The Safer Nursing Care Tool - NHS Employers/media/Employers... · nursing care to meet most or all...

35
The Safer Nursing Care Tool Ann Casey University College London Hospitals NHS Foundation Trust

Transcript of The Safer Nursing Care Tool - NHS Employers/media/Employers... · nursing care to meet most or all...

Page 1: The Safer Nursing Care Tool - NHS Employers/media/Employers... · nursing care to meet most or all of the activities of daily living. 2 May be managed within clearly identified, designated

The Safer Nursing Care Tool

Ann Casey

University College London Hospitals NHS Foundation Trust

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Content

Context

Setting the baseline establishment

The Safer Nursing Care Tool - development

Applying the SNCT in practice

The Safer Nursing Care Tool – implementation

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Context

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December

Approval at Clinical

Boards & NMB /Infor ms Divisional

planni ng process

October

Professional Consultation

Review of Car e Ther mometer Benchmarki ng

NovemberEstablishment

proposals agreed

with H oN/M & Divisional

Managers

September4 week acuity/

dependency/

activity data collecti on

June4 week acuity/

dependency/

activity data collecti on

February

4 week acuity/dependency/

activity

data collecti on

Financial

Analysis

Data Analysis

Data Analysis

Data Analysis

Planning Process

April - New budgets loaded

with r evised establishments

N&M establishment annual review cycle

Setting The Right Establishment

• Using Evidence Based Tools

• Safer Nursing Care Tool

• Birthrate Plus for Midwifery

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Safer Nursing Care Tool -Origins

•No basis for historical staff establishments

•Patients on the wards becoming sicker

•Need to determine critical care capacity

•No simple consistent tool that

- nurses liked

- general managers accepted

•No tool that linked input with outcomes

•Allows benchmarking

•Staffing requirements = quality outcomes

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Acuity/Quality Method

Strengths

Allows for most variables –

discriminates between patients

with differing needs

Measures workload and

patient acuity

Measures throughput

Quality measures included

Easy to use and understand

Weaknesses

Measures actual – not

predictive

Requires validation of data to

prevent ‘gaming’

Not suitable for use in small

wards

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Development

AUKUH Acuity/Dependency tool

Based on Comprehensive Critical Care Classification DH 2000

Added criteria for ‘Stable’ but highly dependent on nursing intervention (1b)

Applied in practice in 10 UK NHS Trusts

Required academic input

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Development

Leeds University Acuity database (1000 wards)

3332 hours activity observed in 86 wards

119000 nursing interventions

Multipliers developed by aligning 2 sets of data

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Development

•Patient needs measured on 2 scales

Leeds Dependency Acuity/Quality rating instrument contains data from1000 wards

AUKUH (SNCT) criteria (based on Comprehensive Critical Care Classification DH 2000)

•Significant level of correlation between 2 scales* •Low nurse assessing error rate

Correlation between

bank staff/drug related incidents/complaints

levels of RNs/no. of falls

bank staff/patient satisfaction/confidence in carers findings

Enough nurses but in wrong place

*Hurst K. Developing & Validating AUKUH’s WP&D System (2005)

*Smith et al. International Journal of Health Care Quality Assurance (2009)

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Field Testing/Validation

•Dual scoring/assessment across 3 sites

Low nursing assessment error rate

Strong correlation across 3 sites

Leeds acuity data recalibrated to create AUKUH/SNCT mulitipliers

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Field testing the Tool

Development of Implementation Guide 9 pilot sites +

University and District General Hospitals

NHS Scotland

Findings

easy to use

acceptable time commitment

guidance sufficient

Critical success factors

systematic application

interrogate trends

consistency – data collection/validation/ time period

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Safer Nursing Care Tool (SNCT) 2013

• Updated criteria definitions & multipliers collection of data on over 40,000 patient care episodes

• Recommended tool by the Chief Nursing Officer for England

• NICE examination of evidence base

• Multipliers being developed that are more specific for certain care areas

1. Care of the older person

2. AMU

3. Children/Young People

4. A&E

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Safer Nursing Care Tool Classifications

Level Descriptor

0 Patient requires hospitalisation Needs met by provision of

normal ward cares.

1(a) Acutely ill patients requiring intervention or those who are

UNSTABLE with a GREATER POTENTIAL to deteriorate.

1(b) Patients who are in a STABLE condition but are dependant on

nursing care to meet most or all of the activities of daily living.

2 May be managed within clearly identified, designated beds,

resources with the required expertise and staffing level OR may

require transfer to a dedicated Level 2 facility / unit

3 Patients needing advanced respiratory support and / or

therapeutic support of multiple organs.

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The multipliers 2013

Level 0 = 0.99

Level 1a = 1.39

Level 1b = 1.72

Level 2 = 1.97

Level 3 = 5.96

(includes 22% uplift for Annual leave etc)

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Key considerations prior to introducing SNCT

•Ensure Executive Board, General Managers, Clinical Directors engaged & supportive

•Ensure data collection & analysis systems are in place & not labour intensive

•Gain co-operation of Ward Sisters/Charge Nurses & Matrons

•Ensure staff are trained and prepared for applying the tool in practice

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Red Rules for practice- organisational level

•Identify a Lead for the project

•Nominate staff to quality control the data collection

•Data collection min 2 times per year

•No changes to establishment until minimum of 2 data sets

•Feedback to sisters/charge nurses

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Red Rules for practice- ward level

•Identify max 3 people to complete scoring on each ward

•MUST include ward Sr/C/N

•Patient scoring at 15.00 hrs approx each day

•Minimum of 20 days

•Weekly external validation by a Matron/Consultant Nurse

(Shelford 2013)

17

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How it is used –In practice

•Ward sister or deputy assigns score to each patient each day

•Completed as part of a walk around beds

•Score for patient occupying bed for largest time in 24 hours

•Direct score entry to iPad

at the bedside

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How it is used- in practice

Assigned Matron/Consultant Nurse - weekly verification of

scoring at the bedside ensures

-must be with the sister/deputy who regularly identifies the level

of care

- consistency of application

- reduces risk of bias

-matrons/consultant nurses allocated to wards outside of own

management

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Feedback from staff

•I have been thinking a lot about the acuity scores since we walked

round together and am concerned that where the audit was delegated

(which it isn't anymore) it may not reflect our true acuity. (Ward Sister)

• I completely forgot to do the validation last week, a call from the ward

would have prompted me ( an external validator)

•charge nurse has everyone down as a 2 , we had a nice chat about

that (external validator)

•There are a number of 1b's this time - primarily for mobility issues:

patients requiring log rolling, regular turns with 2+staff,etc. 1 patient

new palliative diagnosis yesterday so have put them as 1b (has been

referred for counselling so felt appropriate). (external validator)

•I now do the majority of the acuity scoring and only let my deputy do it

in exceptional circumstances as I now understand how my staffing is

set according to this.(ward sister)

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Application in practice

Case studies to work on in groups to determine the levels of care of these patients.

Followed by presentation back to group

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Case Study for practice

No. 1

•41 year old gentleman Low grade Lymphoma,

•On S/C Cyclizine,

•8hrly IV fluid regeime,

•Food Chart

•Washing & dress, toileting independent

Level:

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Case Study for practice

No. 2

•87 year old gentleman,

•had a bladder tumour resection 3 days ago.

•It is 3pm,

• checking his clinical observations he appears to be stable, 6 hourly observations.

•He is asleep just now so not possible to talk with him

BUT

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Case Study for practice

No. 2 cont.

Upon checking with Sister :

•He is very confused particularly at night when he gets very agitated,

•has fallen twice as he is very unsteady on his feet and gets out of bed without asking for help

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Case Study for practice

No. 3

•63 years old lady

•Type II diabetes

•1st day post-op revision hip replacement

•EWS Breached

•½ hourly observations discontinued at

10:00 today

•IV fluids

•Epidural Patient Controlled Analgesia

•Needs assistance with hygiene, toileting,

taking fluids, moving

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Case Study

No. 4

87 years old lady

Pneumonia

Clinical observations stable, 6 hourly

Dementia

Very confused and agitated – at risk of falling

Needs assistance of 2 nurses to mobilise/transfer

Needs assistance with all ADLs

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Case Study for practice

No. 5

John a 28 year gentleman who had his bowel resection 2 weeks ago. He is a very nice man but his wife is so fussy. He can probably go home in next few days.

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Calculating Ward Staffing Establishment

28-bedded ward has:

12 patients at Level 0

7 patients at Level 1a

8 patients at Level 1b

1 patient at Level 2

Sum

12 patients at Level 0 = 0.99 x 12 = 11.88

7 patients at Level 1a = 1.39 x 7 = 9.73

8 patients at Level 1b = 1.72 x 8 = 13.76

1 patient at Level 2 = 1.97 x 1 = 1.97

Total = 37.34 WTE

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Nursing Inpatient Staffing Report

Current V Recommended Status - 2013

(Excludes Band 7's)

Impact of SNCT Recommendation 2013

(Excludes Band 7's) Considerations

Beds

Current FTE for 2013

FTE establishment recommended in 2013

Acuity / Dependency Variance 2013

Number of RN:NA achievable Day Shift

Number of RN:NA achievable Night Shift

RN:Pt Ratio achievable Day Shift(not incl NIC)

RN:Pt Ratio achievable Night Shift (incl NIC)

Commentary- All staffing

ratios/ daily staffing excludes the Band 7 ward

sister unless otherwise stated.

28 36 36.7 -0.70 6+2 4+2 1:5.6 1:7

26 31.4 33.5 -2.10 5+2 4+2 M-F; 4+1 S & S

1:6.5 1:6.5

2 sets of data used only. June

data unrelaible. On one day per

week can have 6+2 therefore

achieving 1:5RN:Pt ratio

12 18 14.4 3.60 3+1 2+1

1:6 1:6

Small ward therefore the

recommended would not provide

adequate 24 hour rota cover.

18.3FTE provides the

ratios/numbers here with a 71:29

skill mix.

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Nursing Inpatient Staffing Report

Current V Recommended Status - 2013

(Excludes Band 7's)

Impact of SNCT Recommendation 2013

(Excludes Band 7's) Considerations

Beds

Current FTE for 2013

FTE establishment recommended in 2013

Acuity / Dependency Variance 2013

Number of RN:NA achievable Day Shift

Number of RN:NA achievable Night Shift

RN:Pt Ratio achievable Day Shift(not incl NIC)

RN:Pt Ratio achievable Night Shift (incl NIC)

Commentary- All staffing

ratios/ daily staffing excludes the Band 7 ward

sister unless otherwise stated.

12 18 14.4 3.60 3+1 2+1

1:6 1:6

Small ward therefore the

recommended would not provide

adequate 24 hour rota cover.

18.3FTE provides the

ratios/numbers here with a 71:29

skill mix.

10 14.5 12.7 1.80 3 2+1 M-F; 2 S&S

1:5 1:5

Small ward therefore the

recommended would not provide

adequate 24 hour rota cover.14.9

FTE will provide this cover with a

skill mix of 88:12. The use of

other therapy staff during day

shift should be taken into

consideration.

15 27.3 20.2 7.10 4+1 3+1 M-F; 3 S&S

1:5 1:5

To achieve the ratios/numbers

here would require 22.8 and

provides a skill mix of 80:20

24 40.6 30.8 9.80 6+1/5+2 4+1

1:4.8/1:6 1:6

8 single rooms therefore add

0.6FTE to recommended =

31.4FTE. Using 31.4FTE can

provide the ratios/numbers

recommended with a skill mix of

75:25/83:17.

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Ward report

INPUTS

•FTE actual V recommended

•Actual Skill mix

•Acuity levels of care ratios

•Nurse:Bed ratios per day available V actual required

Mapped to:

OUTCOMES

•Processes of Care

•Incidence of harm

•Patient Experience

•Staff Experience

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Ward Report

* Current FTE excludes Senior Sr/Charge Nurse

Board HoN Division WardN

ame

% Data

Complianc

e

Acuity

Dependen

cy

Variance

Help with

feeding

Percentag

e of

Complete

Vital Signs

Observati

ons

% Hand

Hygiene

Complianc

e

% Harm

free care

Inpatient

falls with

harm

All

Pressure

Ulcers

Acquired

at UCLH

Preventabl

e Dose

Omissions

Family &

Friends

Test (IP

survey)

Number of

Complaint

s

%

Turnover

%

Sickness

%

Vacancy

%

Temp

Staff

SPH X 83.3 3.1 78.6 95 No data No data 0 0 2 83 NA 37.9 1.7 7 14.5

Outcome-Staff Experience

Nursing & Midwifery Care

ThermometerApr 13 (Monthly)

Input-Staffing Outcome - Process of Care Outcome - Incidence of harm Outcome - Patient

Experience

The Safer Nursing Care tool (SNCT) demonstrates that 30% of the patients cared for during June 2013 were Level 0. Level 0 patients may be those awaiting discharge to home, post operative patients and

those who require assistance of one person for some daily activities such as mobilising. 9% of the patients were level 1a and there were no level 1b in June 2013. This compares to 50% of the patients being

level 0, 8% level 1a and 4% were level 1b in April 2013.

Overall the SNCT recommends a nursing establishment of 26.5FTE for June 2013 however the budgeted establishment is 29.6FTE. Datas compliance on this ward was 83%. The current skill mix is 75RN:26NA

and the Trust recommends that the skill mix should be 70RN:30NA as a baseline.

It is recommended that staffing changes should only be made following 2 or more rounds of data collection.

HoN comment: The ward sister has been away on Maternity leave from September 2012. She has now submitted her resignation and the recruitment process for a replacement is in place. 2 RN to commence

on 1st September.

Top Graph on the left demonstrates the comparison between the budgeted staffing, the recommended

staffing according to the SNCT in June 2013 .

Bottom graph on the left compares the current and Trust recommended skill mix.

On the top right side this graph shows the % of each level of care for the patients during the scoring period.

Level 0 = Usual patients expected to be nursed in this ward, 1a = acutely ill patients who have the potential

to deteriorate, 1b = stable patients with increased nursing support needs i.e. assistance with feeding,

toileting, at risk of harm due to confusion/mobility, 2= High dependency patients requiring intensive clinical

monitoring due to clinical instability.

scoring period as well as the current budgeted nurse to bed ratio.

WTE Comparison For Ward

3028.2

29.6 26.5

0

5

10

15

20

25

30

35

30/04/2013 00:00 30/06/2013 00:00

Current FTE

Recommended WTE

Acuity/Dependency of patients in June 2013 Ward X

Empty

0

1a

1b

2

3

2013 Ward X Skill Mix

74 70

26 30

0

20

40

60

80

100

120

Current Trust Rec.

NA

RN

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Input-Staffing Input-Process of Care Outcome - Incidence of harm

Outcome - Patient & Staff Experience

% Data compliance

Acuity Dependency Variance

Help with feeding

Percentage of Complete Vital Signs Observations

% Hand Hygiene Compliance

% Harm free care

Inpatient falls with harm

All Pressure Ulcers Acquired at UCLH

Preventable Dose Omissions

Recommend to friends/family

% Turnover

% Sickness

% Temp. staffing

100 4 100 98 88.0%

96.0%

0 0 0

90 1.86 0 1.8

73 1 71.4 81 64.7%

100 1 0 1

79 24 2.75 21.7

83 1 100 90.0%

100.0%

100.0%

0 0 0

NA 18 0 25.6

94 1 91.67 100.0%

100.0%

100.0%

0 2 0

NA

Not

avail

Not

available

Not

available

98 -2 No data

No data

98.1%

100.0%

0 1 2

63 26.7 6.3 41

98 -2 No data

No data

99.0%

100.0%

1 0 0

NA 6.9 19.8 0.97

90 5 66.67 100.0%

100.0%

100.0%

0 0 0

NA 0 0 12.7

98 -4 50% 55.0%

92.5%

96.0%

1 1 1

84 14.4 0 29

Divisional/Trust Level report

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Reports

•Report of ratios of levels of care, recommended staffing

establishment, patient outcomes, care processes, patient

experience & staff experience (Care Thermometer)

Per ward,

Per division,

Trust level

Sent to Chief Nurse, DCN, NMB, all wards

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Q&A

Thank you for listening.

If you have any questions at any time email

[email protected]

Or phone 0203 447 2412

[email protected]

0r phone 0115 969 1169