4. METODOLOGÍA EXPERIMENTAL
4.2 Caracterización de materiales
Overview
General medicine and elderly care were identified as key lines of enquiry based on review of the data pack and the information submitted by the Trust. The data pack identified the following issues in particular;
Pneumonia and COPD are flagged as outliers under thoracic, general medicine and critical care for non elective for SHMI and under critical care, thoracic and general medicine for HSMR,
The Health and Social Care Information Centre 30-day stroke mortality is high and improving substantially below the national average in the data to 2010-11 and; The Trust was rated “high” for mortality among diabetic patients, in a report published by the Yorkshire and Humber Public Health Observatory (YHPHO) and the
National Diabetes Information Service.
Summary of findings
The following good practice was identified:
Forget me not and ‘this is me’ for patients with dementia and cognitive impairments on 6A and 6B at Pilgrim Hospital. Involvement of the Alzheimer’s society.
Mortality reviews are being carried out across medicine and junior doctors are involved in the process.
Plan for every patient every day Electronic boards for patient location and separate board to use during board rounds (with plans to link these two). Quality metrics on boards to focus discussions and use of the safety cross for pressure ulcers.
Stroke consultant had easy access to metrics relating to sinap data and could demonstrate progress – information available for all 3 sites from the governance team and benchmarked against national standards- also good engagement from multidisciplinary team and evidence of good thrombolysis rates.The following areas of concern were identified:
Little evidence of care bundles being used effectively,
There is clear evidence that whilst the ULHT Dementia programme is still in its early stages there is a clear strategy and action plan in progress which have been developed with commissioners and partner agencies.
Pain control was found to be generally poor.
Detailed Findings
Good practice identified
Stroke consultant had easy access to metrics relating to sinap data and could demonstrate progress – information available for all 3 sites from the governance team and benchmarked against national standards- also good engagement from multidisciplinary team and evidence of good thrombolysis rates ( Boston
).
The panel identified some areas of best practice on wards 6A and 6B at pilgrim hospital in relation to care of elderly patients with cognitive impairments. There were ‘forget me not’ magnets on the patient board to identify patients with dementia, although there did not appear to be as many as expected. Patients also had a ‘this is me’
document in their notes which is a simple and practical tool that people with dementia can use to tell staff about their needs, preferences, likes, dislikes and interests. This work has been supported by the Alzheimer’s society who provides three members of staff to Lincoln Hospital.
Mortality reviews are being carried out across medicine; the panel understands that the Trust now review every death in medicine although the robustness of these reviews can vary between the three sites. Junior Doctors are also being included in the process for their learning and development.
Outstanding concerns based on evidence gathered Key planned improvements Recommended actions Priority – urgent, high or medium
(i) Lack of awareness of the Mental Capacity and Deprivation of Liberty Act 2005.
Concerns were identified by the panel in relation to the Mental Capacity and Deprivation of Liberty Act 2005.
A particular patient was identified by a nurse consultant on the panel which raised concerns in relation to treatment for delirium. Nursing staff interviewed could not articulate the implications of the actions taken to prevent the patient from leaving the ward in relation to the Mental Capacity and Deprivation of Liberty Act 2005.
Having asked for an expert opinion from the mental health nurse, the mental health nurse failed to follow the delirium guidelines, specifically for this patient; assessment of his painful leg, assessment of his
The Trust has a Mental Capacity Act policy in place which it tells us is compliant with the necessary legislation and updated to reflect recent rulings in case law via the Court of Protection. This was not referred to by staff at ward level during our visit.
Staff should ensure that they are fully compliant with mandatory training requirements and adult safeguarding is given clinical engagement as a matter of urgency.
Outstanding concerns based on evidence gathered Key planned improvements Recommended actions Priority – urgent, high or medium capacity and any deprivation of liberty issues.
Having asked a number of Matrons, sisters and staff nurses the panel’s observations was that there is a lack of understanding of the Mental Capacity and Deprivation of Liberty Act 2005, the most common response was to ask the Trust safeguarding lead.
(ii) Pain control was found to be generally poor
There was consistent infrequent monitoring of pain documented on the vital signs charts across all 3 sites.
The is no standardised pain assessment tool for people with dementia or other patients who cannot express if they are in pain verbally, for example, the Abbey Pain Scale.
A patient with severe dementia and bedbound on ward 5 at Grantham was identified during the announced visit who was grimacing and moaning but had not had a pain assessment, although the staff could articulate how they would identify if a patient was in pain this particular patient had not been identified.
The Trust tells us that there is a pain prevention role in Grantham Hospital. We did not meet this person during our visit to Grantham.
The panel was informed that the Trust plans to implement to Abbey Pain Scale during quarter three, 2013-14.
Audit cycle of pain assessment should be carried out and widely published with a campaign to improve awareness and compliance.
Introduction of pain assessment tool for people with dementia supported by the necessary training.
High
(iii) Little evidence of care bundles being used effectively
There is little evidence of care bundles being used effectively across the three sites.
Recently the sepsis care bundle has been introduced, although a number of staff felt they had not been trained adequately and evidence suggested that it is not always being used effectively. On one surgical ward, the sister had ensured all her staff were trained in the new bundle – this followed an SUI related to sepsis. A matron reported that the bundle arrived on the wards but only about 30% of staff had been
The panel was informed that the agreed mortality reduction plan has a clear roll out of care bundles across the Trust. This process is to be overseen by the PMO.
The Trust should consider effective use of care bundles and staff should be trained in order to deliver effective services.
Outstanding concerns based on evidence gathered Key planned improvements Recommended actions Priority – urgent, high or medium trained in its use.
The panel observed the Oncology ward at Lincoln using the sepsis bundle and we did see that a patient had been admitted the previous might because the bundle highlighted the need for admission.
However, a relative at one of our patient listening events identified that her father was not admitted in a timely matter when he was septic following chemotherapy. The relative was told by a nurse that there were no beds in the hospital. The panel was told by a ward sister that this would no longer happen because of the sepsis bundle now in place. There is a Pneumonia care bundle being developed as a response to it being identified as an outlier. This has not yet been rolled out; the pace at which these care bundles are introduced is a concern and was highlighted by the Trust Board.
(iv) Good practice above for dementia patients is not wide spread across the organisation
The best practice identified above on wards 6A and 6B for dementia patients is not wide spread across the organisation. There were no other wards identified which used the ‘forget me not’ magnet to identify patients with dementia or consistent use of the ‘this is me’ leaflet.
None noted This best practice example should be shared and rolled out to all areas across the three sites which care for elderly patients and those with cognitive impairments.
Support and training is required to ensure it is rolled out and used effectively. An awareness campaign should be considered.