Case studies: Improving the whole journey

Nottingham University Hospitals

Safety in emergency surgery is a real and pressing issue and one that Nottingham University Hospitals – a Sign up for Safety trailblazer – is taking seriously.
Victoria Banks, consultant intensivist, explains. “Emergency surgery patients make up 40 to 50 per cent of surgical work but account for around 80 per cent of the adverse outcomes, including mortality,” she says.

“So they really are a patient group we need to focus on.” Dr Jonathan Mole, consultant anaesthetist adds: “Within emergency surgery there is a group who are identified at particularly high risk – those who undergo an emergency laparotomy (where the abdomen is opened).

“A national audit two years ago showed that the average 30-day mortality rate for these patients was 17 per cent.

“In NUH, between 20 and 35 patients require an emergency laparotomy each month, making it one of the busiest units in the country and providing the potential to benefit significant numbers of patients.”

Case reviews had already identified recurrent themes. “We found these included delays in diagnosis, CT scans, and timely arrival to theatre,” says Dr Banks.

“Data collected for the National Emergency Laparotomy Audit meant that we could map the success of the initiative and provide meaningful feedback. This in turn helped provide impetus to launch a hospital-wide Emergency Surgery safety improvement programme.”

The programme looked at the whole patient pathway. “People tend to focus on the areas they control,” says Dr Mole. “We looked at how we could improve the journey as a whole. Reducing risk and improving outcomes for patients in the days and months following involves lots of small improvements along the patient pathway.”

The main driver in the improvement plan was obtaining a thorough and rapid assessment of patients presenting with abdominal pain to identify those at “high risk of death (HROD)” as early as possible and expediting their care.

“It starts at admission when patients are clerked in and are now routinely assessed for high risk factors such as age, signs of sepsis or organ dysfunction,” explains Dr Banks. “These HROD patients then trigger an expedited CT scan, scan report and an earlier senior review to obtain a diagnosis and a management plan before they have a chance to deteriorate further.”

‘It’s really satisfying that we are starting to see a cultural change’

“The surgical team now routinely score for predicted mortality, allowing them to obtain much better informed consent from patients and their families. When patients get to theatre, there is a new set of evidence-based guidelines for anaesthetists.”

This checklist means that optimal care is delivered at all times.

Surgeons use the P-POSSUM scoring system to quantify risk. A high score now mandates a consultant surgeon to operate and means the patient goes to critical care post-operatively. Since January 2014, overall mortality in emergency laparotomy surgery has dropped from 14 per cent to 11 per cent. Patients are also able to recover more quickly and go home earlier.

The changes are also benefitting other patients having emergency surgery. “One of the things that’s been really satisfying is that we are starting to see a cultural change,” says Dr Banks.

“Surgeons are starting to change how they make decisions and involving senior people earlier in the decision making process. On call patterns are changing and we are seeing lasting change.”

This work, which included a local CQUIN (Commissioning for Quality and Innovation) initiative, initially pre-dated the Sign up to Safety Campaign but, says patient safety programme lead Owen Bennett, the campaign has given it extra impetus. “Sign up to Safety has meant that there is clarity across the organisation around our priorities for safety – emergency laparotomy being one of them,” he says.

“It’s opened up conversations about avoidable harm and the improvement that is already happening and how we can build on it. It’s meant we can have a more medium to long term approach and has provided a mechanism to share what we are doing and to learn from others.”

Dr Mole agrees. “Safety has definitely gone up the agenda. The fact that the trust has prioritised this for three years is fantastic and the work we have been doing is now more appreciated trust-wide.”

East London FT

East London Foundation Trust delivers mental health and community services to some highly disadvantaged people in highly disadvantaged communities. But that has not stopped it taking a system-wide approach to safety and quality.

Amar Shah, associate medical director for quality improvement at the trust, who is also a consultant forensic psychiatrist, explains: “For several years we have been building the case for a new approach to quality and safety. We have been learning from different places around the world that have been using improvement methods to achieve a change in culture.”

The team visited different care settings, in the UK and abroad, to look at how other organisations have built quality improvement and safety into their day to day work. In February 2014, the trust launched its QI programme with the mission of supporting the organisation to provide the highest quality mental health and community care in England by 2020.

This sets two aims of reducing harm by 30 per cent a year and providing the right care in the right place at the right time.

Dr Shah says: “We have been thinking creatively with teams about the ideas they could try, we have been skilling up our staff and service users and aligning the organisation around our improvement goals.

“Our approach is to help teams with some of the things that matter to them; to help them find the space to tackle them and the skills, tools and senior support to get on with it.” Clinical, admin and corporate teams have taken up this work enthusiastically and with some great results.

By May 2015, 1,000 of the 3,700 staff were involved in safety and quality projects. “Fifteen months ago we had 20 to 30 people involved,” says Dr Shah.

One important area for a mental health provider is reducing the use of “prone” restraint – forcibly placing people face down. “There’s no single answer to this and teams have done a range of things… In the last 18 months, we have seen a 56 per cent reduction,” says Dr Shah.

‘Approaches such as safety huddles and risk assessments were used to reduce inpatient violence’

Another team on an adult mental health ward has used different approaches to reduce inpatient violence, such as safety huddles, dynamic risk assessments, and using visual displays shared with staff and patients. The number of violent incidents has halved – and done so sustainably.

In older adult mental health wards – where there is a greater likelihood of assaults on staff than in any other psychiatric inpatient setting – teams have tried a whole range of creative ideas including aromatherapy, sensory stimulation rooms, meaningful daytime activities, pet therapy and more.

They too have seen violence reduce by 40 per cent. “We have seen staff sickness come down and the number of assaults on staff go down,” says Dr Shah.

“We are now spreading the bundle of interventions from our pilot adult ward to all seven adult wards in Tower Hamlets. They are all using the same systematic method but trying different ideas.”

This is the background with which East London FT came to Sign up for Safety in June 2014. They already had a system-wide approach and saw QI and safety improvement not as an add-on but as an organisational transformation programme.

Kevin Cleary, medical director and director for quality and performance, says joining the campaign adds a whole other dimension.

“It is hard to reliably and sustainably improve the quality and safety of healthcare as an isolated provider,” he says. “Being part of networks focused on quality and safety is a critical part of success.

“We need to hear how other organisations are learning, what is working for them and what we can adapt to help us and to share with them our successes and failures. Sign up to Safety is a great opportunity. We could never build the relationships that are possible in this campaign as an individual organisation.

“It provides a definite focus on safety and a positive nudge for us to develop learning relationships with organisations that we would not normally know or meet.
“There is sometimes a belief expressed that mental health services are very different to other health services, but our patient safety issues are really very similar.

“Sign up to Safety is an umbrella under which we can all huddle together and collaborate on patient safety.”