Ronán O Cathasaigh
Mayo University Hospital
Mayo University Hospital
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Part of the Saolta University Healthcare
Group
Acute care to Mayo and parts of West
Roscommon, North Galway and Sligo
Population of 130,552
306 in-patient beds
51 day beds
34,192 ED admissions in 2014
214 ICU admissions in 2014
Patient TM
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1200: BIBA to ED from Home
Increased confusion, pyrexia and dyspnoea
1207 ED triage: Category 3
1222 ED NCHD
1232 IV fluids and oxygen
1244 1st dose of IV antibiotics
1250 Bloods sent including lactate & cultures
Fluid balance chart commenced
1300 Referred to Medical team
Discharged home after 6 days
How did we get here?
•Natural progression from implementation of
NEWS
•2012 Incidents of late identification and
management of Sepsis in ED identified a need
for improvement
ICU admissions
2012
2013
933
797
•14.5% reduction in ICU admissions in 2013
•Highest reduction in admissions from ED (↓21%)
•Mostly due to implementation of NEWS
•11% reduction in Sepsis admissions to ICU in
2013
Implementation of Sepsis National
Clinical Guideline
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Introduced in December 2014
National Sepsis Lead Visit
NEWS Governance Group extended to
include Sepsis
Lessons learnt from NEWS implementation
Governance
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Combined NEWS and Sepsis Group
Driven by HMT
Terms of Reference adapted.
Amendments to existing hospital policies
Incident review template extended to include
sepsis
Education
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Collaboration with NCHD leads
Ward based training
Grand rounds
Weekly scenario-based training
Departmental meetings
Education
Specific sepsis presentations for
 Medicine
 ED
 Anaesthetics
 Paediatrics
 Obstetrics
Sepsis Documentation
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Remains challenging
Auditing
Who completes the sepsis screening form?
Incident Management
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Incident reporting template
Specific learning
Feedback to all stakeholders
Identification of trends
Incident reporting
Incident report number
Patient details
Date of admission
Diagnosis on admission and
management plan
Incident details
If a cardiac arrest call was
made was the patient in
established arrest?
Resuscitation status
Timeline of events
Investigations
Sepsis 6
Result of post mortem
Review of EWS, ISBAR &
Sepsis screening pathway.
Actions/Recommendations
Review of Resuscitation
Actions/Recommendations
Originator contacted re
shared learning
Specific learning
Length of stay
What was the resuscitation status of the patient? Was this clearly/explicitly documented?
1. Blood cultures
4. O2
2. Lactate & FBC
3. Urine output measurement
5. IV fluid resuscitation
6. IV antibiotics
Time
Sepsis screening form
completed
Did the recording of the EWS meet the requirements of the policy i.e. observation frequency.
Was an appropriate escalation to an appropriate doctor made and was this documented using
ISBAR?
Did the doctor respond within the appropriate time as per the escalation protocol?
Auditing
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Share the workload
Students
Antimicrobial Pharmacists
Practice Development
Develop audit tools that will produce useful
data
Audit Findings
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Sepsis documentation
Compliance with Sepsis 6
Antimicrobial Stewardship
ICU admissions
Feedback provided
Action plans
Quarterly newsletter
Audit Findings
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Reduction of 6.9% in patients with Sepsis
requiring ICU admission
Reduction in ALOS by 3 days
(Ref: HIPE, Health Pricing Office & ICU data)
Early Warning Scores
Velit turpis
bibendum
massa
Volume 1
From January 2014 to date all Incident
reports concerned with the EWS are
reviewed by the EWS Committee to identify
any deficiencies in the NEWS process,
provide learning opportunities and to make
recommendations to the Quality and Patient
Safety Department.
August 2014
Common themes from incident reports from
January to June 2014 include:
Mayo General Hospital’s Newsletter for the Early Warning Score Programme
Introduction
The National Early Warning Score
(NEWS) programme has been established
in Mayo General Hospital since 2012. The
implementation of the NEWS programme
is guided by an Early Warning Score
(EWS) hospital Committee whose role is
to provide a local governance structure to
support the implementation of the
programme. The Committee’s terms of
reference have recently been extended to
incorporate the Irish Maternity Early
Warning Score System (IMEWS).
Parameters
The EWS Committee has reviewed a
significant number of serious incidents
of inappropriate use of parameters
and as a result have recommended
that parameters can now only be set
by the Consultant who is responsible
for the patient’s care. The MGH
NEWS policy and ED NEWS policy
will be amended to incorporate this.
ISBAR
The audit of the ISBAR reviewed 50
EWS escalations between January
and June 2014 and found that only 27
(53%) had been recorded using the
ISBAR labels. The ISBAR
communication tool is supported by a
hospital policy. Auditing of the
process is ongoing
The EWS newsletter has been introduced
to inform staff on issues in relation to EWS
including national developments and more
local issues including ongoing, feedback
from EWS incidents and other and
relevant issues
Membership of the EWS Committee
includes:
Dr. Abraham Matthew, Consultant
Anaesthetist (Chair)
Catherine Donohoe, Director of Nursing
and Midwifery
Ronán O Cathasaigh, Resuscitation
Training Officer
Dr, Michael O Neill, Clinical Director
Dr. Elizabeth Brosnan, Consultant
Physician
 3 out of 6 the incidents reported
were concerned with the EWS
escalation protocol not being
followed with the result that patients
were not seen by the appropriate
level of doctor.
 1 of the 6 incidents was concerned
with inadequate observation
frequency. Refer to the escalation
protocol or MGH standard on
recording observations for
guidance on observation frequency
 In 1 of 6 incidents there was a
delay in considering a higher level
of care
Cardiac arrest calls
EWS training
From January-June 2014 54 arrest calls
were made in MGH.
NEWS training is mandatory for all
MGH Medical & Nursing staff. All
NEWS training materials are
available via the following link:
All cardiac arrest call must be reported
via the incident reporting process. These
reports are individually examined by the
EWS group to identify any deficiencies in
the EWS process, provide learning
opportunities and to make
recommendations to the Quality and
Patient Safety Department.
http://www.hse.ie/eng/about/Who/
clinical/natclinprog/acutemedicine
programme/earlywarningscore/ed
ucation.html
Ward based EWS training is
ongoing. Specific requests for
training can be made by
contacting Ronán O Cathasaigh
on bleep 379 or voicemail 3087. It
is planned that training will also be
accessible via HSEland and a pilot
combined BLS/NEWS training
programme in September
From January to June 2014 13 incident
forms were completed following cardiac
arrest calls. This represents a 20%
response rate
In 1 of the 13 cases the patient was
resuscitated despite having a valid,
documented DNR.
When reviewed, 7 of the 13 cardiac
arrest calls were sudden and
unexpected and the NEWS did not
demonstrate any signs of early
deterioration
In 2 of 13 calls the resuscitation status of
the patient was unclear.
Mayo General Hospital’s Newsletter
forcalls
the Early Warning Score Programme
Number of arrest
Compare pre quarter
 In 1 incident the BP was
documented as unrecordable for 3
days. In response large BP cuffs
have been ordered for all wards
Arrest call summary
Audit of EWS documentation
EWS chart
Version 4 of the EWS chart is being prepared at present to allow
for the introduction of the national sepsis screening pathway
available on
http://www.hse.ie/eng/about/Who/clinical/natclinprog/acutemedici
neprogramme/earlywarningscore/Patient_Observation_Chart_8_
04_14_preview.pdf
This pathway will be accompanied by a sepsis screening form
available on
http://www.hse.ie/eng/about/Who/clinical/natclinprog/acutemedici
neprogramme/earlywarningscore/HSE_SEPSIS_Form.pdf
Mr. Iqbal Khan, Consultant Surgeon
The changes to the use of parameters will also be incorporated
into the new chart.
Ms. Bridget Hughes, Consultant
Orthopaedic Surgeon
The MGH NEWS policy and ED NEWS policy will be amended to
incorporate these changes
Andrea McGrail, ADON, Women’s Health
& Children.
Any suggestions for amendments to the chart should be
submitted to Ronán O Cathasaigh
Dr. Andrew Jackson, Emergency
Department.
Incident reports concerning
EWS
Ken Spencer in the Practice Development Department has been auditing
completion of the EWS chart since February 2014. Initially the audit
demonstrated 93% compliance with the MGH Standard on recording
observations. These audits have shown a gradual improvement, with the
audit of the week of July 25th demonstrating 98% compliance. Areas
requiring further improvement include:
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Recording the respiratory rate as a number (Results vary from 071%)
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Dots joined correctly to identify trends (10-70%)
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Initials entered (67-90%
Please refer to the MGH standard on recording observations available on
the MGH Nursing Policy shared drive.
The future
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Paediatric Early Warning Score
(PEWS) in 2015.
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Pilot for electronic EWS
recording
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EWS training via HSEland
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Ongoing and expanding
auditing
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Combined BLS & EWS training
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Development of individual of
individual ward dashboards to
promote excellence in the EWS
process
World Sepsis Day
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Local media involvement
350 attended the event
Staff, patients, relatives and members of the
public.
Presentation of audit findings
Promotion of achievements
Recognise your successes
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Feedback to staff
Newsletter
MUH Quality & Patient Safety Symposium
National Patient Safety Conference
International Forum on Quality and Safety in
Healthcare, Gothenberg 2016
The future
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Development of Group policies
Blended learning
Sepsis e-learning module
Auditing
Pre-hospital/Primary care training
Public education
Future Challenges
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Sustaining progress to date
Documentation
Auditing
Innovation
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Could we save
150 lives in 150
days?
Innovation
Sepsis 6- How hard can it be….?
Thank You