Discusión hipótesis especifica 2

Safety thermometer data were obtained from the three case study sites. Each hospital aggregated, labelled and shared the data in a different way, which limited analysis. Ideally, the data would have been combined

TABLE 9 Summary of ward profile data: site information

Trust characteristic Site 1 Site 2 Site 3

Size Large (> 800 beds) Large (> 800 beds) Very Large (> 1000 beds)

Location Urban Urban with rural catchment area Urban

Bed occupancy (%) > 90 > 90 > 90

Note

The actual bed occupancy rates were not reported to avoid the identification of the hospital.

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TABLE 11 Summary of ward profile data: nursing team

Nursing team

Site 1 Site 2 Site 3

February 2017

January

2017 April 2017 May 2017 July 2017 July 2017

Nursing staff establishment at the time of data collection

Band 7 1.0 1.0 1.0 1.0 1.0 1.0 Band 6 2.0 2.0 3.6 3.6 4.9 2.1 Band 5 15.19 17.29 17.2 20.9 21.5 12.7 Band 4 9 0 2.6 6.6 0 0 Band 3 0 0 6.5 5.8 0 0 Band 2 15.09 11.09 19.6 7.1 9.5 12.4 Total 33.28 31.38 50.5 45.0 36.9 28.2

Vacancy rate 4 (FTE) 4 (FTE) 4.4 (FTE) 8.1 (FTE) 19.78% 9.69%

Agency/bank use 127 shifts covered by temporary staff 82 shifts covered by temporary staff 6.7 (FTE) l 2.0 RN l 4.7 HCA 11.4 (FTE) l 4.0 RN l 7.4 HCA 8.06 (FTE) 4.57 (FTE) Sickness RN: 19.74% HCA: 0% RN: 11.56% HCA: 45.08%

1.1 (FTE); 3.0% 2.2 (FTE); 5.4% 2.54 (FTE) 0.38 (FTE)

FTE, full-time equivalent.

TABLE 10 Summary of ward profile data: ward information

Ward characteristic

Site 1 Site 2 Site 3

Ward a Ward b Ward a Ward b Ward a Ward b

Specialty Health care for

older people

Acute medicine, endocrinology

Acute trauma orthopaedic

Health care for older people

Acute medicine, cardiac and respiratory

Health care for older people Number of beds 24 24 32 32 26 18 Predominant ward layout

3–7 bed bays 3–7 bed bays Single, en suite rooms

Single, en-suite rooms

4 bed bays Nightingale

Nursing organisation

NS Three teams NS Four teams NS NS

Shift pattern 12-hour shifts 12-hour shifts Combination of 12-hour shifts and early (07.00–13.30) and late (13.00–19.30) shifts Combination of 12-hour shifts and early (07.00–13.30) and late (13.00–19.30) shifts

12-hour shifts 12-hour shifts

TABLE 12 Summary of ward profile data: implementation of IR

Implementation of IR Site 1 Site 2 Site 3

When introduced Some discrepancy; some time

between 2009 and 2012, most likely 2011

Some discrepancy, some time between 2014 and 2016, most likely 2014

Because of staff changes, the exact date is unclear; it was around 2012/13

Circumstances Part of a strategy to reduce

patient harm and increase care quality

Part of the strategy to reduce increased falls risk due to a predominantly single-room environment and develop compassionate care

Ward managers able to decide whether to implement IR or not. The majority of wards were thought to be implementing it at the time of the study Staff involvement Not initially, but recognised

that this was ill-judged and staff were involved to redesign the IR process and documentation, which was piloted on some wards before roll-out to all wards

Managers reported a period of testing and piloting, although they think that IR was probably implemented too quickly across the trust

Owing to staff changes, it is unclear the degree to which staff were involved in implementation

Documentation Four-page A4 booklet.

Has been frequently revised according to perceived need. Includes 4Ps questions and the‘Is there anything else I can do for you?’ question

Two-sided form. Includes 4Ps questions and the ‘Is there anything else I can do for you?’ question

l Two versions of the IR form depending on a patient’s pressure sore risk score (Waterlow score of < 10 or≥ 10). Both are part of a 49-page nursing documentation bundle

l IR form for those with a Waterlow score of < 10 includes 4Ps questions but not the‘Is there anything else I can do for you?’ question

l IR form for those with a Waterlow score of≥ 10 includes assessment of surface, skin, position, incontinence and nutrition but not the 4 Ps questions or the‘Is there anything else I can do for you?’ question

Trust IR policy Detailed trust policy Detailed trust standard

operating procedure

No formal IR policy

Frequency of IR Hourly between 8.00 and

22.00, every 2 hours between 22.00 and 8.00 hours. Time intervals pre-written onto form

Frequency could vary according to risk assessment as long as rationale was recorded. Minimum frequency of every 4 hours. Time of IR was not specified, so specific time was entered by staff

l IR form for patients with a Waterlow score of < 10 is every 2 hours, with time intervals written onto form

l IR form for patients with a Waterlow score of≥ 10 asks staff to‘continuously’ complete the form and staff are required to write in the time the patient is seen

Who does IR Both HCAs and RNs. RN

required to complete IR at 2.00, 8.00, 12.00, 16.00, 20.00 hours

Any member of clinical staff who had read the IR standard operating procedure and had received training in SKIN and Falls bundles

Both RN and HCA staff

Adaptation of IR beyond Studer format

IR documentation included questions about mobility, bed rail position, special mattress, body map to record skin integrity and presence of medical devices

IR documentation included questions offering drinks/snacks, falls prevention, body map to record skin integrity and presence of medical devices. Space available to document any actions resulting from IR

IR form for patients with a Waterlow score of_{≥ 10 included} assessing skin inspection, nutrition and special mattress needs

SKIN, surface check, keep moving, incontinence, nutrition.

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into one table and then trends over time that might relate to IR would have been explored, for example a decrease in harms such as pressure sores at the time of IR being initiated in each hospital. However, the site differences meant that each hospital had to be analysed separately. There were also the following additional limitations:

l The data from different sites covered different time periods.

l IR was implemented before the safety thermometer data that could be accessed (there may be older, similar audit indicators, but not in a consistent format that could be compared across sites and months).

l Two sites gave aggregate data only, not at patient level.

l Case mix could not be considered with the safety thermometer data as there were no variables to give context for each patient, such as demographics, prescriptions and diagnoses.

l Sample size was small, at about 24 per month.

l An assumption that there were no inclusion biases was required.

Charts of the various harms were drawn as percentages, changing over time, for each ward. On these, the 95% CI is shown: this is the range of percentages that could contain a true rate of harms, given that sometimes the safety thermometer data will, by chance, pick up too many harms and sometimes too few. If a horizontal line can be drawn across the chart that does not leave that green area, then that means that the data obtained were not inconsistent with there having been no trend over time at all. However, even this basic form of statistical inference needs a further caveat: examining several wards over many months on several indicators is likely to produce an apparently interesting pattern just by chance. For this reason, these charts were used simply to feed into discussions in interviews and to contextualize observational data. Figure 3 shows the percentages of any new harms for each ward (anonymised) that provided data. In each case, IR had been initiated before the safety thermometer data began.

One case study site (site 2) identified wards as having different identities before and after a change of building location; the data were analysed on this basis. There are, therefore, eight wards highlighted in Figure 3 instead of six.

January 2014 January 2012 0 20 40

All new harms (%)

Time point (a) January 2016 January 2018 January 2012 0 20 40

All new harms (%)

January 2014 (b) January 2016 January 2018 Time point

January 2012 0 20 40

All new harms (%)

January 2014 (c) January 2016 January 2018 Time point January 2012 0 20 40

All new harms (%)

January 2014 (d) January 2016 January 2018 Time point January 2012 0 20 40

All new harms (%)

January 2014 (e) January 2016 January 2018 Time point January 2012 0 20 40

All new harms (%)

January 2014 (f) January 2016 January 2018 Time point January 2012 0 20 40

All new harms (%)

January 2014 (g) January 2016 January 2018 Time point

FIGURE 3 Percentages of any new harms for each case study ward. (continued )

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