scottish patient safety programme highlight report - NHS Lanarkshire

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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
SCOTTISH PATIENT SAFETY PROGRAMME HIGHLIGHT REPORT the ‘way we do things’ within NHS Lanarkshire e.g. is becoming routine as part of our culture - now features on much of our documentation and our safety briefs. GWP10: Peripheral Vascular Bundle: All at target GW02: SABs per 1000 occupied bed days Although all acute sites have demonstrated considerable improvement since baseline, there have been small SAB increases and slight variation noted although general targets met. Work has begun testing CVC insertion and maintenance bundles in general wards. Heart Failure Bundle: Testing has begun against the bundle and will be reported in due course Progress demonstrating compliance and spread for General Wards. Also, includes some associated hospitals Hand Hygiene
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scottish patient safety programme highlight report - NHS Lanarkshire

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