Quality Account – Clinical effectiveness category

Why has this been put forward as a priority option for our Quality Account?

The World Health Organisation has undertaken a number of global and regional initiatives to address surgical safety including the introduction of the Safe Surgery Checklist. The checklist identifies the three phases of an operation, each corresponding to a specific period in the normal flow of work:

• Sign In Before the Induction of anaesthesia
• Time Out         Before the incision of the skin
• Sign Out          Before the patient leaves the operating room.
• PACU              Signed by PACU at handover of patient

In each phase a checklist coordinator must confirm that the surgery team has completed the listed tasks before the operation begins.

The National Patient Safety Agency introduced the World Health Organisation (WHO) surgical checklist as an alert in February 2009.

Monthly spot check audits have been carried out since June 2011 to assess compliance with a random five patients undergoing a procedure in areas such theatre, endoscopy, cardiology and radiology (a total of 41 areas are assessed).

The use of the surgical safety checklist has been implemented to enhance patient safety and reduce the risks of clinical incidents.  The completion of the checklist as part of a quality monitoring system provides assurance to the organisation that patients are being safely prepared and cared for during operative/invasive procedures.

The best national practice standard is for all spot check audits to achieve 100% compliance with completion i.e. each section of the checklist is fully completed, and if not, action is taken immediately at a local level to address the areas of non / poor compliance.

Following this, an exception report is produced to explain the results and highlight the necessary steps that are now being taken to reduce the risk of non / poor compliance happening again.

There is concern that these audits have become a ‘tick box’ exercise.  To this end areas are encouraged to undertake a live observational study of the WHO checklist, noting areas where there are discrepancies, producing short tracking reports for review across divisional and Trust wide meetings as appropriate.

These live audits should be conducted by each clinical area at least once (ideally twice) a year – low data submission for the live audits has been noted, therefore a Trust wide picture of annual compliance cannot currently be accurately determined.

What are we planning to do?

Cross area review and auditing – Staff that undertake the live audits do so outside of their usual clinical area. For example, a Radiology staff member may attend Theatre to look at the WHO checklist practice outside of their normal area of work, and vice versa. This is considered best practice as issues can be identified with fresh eyes, issues that perhaps weren’t seen or realized before.

We plan to look at the live auditing requirements in more detail, to understand why these aren’t being completed as required – reviewing identified constraints and reasons for any lack of engagement with this process.

An auditing rota may be implemented to monitor compliance and completion across clinical areas.

The current audit tool will also be reviewed to ensure this is as simple (and quick) for staff to complete as possible, ensuring information can be collected easily for addition to the annual report.

Why has this been put forward as a priority option for our Quality Account?

Sepsis is an infection of the blood stream resulting in a cluster of symptoms such as a drop in blood pressure, increase in heart rate and a fever. If left untreated, it is a life-threatening condition.

The National Early Warning score (NEWS2) is a standardised scoring system which is used to determine the degree of illness of a patient based on physiological parameters (respiratory rate, oxygen saturation, systolic blood pressure, pulse rate, level of consciousness or new-onset confusion and temperature). There is a requirement to assess patients with suspected sepsis who are aged 16 years or over to identify risk factors using the scoring system. The outcome of the sepsis screening guides what treatment is taken forward.

Screening compliance is audited across the trust via the Excellence in Care quality audit. It aims to promote assurance that documentation of patient care is completed across all inpatient wards at Conquest Hospital and Eastbourne District General Hospital.

This audit is to assess whether screening compliance has been adhered to, whether initiated upon arrival to ED before admission to a medical ward and whether there is documented evidence in the notes if a patient hasn’t had screening initiated if they are deemed high risk (>5 NEWS2).

Recent audit activity has shown that compliance with sepsis screening for both Urgent Care and Medicine Divisions required more in-depth review to be undertaken of the process in which the compliance data is being captured.

What are we planning to do?

Sepsis compliance will be monitored monthly through the Clinical Outcomes Report which provides assurance of overall outcomes for each Division and highlights key areas of improvement for monitoring.

Quality Improvement work will be undertaken to review the process, identify any gaps and make changes in the process to improve the way we capture the compliance data.

Audit results will be shared across the Division for learning and education. Full robust action plans will be implemented to ensure compliance is adhered to.

Why has this been put forward as a priority option for our Quality Account?

Admission into hospital brings people who smoke into contact with healthcare professionals who can provide advice and help to stop smoking completely or temporarily during admission. Hospitals are smoke-free environments without the usual cues and prompts to smoke and so admission to hospital offers an opportunity to quit.

National audits of the management of tobacco dependency in acute care trusts highlighted the shortfalls in the treatment of tobacco dependence for inpatients. Tobacco Dependence is a chronic relapsing clinical condition that requires active treatment. Smokers are 36% more likely to be admitted to hospital, with one smoker every minute in the UK being admitted.

Expert support and nicotine replacement therapy at the point of hospital admission increases abstinence from smoking at 6 months by 54% and treating tobacco dependence is now a standard of care in the NHS.

We aim to support the NHS Long-Term Plan’s focus on treatment and prevention of illness by supporting patients to adopt temporary abstinence whilst in hospital. Stopping smoking is the best thing any patient can do to improve their recovery and future health, reducing lung and heart complications, improving wound healing time and reducing infection, reducing the length of stay in hospital and improved treatment response as well as reduced risk of admission within 30 days and 1 year.

In addition, we envisage this helping towards closing the gap on the health inequalities faced in our most deprived areas. Smoking cessation positively impacts all five key clinical areas of the Core20PLUS5 approach to reducing health inequalities.

Core20PLUS5 is a national NHS England approach to inform action to reduce healthcare inequalities at both national and system level. The approach defines a target population – the ‘Core20PLUS’ – and identifies ‘5’ focus clinical areas requiring accelerated improvement.

Good care is linked to positive outcomes for patients and staff satisfaction.  For patients to feel supported in the care episode the full clinical picture must be identified and treated.  Informing, supporting and listening will aid them to make meaningful decisions and choices about their care and this may be impaired for those who are suffering from the effects of nicotine withdrawal.

The NHS Constitution, the Outcomes Framework and the NICE Quality Standards for Experience reinforce the need for patient-centered care. Our services must meet the needs of the communities we serve, and we know that this includes a higher than the national average number of smokers within the area.

What are we planning to do?

Using quality improvement methodology and following evidence-based programs we will support and treat those with tobacco dependence and use harm reduction approaches for people who are not ready to stop in one go.

Developing our electronic patient record to improve identification of smokers will enable us to support tobacco dependence treatment as soon as possible after admission. The addition of protocols to support the supply and administration of Nicotine Replacement Therapy will also support the acute management of nicotine withdrawal.

We know that people who smoke find it easier to remain smoke-free where smoking is completely prohibited, so we will provide in-house smoking cessation clinics for staff which will be underpinned by our smoke-free policy, ensuring staff do not smoke on site nor assist patients to smoke on hospital grounds. We will support staff with education and skills to assess and give very brief advice and establish a champion network to support enhanced understanding and shared learning regarding prevention.

Stakeholder involvement will aid us in developing resources and a communications plan tailored to support delivery of the programme to different areas. People should be asked about tobacco use in a way that suits their needs and preferences so they will have access to an interpreter or advocate if needed along with easy read support.

Targets will be monitored against national ambitions, and we will continue to build upon the collaborative work with locally commissioned services to ensure patients receive help to quit after discharge including information, practical advice and encouragement.

Why has this been put forward as a priority option for our Quality Account?

The Commissioning for Quality and Innovation (CQUIN) framework supports improvements in the quality of services and the creation of new, improved patterns of care.

CQUINs pressure ulcer audits in 2024 have shown improvements in ward level care, however there is an opportunity for further improvement in early assessment and intervention for unplanned admissions in gateway areas (Emergency departments and assessment units for example).

Increasing numbers of patients attending our Emergency Departments means that patients are spending longer in these areas than usual.

Learning from incidents and inquests has demonstrated delays in the application of preventative measures to reduce the risk of pressure damage.

The number of and rate of pressure damage per 1000 bed days for inpatients increased in 2024.

What are we planning to do?

1. Quality Improvement project to work closely with gateway areas for unplanned admissions, to improve completion of Purpose T risk assessments within 6 hours of decision to admit.
   PURPOSE-T is an evidence-based risk assessment tool that identifies adults at risk of developing pressure ulcers and supports nurse decision-making for both primary prevention and secondary prevention and treatment of existing and previous pressure ulcers.
2. Work with our Deputy Chief Operating Officer and digital team to resolve delays in patients being admitted on Nervecentre on transfer from Emergency Departments.
3. Improve documentation of actions/care given to reduce pressure damage including mobilisation and position changes for patients with reduced mobility.
4. Explore in-reach opportunities by specialities to reduce the time patients are in the Emergency Department waiting for beds on wards to receive optimum care.
5. Improve communication on discharge of patients with significant pressure damage by the introduction of an electronic Pressure Ulcer Passport (PUP) – this will initially be via designing a bespoke form on eSearcher (Trust clinical information system) sent to Health Social Care Connect (HSCC).
6. Introduce safe and secure digital means to share patient pressure ulcer care and treatment information with care providers with patient consent.
7. Seek support from NHS Sussex to facilitate a standardised process for the reporting and learning from pressure damage incidents across Sussex in line with Patient Safety Incident Response Framework (PSIRF).
8. Introduction of sharing learning across the organisation using the Datix Cloud IQ Safety Learning System.
   Datix Cloud IQ (DCIQ) enables healthcare organisations to understand adverse events and implement strategies to enhance the delivery of care.