National SAFE collaborative
Ward 6N at the Royal Free Hospital has been a pilot site for the National SAFE (Situational Awareness for Everyone) collaborative led by the Royal College of Paediatrics and Child Health (RCPCH) and funded by the Health Foundation. The quality improvement (QI) project led by Dr Jane Runnacles, consultant paediatrician, and Ade Adamolekun, paediatric matron, has involved bringing together all staff groups to improve patient safety on the ward, specifically to improve recognition of the deteriorating child through increased situational awareness.
Our multidisciplinary team, including paediatric nurses Ronelle Miguel, Karl Piller and Dev Begic, play specialists Abbi Spurdle and Natalie O’Keefe, physician’s assistants Leyla Yildiz and Givan Zangana, manager Ed Savills, junior doctors and consultants has been recognised nationally as a leading site for engaging a diverse range of staff groups and parents. We have presented our work at conferences including the 2015 annual RCPCH conference.
Implementation of multidisciplinary safety huddles
Cincinatti Children’s Hospital safety “huddle” technique, is a ten minute open exchange of information between all staff members on the ward to encourage information sharing and equip professionals with the skills to identify children at risk of deterioration or harm. We huddle on ward 6N twice a day (9.30am and 9.30pm), meeting in the office behind the nurses station after medical handover (at the start of the day and night shifts).
Since October 2014, morning and evening ward safety huddles are occurring 100% of the time. All ward staff members are present: medical, nursing teams, eating disorders unit, ward administrators, domestic staff, play specialists, student nurses and medical students.
A proforma identifies (or “flags”) patients as “watchers” (eg those at risk of deterioration with increasing early warning scores, on high risk/unfamiliar therapies, parental concern, clinician “gut feeling”, safeguarding concerns). We are particularly keen for parents to express any concerns they have to the nurse looking after their child so they can bring this information to the huddle for discussion.
Feedback from all staff members has been extremely positive: huddles improve situational awareness and empower all staff, however junior, to raise concerns. Huddles also improve team working with the opportunity to learn about each other and improve care for the patients through improved communication.
QI champions to improve PEWs chart compliance
We have been using PEWS (paediatric early warning score) charts since 2010 to help recognize the deteriorating child and escalate concerns. Vital signs or “observations” including the child’s heart rate and respiratory rate are recorded regularly by nursing staff on specially designed charts with a scoring system to help identify children who are becoming more unwell. These include guidance on escalating concerns to the medical team.
A junior charge nurse on the ward has been a PEWs “champion” since January 2015, reviewing 20 charts/month as part of the SAFE project. PEWs chart compliance has increased from 70% to 100% by engaging all nurses on the ward and training student nurses.
Learning from deterioration and disseminating to the team
Multidisciplinary notes of all patients who have required high dependency care or transfer to intensive care are analysed on a monthly basis using the RECALL tool (Rapid Evaluation of cardiorespiratory arrests with Lessons for Learning). There are always lessons to learn for all members of the multidisciplinary team and we are committed to continual improvement. A junior doctor champion spreads learning via a new quarterly risk newsletter to all paediatric staff. Dr Kin Man, consultant paediatrician, leads the newsletter.
Introduction of 'daily plan' whiteboards to improve communication with parents
Since May 2015 bedside whiteboards have been introduced to improve communication with parents. A daily plan is agreed with patients and/or parents and listed on the whiteboard during the morning ward round (for example times of medication/tests and parent’s schedules).
The play specialists Abbi Spurdle and Natalie O’Keefe have engaged patients in the design of these boards and are champions for the daily plan boards on the ward, led by Dr Victoria Dublon, consultant paediatrician.
Engaging parents in ward safety culture: leaflets and noticeboard
We are designing a safety noticeboard for parents with information about the SAFE programme including data to show improvement. A "safety checklist" leaflet has been co-designed by a junior doctor with parents to educate parents on recognising deterioration and empowering them to speak up if they are concerned: “If you see something, say something”.
The Royal Free London has been recognised by the RCPCH clinical lead for SAFE as leading the way for this national project and this was highlighted in a recent letter to our trust chief executive. We have also been invited to contribute to a national toolkit for the SAFE programme and help facilitate learning sets for the next wave of SAFE collaborative sites.