. She provides her contact details above.

Best wishes

Stephanie

Hi Anne

As part of informed consent you should be given all of the options available to you and talked through the pros of cons of each. This should include general anaesthetic. This will help you to make an informed decision that feels right for you. You could ask to speak to your GP about this and it is worth mentioning your previous experience in relation to pain.

You can also request to have a chaperone with you for the procedure which may help you feel supported. If you are awake for the procedure, speak to the staff performing the procedure about how they will check in with you to make sure they obtain continued consent throughout and that you are happy for them to continue.  

Talk to them about your previous experiences and the importance of being able to pause or stop the procedure if you do need to. Some people have found it useful to have someone there with them to drive them home afterwards too, even if this hasn't been highlighted as a necessity in any of the info given to you beforehand.  

I am so sorry you have had a difficult experience previously and did not feel you had been informed of what what going to take place. That is not in line with informed consent and should not have happened to you. 

@ElspethJ that doesn't sound like it offered what you needed? What services would you like to see available for people with Long Covid, particularly those who haven't been hospitalised? Did your GP give any indication that anything else was in the pipeline?

From the Head of ICU at the Royal Free (shared via Facebook):

“Dear All, 

I have just finished a very useful ICU / NHS Nightingale teleconference, the aim of which was to consolidate experiences about CV19 and how best to manage the disease. I have provided a summary below. Please understand that the information is experience, not evidence. I think it highlights a number of areas that we need to discuss URGENTLY as a group. The take home message is that advice given at the beginning of this journey needs to be adapted as we learn more about CV19. The other important thing to begin to understand is that this disease has distinct phases and treatment will differ as patients move through these phases. 

The call had about 80 people on it, most listening. There were about ten “experts” invited to speak, from high volume centres. I represented our site. Others included Georges, GSST & Brompton. 

Ventilation
- Early high PEEP is probably not the right strategy and may be harmful. This is not ARDS in the early phase of the illness. 
- Avoid spontaneous ventilation early in ICU admission as also may be harmful.
- There is clear microvascular thrombosis happening in the pulmonary circulation, which leads to an increased dead space.
- Also some evidence of early pulmonary fibrosis reported from Italy, possibly oxygen related, possibly inflammation related. 
- Not many patients have reached extubation yet in London, re-intubation seems to be common. I highlighted our experiences of airway swelling / stridor / reintubation. 
- Brompton are seeing wedge infarcts in the lungs on imaging, along with pulmonary thrombosis without DVT. 
- Proning is essential and should be done early. Don’t just do it once. Threshold for many centres is a PF ratio of 13, but all agreed, do it even earlier. 
- Early on in the disease, the benefit of proning lasts < 4 hours when turned back to supine, as the disease progresses into a more ARDS type picture, the effect is more long lasting. 
- Many centres using inhaled nitric oxide and prostacyclin with good effect. Tachyphylaxis with NO after 4-5 days. 
- Generally people are using humidified circuits with HMEs. 
-  A very interesting thing they are doing at Georges is cohorting by phase of disease i.e. early, late, extubation / trachy. It involves more moving of patients but helps each team to focus on things more easily. 
- Leak test before extubation is crucial, others are also seeing airway swelling. 
- Wait longer than usual before extubating, high reintubation rates reported. Do not extubatne if inflam markers still high. 

My conclusions from this are:
- Less aggressive PEEP strategy at the beginning of the disease and go straight for proning. 
- Thromboembolic disease is prevalent, look for it. No one is sure about whether we should anti-coagulate everyone, this is probably too risky. 
- An extubation protocol is needed immediately.  
- We should consider using inhaled prostacyclin again (like we previously did) as it seems to be working early in the disease.

Fluid balance
- All centres agreed that we are getting this wrong. 
- Most patients come to ICU after a few days of illness where their temp was 38-40 and they were hyperventilating i.e. severely dehydrated. 
- High rates of AKI being caused by over zealous driving with frusemide, leading to unnecessary CVVHF. 
- Hypovolaemia leads to poor pulmonary perfusion and increased dead space. 
- Centres echo’ing their patients are seeing a lot of RV dysfunction without raised PA pressure. 
- Many have improved oliguria by dropping the PEEP i.e. these patients are really hypovolaemic. 
[On nights I have observed many of our patients with a zero fluid balance and temperature of 39 i.e. they will be 2-3 litres negative in reality.]
- Most centres are therefore now backing off of strict zero balance, particularly in hyperpyrexia. They are moving more towards avoidance of large positive fluid balance. 
- Lung ‘leak’ not as prominent in this disease as classic ARDS

My conclusions from this are:
- Avoid hypovolaemia as it will impede gas exchange and cause AKI. Progression to CVVHF increases mortality. 
- Avoid hypervolaemia
- How we achieve this is difficult, but the frusemide and noradrenaline cocktail needs to be carefully tailored, especially in pyrexial patients. 
- Echo patients to understand their volume status. 

Renal
- Higher than predicted need for CVVHF - ? Due to excess hypovolaemia. 
- Microthrombi in kidneys probably also contributing to AKI.
- CVVHF circuits clot frequently. Georges and Kings now fully anticoagulant the patient (rather than the circuit) as it is the only way they can prevent this. One centre using full dose LMWH as they have run out of pumps. 
- Kings now beginning acute peritoneal dialysis as running out of CVVHF machines. 

My conclusions from this are:
- Aggressive anticoagulant strategy required for CVVHF, potentially systemic. 
- If we run out of machines, PD may / may not help (our previous experiences with it are not great, but I have no alternative other than using CVVHF like intermittent dialysis and sharing machines)

Workforce
- A ’tactical commander’ is essential on every shift, who is not directly responsible the care of ICU patients. 
- Most centres now getting towards 1:6 nursing ratio with high level of support workers on ICU. 
- Training has largely fallen by the wayside as it is too large a task. People are being trained on the job. 

My conclusions from this are:
- On call consultant to coordinate but not be responsible for patients (as is the model we have now adopted).
- We need one support worker per patient. Other centres are using everyone they have. From med students to dental hygienists. We are behind the curve ++ with this. Last time I was on a night shift, theatres were full of non-medical staff refusing to help ICU - this is unacceptable.

There were some brief discussion about CPAP:
- Proning patients on CPAP on the ward is very effective, I tried it the other day - worked wonders.
- Prolonged use of CPAP may (I stress the word may) lead to patients being more systemically unwell when they get to ICU. 
- Considerable oxygen supply issues with old school CPAP systems. 

My conclusions from this are:
- As per local guidelines, assess the effectiveness of CPAP after an hour, if it isn’t effective then bail out and consider intubation. 
- If effective, regular review is required. If at any point it is failing, bail out and consider ventilation. 
- Whilst we may have a shortage of ventilators, holding people indefinitely on CPAP may be short-sighted as it may be converting single organ failure into multiple organ failure. 

OK, that’s all I have. 

I will stress again that this is simply a summary of discussions, none of which are backed up by large, robust multi-centre RCTs. 

My conclusions after each section are nothing more than suggestions to be discussed. 

We need to adapt fast to what we learn about this disease and learn from our colleagues at other centre. We are all in this together and joined up thinking is required. 

Lastly, we desperately need to look at our own data to understand whether we are getting this right or not. 

Good luck, stay stay safe and be kind to one another. 

Dan
Daniel Martin OBE
Macintosh Professor of Anaesthesia
Intensive Care Lead for High Consequence Infectious Diseases
Royal Free Hospital
London

Please share your comments below.

A Facebook follower, commented the following re emergency dental services and local responses...

My mum has been losing weight for almost six months (unexplained). She is undergoing tests to see if she has a rare adrenal tumour. Due partly to how long the analysis takes for these tests, they have taken a long time. Her consultant appointment is due end of April - now to be done over the telephone.

If they do discover it is the adrenal tumour, she would need further investigation to identify whether or not it is cancerous (usually not cancerous) and potentially an operation to remove it so she can recover (fairly good outcome stats). My concern is that if this appointment gets cancelled, she cannot afford to continue to lose more weight, she will literally waste away (she is only 7 stone something at the moment). Will she just be left to deteriorate? 

Hi, these may be of interest/help...

Mental health and well-being during coronavirus crisis (15 March 2020)

WHO: Coping with stress during the 2019-nCoV outbreak
 

This blog may be of interest to this thread too - Coronavirus means difficult, life-changing decisions for me and my cancer patients

I'm being made more and more aware of this lately too. It led me to this very interesting blog site ...

Not sure if this is the same one Helen, but there's a documentary with Stacey Dooley out tomorrow - she spends some time in a '136 unit' (designated place of safety).

https://www.bbc.co.uk/programmes/p082bxzn