Welcome Alison. Can you start by telling us a little about your team and the patients this alert system supports?
Our team consists of medical Consultants who are also specialists in Respiratory Medicine and Critical Care, a Nurse Consultant, Nurse Specialists, Specialist Physiotherapists, a Health Care Assistant and crucial administrative support. We have an established relationship with the paediatric LTV service, and jointly host clinics to provide a seamless transition for children on ventilation into our care.
In Newcastle, we currently support more than 1000 patients on long-term ventilation or cough augmentation in the community setting. We see 400 new referrals each year, mostly referred to the service from other hospital specialists. Many of our patients have neuromuscular conditions, but others have chest wall problems, central and obstructive sleep apnoea, spinal cord injury and COPD. We support patients who receive both invasive (tracheostomy) ventilation and non-invasive ventilation.
Our team looks after many patients who require long-term ventilation outside of the hospital setting, and many of these patients will, at some point, require hospital admission.
In some cases this is a planned or elective admission but other times this is an emergency admission.
It is good practice, at the time of treatment initiation for the patients and their care givers to be instructed to let the Long-Term Ventilation (LTV) team know in advance of any planned / elective admission.
This is in case any preparation is required in terms of optimising ventilation or consideration of inpatient placement.
Emergency admission does not allow for such preparation.
How would your team prepare for one of your patients being admitted to the trust?
It is important to note that our patients can be admitted to wards across our Trust.
In order to maintain patient safety, it is important that certain actions take place once the LTV team are aware of the admission.
This is to ensure:
- There is the opportunity for the LTV Team to provide support, training and equipment as required.
- The patient has their respiratory support equipment (Ventilation and / or Airway Clearance Device) with them when they are admitted.
- They have been admitted to an environment that has the appropriate skills to support the patient and is able to offer an adequate level of supervision. This will be dependent upon the patient’s level of dependence and / or the presence of the usual care giver.
- There is appropriate understanding among the ward staff of the patient’s need for respiratory support.
- Acknowledgment that this treatment is not CPAP.
- A clear understanding of risks surrounding potential requirement for general anaesthetic if the reason for admission is surgical.
What was it that highlighted the need to implement this new alert system?
We recognised a lack of knowledge, training and support amongst ward staff, as a result of:
- Datix submissions (incident reports)
- Patient complaints
- Feedback from Coroner's inquests
- Staff feedback
Modifiable factors which could improve safety amongst this high-risk patient group were identified as part of this process.
What were the initial steps?
A policy was developed, which included recommendations concerning the management of patients under the care of the LTV service during hospital admission.
This policy was written by Dr Ben Messer, LTV Clinical Lead, using a collaborative approach. The development of the policy included consultation with all members of the wider multi-disciplinary team (MDT), who may be involved in the patient pathway during an admission.
A further output was to develop the electronic alert system, linked to the patient record which notifies the LTV service if a patient under their care was admitted to the Trust site.
How does the alert system work?
Alerts are developed through a tool called DiscernDev. Each alert generally has its own rule built, and each rule comprises of three sections:
Evoke, Logic and Action.
Evoke section: the Evoke (or trigger) tells the system “when” to start an evaluation i.e. when an order is placed or a result is verified.
Logic section: the logic section is the "if" section. It searches the database for relevant information or data qualifiers. i.e. IF the patient is in this location and IF the patient has Problem Code “X” recorded on their record.
Action section: the action section is the “then” section. It completes the appropriate action. For example, send an alert message to the screen when the chart opens, or send a message to specified users ‘Message Centre’ inbox.
When the team receives an “alert”, what happens?
The ‘Message Centre’ system is checked and reviewed by the LTV team at least once daily.
A list of patients admitted to the Trust in the last 24 hours is recorded.
As a result of the electronic ‘alert’, an email is generated from the LTV team to the nurse in charge and consultant of the admitting ward.
This contains standard text relating to the patient being on NIV (and not CPAP) and details the contact information for the LTV team.
The LTV team may also contact the clinical area, and review any training needs for the staff as well as conducting clinical review of the patient (with regard to their LTV requirements).
In addition, as Home Ventilation is classified as a Clinical Risk in the previous step, a flag is placed against the patient record in PowerChart (the electronic patient record).
Have you put any other patient safety measures in place?
A sticker is placed on each device used by the patient that has clear contact information for the LTV service. The sticker also clearly defines the device as being a ventilator and not a CPAP device.
Information, supported with patient held documentation is given at the point of NIV set up asking that the LTV team are notified if the patient is admitted.
As we are a region-wide service, these additional measures provide a mechanism for the patient, relative or ward teams to contact the LTV team if the patient is admitted to another hospital site. The EPR alert system only works for patient admitted within this Trust.
In terms of evaluation, informally we have received feedback from other wards and departments that they recognise when a long-term ventilation patient is admitted, and are aware of the requirement to provide notification. We have seen a reduction in the number of Datix incident reports and overall, the care of the patient feels more joined-up.