Leeds Teaching Hospital Ward Healthcheck Metrics Programme

Ward Healthcheck paper - Appendix 2 Appen Leeds Teaching Hospital Ward Healthcheck Metrics Programme

Metrics Information Introduction The nursing care Metrics were initially developed in the north west of England by Suzanne Hinchliffe, Chief Nurse and have subsequently adopted by the National Patient Safety Agency as a national care indicator set. Leeds Teaching Hospitals have linked with University Hospitals of Leicester (UHL), one of the Trusts that teach this initiative and influences its development nationally. The nursing care indicators cover those areas which are our highest concerns in terms of risk: Patient observations Pain management Falls assessment Pressure area care Nutritional assessment Medicine prescribing and administration Resuscitation equipment Controlled medicines Venous Thromboembolic Disease (VTE) Patient dignity Infection prevention and control Discharge Continence These Metrics measure our standards of record-keeping for the core activities that we undertake for our patients, how we assess their needs and plan and deliver care to meet their needs. It is vital that they demonstrate our professionalism and give an accurate and contemporaneous record of our patients care. The information set out in this document should assist both auditors and practitioners to achieve a successful outcome. Concurrently, we will collect information from our patients about their experience of care; the Friends & Family data and some workforce data will be available on the ward Healthcheck to contribute to the ward profile. The information collected during this audit determines the Red/Amber/Green rating on the ward Healthcheck, so when looking at the Healthcheck on your computer the number will be the outcome and the RAG rating will reflect the compliance with the steps set out in each of the metrics below. E.g. a ward 2

could have a 0 for pressure ulcers and be Red, this indicates that although the ward had no pressure ulcers the previous month the metrics audit demonstrated that the process for assessment and planning was not being followed. Key to a successful audit: The metrics audit programme is designed to review patients records to provide vital information about ward practices against agreed policies, procedures and ways of working. When the audit is undertaken the auditor will review patients records and information available on the ward in relation to the metrics identified above. This booklet is designed to give ward teams information about the metrics, the audit and what the auditor will look for and how the auditor will decide if the records are compliant or not. Top Tips: All charts and assessment documents to have details of ward, patient name, date of birth and NHS number/pas number clearly visible. NEWS chart, Nursing Specialist Assessment Document and if care needs are identified the relevant Care Plans should be available at the end of the patients bed. The Nursing Specialist Assessment All in-patients will have a fully completed Nursing Specialist Assessment (NSA) within the first 4hrs of admission or on transfer or change of condition. This will be completed by a registered practitioner. The NSA should have the ward, patient name, date of birth and NHS number/pas number clearly displayed. If the patient has been identified through the NSA as requiring further skin assessment a Braden will need completing within 6 hours of admission If the patient has been identified through the NSA as a falls risk on the NSA a falls risk assessment will need to be completed within 6 hours of admission. The patient Nutritional needs will be assessed on the NSA within the first 4hr of admission. If they are deemed at risk a MUST assessment will be required to be completed within 6 hours of admission and at least weekly thereafter. Patients should have individualised Care Plans to meet specific care needs identified through the Nursing Assessment within 24hrs of admission 3

Continence should be assessed on the NSA within 4hrs of admission and further individualised care plans if required in place within 24 hours of admission Printed name, signatures, job role, date and time must be visible and legible where required. All entries should be in black ink.. Charts Charts to be completed professionally i.e. accurately, neatly and in black ink. Pain assessments must be recorded on NEWS chart, using the 0 3 pain scale Fluid balance charts completed with cumulative balance and available at the bedside for patients that require monitoring i.e. Patients having IV fluids, drains and infusions. All patients should be weighed within 48hr of admission and as indicated following the nursing assessment. Where required a nutritional care plan should be in place, this should identify the frequency of recording the patients weight. General & Environment Hand hygiene audit results should be displayed on the IPC board with an action plan if required. Gel sanitiser should be available by every bed unless infection prevention have advised otherwise. Staff looking professional following uniform policy e.g. bare below the elbow, long hair tied up, no stoned rings, other jewellery or wristwatches. Discharge planning needs to commence at pre-assessment clinic for planned admissions or within 24 hours of admission. This includes an estimated date of discharge/ clinically fit for discharge date recorded and visible on the ward board. 4

Summary of Care Metrics PATIENT OBSERVATIONS A. All patient observation documentation will provide details of ward, patient name, date of birth and NHS number/pas number B. All patients will receive at minimum twice daily observations of temperature, pulse, blood pressure and respirations, level of consciousness and oxygen saturations and pain assessment. C. All patients will be assessed against Early Warning Score system in accordance with Trust policy. D. 24 hour cumulative balances will be evident on all fluid balance observations. E. Referral to outreach will be evident for all patients meeting referral criterion.- PAIN MANAGEMENT A. All pain assessment documentation will provide details of ward, patient name, date of birth, NHS number/pas number. B. The pain status of all patients will be assessed on admission. C. The pain status of all patients will be recorded on NEWS chart as a minimum twice daily. D. Individualised Care plans will be evident for all patients where pain is identified. E. Patients pain needs will be re-assessed on the NSA at least weekly, on transfer or a change in condition. F. Analgesia administration and efficacy will be recorded for all patients as indicated. FALLS ASSESSMENT A. All risk assessment documentation will provide details of ward, patient name, date of birth, NHS number/pas number B. All patients will be risk assessed within 4 hours of admission this will be evident on the NSA which will be dated and signed by the assessing staff member. C. A further risk assessment will be undertaken for all patients being identified at risk D. Care plans to minimise falls will be evident for all patients assessed as being at risk. E. A bed rail assessment will be undertaken on all those patients identified at risk. 5

PRESSURE AREA CARE A. All risk assessment documentation will provide details of ward, patient name, date of birth, NHS number/pas number. B. All patients will receive a tissue viability risk assessment on admission. The initial assessment to be completed on the NSA within 4hrs, if at risk the PU booklet to be completed within 6hr. C. Care plans will be evident for all patients identified at risk. PU booklet to be completed with daily evaluation if patient deemed at risk. D. Patients will be re-assessed as required in accordance with care plan documentation. E. Care plan evidence of pressure area care/support interventions will be available for all patients identified at risk. NUTRITION A. All risk assessment documentation will provide details of ward, patient name, date of birth, NHS number/pas number. B. All patients will receive a nutritional assessment on admission which will be dated and signed by the assessing staff member. Initial Nutrition assessment will be completed on NSA within 4hr if deemed at risk a further assessment will carried out within 6hr and plan of care completed within 24hr. C. All Patients should be weighed if possible within 48 hr of admission This information should be captured on the NSA or the Trust Weight chart. D. Care plans identifying nutritional support interventions and demonstrating implementation will be evident for all patients identified at risk. E. Patients will be re-assessed as required. F. Care plan documentation highlighting dietetic referral will be evident for those patients meeting referral criterion. MEDICINE PRESCRIBING AND ADMINISTRATION A. All patient prescription documentation will be legible and provide details of ward, patient name, date of birth, allergy status, NHS number/pas number, weight and consultant. B. The prescriber s details are present for each prescription and have a legible name, signature and contact number. C. Omission codes will be evident and completed in line with Trust policy. Omission codes will be evident for all medication not administered as prescribed. D. The status of patients with a potential/actual medication allergy will be identified. E. All IV medicines administration must have evidence of two signatures as per Trust policy. 6

F. Patient identification wristband is present for all patients and where appropriate they will have the allergy wristband. RESUSCITATION EQUIPMENT A. There is evidence that all resuscitation equipment is checked on a daily basis and signed and dated by the assessing member of staff. CONTROLLED MEDICINES A. Controlled medicines are stored in a designated controlled drug cupboard which is locked. Furthermore the Key for this cupboard is managed separately to the other keys. B. Controlled medicines checks take place minimum once a week and there is evidence of two registered practitioners signatures and date. C. The ward fridge must be locked and recorded evidence of the fridge temperature being checked daily VTE A. Assessment form will provide details of ward, patient name, date of birth, date and NHS number/pas number. B. Assessment completed on admission and is signed and dated. C. Patient information leaflet on preventing VTE given to the patient. PATIENT DIGNITY A. Patient can reach their call bell. B. Patient appears warm and well cared for, with their modesty maintained. C. The ward environment is clean, tidy and clutter free D. The ward/area provides single sex bays/single sex ward accommodation, with designated bathroom facilities available for each sex. E. Staff communicate in an appropriate compassionate manner to patients. F. Patient s preferred name is clearly documented on admission. INFECTION PREVENTION AND CONTROL A. Alcohol Gel is available in line with Trust Guidance. B. Ward Hand Hygiene audits are completed in accordance with Trust Policy. C. Care plan documentation (and implementation) will be evident for those patients who are identified with an alert organism/condition. This documentation will provide details of ward, patient name, date of birth, NHS number/pas number. 7

D. Care plan documentation (and implementation) will be evident for those patients with invasive devises. This document will provide details of patient name, date of birth, NHS number/pas number. E. Evidence of adherence to uniform policy and personal protective equipment is worn according to the Trust guidance. DISCHARGE A. Assessment form will provide details of ward, patient name, date of birth, number, date, and NHS number/pas number. B. Estimated discharge date/ medically fit for discharge date is recorded and visible on the ward board. C. Evidence of TTOs/EDAN completed 24hr prior to discharge. D. Does the ward have the Discharge Folders available? CONTINENCE A. All patients will have their continence assessed. The initial assessment will be documented on the NSA within 4hr of admission. Assessment form will provide details of ward, patient name, date of birth, date, and NHS number/pas number. B. Continence care plan is evident for patients with a catheter in situ. C. The catheter care plan is signed, printed name, job role dated and timed. D. Catheter bags are attached to a catheter holder and are dated. Nursing Metrics Programme Care Indicators Auditors will approach the nurse in charge on arrival to the ward and introduce themselves and explain this is the Metrics monthly audit focussing on the assessment of care needs and documentation of care delivered using the NSA, nursing care plans and NEWS Charts. The auditor will take a random sample of 10 patients documentation from across the ward environment; patients in source isolation can be included in the audit. Patient Observation Indicator Information for this indicator should be found on the NEWS chart at the end of the bed. A. All patient observation documentation will provide details of ward, patient name, date of birth, NHS number/pas number B. Has the frequency of observations been prescribed by a registered practitioner as a minimum of daily 8

The frequency of observation required should be documented on the front of the chart. C. All patients will receive minimum twice daily observations of temperature, pulse, blood pressure and respirations, level of consciousness (AVPU), oxygen saturations, pain and a recorded NEWS. Has the patient had the above completed & recorded at least twice daily D. All patients will have a NEWS score that has been calculated correctly, escalated and reviewed by the relevant practitioner in accordance with policy E. Referral to outreach will be evident for all patients meeting referral criterion. You may need to look at notes for evidence of when or why the patient on clinical judgment was not referred. If no documented evidence can be found mark as No. If no NEWS that would have triggered referral mark as N/A. F. 24 hour cumulative balances will be evident on all fluid balance observations. Patients receiving IV Fluids require a fluid booklet if this is absent please mark as no. Pain Management Indicator Criteria Information should be found on the NEWS chart at the end of the bed. A. All pain assessment documentation will provide details of ward, patient name, date of birth, NHS number/pas number. All entries should be legible signed, name printed and job role recorded If any of the above are missing mark as No. B. The pain status of all patients will be assessed on admission; this will be evidenced within the NSA. C. The pain status of all patients will be recorded. This should be recorded on the NEWS chart with each set of observations carried out. D. Are there individualised pain care plans evident for patients with care need in relation to pain? This applies to patients with a pain score of 2 or more, or assessed on the NSA of having chronic pain/acute pain. If pain care plan not required please score mark as N/A. E. Is their evidence that the Patients pain has been re-assessed on transfer or change of condition? Falls Assessment Indicator Criteria Information for this should be found at the end of the bed.. A. All Documentation will provide details of ward, patient name, date of birth, date and NHS number/pas number. All entries should be legible signed, name printed and job role recorded. If any of the above are missing mark as No. B. All patients will have an initial risk assessment completed on the NSA. C. If the patient is deemed at risk has a further risk assessment been completed? 9

D. If the patient is at risk do they have in place a plan of care that demonstrates the interventions required to minimise the risk of falls? E. If the patient is identified at risk has a bed rail assessment been completed? If bedrails not required mark as N/A. (NSA prompts the need for bedrail care plan assessment document.) Pressure Area Care Indicator Criteria Information for this should be found at the end of the bed. A. All risk assessment documentation will provide details of ward, patient name, date of birth, NHS number/pas number and date. All entries should be legible signed, name printed and job role recorded. If any of the above are missing mark as No. B. All patients will have an initial assessment completed on the NSA. C. If the patient is deemed at risk or has a pre-existing pressure ulcer. The pressure ulcer booklet will have been commenced. D. Patients will be re-assessed as required in accordance with care plan documentation. Minimum of weekly on the NSA and daily if PU booklet is required. E. Care plan evidence of pressure area care/support interventions will be available for all patients identified at risk. Nutritional Assessment Indicator Criteria Information for this should be found at the end of the bed. A. All risk assessment documentation will provide details of ward, patient name, date of birth, NHS number/pas number and date. All entries should be legible signed, name printed and job role recorded. If any of the above are missing mark as No. B. All patients will receive an initial nutritional assessment completed on the NSA C. All patients should be weighed on admission as this information is required for the prescription chart. In some circumstances it will be impossible to weigh the patient if they are too ill; on bed rest; cannot be moved etc this should be documented and a visual assessment should be carried out as per NSA. D. If the patient is deemed at risk, are there a further assessment and a clear documented care plan that demonstrates evidence of nutritional support and completed food charts. Care plans demonstrate evidence of nutritional support interventions for all patients identified at risk. If patients have food charts with gaps or if patients are enteral/parenteral feed do they have plans to support this. Please mark as No if they do not. E. Patients will be re-assessed as required on the NSA as a minimum of weekly and if at risk on the Nutritional Screening Tool. 10

F. Care plan documentation highlighting dietetic referral will be evident for all those patients meeting referral criterion This information may be in the medical notes. If not at risk mark as N/A. Medicine Prescribing & Administration Indicator Criteria A. All patient prescription documentation will be legible and provide details of ward, patient name, date of birth, NHS number/pas number, weight and allergy status. If any of the above are missing mark as No. B. The prescriber s details are present for each prescription and have a legible name, signature and contact number. If any of these are missing from any medication prescribed please mark as No C. Omission codes will be evident and completed in line with Trust policy. Omission codes will be evident for all medication not administered as prescribed. If a dose has not been crossed referenced with an action please mark as no D. The status of patients with a potential/actual medication allergy will be identified. E. All IV medicines administration must have evidence of two signatures as per Trust policy. F. Allergy wristband should be evidenced where appropriate. Patient identification wristband is present for all patients. The information required on the I.D band is Name date of birth NHS number/pas Number Resuscitation Equipment Indicator A. Is there evidence that the defibrillator and crash trolley equipment are checked on a daily basis and signed and dated by the assessing member of staff. The checklist should be kept on the crash trolley please ensure you review 4 weeks worth of checks. If the register has gaps within this period please mark as NO. Controlled Medicines Indicator Criteria A. Are the controlled drugs stored within a designated controlled drug cupboard and is the cupboard locked. B. Is there recorded evidence of all the controlled drugs being checked once per week as a minimum, by two registered practitioners C. Is the CD key managed separately to the other keys. D. Is the ward medicine fridge locked. All fridges that are used to store medication are required to be locked. If an area has more than one fridge and both do not follow policy please mark as no. E. Is there recorded evidence of the fridge temperature being checked daily. All fridges that are used to store medication require daily checks. If an area has more than one fridge and both do not follow policy please mark as no. Please ensure you review 4 weeks worth of checks. 11

VTE Indicator Criteria A. Assessment form will provide details of ward, patient name, date of birth, NHS and date. If any of the above are missing mark as No. B. Has the patient been given written information, (Avoiding Venous Thromboembolism information Leaflet WNA930) Patient Dignity Indicator Criteria A. Patient can reach their call bell. Auditor to observe if a call bell is accessible. B. Patient appears warm and well cared for with their modesty maintained. Auditor to observe. C. The ward environment is clean, tidy and clutter free Auditor to observe bay areas and bathrooms D. The ward/area provides single sex bays/single sex ward accommodation, with designated bathroom facilities available for each sex E. Staffs communicate in an appropriate compassionate manner with patients. Auditor to observe. F. Patient s preferred name is clearly documented on admission. Infection Prevention and Control Indicator Criteria A. Does the bed space have alcohol gel available? B. Is there evidence on the ward that the hand hygiene audits are completed in accordance with the Trust Policy. Please identify the ward IPC/ Patient safety board for results of hand hygiene audits completed during the past 2 months and associated action plans. (Action plans must be up and in place for hand hygiene audit result that are below 95%) If there is no result or no action plan when required please score as No. C. Observe the ward staff in the clinical environment to ensure they decontaminate their hands: before patient contact, before a clean/aseptic procedure. After body fluid exposure risk, after patient contact, after contact with the patient surroundings. Auditor will observe staff (Please witness ten instances during the visit of any of the above processes). D. Patients identified with an alert organism/condition (MRSA, CDIFF) should have a source isolation care plan, the side room should have the yellow signage displayed and the door should be shut or a risk assessment completed Identify any patient with alert organisms (ie MRSA, C Diff or other that requires isolation) at least one to be included in audit if on ward. All risk assessment documentation will provide details of ward, patient name, date of birth, NHS number/pas number and date. All entries should be legible signed, name printed and job role recorded. E. If the patient has an invasive device insitu is there documented evidence of indication for insertion and a VIP or CLESS score completed, an individual care 12

plan stored at the bedside Care plan documentation. VIP and CLESS scores should be completed as stated on the documentation. All other vascular devises should have a documented insertion/indication and a 24hourly review. F. Evidence of adherence to uniform policy and PPE is worn according to Trust guidance. Auditor will observe as many clinical staff on duty during the visit. Please score No per member of staff not following policy and N/A for the boxes when less than 10 staff available. Discharge Indicator Criteria A. Assessment form will provide details of ward, patient name, date of birth, number, date. NHS number/pas number. B. Estimated discharge date/ medically fit for discharge date is recorded and visible on the ward board. C. Evidence of TTOs/EDAN completed 24hr prior to discharge. D. Does the ward have the discharge folders Continence Indicator Criteria A. All Assessment forms will provide details of ward, patient name, date of birth, NHS number/pas number and date. All entries should be legible, signed, name printed and job role. If any of the above is missing please mark as No. B. All patients will have an initial assessment in relation to their continence needs; this will be evidenced on the NSA. C. If the patient has a catheter, is there an insertion care plan and a daily evaluation care plan completed. Continence care plan is evident for patients with a catheter in situ. D. If the patient has a catheter is it attached to an appropriate catheter holder. E. If the patient has been highlighted as having continence issues on the NSA, is there a documented plan of individualised care in place?. The aim of this programme is to provide robust information for the clinical teams setting out where they are doing well or where they might need to focus attention to improve patient assessment and safety. 13