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Delivering Clinical Improvement for Patient Safety. Eddie Docherty Consultant Nurse for Acutely Unwell Adults Susan Hannah Practice Development Lead - Clinical Improvement. Mortality Case Note Review. Modified Early Warning Scoring Admission to HDU Unusually high DNAR orders

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Delivering Clinical Improvement for Patient Safety

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delivering clinical improvement for patient safety

Delivering Clinical Improvement for Patient Safety

Eddie Docherty

Consultant Nurse for Acutely Unwell Adults

Susan Hannah

Practice Development Lead - Clinical Improvement


Mortality Case Note Review

Modified Early Warning Scoring

Admission to HDU

Unusually high DNAR orders

Review of complex patients over weekend and holiday periods

Note Keeping

End of life care

Discharge Letters

Development of appropriate action plan

50 consecutive deaths

IHI 3x2 matrix

GTT applied to box 4 patients

Review of additional diagnostic groups

External validation

Cardiac Arrest Review

DNAR Review


Delivering Clinical Improvement for

Patient Safety

Outcome Primary Driver Secondary Driver

Emergency Response Team created

Testing of process for call and referral

Complete. Live service testing May 2010

Spread June 2010.

Measure use and type of calls.




Reducing HSMR

and Improving

Outcomes for

acutely unwell




Safety Briefs

‘Back to Basics’ programme across

the organisation over next 12 months.

Measure compliance with MEWS & SBAR

using SPSP approach -Sustainable spread.

emergency response team process design
Emergency Response TeamProcess design

What did we need the team to do?

Who should be on the team?

How do we get the team to the patient- right patient & right time?

How do we test it?

How do we evaluate it?

How do we sustain?


Patient in Cardiac Arrest?


Activate the Cardiac Arrest team via 2222


  • Emergency Response Team callout Criteria
  • General Ward Area
  • Airway
    • Any airway compromise
  • Breathing
    • Respiratory Distress/ progressive dyspnoea
    • Respirations less than 8/min or greater than 30 min(new, persistent)
    • Sa02 less than 88% on oxygen(new, persistent)
    • Increase in oxygen requirements to 50%
  • Circulation
    • HR >130 or HR< 40
    • Blood pressure less than 90mmHg (new, persistent)
    • Symptomatic dysrythmia
  • Disability
    • Acute change in mental state
    • Decreased responsiveness (new, persistent)
    • Seizure activity
  • Exposure
    • Uncontrolled pain despite treatment
    • Staff concern eg sustained chest pain despite nursing intervention
    • Uncontrolled bleeding

Does the Patient meet the ERT call out criteria or are they triggering a MEWS >4

Patients own team unavailable or unable to attend in 30 mins or request ERT activation

Contact Patients own team, develop a continuing

plan of care

Activate the Emergency Response team*

ERT team Assess and initiate appropriate intervention

Documentation by ERT, follow up protocol activated

Contact Patients own team and develop a continuing plan of care

ERT Activation and feedback Pathway

* Dial 0 Switchboard and ask them to fast page the Emergency Response Team


Board level engagement

Operational team- nurse consultant, 2 medical consultants & consultant anaesthetist –influencing & engagement

Team member engagement- ownership and “marketing”

Medical staff- non threatening, integrative

WARD BUY IN- small cycles of change , test, retest, systems & PEOPLE

  • Associate director of medicine and nurse consultant ‘road show’
  • Clinical director level / ward manager/ critical care ‘champions’- influencing the key influencers
  • Taking it to the wards- not waiting for them to come to us.
  • Making sure its safe –


one patient & one nurse- one area - one week

back to basics what s it all about
Back to Basics – what’s it all about?

Situation - identified need to improve MEWS, communication and escalation, staff awareness of safety issues .

Background - available data highlights areas for improvement in current practice through SBAR, Safety Briefs

Assessment – measuring and testing change via audit and PDSA methods provides evidence of improvements and supports sustainability

Recommendation – an approach to achieving sustainable improvements in practice with empowered, skilled staff who perform at an optimal level to reduce risk and ensure patient safety


Early recognition of deteriorating patientsComplete and accurate MEWS and action plan recordingRegularity of observations according to clinical concernNursing staff escalation to medical staff where expectedAppropriate response of medical staff to MEWSConsistent approach to documentation of decision making

What do we need to improve?

how are we going to achieve this
How are we going to achieve this?

Model focuses on a facilitated approach to driving improvements through clinical supervision and 1:1 approach to supporting ward staff

Identified first four wards - testing a variety of approaches to implement all aspects of improvement through involving staff in processes (audit, improvement methodology, using data for change)

Supporting staff to understand and engage with SPSP work and relating this to other key drivers within the organisation

integration of key national drivers
Integration of Key National Drivers

Building on Success Through Integration

Scottish Patient Safety Programme

Leading Better Care

Better Together

Healthcare Associated Infection







Releasing Time to Care






Rights Relationships & Recovery

Joanna Briggs Initiative (JBI)



the challenges

The Challenges

Engaging with and involving all staff in developments – very busy acute ward environments

Tailoring facilitation to implement SBAR and Safety Briefs

in specific clinical environments – testing a variety of approaches

Resource intensive – dedicated facilitation for each ward required

to achieve sustainability

Ensuring an individualised approach while keeping a firm view on the desired outcomes within acceptable timescales

work in progress like big pdsa
Work in Progress like big PDSA

What changes are we going to make based on our findings?

Build in Quality Assurance Processes

Know exactly what we aim to achieve and how we will do it


Study Do

Improvement Programme and developed spread plan

What were the results?

Measure and evaluate implementation

Early Days yet.....