Improving care in the ED – one department’s response to the

Francis report

Gavin LloydConsultant Emergency Physician and ED Patient ChampionRoyal Devon & Exeter Hospital

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“Care”: the basics• Smiling face to welcome me

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• Reassurance that I’ll be looked after• How about some quality pain relief?

• Keep me informed (on my patient journey)• Keep me fed and watered if I'm here for ages

• Respect and dignity

Basic Care:

Look after me

Gold standard Care:

Look after me as if I were one of your own

“Are we providing a safe, committed, compassionate and caring service?”

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Shopfloor quality assurance

Fluid Oxygen Aspirin Early abx

PropofolSuxBipapElectricity

Time

Omeprazole for resus room haematemsis??

Basic care!

Clopidogrel for potential ACS??

Driving better care

Sedation

Enlightenme modules

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Overview of talk

One department’s drive towards better “care”:

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• Achievements• Plans in progress• Aspirations• Failures

• Challenges• Measuring care• Resources

Go and champion care in your ED!

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Context

• Royal Devon & Exeter Hospital• 320 patients a day, 20% children• Trauma unit• 10 consultants 8am-10pm+, 365 days a year• Full MG rota, 10 WTEs• Nights: 1 MG, 3 juniors• Ethnically not diverse

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Prior work

• Appointments for bereaved relatives with a senor clinician

• 2014 CQC patient summary

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Achievements

1. The (senior) meet and greet

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• Essential first part of the RAT• Patients +/-

relative(s)/friend/carer• Plan B – dovetail with a MG• Plan C – majors triage nurse

Achievements

2. Care rounds

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• Selected patients• “Permission”• Introduction• “How have we as a

department care for you today?”

• Hot feedback• Written feedback to team via

email and newsletter

Achievements

2. Care round checklist (for patient +/- relatives)

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• How have we as a team cared for you today?• Kept you informed?• Pain relief?• Fed and watered?• What do you think we could have done better?

Achievements

3. Skin Care• Ambulance triage skin assessment• Mattress toppers for ?#NOFs• Otherwise directly on to a bed for vulnerable

patients

Other achievements• Letter regarding ‘care’ issued to all new staff including agency• ‘Care’ focus in induction of new doctors• Privacy in reception for those patients presenting with

personal complaints• Letter issued to all doctors involved in a complaint, offering

second victim support from a senior clinician• Trainer of the year award to promote good education• Productive care initiatives from junior doctor cohorts’

feedback• Regularly updated foreign language speakers list • Written confirmation of regular cleaning displayed in the

toilets

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Other achievements

• Partitioning of a previously open minors are to improve dignity

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Other achievements

• Monthly ED newsletter with a ‘care corner’

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Care initiatives in development

1. Comfort rounding

• Targeting all staff• Volunteers!• Medical students

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Care initiatives in development

2. Nominated champions for pain/# NOF/urinary retention

Problem: poor performance guaranteed by• Taking your eye of the ball/inertia• Staff turnoverSolution:• Champions!• Standardised bimonthly reminders on audit issues

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Care initiatives in development3. Bespoke management plans for frequent

attenders:

• 28 patients with >100 attendances• 2 patients per consultant/1 per supervised MG• Signed off at ….. • RCEM suggest those with >30 attendances in last 12 months

JH (DOB, Hospital Number.....) Background – frequent attender with physical DSH; very amicable and

compliant.Clive Urdaibay’s suggestion – secure a theatre grade staple gun and

close her wounds under the influence of standard entonox. Offer crisis input, but in Clive’s experience this is unlikely to be taken up.

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Care initiatives4.The waiting room (and other waiting areas)

• Telly - 24hr BBC news channel with subtitles

• Free Wi-Fi access• Charity bookstall• Magazines top ups in all

waiting areas• Some rearranging

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Other care initiatives in development

• OOH eye presentation that can safely be deferred to normal hours and return for eye nurse practitioner assessment in normal hours

• A welcome (and explanatory) leaflet for those patients attending with DSH

• Spotlight: a written letter highlighting the contribution of a staff member and sent to their home address

• Copies of all complaints sent to ED patient champion with monthly feedback via newsletter

• Provision of pillows!• Looking after/welcoming specialty team in ED• Ensuring staff take their breaks• Independent senior nurse observations

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Failures

• Patient passports ref. Newstead et al EMJ 2013

• Written information for patients regarding their journey – whiteboards/cards

• Elderly name badging• New faces board

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Aspirations

• Communication skills training• Better information for the waiting room

regarding time to be seen

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Tapping in to junior doctor thinking

Please consider some initiatives that could improve “care” in our ED. Consider for example:

•An “off legs” 88 year old female found on her floor by her carers•A 3 month old boy with mum with poor feeding, crying and +/- temperature•And all the rest of minors/majors/resus

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Efficiency suggestions from the juniors

• Stocking up of blood trolleys three times a day• Oral rehydration therapy for pre-school

children and babies initiated at triage• Paramedics bloods!• Computer access

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Computer access

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Efficiency suggestions from the juniors

• Stocking up of blood trolleys three times a day• Oral rehydration therapy for pre-school

children and babies initiated at triage• Paramedics bloods!• Computer access• Stack of chairs for relatives• More stools for staff

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Challenges

• Exit block/ignoring the prescription• Patients who shouldn’t be in ED in the first place• Excessive work load/gaps in staff rotas• IT problems• Competing interests• More challenging patients: alcohol

excess/DSH/the delirious/deaf/learning difficulties

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Measuring Care

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Measuring care

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Caring Inadequate Outstanding

By caring, we mean that staff involve and treat people with compassion, kindness, dignity and respect.

Feedback High or rising level of complaints re care

Substantial numbers of letters of praise

Interview Indifference or disdain demonstrated by more than 1 senior member of staff

Evidence of widespread engagement in promoting patient welfare and outcomes

Family and Friends No participation or return rate < 10 %

Return rate > 30%

Environment Lack of privacy reported or observed on a regular basis

Provision of privacy for all patients in the majors/ resus at all times

Governance (from a CQC perspective)

• NICE compliant guidelines• Safeguarding children/domestic violence• Incident reporting and learning from them• Learning from audits

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Resources

QEC Best Practice Guidelines:Management of Domestic abuseEnd of life care for Adults in the EDChaperones in the ED

Suffering in the ED Body et al. EMJ

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March 2015

March 2015

March 2015

January 2015

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Francis Report

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Go and champion care in your ED!

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