scottish patient safety programme highlight report - NHS Lanarkshire

SCOTTISH PATIENT SAFETY PROGRAMME
HIGHLIGHT REPORT
Work stream Elements and Progress:
Blue – Completed
Green – On target
Amber – Delayed, but expected to recover in-year
Red – Delayed, not expected to recover in-year
CRITICAL CARE: All green, except Multidisciplinary rounds which is amber / green (depending on site).
Some excellent outcomes are being achieved.
CCP1 / CCP2: % Compliance with Ventilator Associated Pneumonia (VAP) Bundle: Compliance at
goal in all units. Variation remains with ALOS on mechanical ventilation – all sites. Reintubation rates low and
fairly stable. CCO1:Ventilator Pneumonia Rate: Nil at Wishaw since August 2009, Hairmyres since
December 2009 with isolated recent VAPs at Monklands
CCP3: % Compliance with Central Line Insertion Bundle and Central Venous Catheter Maintenance
Bundle: All at target for insertion bundle. All units at target with maintenance bundle. CCO2: Central line
bloodstream infections: Nil at Hairmyres since November 2008, nil at Monklands since September 2009
and nil at Wishaw since March 2010.
CCO6: Glucose Control: In place across all three critical care areas. All units at goal of >95% compliance
CCP4: Hand Hygiene: At goal in all three critical care units. CCO8:C.difficle associated disease rate: Nil
at Monklands since July 2010 with periodic individual cases at the other two sites over recent months
CCP5: % Achievement of multidisciplinary rounds: Making excellent progress at Monklands and Wishaw
with both at goal.
CCP6: Daily Goals: Daily goals sheet in place in all three areas and compliance good.
CCP8: Peripheral Vascular Cannula: All at goal. CCO4: SABs per 1000 AOBDS: Nil SABs at Hairmyres
since July 2010, nil at Monklands since August 2010 and nil at Wishaw since October 2010.
CCB1: ALOS: Reduced at Wishaw since programme onset
Process measure compliance target - ALL measures 95%
General Wards: All green: Excellent progress with all measures and spread throughout all general wards
and most associated hospitals (latter as relevant)
GWP1: Early Warning Scoring System (EWS): GWP2: % time respiratory rate recorded: GWP3:%
appropriate interventions: Compliance remains excellent and this is also seen at casenote reviews.
GWO1: Crash call rate: Crash calls rates reducing below baseline levels, especially Monklands, some
variation at other two sites.
GWP10: % compliance with hand hygiene: At target in the three sites and maternity. Spread to all
associated hospitals GWO4 C. difficle associated disease rate: excellent results.
GWP6: %compliance with Safety Briefings: All acute sites at target. Being used as a main vehicle for the
review of run charts and actions as well as other core questions and topics. Also being used to distribute
theme of the week.
GWP4: Rapid Response: Hospital Emergency Care Teams (HECT) in Place. Number of calls reducing
variation at Wishaw where there has been a recent rise (although not to baseline level). Overall reduction
may be in response to earlier identification of deteriorating patient (MEWS scoring).
GWP8: SBAR (reporting): All at target. Reporting % trained challenging as SBAR is now incorporated into