Unlocking the potential: how student led projects can improve service delivery and enable workplace based education on Human Factors Kimberley Begg Lorraine Armstrong Kirsty Mcneil Elaine Mccleary Pam Cumming Sarah Macpherson

C.A.U.T.I Daily review Record in the icu Kimberley Begg Staff Nurse NHS Forth Valley 19/03/2014 Beardmore Conference Centre

Introduction Background What we did Daily Review Record in practice Did it make a difference? Implications for future practice

Background 2010 - Initially created at University 2010 - Letting people know 2010 - PDSA cycles in ICU whilst a student 2010+2011 - Attended SPSP conferences August 2012 Staff education Implementation in ICU

So... What is it? Single sheet document called ‘CAUTI Daily Review Record’ Follows the patient’s catheter – (bundle) Full of prompts and tick boxes Works in conjunction with a label on the drainage bag

Why is the change needed? Reduce incidence of CAUTI Improved catheter maintenance/management Inconsistency with what is accepted as sufficient documentation Reduce extended hospital stays Financial benefits PROMOTES PATIENT CENTRED CARE AND PATIENT SAFETY

What we did Pre-implementation audit Staff education (inc NA and StN) Implementation of CAUTI Daily Review Record and Labelling technique Staff support Feedback/PDSA cycles/improvements made that were unique to ICU Poster updates – staff involvement Post-implementation staff compliance – 98%

CAUTI Daily Review Record in practice Fairly well received Better knowledge of when catheter due out/drainage bag changes etc

Implications for future practice lectures on my journey through quality improvement project to encourage students Aim to spread hospital wide – education pack, currently being trialled in theatre Staff will have improved awareness of their patient’s catheter, - insertion date, removal date, drainage bag renewal date etc.

Conclusion Importance of quality improvement in undergraduate curriculum Students now have QI projects as part of their final placements In order to pass the course students are expected to complete IHI modules Promotes personal development

Improving the identification and diagnosis of delirium Kirsty McNeil 3rd Year Medical Student

Project Background Delirium is under recognised in acute care The project was carried out in the Acute Medical Unit of Ninewells Hospital We looked at the prevalence of delirium in patients 75 and above and how many of these had been diagnosed as having delirium Only 10.5% of patients with delirium were identified Delirium increases morbidity, mortality and can double the length of stay in hospital. A local team in Tayside collected some data which revealed that there was a high prevalence but poor recognition and management of delirium within acute care. This is what prompted us to initiate an improvement project to improve these results. Using the 4AT tool and looking at patients admitted aged 75 and over we collected our own background data* which reflected the data already collected showing that 54% of the patients had delirium but only 10.5% of those were identified as having delirium. We looked at 70 patients aged 75 and over who had been admitted in five 24 hour periods in the same week excluding those who were under 75, who had been referred with a diagnosis of delirium from their GP and those who had been transferred to another hospital or sent home by the time we collected the data. We identified 38 of the 70 patients as having a 4AT score of 4 or more (suggesting delirium) however only 4 of these 38 were identified.

Changes Feedback of Background Data Visual Aids Education Sessions for All Staff Implemented the 4AT tool Trialled a Delirium Pathway designed by a team within NHS Tayside Nurse educations sessions carried out Feedback Sessions carried out Implementation of delirium pathway Firstly we fed back the data we had collected at the doctor’s safety briefings. After this we saw a significant increase in the identification of delirium, however, this change wasn’t sustained for long. We carried out education sessions in which nurses, axillary nurses, physiotherapists and other members of the team came to and had a chance to ask any questions they had. We also used this opportunity to introduce the 4AT tool and plans for moving forward. We then implemented the 4AT with nurses carrying this out when they completed the functional screen. The delirium pathway was also successfully trialled for a week and then evaluated by members of the team. This was quite a big change and therefore will need more testing before it could be implemented.

Students and improvement The data collected by students has prompted a team within NHS Tayside to continue with the delirium work Getting Students Involved: delirium awareness week, ongoing improvement project Big Projects need time and people From my experience using students is a great way to sustain an improvement project. After our project ended, the delirium project continued with doctors and nurses still working to improve the diagnosis and management of delirium. I have continued the delirium work myself and go to the monthly meetings and help with the delirium awareness week which is happening this week in Tayside. Some improvement projects involve changing systems and attitudes which cannot happen overnight and therefore it is important to have a big team of people who can help. There is also a lot of students who will one day be working as part of the MDT and it’s important they have the skills to make improvements as that is the way forward in Healthcare.

Human Factors for a Safer Scotland Elaine McCleary and Pamela Cumming Student Nurses University of Dundee

Improving early recognition of delirium using SQiD (single question to identify delirium) Our aim was for 95% of multidisciplinary staff to incorporate SQiD into daily practice in the Acute Surgical Receiving Unit of a large teaching hospital, by the end of an 8 week period. During a test, this was achieved, although the project changed direction several times. Hello, My name is Pamela Cumming and this is Elaine McCleary and we are 3rd year student nurses at Dundee University. In November last year we undertook an improvement project whilst on an 8 week clinical placement in Acute Surgical Receiving Unit of Ninewells Hospital. The project was to improve the early recognition of delirium using SQiD (Single Question to Identify Delirium – the question asked was “Is this person more confused than before?” The AIM was for 95% of multi-disciplinary staff to incorporate SQiD into daily practice, which we achieved during a PDSA test.

How did the experience help us as health care professional students? We gained an understanding of undertaking Quality Improvement in the 'real world' and the continual cycle of professional and personal development and improvement. We also developed an understanding of human factor science in this process, recognising how teamwork or communication, for example, influences the trajectory or success of a project. Communication was one of the key human factors responsible for the success of our project, and our communication skills developed continuously. Communication was vital for explaining the reasons behind the project and promoting the benefits to patient safety through early recognition of delirium. This was necessary to motivate staff and maintain project momentum and teamwork within the ward.

What did we learn about how students can help the NHS to improve health care? Quality Improvement science provides the tools to enable students to initiate, test and improve systems and processes. Awareness of Human Factors science is necessary to help understand the factors which either positively or negatively affect the success of such systems. We understand it is everyone's business and is a way of thinking. Elaine We feel QI science empowers us to improve practice and improve patient safety. Understanding Human Factors science goes hand in hand with this, improving the effectiveness of the process. As this slide says – it’s everyone’s business. Although we were involved with improvement which was part of national initiative it’s important to remember QI can be applied to any process and finding out from staff what they really want improved is perhaps the best way to begin, ensuring it is not seen as a burden to their existing workload. Students continually move between clinical placements and can bring with them transferrable ideas for good practice.

Quality improvement projects create further opportunities…. IHI 25th International Forum, Orlando, Florida. December 2013 Undertaking the QI project has helped us in the transition from awareness to understanding and this was further enhanced by our attendance at this conference in Florida which brought together over 5000 people from 62 countries around the world who are engaged in QI. We were truly immersed in it and hope to continue to build on the connections we have made, to ensure that good practice continues to be shared.

Sarah Macpherson 5th year medical student Improving the efficiency and start time of trauma theatre at the Royal Alexandra Hospital Sarah Macpherson 5th year medical student

Project Background Project done as 2nd year student Busiest trauma theatre in Scotland Evening sessions proposed to deal with workload Currently inefficient, many delays Running theatre costs £1200/hour Late start main problem

Example Plan Do Study Act Cycle Theatre coordinator nurse had inadequate time to change into theatre scrubs Team decision for nurse to take list to theatre reception area to avoid this problem Not achieved List to be taken to trauma theatre by theatre coordinator nurse by 8am

Results Theatre start time improved by average 30mins NHS saving of £600 per day Average 1 more operation every day Benefits for patients Scheduled staff breaks as planned Patients now spend less time waiting for their operation in the ward. As a result, they are less likely to have procedures postponed, meaning less time in pain or discomfort, less time spent in hospital and less chance of picking up a nosocomial infection. Staff can have scheduled breaks when theatre starts on time, resulting in a less stressful working environment.

How can students help the NHS to improve healthcare? Fresh eyes Useful part of project team Less time pressure than employed staff Can directly contribute to improved healthcare systems and efficiency and thus saving money Investment in human factors training is valuable to promote improvement Fresh eyes – jr students valuable resource. not working in the system so challenge current ways of doing things, bring new ideas to the table. Useful as part of project team, liase with different members of MDT – drs, nurses, th coordinators, managers. Have time to spend if done as part of student selected block, summer scholarship This simple project demonstrates role that students can have in saving valuable NHS resources and importantly improving efficiency and safety of care for patients

How did the experience help me as a medical student? Gained in confidence – solid grounding for clinical years Better understanding of the patient experience from patient shadowing 1st experience in quality improvement Will be better prepared to initiate changes where required in future Confidence in clinical team Something I will take into my future post as a junior doctor

RHIC and the Quality Improvement Hub Edinburgh, 6 May 2014