THE NEWCASTLE UPON TYNE HOSPITALS NHS FOUNDATION TRUST
Board Paper - Cover Sheet
Date
14/10/2015
Lead Director
Report
Author
Classification
Report Title
Harm-Free Care
Nursing & Patient Services Director
Agenda Item A5(vi)
Helen Lamont, Nursing and Patient Services Director
Frances Blackburn, Deputy Director of Nursing and Patient Services
Freeman Hospital
NHS Unclassified / NHS Protect / NHS Confidential
Purpose (Tick
one only)
Approval
Links to
Strategic
Objectives
 To put patients and carers at the centre of all we do and to
provide care of the highest standard in terms of both safety and
quality.
 To continue to be recognised as a first-class teaching hospital,
counted amongst the top 10 in the country, which promotes a
culture of excellence, in all that we do.
Regulation 9,12
Domains
 Safe
 Effective
 Well-led
 Responsive to people’s needs
No.
Links to CQC
Domains/
Fundamental
Standard(s)
Identified
Risk? (If yes,
risk
reference)
Resource
Implications
Legal
implications
and equality
and diversity
assessment
Benefit to
patients and
the public
Report
History
Next steps
Discussion
For
Information 
No resource implications.
This paper demonstrates that the Trust takes seriously its
responsibilities in relation to Equality and Human Rights, and Health
and Safety and recognises that individual needs need to be
responded to. It also demonstrates Trust commitment to the Duty of
Candour.
Demonstrates Trust commitment to providing services which are
safe and do not harm patients and that where harm occurs this is
reviewed in detail to consider what learning can be taken to improve
the care of all patients and meet the needs of all patients. Provides
examples of practice development that have been undertaken to
meet these duties.
Regular Report – previous report June 2015.
Trust Board.
Agenda item A5(vi)
THE NEWCASTLE UPON TYNE HOSPITALS NHS FOUNDATION TRUST
HARM-FREE CARE
EXECUTIVE SUMMARY
The delivery of ‘Harm Free Care’ as defined by the National Mandated Safety
Thermometer is a key quality issue for all NHS organisations and the prevention of
pressure ulcers and patient falls is at the centre of this. The Trust has made the
prevention of both harms a priority by supporting initiatives led by the Nurse
Consultant for Tissue Viability and the Falls Prevention Coordinator.
Both pressure ulcers, and patient fall incidents, are closely monitored and
analysed. There has been a downward trend in the incidence of both harms
across the Trust but the priority remains to achieve zero pressure ulcers and a
further reduction in falls, particularly falls with harm. Safety Thermometer, a
national, monthly point prevalence audit reinforces the Trust’s good position in
reporting low levels of harm from both pressure ulcers and falls (see Appendix 1).
This paper provides detail of the Trust position in relation to pressure ulcer, and
falls prevention, providing the Board with recent data analysis, ongoing initiatives
and achievements.
RECOMMENDATION
To i) receive the briefing and note the actions taken to date and ii) endorse the
actions proposed.
Helen Lamont
Nursing and Patient Services Director
Fania Pagnamenta
Nurse Consultant Tissue Viability
Rachel Carter
Falls Project Practice Development Coordinator/
Falls Prevention Coordinator
19th October 2015
THE NEWCASTLE UPON TYNE HOSPITALS NHS FOUNDATION TRUST
HARM-FREE CARE
1.
INTRODUCTION
The Board is aware of the ongoing work streams in relation to pressure ulcer and
falls prevention to ensure the delivery of ‘Harm Free Care’. This paper provides an
up to date analysis of recent data, including current Trust position and an overview
of current initiatives and future work streams.
Pressure ulcer prevention is driven by education and training of staff on the
importance of turning patients at regular intervals. The Tissue Viability team
ensures that they review all patients who develop pressure damage to guarantee
that these incidents are reported accurately and the correct treatment is delivered
to the patient. The efforts of the team and Clinical Staff have been reflected in the
significant reduction in total number of pressure ulcers reported across the Trust
and this is consistent with monthly Safety Thermometer data (see Pressure Ulcer
Dashboard, Appendix 2).
Patient falls prevention has been driven through the Falls Prevention Coordinator
leading on the Trust ‘No Falls On My Patch’ campaign. The detailed analysis of
falls incident data, including the Route Cause Analysis (RCA) process for all falls
graded moderate and above, has led to significant changes to the way patients are
assessed and the interventions that are put in place to prevent falls. A significant
focus has been placed on falls prevention being a key part of induction training
and education which has helped to embed these practices and has led to a
downward trend in the number of falls reported across the Trust and an associated
reduction in harm from falls.
The challenges to maintaining these reductions in harm from both pressure ulcers
and falls will continue as the number of admissions to the Trust is set to continually
increase and with this comes further demands on staffing, this is particularly so of
Nursing Staff, who are the frontline care providers in relation to pressure ulcer and
falls prevention. For falls, the increase in the number of highest risk patients
(patients aged 65 and over) has continually increased in recent years and with an
ageing population this is set to increase further, therefore increasing the demands
on staff to ensure all falls prevention measures are in place all of the time.
2.
PRESSURE ULCERS
Pressure ulcers have become a key quality issue for the NHS. The published
results of the Safety Thermometer data does influence public perception of the
quality of care delivered by the Trust, it is noted that the Trust is ‘good performer’
in the context of Safety Thermometer data, which reports Trust acquired ulcers as
“harm”, and has been submitted since April 2013.
The best strategy for pressure ulcer prevention is turning patients as often as
possible, at times hourly turns are necessary: this is time consuming for staff on
the ward and a change of ward routine is necessary to embed this practice.
1
Therapy mattresses, heel elevation, other equipment (such as SkinIQ) are great
adjuncts but never replace good turning practices and good skin care.
Tissue Viability staff review all patients who develop pressure damage whilst in our
care, this ensures data is validated, which requires an experienced “eye” and
advice and education is provided. In a month the team respond to between 250
and 300 referrals, of which 50% relate to pressure damage reviews. The
remaining 50% relate to complex wound care.
DATA ANALYSIS
a)
Safety Thermometer: the worst ulcer is reported as a New “harm” (Trust
acquired) or Old “harm” (non-Trust acquired) on one finite day of the month
(true prevalence data). Safety Thermometer data is no longer part of
CQUIN but is seen as a quality indicator of the Trust’s performance.
b)
DATIX is the method by which staff report any category of ulcers and
moisture lesion. The report highlights whether these ulcers are Trust
acquired (hospital acquired and District nurses’ case load acquired) or nonTrust acquired. These reports are the most accurate and useful to analyse.
The trend since January 2013 is a general reduction; however the reduction
is not consistently maintained over the month. As the best strategy is to turn
patients and to achieve this manpower is required, the nursing shortages
experienced in the Trust have undoubtedly been reflected in those areas
where best preventative practice have not been fully embedded.
c)
The latest Dashboard is provided at Appendix 2.
Table 1: Accumulative number of pressure ulcers and moisture lesions from April
2013 to August 2015 (Trust acquired only)
160
140
120
100
80
60
40
20
0
2
Table 2: Total number of pressure ulcers and moisture lesions from April 2013 to
August 2015, by depth of damage
80
70
60
50
Cat II
40
ML
Cat I
30
Cat III
20
Cat IV
10
Jul-15
Aug-15
Jun-15
Apr-15
May-15
Mar-15
Jan-15
Feb-15
Dec-14
Oct-14
Nov-14
Sep-14
Jul-14
Aug-14
Jun-14
Apr-14
May-14
Mar-14
Jan-14
Feb-14
Dec-13
Oct-13
Nov-13
Sep-13
Jul-13
Aug-13
Jun-13
May-13
0
CONTINUING WORK
The Taskforce group continues to meet monthly. It has led work to:
a)
b)
c)
d)
update the Time2Turn Skin Care bundle (NUTH 289)
update of the “Give me 5 minutes of your time” teaching cards
update of the Pressure Ulcer prevention and treatment policy
update of the Skin Care guidelines
ONGOING INITIATIVES
a)
Recognition of the nurse staffing requirements: the single most important
action for the prevention of pressure ulcers is a strict regime of positional
changes (i.e. turning patients) and this will take nursing time.
b)
Ongoing education regarding pressure damage prevention and the
embedding of the Time2Turn initiatives continues. This includes use of
different types of mattresses (Foam, RIK and StaticAir) as well as products
used in the prevention of moisture lesions (ie SkinIQ, Bowel Management
System, and urinary containment products).
c)
Root Cause Analysis of all Trust acquired category III or IV pressure ulcers
continues by clinical teams and tissue viability prior to reporting as Serious
Untoward Incidents (SUI).
During June, July and August, 14 Root Cause Analyses have been undertaken; 13
in acute and 1 in community.
Learning in acute care has been:
-
Patients not turned sufficiently and consistently
Inconsistent documentation
Staff not recognising that, when a patient’s condition deteriorates, their risk
of developing pressure ulcers increases
3
-
Patients sitting in a chair for too long a period, with ill-fitting slippers
Patients spend a considerable time on other departments (i.e. X-ray;
dialysis; out-patients, etc.) and communication between wards-departments
has to include pressure ulcer prevention.
Learning in community care has been:
-
Failure to undertake an holistic assessment, record the Braden score, plan
preventative care and document these on the Systm1 templates.
To encourage MDT liaison e.g. with podiatry teams when sharing patient’s
care
For Registered Nurses to consider complexity of patient before delegating
care to unregistered staff.
-
d)
Regional collaborative work: The Trust is participating in a regional Pressure
Reduction collaborative, led by South Tyneside Foundation Trust following
funding from Academic Health Science Network. Annette Bartley who has led
national and international work facilitates this work there are 4 Trust teams
and 1 Newcastle Nursing Home participating.
Four areas have been selected from our acute wards to join this work stream:
-
Ward 22 and 23 RVI (Trauma Orthopaedics)
Ward 8 FH (Vascular)
Ward 16 FH (Care of the Elderly) – this ward has recently been closed,
therefore the team will re-join the collaborative work once they reopen.
Whitfield Court also joined the collaborative. This home has always
been very proactive in the prevention of pressure ulcers and their input
will be beneficial to disseminate their learning to those Care Homes
who are struggling to prevent pressure damage.
Aim: the aim of the collaborative is to achieve a 50% reduction of acquired
pressure ulcers and this is achieved by a cycle of auditing, test-implement-test
‘Plan-Do-Study-Act’ (PDSA) cycle.
Objectives:



Measure number of pressure ulcers and moisture lesions.
Audit of FOCUS charts to reach 100% and be sustained, as there is
strong correlation that this enables wards to prevent ulcers from
developing.
Introduce new practices individualised to each ward that enhance
pressure ulcer prevention and test/audit if these make any difference.
Achievements:
1. Ward 22 RVI
 Achieved 100% accuracy in their weekly FOCUS chart audits.
 Introduced Safety Briefings
 Targets:
- April, May and June = 18 ulcers
- Target to achieve is 9 over 3 months.
4
- July, August and half of September = 5 - on target to achieve
50 % reduction.
2. Ward 23 RVI
 Achieved 92% accuracy in their weekly FOCUS chart audits.
 Introduced Safety Briefings
 Targets:
- April, May and June = 14 ulcers
- Target to achieve is 7 over 3 months.
- July, August and half of September = 3 – on target to achieve
50% reduction.
3. Ward 8 FH
 Working on their weekly FOCUS chart audits (best score 80% but
not yet consistent).
 Introducing the delivery of patient information during “Nurse in
charge ward round”.
 Targets:
- April, May and June = 13 ulcers
- Target to achieve is 7 over 3 months.
- July, August and half of September = 4 – on target to achieve
50% reduction.
3.
e)
All other Wards’ targets:
From 1st of October, wards will also be asked to achieve a 50% reduction
from their (April, May and June data), by the end of December and then
sustain it for a period of 3 months. It is hoped that the learning undertaken by
those wards involved in the Collaborative, will assist the Task Force Group
achieve this ambitious target.
f)
Improve communication between Acute and Community. Data analysis of the
incident that occurred in July 2015 highlighted that a number of patients who
were known to the District Nursing team were admitted to Acute Care with
existing damage. In 50% of these patients, no risk assessment had been
undertaken by the DN team, this may have been due to the nature of the
District Nursing involvement with these patients. Conversely, the Acute
teams failed to let the DN team know that: a) one of their patients had been
admitted with damage. (Even if it had healed whilst in hospital, the area
would remain vulnerable to subsequent damage and would require input by
DNs once discharged); b) patients who had developed ulcers whilst in acute
care would require full assessment by DN once discharged.
FALLS
Through the publication of a variety of guidelines, including the 2013 NICE CG161,
hospital falls prevention has become a key priority across NHS organisations. This
has been reinforced by the Institute for Innovation and Improvement campaign to
deliver ‘Harm Free Care’, where the absence of a fall on one set day per month,
measured by the Safety Thermometer, contributes to the delivery of ‘Harm Free
Care’.
5
Despite this focus on reducing patient falls, they remain the most frequently
reported patient safety incident in NHS organisations (over 200,000 falls are
reported in acute hospitals alone each year). Due to this high number of incidents
and the varying sizes of organisations it is necessary to use an alternative method,
rather than total numbers of falls, to analyse falls data. The method used is
measuring falls/1000 occupied bed days which then provide a falls rate, making it
easier for organisations to compare themselves to the National Acute Trust
average of 6.8 falls/1000 bed days. The Trust consistently performs well in relation
to this target as an overall yearly average although monthly variation does exist
(current average for 2015/16 to date is 6.1 falls/1000 bed days, April-August
inclusive) (see most recent Falls Dashboard in appendix 3).
The Trust has made patient falls prevention a part of its priorities since 2011 with
the introduction of the ‘No Falls On My Patch’ campaign. This has been the driving
force to implement key practices in falls prevention, through changes to
assessment and recommendations for implementation which has included the
purchase of over 100 low level beds, the trust wide provision of non-slip slipper
socks and the implementation of the Intentional Rounding tool, FOCUS Chart. The
reasons why patients fall are often complex and multifactorial therefore to prevent
falls there cannot be ‘a one size fits all’ approach. It is therefore essential that the
reasons why a patient is at risk are identified and the suitable intervention plan is
put in place. It is therefore this key message that continues to be embedded into
practice and this is the focus of the education and training that is delivered to staff
across the Trust.
DATA ANALYSIS
DATIX incident reports provide the most useful data to analyse for patient falls
incidents. On average there is approximately 270 fall incidents per month and
each of these DATIX reports is reviewed by the Falls Prevention Coordinator to
determine whether a Route Cause Analysis (RCA) is required (all falls where the
patient suffers harm graded as moderate or above require an RCA). The overall
monthly data (including all grades of falls) is then analysed to identify any trends or
key learning.
June, July and August Data Analysis
Total number of falls = 796
Falls/1000 bed days = 6.0
Falls resulting in harm graded moderate or above = 24
Summary of learning from RCA process:


Ensure appropriate falls prevention interventions are put in place to
prevent the first fall, rather than as a reaction to a fall. For example, low
level beds and allocation of higher visibility bed spaces for high risk
patients. Also, intentional rounding by the use of FOCUS charts is
essential to prevent falls in patients who are likely to mobilise against
advice and unlikely to use their call bell to summon assistance.
Patients who have had an unwitnessed fall and are on anticoagulation
therapy must have neurological observations completed as per post fall
protocol.
6




Trolleys in A&E department must be kept at their lowest level when
patients are unaccompanied.
Reinforcement of appropriate footwear – specifically if patients have
brought in their own version of slipper socks.
Reinforce use of falls documentation and education for staff on how to
complete falls care bundle appropriately.
Risk Manager currently reviewing a fall on the escalator in New Victoria
Wing and signage that is in situ.
Monthly variation in total number of falls does continue and this is demonstrated in
Graph 1 below. However what is also clear is that since April 2013 to date there
has been a downward trend in the total number of falls. This is significant as the
number of admissions to the Trust has continually gone up within the same period.
Additionally, since changes were made to the falls assessment process there has
been an increase in the number of at risk patients year on year, with some wards
consistently reporting 100% of patients at risk of falls (particularly within Care of
the Elderly). It is not without challenge that this reduction has been seen,
particularly with the current demands on nurse staffing. Therefore the continuation
of falls prevention education and embedding of priority initiatives remains key to
sustaining this reduction.
Furthermore, 2014/15 saw a 17% reduction in serious harm from falls compared to
2013/14 with a further 6% reduction currently being reported for 2015/16. This
again is significant due to an ageing population and frailty of patients being
admitted to the Trust.
Graph 1.
ONGOING INITIATIVES
a) Ongoing education regarding falls prevention via the healthcare academy
and preceptorship programme. This includes education on a range of
preventative measures and products used within the trust, such as
enhanced observation, low level beds and movement sensors. Embedding
of Trust initiatives, such as, the falls risk assessment screening tool, falls
care bundles, FOCUS charts and post falls assessment checklists are
included in this education.
7
b) Root cause analysis of all Trust acquired falls resulting in moderate, major
or catastrophic harm continues to be led by the Trust falls prevention coordinator.
c) Post Fall Assessment Checklist – this is currently being trialled on the Care
of the Elderly wards at Freeman and is an adjunct to the Post Fall Protocol
which already exists. The purpose of the checklist is to assist Nursing Staff
and Medical Staff with post fall documentation, ensuring that all key
elements of a post fall assessment are completed and documented. This
document was created in line with the NICE Quality Standard (QS86),
published March 2015, which provides clear guidelines about post fall care.
The RCA process had also previously identified some evidence of poor post
fall assessment documentation and therefore it was essential that this work
stream was commenced.
d) Regional Collaborative Project – The Trust was successful in an application
for funding from the North East and North Cumbria Academic Health
Science Network (NENC AHSN) to lead on a patient falls prevention
project, working collaboratively with South Tees Hospitals NHS Foundation
Trust (STHFT) and County Durham and Darlington NHS Foundation Trust
(CDDFT). The project commenced on 1st August 2015 and aims to embed
the best practice guidelines called FallSafe, produced by the Royal College
of Physicians (RCP) across 6 wards per Trust. The project will utilise
service and quality improvement methods to change practice and culture
from ‘falls are inevitable’ to ‘falls are preventable’. The project is now
underway with a launch event planned for October 2015 where project ward
staff are invited to increase knowledge and skills in relation to falls
prevention and service improvement. This day will also allow the sharing of
previous service improvement experiences and challenges through an
expert led workshop in the afternoon.
4.
SUMMARY
The Trust is currently performing well in relation to delivery of ‘Harm Free Care’ in
respect of prevention of pressure ulcers and patient falls. This is supported
through the detailed analysis process of Trust incident data and from monthly
Safety Thermometer data. However, to drive further improvement the Trust will
need to maintain the effort of both the ‘Time 2 Turn’ and ‘No Falls On My Patch’
campaigns. The Tissue Viability and Falls Prevention teams will endeavor to
continue the targeted education and training of staff and the on-going analysis of
data to determine key learning which will be disseminated across the Trust.
8
5.
RECOMMENDATION(S)
To i) receive the report ii) note the actions taken / approve the proposal/direct
another body to follow up the action.
Helen Lamont
Nursing and Patient Services Director
Fania Pagnamenta
Nurse Consultant Tissue Viability
Rachel Carter
Falls Project Practice Development Coordinator / Falls Prevention
Coordinator
19th October 2015
9
Appendix 1 – Safety Thermometer Funnel Plot data for Pressure Ulcer Prevalence and Falls with Harm (data inclusive up to and
including September 2015)
NUTH
10
NUTH
11
Appendix 2 – Pressure Ulcer Dashboard – August 2015
12
Appendix 3 – Falls Dashboard – August 2015
13