West Suffolk Hospital NHS Trust
Report To:
Trust Board
Date:
January 2012
Title:
Quality and Performance Report
Report of:
Nichole Day, Executive Chief Nurse
0
Introduction
This Quality Report provides the narrative for performance in three key areas: Quality priorities, CQUIN
performance and local issues requiring escalation. It should be read in conjunction with the Ward and Trust
dashboards.
The layout of this report identifies performance data followed by themes identified during the analysis process
and actions being taken. The ward quality report summary has been used to highlight wards that have a
number of red scores and these are discussed within the report.
1
1. To further reduce hospital acquired infections
Aim: To reduce hospital acquired MRSA bacteraemia to no more than 2 cases and C. difficile infection to no
more than 29 cases between April 2011 and April 2012
Number
3
MRSA
Number
Total no of MRSA
bacteraemias:
Hospital
2
MRSA Cumulative
Ceiling: Hospital
Acquired
1
1
0
0
0
0
0
0
0
0
0
Apr May Jun
Jul Aug Sep Oct Nov Dec Jan Feb Mar
MRSA Cumulative
Actual: Hospital
Acquired
30
Total no of C. diff infections: Hospital
Total no of C. diff
infections: Hospital
25
20
C. diff cumulative
ceiling: Hospital
15
10
5
0
Apr May Jun
Jul Aug Sep Oct Nov Dec Jan Feb Mar
C. diff cumulative total
hospital infections (to
date)
There were no cases of MRSA or MSSA bacteraemia during December.
There was 1 case of clinically significant hospital acquired C. difficile during December (giving a total of 17 year to date).
In respect of compliance with the High Impact Interventions (HII), all interventions scored 100% except peripheral cannula ongoing care
(96%) and urinary catheter ongoing care (92%). This was related to documentation and has been discussed at the Matron’s
performance meeting and will be addressed by the Matrons.
The sideroom audit during December demonstrated that of the 32 siderooms available: 21 were used for Infection control purposes. 1
sideroom was empty and available for isolation. No high risk patients were not isolated at that time.
2
1. To further reduce hospital acquired infections
Aim: To improve the management of antibiotics by achieving 100% compliance with antibiotic policy
The compliance with antibiotic prescribing policy was 97% in December.
1 out of 31 patients (3%) received non-guideline/unauthorised antibiotic treatment:
This patient was treated with Co-Amoxiclav for a urinary tract infection; the guideline treatment is Trimethroprim or Nitrofurantoin. The
patient had not had a urine sample sent to microbiology this admission to indicate the use of Co-Amoxiclav, nor were there any
contraindications for the use of the guideline antibiotics. Co-amoxiclav usage has improved compared with previous months and this is
reflected in the improved overall results.
%
A report on the proposed changes to antibiotic audits is
provided in Appendix 1 of this report.
Antibiotic Prescribing
100
Antibiotic
Audit:
Prescribing
80
60
40
Target
20
0
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
Actions taken/proposed:
The results have been fed back to the individual ward Consultants, Ward Managers and Pharmacists via email.
On 13th December the Antibiotic Audit Nurse presented the recent antibiotic audit results at the Medical Clinical Governance
afternoon and gave a presentation on correct antimicrobial prescribing. The possibility of the Antibiotic Audit Nurse attending
individual ward governance meetings to enable face-to-face reporting and action plans was discussed and it was agreed that details
of these meetings will be provided to facilitate this.
A copy of the abbreviated antibiotic guidelines was included in the junior doctor induction packs, to try to minimise the effect that the
junior doctor change-over may have on antibiotic prescribing. Gemma Kerridge, Antimicrobial Pharmacist, presented the correct use
of the antimicrobial page on the drug chart at the junior doctor’s induction on Friday 9th December 2011.
3
2a) To achieve the highest levels of patient safety
Aims
i) To assess at least 98% of admissions for risk of VTE
ii) Provide prophylaxis to 100% patients at risk
VTE assessment performance/ issues and actions
%
100
%
VTE: Completed risk assessment (monthly Unify audit)
VTE:
Completed risk
assessment
(monthly Unify
audit)
98
96
94
VTE: Prophylaxis compliance
100
VTE:
Prophylaxis
compliance
80
60
40
92
Target
Target
20
90
0
88
Apr May Jun
Jul Aug Sep Oct Nov Dec Jan Feb Mar
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
Compliance with risk assessment was 95.6% for December. Prophylaxis compliance was 98%.
4
2b) To achieve the highest levels of patient safety
Aim: To reduce the number of patients who fall in hospital by 35% in the last quarter of 2011/12
Patient Falls
The CQUIN ceiling is 147 falls in Quarter 3. The total number of falls in
December was 44 which brings us to a Q3 total of 140 falls, meeting the
CQUIN target. Q4 ceiling will be 126 falls across the quarter.
The wards with significantly increased fall rates against their normal
performance were F6 and G1. F6 had a very difficult, aggressive patient who
had all interventions in place (low bed, 1:1 nursing) but fell 3 times as he
refused assistance to mobilise.
Number
70
Falls
No of patient falls
60
50
No of patient falls
resulting in harm
40
30
20
10
0
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar
No. of serious
injuries or deaths
resulting from
falls
The number of falls have now been reduced to a level where it is difficult to identify themes and different issues are identified each month.
These are very difficult to reduce further when balancing the need for rehabilitation with patient safety, therefore it is felt that the only way
to make further progress is to ensure that the expertise of other professional groups is fully utilised and a joint approach to problem
solving further developed.
Actions
The Head of Nursing met with AHP leads to discuss falls and joint actions that could be developed. As a significant number of falls
happen in our patient toilets, the OT lead will review toilet facilities for grab rail availability, toilet raiser seats etc. The AHP leads are now
sent 10 falls concise RCAs/ month to review and consider further preventative actions that could provide benefits to a wider group of
patients.
5
:
2c) To achieve the highest levels of patient safety
Aim: To reduce the number of avoidable Grade 3 and 4 pressure ulcers by 80% in the last quarter of
2011/12
Pressure Ulcers
5 patients developed ward acquired pressure ulcers this month:
•A #NOF patient developed a Grade 2 heel pressure ulcer on F3. This was considered avoidable as the leg trough was putting
pressure onto the heel and should have been noticed.
•Two patients on G5 developed pressure ulcers. One was considered unavoidable as the patient refused all preventative care and
one patient developed an avoidable pressure ulcer - there was no evidence of risk assessment or preventative care.
•A patient on the Coronary Care Unit was admitted with a Grade 1 pressure ulcer which deteriorated to a Grade 2 pressure ulcer due
to his poor physical condition. This was considered unavoidable as the patient was on the Liverpool Care Pathway and refused care.
•A patient on F7 developed Grade 2 sacral pressure ulcers. A pressure relieving mattress was unavailable for this patient, therefore
this is classified as avoidable.
Number
12
Pressure ulcers
No of patients with
ward acquired pressure
ulcers
10
8
6
4
No of patients with
ward acquired Grade 3
or 4 pressure ulcers
2
0
Apr May Jun
Jul Aug Sep Oct Nov Dec Jan Feb Mar
6
3a/b) To continuously improve the experience of patients using our services
Aims: At least 90% of patients would choose to use the hospital again. To achieve at least an 85% satisfaction
rating in our internal patient experience surveys
Survey results
Survey
Overall
satisfaction
Recommender
question
Inpatients
91%
99%
Outpatients
93%
100%
Short stay
96%
100%
A&E
98%
100%
%
Overall percentage scores for the surveys for December are provided in
the table (left).
Individual question scores were high for all questions in the Outpatients,
A&E, and short stay surveys. A breakdown of the scores for the questions
in the inpatient survey are provided below and overleaf. Following
feedback from the last Board meetings the graphs have been presented
differently this month and broken down into 3 graphs to aid clarity. The
recommender question and overall satisfaction with the care provided
have been removed from the graphs as these are reported in the table and
are consistently high. The question on noise at night was changed in
September and broken down into 2 questions, one relating to noise from
patients and the other noise from staff.
In your opinion, how clean was the hospital
room or ward that you are in?
Patient Satisfaction: In-Patient
100
Were you ever bothered by noise at night
from other patients?
95
90
Were you ever bothered by noise at night
from hospital staff?
85
Were you ever bothered by noise at night
from other patients or hospital staff?
80
75
Were staff professional, approachable and
friendly?
70
Did you find someone on the hospital staff
to talk to about your worries and fears?
65
60
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
Were you involved as much as you wanted
to be in decisions about your condition and
treatment?
7
3a/b) To continuously improve the experience of patients using our services
Aims: At least 90% of patients would choose to use the hospital again. To achieve at least an 85% satisfaction
rating in our internal patient experience surveys
Survey results
%
Were you given enough
privacy when discussing your
care?
Patient Satisfaction: In-Patient
100
95
Were you given enough
privacy when being examined
or treated?
90
85
80
Did nurses talk in front of you
as if you were not there?
75
70
Did doctors talk in front of you
as if you were not there?
65
60
%
100
Patient Satisfaction: In-Patient
95
Before hand did a member
of staff answer your
questions regarding your
operation/procedure?
90
85
80
75
70
Did the anaesthetist or a
member of staff explain to
you how you would be put
to sleep in a way you could
understand?
65
60
55
Timely response to call bells
50
55
50
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar
As reported last month, the scoring related to the question on call bell response times was changed in September to reflect the
scoring within the national patient survey, hence the reduction in scores. The average call bell response times in December on the
wards with the new call bell system are displayed below. The two questions in the graph on the right are mainly relevant to surgical
patients.
Overall average
response times
F3
F4
F5
F6
G3
136
seconds
84
seconds
101
seconds
144
seconds
118
seconds
8
3c) To continuously improve the experience of patients using our services
Environment and Cleanliness
The overall Trust score was 91% and all clinical areas scored greater than 85% except F7 who scored 67%.
A number of issues have resulted in a low score for Ward F7 this month. Refurbishment of the neighbouring ward has led to unacceptable
increases in dust levels that have been addressed with the contractor. Issues have also arisen since the ward move related to poor ward practices
and problems with team working between housekeeping and nursing staff. A meeting has been held with all parties and an action plan agreed.
Formal monitoring by the housekeeping supervisor has been initiated to ensure that improvement is maintained..
%
Environment and Cleanliness
100
98
Environment and Cleanliness
96
94
92
90
88
Target
86
84
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
9
4a) To achieve optimal clinical outcomes and effectiveness
Aim: To consistently achieve a Hospital
Standardised Mortality Ratio that is below the
expected rate
Rolling 12 Month HSMR-All Admissions
90
85
80
75
70
Oct
National Rate Apr
09May Jun Jul 09Sep
09from last
May 09- 09-Jul Aug Aug 09- 09-Oct Nov
reporting
10 Jun 10 10
10 Sep 10 10
10
period
Rolling 12 Month HSMR-All
Admissions
Rolling 12 Month HSMR-Non
Elective
Sep 10-Oct 11
Aug 10-Sep 11
July 10-Aug 11
June 10-July 11
May 10-June 11
Apr 10-May 11
Mar 10-Apr 11
Feb 10-Mar 11
Jan 10-Feb 11
Dec 09-Jan 11
Nov 09-Dec 10
Oct 09-Nov 10
Sep 09-Oct 10
Aug 09-Sep 10
Jul 09-Aug 10
Jun 09-Jul 10
May 09-Jun 10
65
Apr 09-May 10
HSMR remains well below the expected level as can be seen by
the overall mortality shown in the graph and the table giving a
mortality rate for the five Dr Foster - How Safe is Your Hospital
indicators. This table provides information on relative risk, with
red, blue and green traffic lighting. Blue indicates that the score is
within the standard deviation.
Nov
Apr
09Dec Jan Feb Mar
10Dec 09-Jan 1010- 10-Apr May
10
11 Feb 11Mar 11 11
11
May June
1010June July
11
11
July
10Aug
Aug 10-Sep Sep 1011
11
Oct 11
-
76.5
89
89
87.8
86.3
84.6
84.1
80.3
81
79
79.3
76.9
76.3
76.3
84.8
83.6
83.2
82.3
-
79.6
89.1
89.1
88.1
86.7
84.8
84.2
80.3
81.1
79.1
79.4
77.1
76.4
76.4
85
83.9
83.4
82.6
SMR Stroke (Acute
Cerebrovascular Disease)
86.2
79.4
87.8
86.8
88.7
88.6
84.2
84.4
79.7
80.5
75
78.1
74.3
74.2
74.2
76.5
77.8
71
67.7
SMR - Heart Attack (AMI)
90
92.1
93.7
94.5
89.4
82.4
78.5
77.9
81.8
94.1
82.5
79.6
77.7
71.1
71.1
69.7
67.7
71.5
64.9
SMR - FNOF
81.6
64.7
73.3
69.2
60.7
62.9
66.2
66.9
67.4
65.9
64.2
64.3
64.1
62.4
62.4
88.7
76.4
82.1
85.5
Mortality from Low Risk Conditions
0.84
0.67
0.62
0.62
0.53
0.49
0.44
0.49
0.45
-
-
0.55
0.6
0.51
0.51
0.52
0.57
0.58
0.54
10
Local issues requiring escalation
Patient Experience
Ward surveys
CCU and G4 had 4 red scores on their patient experience relating to noise at night, call bell response times and staff talking in front of
them, These areas experienced pressures created by increased patient throughput and patient dependency during December,
compounded in the case of G4 by staffing pressures as a result of Norovirus. These patient experience results will be escalated to the
ward governance meetings and actions developed.
11
Other
OTHER PERFORMANCE
STANDARDS
•
Overall, performance against other performance standards remains good.
•
The area’s for exception reporting this month are:-
•
Cancer 62 day. Performance was below standard for December, however did achieve for the quarter. Performance was affected in December
due to the holiday period and less elective operating
•
Stroke TIA. This was below standard for December, this was due to late referrals from GP’s to the Trust, combined with annual leave. Regional
stroke performance for quarters 1and 2 is attached to this report for information. It show that WSH performance overall is good, although there is
always scope to improve.
•
A&E. There was a significant wait for one patient of over 11 hours in December. This was a patient who was referred to the mental health
services and there was a delay in attendance to the A&E department. The Trust and the PCT are in discussion with the Mental Health Trust for a
new service level agreement for response times from April 2012.
•
The ambulance handover times for A&E have been static for several months, although it should be noted have improved significantly from this
time last year. One of the key challenges relates to the arrival of GP expected patients in the department. The new EAU is scheduled to open at
the end of January, and whilst this in itself will not solve all the issues with regard to handover times, it is anticipated that the additional
assessment capacity in EAU will enable more patients to be seen directly in that department and not attend A&E.
•
18 week performance remains good. There are challenges with diagnostic waiting times for endoscopy, but performance is within the tolerance
allowed 1% of patients waiting over 6 weeks.
12
Local Priorities - Governance Dashboard
Indicator
Performance target
National safety
alerts
Number of NPSA alerts beyond national implementation deadline
R
A
>=5
1-4
G
Dec11
0
2
Commentary
Two NPSA alerts remain overdue and on the Risk register: PSG/2007/001
Medicines reconciliation and SPN/2008/014Right Patient Right Blood. Two
were closed this month:
RRR/2010/019 Safer ambulatory syringe drivers due 6th December closed
off within required deadline.
SPN/2007/016 Early identification of failure to act on radiological imaging
reports been closed off late following approval at the Operational Steering
group of Policy PP203 Validation of results. An audit tool is being
developed to monitor the implementation of this policy which also meets
the requirements of the NHSLA criterion 4.4 Diagnostic testing
procedures.
Timely
completion of
Red incident
investigations
and action
RCAs (non SIRI) completed more than 45 days after incident
reported
>=1
Actions beyond deadline for completion
>=5
Timely
reporting of
SIRIs to NHS
Suffolk
SIRIs 2 day report beyond timeframe
Risk
assessments
Active risk assessments in date
<75%
Outstanding actions in date
<75%
NICE
0
0
0
0
>=1
0
0
SIRIs 7 day report beyond timeframe
>=1
0
0
SIRIs 45 day reports beyond timeframe
>=1
0
0
75 – 94%
>=95%
95%
75 – 94%
>=95%
95%
1-4
TA (Technology appraisal) business case beyond agreed
deadline timeframe
>9
4-9
0-3
4
IPG (Interventional procedure guideline) baseline assessments
beyond agreed deadline timeframe
>9
4-9
0-3
8
CG (Clinical guideline) baseline assessments beyond agreed
deadline timeframe
>9
4-9
0-3
10
Clinical Audit
Trust participation in relevant ongoing National audits (reported
by Quarter)
<75%
75 – 89%
>=90%
97%
Complaints
Response within 25 days or negotiated timescale with the
complainant
<75%
75 – 89%
>=90%
100%
Complaints resolved with first written response
<75%
75 – 84%
>=85%
100%
0
0
<=5
3
Red complaints actions beyond deadline for completion
>=5
1-4
Number of PALS contacts that became formal complaints
>10
6-9
The one SIRI reported in December had the relevant reports submitted
within the required timescale
The three SIRI 45-day reports due in December were all submitted within
the agreed timescales
There has been a significant improvement in outstanding TA business
cases following continued clinicians engagement with pharmacy. IPGs
have been reduced to 8, but CGs are still high at 10. A series of targeted
follow up meetings with the clinical leads have been planned to address
this.
13
Local Priorities Care Quality Commission (CQC) Quality & Risk Profile
Background
The CQC publish a monthly Quality & Risk Profile (QRP) outlining the external sources of data which can be used to assess a Trust’s level of
compliance using a statistical assessment to identify if a Trust’s performance is much worse than expected; worse than expected; tending towards
worse than expected; similar to expected; tending towards better than expected; better than expected or much better than expected. The expectation is
that each Trust will study this QRP and use it to provide evidence of compliance and/or act upon those areas highlighted as below expected. In
addition, this report contains Negative Comments or Positive Comments taken from local engagement, external inspectors’ reports and a range of
other sources. The Quality and Risk Committee review in detail progress to address areas of concern.
November and December QRP – new items in the Positive / Negative categories. There were also 38 items graded as “Similar to expected”
Item
Score
No. of items
Narrative
CQC Complaints Review [Nov]
Negative Comments
9
This was a CQC internal exercise drawing together all info held on complaints and
matched against Outcomes. Whilst only three complaints were listed, extracts were
quoted within the outcomes nine times. Clarification was obtained from the CQC as to
which complaints there were and it identified two that have been successfully resolved
and one that was anonymised and so the CQC lead could not identify it.
Intelligence from local engagement [Nov]
Positive comments
12
Positive feedback from a variety of sources where the CQC has expressed satisfaction
with the actions taken by the Trust to address issues following reported incidents.
Rate of reporting per six months of admissions to
the National Reporting Learning System (NRLS) for
small Acute trusts [Nov]
Tending towards worse
than expected
1
This was also included as a concern in the CQC’s August 2011 review and more detail is
provided as a separate slide in this report.
National Sentinel Stroke Organisational Audit [Dec]
Worse than expected
Tending towards better
than expected
3
1
Intelligence from CQC Compliance Review [Dec]
Negative Comments
Positive comments
3
4
Intelligence from LINks Quality Accounts [Dec]
Negative Comment
1
Intelligence from Other Third Party Groups [Dec]
Negative Comment
1
Intelligence from Other Third Party Groups [Dec]
Negative Comment
1
Intelligence from Other Third Party Groups [Dec]
Positive Comment
1
Intelligence from NHS Choices [Dec]
Positive Comment
1
Negative comment relate to: lack of a report analysing views of patients, formal links with
patient/carer organisations and lack of a strategic group responsible for stroke with at
least 3 members. The National Sentinel Stroke Audit recommendations are being self
assessed and managed through the Trust’s Best practice publications policy process
PP(10)205
This correlates directly to the CQC (October) visit report. The 3 Negative comments link
back to the 3 Outcomes for which minor concerns were stated. The Trust action plan is
being monitored by the Quality & Risk Committee.
Feedback on details of these has been obtained from the CQC. None were directly
attributable to an individual incident/complaint or risk and there were no themes in the
issues noted. The LINks review appears to be based on the Trust’s National Inpatient
Survey results.
14
Local Priorities
Patient Safety Incidents resulting in harm
(including serious harm) and Serious
Incidents Requiring Investigation (SIRIs)
The overall rate of incidents resulting in harm has
shown a decrease in the last month to 76. The
number of serious incidents is three. The number of
SIRIs reported in December was one (an outbreak
of Norovirus).
NRLS analysis shows that WSH has a reporting
rate of 4.4 per 100 admissions, which is at the
lower end of reporting rates for our small acute
peer group and this has been highlighted as
“tending towards worse than expected” by the CQC
on the Trust Quality & Risk Profile. More detailed
analysis of NPSA data is provided on the next
slide.
The three serious incidents in December were: the Norovirus outbreak (SIRI), a worsening of infection due to missed doses of antibiotics and a third
which relates to the care of a patient with an ectopic pregnancy which is still awaiting confirmation of final grading and so remains Red until confirmed
otherwise.
Themes from 2011 SIRIs
The number of reported SIRIs over the last year (excluding May) has fallen slightly. There is evidence to suggest that SIRIs relating to pressure ulcers,
falls and information governance have reduced. In addition there have been no nasogastric tube incidents and only one maternity incident, both of
which are reductions compared to 2010. Incidents of infectious outbreaks (eg C difficile and Norovirus) still occur at sporadic intervals. No theme is
identifiable from the remaining SIRI.
Local Priorities
Patient Safety Incidents reporting to NPSA
National Reporting and Learning Service
(NRLS)
The first axis of the graph shows the number of
patient safety incidents (including near miss and no
harm) for the period Jan – Dec 11. The ‘Median’ line
shows the number of incidents required to be
reported (to the NRLS) to be the median Trust for
incidents per 100 admissions in the small acute Trust
category (6.2 based on the Oct 10 – Mar 11 dataset).
There is a downward trend in the reporting of
incidents overall from April onwards which appears to
be based mainly on a reduction in the number of
reported falls with no/minor harm. The Datix
implementation project recognises the need to
ensure that staff are encouraged to report through the
new system but this needs to consider what the
causes of low reporting are due to. A plan has been
agreed to ensure effective communication of reporting arrangements and sharing of learning from incidents.
This is linked to the implementation of the new electronic incident reporting procedure. The second axis of the graph shows the percentage of
incidents leading to serious harm (as a % of all reported incidents including ‘no harm’ and ‘near miss’). The axis is set from 0% to 10% to clearly
demonstrate fluctuations month on month. The percentage of incidents leading to serious harm (major or catastrophic) was identified as a concern in
the Trust NRLS benchmark reports. Since April, a senior review of all incidents in these categories (and those categorised as moderate) is being
undertaken weekly to ensure accuracy of level of harm grading. This led to a drop in this category from April to August but then this rises again from
September.
The Trust proforma for completion at the end of the RCA asks (amongst other things) whether the outcome to the patient occurred directly as a result
of failings in care, coincidental to any failings in care (or unable to conclude either way). This has allowed the downgrade of a small number of
incidents originally graded as Major or Catastrophic before submission to the NRLS when the RCA review identified that the outcome to the patient
was not affected by any care issues. This is reflected by updating the previous months’ data on the graph every month. Incidents in the most recent
period Nov/Dec that have not completed the RCA process may be subject to this downgrade after the investigation but this assumption should not be
made prematurely and (based on the experience of Apr-Sept) it is likely that most will remain unchanged.
Local Priorities
Complaints
Complaints response within agreed timescale with
the complainant: 100% of responses due in
December were responded to within the agreed
timescale (target 90).
Of the 16 complaints received in December , the
breakdown by Primary Directorate is as
follows: Medical (7), Surgical (4), Clinical Support
(2), Women & Child Health (2) and Facilities (1).
Trust-wide the most common problem areas are
as follows:
Aspects of clinical care
11
Attitude of staff
8
Communication & information
2
This breakdown reflects an expected distribution across the categories. (Please note that more than one category can be allocated to each complaint
so the total number of problem areas does not correlate with the total number of complaints).
Themes from red complaints
There have been no red complaint investigations completed since the last report. However, there are five on going red investigations that are
expected to have been completed prior to the next report. All actions identified from Red complaints are currently within deadline for completion.
17
Local Priorities
PALS (Patient Advice & Liaison Service)
The revised PALS database is now functional
and, together with prompt recording of contacts
and enquiry details, accurate and meaningful
information is now readily available. As
previously reported, categories are being collated
to correspond with the categories for formal
complaints but additional information is being
recorded on primary and secondary concerns. A
comparison of the number of enquiries dealt with
from January to December 2011 is given in the
chart and a synopsis of enquiries received for the same period is given below. Trust-wide, the most common five reasons for contacts are as follows:
Communication/Information (oral or written)
21
Attitude of staff
14
All aspects of clinical treatment
18
Transport (ambulances and other)
12
Appointments (delays / cancellations)
6
Communication, concerns about aspects of clinical treatment and general enquiries remain the most prominent reasons for contacting PALS.
However, there are no trends identified for specific groups of staff, speciality or discipline.
The PALS Manager continues to deal with requests for information which can vary from clarification of hospital procedure to specific details about
treatment given; future care plans; outcome or length of time waiting for results of tests and discrepancies about diagnosis and/or discharge
arrangements.
A number of queries also relate to appointment dates and length of time waiting for these; the length of time waiting in clinics; and general enquiries
about services not directly managed by West Suffolk Hospital.
The PALS Manager frequently helps to improve communication between the Trust and patients’ family members both in this country and abroad.
Any issues which are not able to be dealt with by PALS are directed, if appropriate, to the formal complaints process.
The very nature of the PALS service requires responses to queries, concerns or complaints to be dealt with expediently. A Target of 80% for
responding fully (completing the enquiry) within 48 hours has been set or within a timeframe agreed with the enquirer. This target is currently being
monitored and evidence of compliance will be submitted in the new year, after three months data has been collected.
Appendix 1
Antibiotic Audit Programme
The rolling antibiotic audit programme identifies current
antibiotic prescribing practice within the West Suffolk
Hospital and areas for improvement. 14 ward areas
across Medical and Surgical Directorates are audited
quarterly. Exceptions are:
•Critical Care - as they have a daily Microbiology ward
round.
•Women’s and Children’s Directorate (Wards F1, F11
and F12) have been excluded until their updated drug
chart, including the antimicrobial section, is in use. If
any antibiotic prescribing issues arise on F1, F11 or
F12 then auditing can be performed, separate from the
programme.
Additional audits are carried out in wards where there
is a period of increased incidence of Clostridium
difficile.
Methodology
Audits are carried out monthly on approximately a third of
wards. All patients on antibiotic treatment on those wards are
included, by reviewing all of the drug charts for the patients
on the ward at the time of the study. For those identified to be
receiving antibiotics, further data is collected using medical
notes, observation charts and IT pathology systems.
Six standards from the Trust Antibiotic Guidelines are
audited:
1.All drug allergies must be specified on the drug chart.
2.The clinical indication for antibiotics must be stated on the
drug chart.
3.Course length must be stated on the drug chart.
4.Patients will receive IV antibiotics for a maximum of 72
hours unless there is a valid clinical reason.
5.All patients will be prescribed antibiotics as per the Trust
Antibiotic Guidelines or on advice from a Consultant
Microbiologist.
6.Appropriate samples will be sent to microbiology (to enable
narrower spectrum antibiotics to be used at earliest
opportunity).
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Following each ward’s audit, results are emailed to the
ward Consultants, Ward Manager, Senior Matron and
Pharmacist. Overall results were produced quarterly,
with a ‘RAG’ spreadsheet distributed to all wards and for
inclusion in the quality reports and for discussion at the
Antimicrobial Management Group, Drugs and
Therapeutics Committee and the Infection Prevention
Implementation Group.
More recently, monthly reporting has been required by
NHS Suffolk and therefore the results for those wards
audited have been reported and the results included in
the Trust quality report. This means that the data cannot
be compared on a ‘like-for-like’ basis each month. It is
therefore planned that the following wards are to be
audited in the same month each quarter to allow for
some continuity.
Month 1
Month 2
Month 3
F4
F3
F6
F5
F9
F7
G4
G1
G3
F10
G5
G8
CCU
EAU
National recommendations (Department of Health)
2011) are that organisations develop their own audit
programmes, targeting specific components of best
practice antibiotic prescribing, with at least annual point
prevalence studies. Whilst we audit against all elements
of practice identified in the recommendation, other
Trusts identified in the above report, audit a selection of
the elements. Our audit programme is therefore more
comprehensive in comparison and the infection
prevention team feel that it is more useful in changing
practice than a less detailed monthly audit.
Whilst we audit six criteria, the figure that is reported to
NHS Suffolk and included in the Trust quality report is
compliance with criterion 5; “all patients will be
prescribed antibiotics as per the Trust Antibiotic
Guidelines or on advice from a Consultant
Microbiologist.”
The following graph shows the overall compliance
achieved encompassing the six audit standards,
against the compliance with the antibiotic prescribed as
the guidelines.
20
Antibiotic choice as per Trust guideline vs overall audit complinace
120%
100%
80%
All patients will be prescribed antibiotics
as per the Trust Antibiotic Guidelines or
on advice from Consultant Microbiologist
Overall compliance
60%
40%
20%
0%
Q1, 201011
Q2, 201011
Q3, 201011
Q4, 201011
Q1, 201112
The graph demonstrates the improvements that
have been made in antibiotic prescribing practice
since the audit programme began in January 2010.
In that time a number of initiatives have been
implemented to help improve prescribing practice,
including the addition of a new antimicrobial
prescribing page on the hospital drug chart,
abbreviated copies of the antibiotic guidelines
provided to medical staff and an antibiotic
awareness session on the nurse mandatory training.
Q2, 201112
Q3, 201112
Despite all of these changes to practice and educational
sessions, we are still failing to achieve the 100% target. With
the number of individual patient factors to be taken into
consideration when prescribing antibiotics, such as allergies,
microbiology sensitivities, renal and hepatic function etc, a
more realistic target would be 98%. This still represents a
challenging measure, still sets a high standard to achieve and
the additional prescribing information that is collected in the
audit process but not reported, such as sending of
microbiology samples and de-escalating intravenous treatment
to oral, would ensure that the patients are not being put at risk.
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