Patient safety

10 things NHS trusts should already be doing

This issue of Effectiveness Matters has been produced in collaboration with the AHSN for Yorkshire and the Humber.

CRD is part of the NIHR and is a department of the University of York. CRD provides decision makers with research-based information about the effects of interventions used in health and social care. The views expressed in this bulletin are those of the authors alone and not necessarily those of the AHSN, NIHR or the University of York.

The Francis Report detailed some of the worst failings in care and unnecessary harm to have occurred in the NHS.

The government announced a series of measures they hope will deliver a culture of zero-harm and patient centred care in the NHS.

There is a large evidence base that the NHS can draw upon to inform their efforts to improve patient safety.

The ten key practices highlighted in this bulletin range from establishing a culture for patient safety through to interventions aimed at reducing specific events.

Clear and visible leadership, engagement of front-line clinical staff and interventions that target prevailing attitudes are key.

Delivering harm free care should involve routine monitoring of meaningful outcomes. Areas of concern can be identified and targeted so that improvements can be sustained.

Background

The Francis Report of the public inquiry into Mid-Staffordshire NHS Foundation Trust provided detailed analysis of some of the worst failings in care and unnecessary harm to have occurred in the NHS.1

The government has responded by announcing an overhaul of the regulatory system and a series of measures they hope will deliver a culture of harm free and patient centred care across the NHS.2

The Berwick Report stated that the single most important change the NHS can make is to become a system devoted to continual learning and improvement.3

There is a large evidence base that NHS Hospital Trusts can draw upon to inform the development, implementation and routine monitoring of patient safety practices locally.

The American Association for Healthcare Research and Quality (AHRQ) report Making Health Care Safer II4,5 summarises the evidence for a range of practices. These range from establishing a culture for patient safety through to interventions aimed at reducing specific events.

This issue of Effectiveness Matters summarises this and other recent relevant systematic review evidence to highlight ten practices that NHS Trusts should be doing.

Promoting a safety culture

The Francis Report has highlighted that culture is central to efforts to improve patient safety.1

The evidence on promoting a patient safety culture is of limited quality, but what is available suggests that multifaceted strategies may be beneficial6. Successful strategies commonly incorporate team training, mechanisms to support team communication and involve routine senior executive engagement in front-line safety walkabout rounds. Walkabouts fit with calls for Trust boards to be doing much more to exercise clear and visible leadership to improve the quality of care their organisations provide.1,7

Trusts should consider incorporating these elements into their own efforts to promote a safety culture and should routinely evaluate their impact on relevant outcomes such as reductions in avoidable errors and patient harm.

The Francis Report has re-emphasised the need for Trusts to put patient experience at the heart of health services – actively seeking and acting on patient feedback and reviewing and learning from complaints. A recent systematic review provides some, albeit limited, evidence that there is a consistent positive association between patient experience and clinical outcomes - including patient safety.8

Hand hygiene compliance

Hand hygiene is crucial for reducing hospital acquired infections, but historically compliance has been low. Evidence suggests that multi-component compliance interventions can be effective.9

Statutory criteria for NHS infection control were introduced in 2006. Around the same time, the Department of Health rolled out the national Cleanyourhands campaign to all hospitals in England and Wales. The main components of the campaign were provision of alcohol hand rub at the bedside, display of ‘clean your hands’ posters, regular audit and feedback of compliance, and provision of materials asking patients to remind healthcare workers to clean their hands. Analysis of the impact of Cleanyourhands across 187 Trusts has shown that the campaign was associated with reduced rates of the hospital acquired infections S. aureus bacteraemia and C. difficile infection.10

Sustaining compliance over the longer term can be difficult.9 A well conducted trial involving 16 NHS Trusts already implementing the Cleanyourhands campaign found that personalised feedback coupled with personalised action planning produced moderate but significant sustained improvements in hand hygiene compliance. Effects were more marked on intensive care units ( ICUs), where it was easier to implement.11

Preventing venous thromboembolism

Venous thromboembolism (VTE) is an important cause of death and morbidity in hospitalised patients. NHS Trusts are now mandated to risk assess 95% of patients for VTE on admission in order to receive their CQUIN payment.12

Venous thromboembolism prophylaxis for specific populations is well established.13 Although there are significant risks and risk stratification is essential to ensure that prophylaxis is targeted appropriately.

NICE recommends that all patients are assessed for risk of bleeding before pharmacological venous thromboembolism prophylaxis is offered.14 Where patients are at increased risk of VTE, which is not outweighed by risk factors for bleeding then NICE recommend mobilisation of the patient as soon as possible, pharmacological and mechanical prophylaxis, and patient information and discharge planning that includes VTE-relevant information.

Reducing inpatient falls

There is consistent good quality evidence that multi-component interventions are effective in reducing inpatient falls.15

Components most commonly included in interventions of this type are staff and patient education, tailored bedside signage, alert wristbands, advice on footwear, toileting schedules, medication reviews, and post fall reviews to identify causes. Evidence is lacking to show which of these, singly or in combination, are most important for success.

Factors consistently associated with implementation success are senior and ward level leadership support, engagement of front-line clinical staff in the design of the intervention, guidance by a multidisciplinary committee, use of information systems on falls data, attitude change away from the inevitability of falls, and education or training to promote adherence to implementation.

NICE recommends that multifactorial risk assessment is undertaken to identify and manage a patient's individual risk of falling during their stay.15

Reducing pressure ulcers

There is moderate quality evidence that multi-component interventions can reduce pressure ulcers in acute settings.17

Components most commonly included in interventions of this type are simplification and standardisation of pressure ulcer specific interventions, involvement of multidisciplinary teams and leadership, designated skin champions, regular staff education with updates on ulcer rates and product changes and use of practice guidelines. Sustained audit and feedback is important for promoting accountability and recognising success.

Interventions which were not dependent on maintaining a particular staffing level appeared to be easier to sustain once implemented.

Reducing urinary catheter use

Catheter associated urinary tract infections are the most common healthcare associated infection; the vast majority of these are avoidable.

There is evidence of moderate quality for interventions that remind clinicians of the presence of urinary catheters and prompt their timely removal.18

Use of either reminders or stop orders reduced the length of catheterisation; stop orders reduced the rate of catheter associated urinary tract infections.18

Reminders and stop orders appear to be low cost and low risk. However, successful implementation may be dependent on attitude change and routine audit and feedback may be required to sustain compliance over the longer term.19

Antibiotic prophylaxis at the time of catheter removal could have a role in preventing associated urinary tract infections,20 but there is currently insufficient evidence to support routine use.

Pre-operative checklists

Several pre-operative and anaesthesia checklists have been developed in an attempt to prevent mistakes related to surgery.

Since 2010, all NHS Trusts in England and Wales have been mandated to ensure an executive and a clinical lead are responsible for the implementation and recorded use of the WHO surgical safety checklist for every patient undergoing an operation.

Analysis of the implementation of the WHO checklist in eight countries and nearly 4,000 procedures found reductions in the rates of death and complications among patients undergoing (non-cardiac) surgery.21 Improvements in post operative outcomes were associated with a small but significant change in clinician attitudes and perceptions of improved teamwork and safety climate.22

A recent systematic review found that safety checklists can improve inter-professional teamwork and communication in the operating theatre. When used sub-optimally, or when not all team members are engaged in the process, checklists may adversely affect team performance.23

An evaluation of the implementation and use of the WHO Checklist in NHS Trusts is ongoing.

Ultrasound for central line placement

Central venous cannulation can be unsafe. There is good quality evidence to support the use of real time ultrasound-guided techniques to facilitate central venous cannulation to reduce the risk of misplacement and associated complications.24,25

NICE recommends that 2-D imaging ultrasound guidance should be the preferred method in adults and children in elective situations.26 NICE states that anyone using 2-D imaging ultrasound guidance to insert central venous catheters should have appropriate training. Simulator based training can improve implementation and use.24

There is evidence that real time ultrasound guidance may also be beneficial for other kinds of catheter insertions.24,25,27,28

Central line bundles

Central venous catheters are used to provide long-term venous access. Central line related bloodstream infections can lead to severe problems such as sepsis but are also largely preventable.

Care bundles are groupings of practices that when applied together can improve the quality and safety of care delivered. There is reasonable evidence to support the use of a central line bundle of five practices.29

These are hand hygiene before insertion, use of sterile maximal barrier precautions such as masks and gloves, use of chlorhexidine for skin antisepsis, selection of subclavian vein as the preferred site for insertion and avoidance of the femoral site and prompt removal of unnecessary lines.

This bundle appears to be successful in reducing central line related bloodstream infections within ICUs but its effectiveness outside this setting has yet to be established.

Ventilator bundles

Ventilator associated pneumonia (VAP) is the most common ICU acquired infection. Ventilator bundles are widely recommended for VAP prevention and commonly involve four key practices. These are: head of bed elevation; sedation vacations; use of chlorhexidine; and use of subglottic suctioning endotracheal tubes.

There is good quality evidence to support the use of subglottic suctioning endotracheal tubes and to support the use of chlorhexidine.30 There is moderate quality evidence that sedation vacations reduce patients' risk of VAP as well as other mechanical ventilation associated complications. Evidence to support the use of head of bed elevation by at least 30 degrees is lacking.

Implementing other safety practices

The evidence for patient safety extends beyond the ten practices highlighted in this bulletin.

Working with the Yorkshire and Humber AHSN, we are planning further translation and dissemination of what is already known about effective patient safety practices to enhance awareness and uptake in the NHS.

About Effectiveness Matters

Effectiveness Matters is a summary of reliable research evidence about the effects of important interventions for practitioners and decision makers in the NHS and public health. It is produced by the NIHR Centre for Reviews and Dissemination at the University of York in collaboration with subject area experts. Effectiveness Matters is extensively peer reviewed.

This issue summarises evidence from the AHRQ report Making Health Care Safer II and other recent systematic reviews. It was produced by CRD in collaboration with the AHSN for Yorkshire and the Humber.

This issue was written by Paul Wilson, Gill Norman and Mark Rodgers. We would like to acknowledge the helpful assistance of the following who commented on the text: Michael McCooe, Noemi Kelemen and John Wright (all Bradford Teaching Hospitals NHS Foundation Trust), Andy Smith (University Hospitals of Morecambe Bay NHS Foundation Trust) , Alison Cracknell and Steve Smye (both Leeds Teaching Hospitals NHS Trust), Dawn Lawson (Yorkshire and Humber AHSN).

If you would like to suggest any topics you want us to address as a priority please contact us at crd-web@york.ac.uk.

References

  1. Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry (Chaired by Robert Francis QC). London: The Stationery Office, February 2013.
  2. Department of Health. Patients First and Foremost: the Initial Government Response to the Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry. London: The Stationery Office, March 2013.
  3. Berwick review into patient safety
  4. Shekelle PG, Wachter RM, Pronovost PJ, Schoelles K, McDonald KM, Dy SM, Shojania K, Reston J, Berger Z, Johnsen B, Larkin JW, Lucas S, Martinez K, Motala A, Newberry SJ, Noble M, Pfoh E, Ranji SR, Rennke S, Schmidt E, Shanman R, Sullivan N, Sun F, Tipton K, Treadwell JR, Tsou A, Vaiana ME, Weaver SJ, Wilson R, Winters BD. Making Health Care Safer II: An Updated Critical Analysis of the Evidence for Patient Safety Practices. Comparative Effectiveness Review No. 211. Rockville, MD: Agency for Healthcare Research and Quality. March 2013.
  5. Shekelle PG, Pronovost PJ, Wachter RM, McDonald KM, Schoelles K, Dy SM, Shojania K, Reston JT, Adams AS, Angood PB, Bates DW, Bickman L, Carayon P, Donaldson L, Duan N, Farley DO, Greenhalgh T, Haughom JL, Lake E, Lilford R, Lohr KN, Meyer GS, Miller MR, Neuhauser DV, Ryan G, Saint S, Shortell SM, Stevens DP, Walshe K. The top patient safety strategies that can be encouraged for adoption now. Annals of Internal Medicine 2013; 158(5 Pt 2):365-8.
  6. Weaver SJ, Dy SM, Lubomski LH, Wilson RF. Promoting a Culture of Safety. (Chapter 33). In: Shekelle PG, Wachter RM, Pronovost PJ, et al. Making Health Care Safer II: An Updated Critical Analysis of the Evidence for Patient Safety Practices. Comparative Effectiveness Review No. 211. Rockville, MD: Agency for Healthcare Research and Quality. March 2013, pp 67-72.DARE Critical Commentary / Original publication
  7. The King’s Fund. Patient-centred leadership: Rediscovering our purpose. London: The King’s Fund, 23 May 2013.
  8. Doyle C, Lennox L, Bell D. A systematic review of evidence on the links between patient experience and clinical safety and effectiveness. BMJ Open 2013; 3(1) doi:pii: e001570.
  9. Pfoh E, Dy, S, Engineer C. Interventions To Improve Hand Hygiene Compliance: Brief Update Review. (Chapter 8). In: Shekelle PG, Wachter RM, Pronovost PJ, et al. Making Health Care Safer II: An Updated Critical Analysis of the Evidence for Patient Safety Practices. Comparative Effectiveness Review No. 211. Rockville, MD: Agency for Healthcare Research and Quality. March 2013, pp 67-72.
  10. Stone SP, Fuller C, Savage J, Cookson B, Hayward A, Cooper B, Duckworth G, Michie S, Murray M, Jeanes A, Roberts J, Teare L, Charlett A. Evaluation of the national Cleanyourhands campaign to reduce Staphylococcus aureus bacteraemia and Clostridium difficile infection in hospitals in England and Wales by improved hand hygiene: four year, prospective, ecological, interrupted time series study. BMJ 2012; 344:e3005.
  11. Fuller C, Michie S, Savage J, McAteer J, Besser S, Charlett A, Hayward A, Cookson BD, Cooper BS, Duckworth G, Jeanes A, Roberts J, Teare L, Stone S. The Feedback Intervention Trial (FIT)- improving hand-hygiene compliance in UK healthcare workers: a stepped wedge cluster randomised controlled trial. PLoS One. 2012;7(10):e41617.
  12. NHS Commissioning Board. Commissioning for quality and innovation (CQUIN): 2013/14 guidance. February 2013.
  13. Haut ER, Lau BD. Prevention of Venous Thromboembolism: Brief Update Review. (Chapter 28). In: Shekelle PG, Wachter RM, Pronovost PJ, et al. Making Health Care Safer II: An Updated Critical Analysis of the Evidence for Patient Safety Practices. Comparative Effectiveness Review No. 211. Rockville, MD: Agency for Healthcare Research and Quality. March 2013, pp 303-309.
  14. National Institute for Health and Clinical Excellence. Reducing the risk of venous thromboembolism (deep vein thrombosis and pulmonary embolism) in patients admitted to hospital. NICE Clinical Guideline 92. London: National Institute for Health and Clinical Excellence, January 2010.
  15. Miake-Lye IM, Hempel S, Ganz DA, Shekelle PG. Preventing In-Facility Falls. (Chapter 19). In: Shekelle PG, Wachter RM, Pronovost PJ, et al. Making Health Care Safer II: An Updated Critical Analysis of the Evidence for Patient Safety Practices. Comparative Effectiveness Review No. 211. Rockville, MD: Agency for Healthcare Research and Quality. March 2013, pp 178-200. DARE Critical Commentary / Original publication
  16. National Institute for Health and Clinical Excellence. Falls: assessment and prevention of falls in older people. NICE Clinical Guideline 161. London: National Institute for Health and Clinical Excellence, June 2013.
  17. Sullivan N. Preventing In-Facility Pressure Ulcers. (Chapter 21). In: Shekelle PG, Wachter RM, Pronovost PJ, et al. Making Health Care Safer II: An Updated Critical Analysis of the Evidence for Patient Safety Practices. Comparative Effectiveness Review No. 211. Rockville, MD: Agency for Healthcare Research and Quality. March 2013, pp 212-232. DARE Critical Commentary / Original publication
  18. Meddings J, Rogers MA, Macy M, et al. Systematic review and meta-analysis: reminder systems to reduce catheter-associated urinary tract infections and urinary catheter use in hospitalized patients. Clinical Infectious Diseases 2010; 51: 550–60. DARE Critical Commentary / Original publication
  19. Meddings J, Krein SL, Fakih MG, Olmsted RN, Saint S. Reducing Unnecessary Urinary Catheter Use and Other Strategies To Prevent Catheter-Associated Urinary Tract Infections: Brief Update Review. (Chapter 9). In: Shekelle PG, Wachter RM, Pronovost PJ, et al. Making Health Care Safer II: An Updated Critical Analysis of the Evidence for Patient Safety Practices. Comparative Effectiveness Review No. 211. Rockville, MD: Agency for Healthcare Research and Quality. March 2013, pp 73-87.
  20. Marschall J, Carpenter CR, Fowler S, Trautner BW. Antibiotic prophylaxis for urinary tract infections after removal of urinary catheter: meta-analysis. BMJ 2013; 346: f3147 DARE Critical Commentary / Original publication
  21. Haynes AB, Weiser TG, Berry WR, et al. A surgical safety checklist to reduce morbidity and mortality in a global population. New England Journal of Medicine 2009; 360: 491–9.
  22. Haynes AB, Weiser TG, Berry WR, et al. Changes in safety attitude and relationship to decreased postoperative morbidity and mortality following implementation of a checklist-based surgical safety intervention. BMJ Quality and Safety. 2011; 20: 102–7.
  23. Russ S; Rout S; Sevdalis N; Moorthy K; Darzi S; Vincent C. Do Safety Checklists Improve Teamwork and Communication in the Operating Room? A Systematic Review. Annals of Surgery (in press).
  24. Shekelle, PG, Dallas P. Use of Real-Time Ultrasound Guidance During Central Line Insertion: Brief Update Review. (Chapter 18). ). In: Shekelle PG, Wachter RM, Pronovost PJ, et al. Making Health Care Safer II: An Updated Critical Analysis of the Evidence for Patient Safety Practices. Comparative Effectiveness Review No. 211. Rockville, MD: Agency for Healthcare Research and Quality. March 2013, pp 172-177.
  25. Wu SY, Ling Q, Cao LH, Wang J, Xu MX, Zeng WA. Real-time two-dimensional ultrasound guidance for central venous cannulation: a meta-analysis. Anesthesiology 2013; 118: 361-375.
  26. National Institute for Health and Clinical Excellence. Guidance on the use of ultrasound locating devices for placing central venous catheters. NICE Technology Appraisal 49. London: National Institute for Health and Clinical Excellence, September 2002.
  27. Brass P, Hellmich M, Kolodziej L, Schick G, Smith AF. Ultrasound guidance versus anatomical landmarks for internal jugular vein catheterization. Cochrane Database of Systematic Reviews (in press).
  28. Brass P, Hellmich M, Kolodziej L, Schick G, Smith AF. Ultrasound guidance versus anatomical landmarks for subclavian or femoral vein catheterization. Cochrane Database of Systematic Reviews (in press).
  29. Chopra V, Krein SL, Olmsted RN, Safdar N, Saint S. Prevention of Central Line-Associated Bloodstream Infections: Brief Update Review. (Chapter 10). In: Shekelle PG, Wachter RM, Pronovost PJ, et al. Making Health Care Safer II: An Updated Critical Analysis of the Evidence for Patient Safety Practices. Comparative Effectiveness Review No. 211. Rockville, MD: Agency for Healthcare Research and Quality. March 2013, pp 88-109.
  30. Winters BD, Berenholtz SM. Ventilator-Associated Pneumonia: Brief Update Review. (Chapter 11). In: Shekelle PG, Wachter RM, Pronovost PJ, et al. Making Health Care Safer II: An Updated Critical Analysis of the Evidence for Patient Safety Practices. Comparative Effectiveness Review No. 211. Rockville, MD: Agency for Healthcare Research and Quality. March 2013, pp 110-116.