Neuraxial Connector Surveillance Training Clinical Instrument Surveillance Programme Public Health Wales Neuraxial Connector Surveillance

Background 2009 patient safety alert requiring neuraxial procedures to use non-Luer connectors Spinal, epidural and regional infusions and bolus doses and lumbar punctures Wales Neuraxial Connector Reference Group set up by Welsh Government to oversee this Concerns over unexpected clinical consequences, eg. wholesale change in tonsillectomy instruments Neuraxial Connector Surveillance

Nrfit (non-Luer) Connectors Delays due to dissatisfaction with proprietary connectors An initiative of an international standard ISO standard connector (Nrfit) will be implemented in January 2017 in California To be introduced in April 2017 in Wales Neuraxial Connector Surveillance

Excluded: facet joints Regional nerve blocks? Background continued WNCRG subgroup have agreed all neuraxial procedures using neuraxial equipment will be covered Excluded: facet joints Regional nerve blocks? Neuraxial Connector Surveillance

Clinical Instrument Surveillance Programme (CISP) Our aim is to improve patient safety through surveillance Experience in surveillance of changeover from reusable to single-use tonsillectomy instruments Detected instrument problems at the time of surgery and patient complications Benefits of surveillance: Identify problems quickly and efficiently so they can be addressed Provide reassurance to clinicians of devices use Improve patient safety Neuraxial Connector Surveillance

Neuraxial project - CISP Agreed by WNCRG subgroup To monitor the safety of the introduction of non-luer connectors in Wales by detecting changes in complication rates and device problems on introduction Device usage, device problems, procedure complications, patient complications Reports of these outcomes and alerts of potential problems issued to health boards and Welsh Government. Clinicians can get their data on request Surveillance includes: All health boards, all specialities and independent hospitals Neuraxial Connector Surveillance

Neuraxial project – CISP Agreed by WNCRG sub group Data set and web form agreed Training Train the trainer Baseline data collection Now until change over Continuous surveillance essential Data collection post change-over April 2017 Minimum 6 months (funding dependant) Neuraxial Connector Surveillance

How are procedures reported? Web form Accessed from any computer/device with health board intranet access at: http://neuraxial.cymru.nhs.uk/Nxl/Dataentry.aspx Shortcuts exist on health board computers: Can be accessed via Wales Clinical Portal from all HBs?? ABMU (IE favourites under Clinical Systems) Aneurin Bevan (desktop shortcut to intranet Apps Page) Hywel Dda (shortcut in start menu) Training material at: http://www.wales.nhs.uk/sites3/page.cfm?orgid=457&pid=72625 Neuraxial Connector Surveillance

Device types for procedures Epidural Epidural kit Administration set Epidural (Tuohy) needle Epidural catheter/connector LOR syringe Syringe (slip) Syringe (lock) Drawing up needle Drawing up disc filter Spinal/epidural filter Spinal Spinal needle Introducer needle Procedures Device type CSE CSE kit Administration set Epidural (Tuohy) needle Spinal needle Introducer needle Epidural catheter/connector LOR syringe Syringe (slip) Syringe (lock) Drawing up needle Drawing up disc filter Spinal/epidural filter Spinal catheter Spinal catheter/connector Lumbar puncture Manometer 2/3 way tap C-section wound care management training

2. Procedure complications 1. Device problems 2. Procedure complications 3. Patient complications Neuraxial Connector Surveillance

Patient and procedure details Neuraxial Connector Surveillance

Devices used and any problems with devices Neuraxial Connector Surveillance

Procedure complications Neuraxial Connector Surveillance

Patient complications within 28 days Neuraxial Connector Surveillance