1. Insert name of presentation on Master Slide Making Quality Everyday Business Welsh Ambulance Services NHS Trust National Learning Event – 11 th May 2012

2. Deliver and sustain excellent services that meet the needs of patients and maximise clinical outcomes. Treat patients well and help them with their problems Deliver safe, high quality services Provide timely access to services. Primary Driver Secondary Drivers Improve stroke care Deliver Effective care pathways & pro- active community orientated care Rapid Response to acute illness (PHEWS) Reduce harm and variation Zero tolerance of HCAI Reducing HCAI Falls prevention in the community Improve cardiac services Stroke ‘Focus on’ pathways Improve major trauma & Acute illness services Engage workforce Leading the way to quality and safety improvement Ensure timely access to services Improve clinical leadership Acute coronary syndrome Fractured neck of femur MDT in Control Centre Priority improvement projects Welsh Ambulance Services NHS Trust

3. Healthcare Associated Infection Vehicle and Station cleanliness is at the forefront of the Trust’s reducing Healthcare Associated Infection plans. An online Infection Prevention & Control Vehicle and Station Audit Tool has now undergone a PDSA and evaluated successfully. Each Ambulance Station is now responsible for auditing the vehicles and Station utilizing the new on-line audit tool. A Quality Assurance process will be undertaken by the 3 Regional Infection Prevention Leads Current results:- Welsh Ambulance Services NHS Trust

4. Healthcare Associated Infection Welsh Ambulance Services NHS Trust Compliant > 80% Border Line 50 - 80% Non Compliant < 50% Audits to Date 24 Stations 33 EMS Vehicles 8 RRV ‘s 10 PCS

5. Healthcare Associated Infection Welsh Ambulance Services NHS Trust STOP Campaign Each Station has displayed a poster Each Vehicle has a sticker attached to the sharps container as a reminder. Staff have received an update regarding the campaign via the Trust’s Intranet.

6. RRAILS – Pre Hospital Early Warning Scoring (PhEWS) Tool The use of an early warning system in the pre-hospital setting could benefit patients when there are capacity problems in accepting Emergency departments. A pre hospital early warning score has been developed and desk top tested using 300 patient care records. A PDSA to test the tool in the live environment commenced on 1 st November for patients awaiting admission Wrexham Maelor emergency department. This study aimed to allow patients to be prioritised in line with their clinical condition, for admission to the department. Crews from 6 ambulance stations in North Wales participated in the study will consisted of 30 patient episodes.

7. RRAILS – Pre Hospital Early Warning Scoring (PhEWS) Tool Patient Criteria Inclusion Patients aged 18 years and over Patients brought to the ED by the Ambulance Service and awaiting admission to the department. Exclusion Patient below 18 years Patients who have been/or are actively being resuscitated (as these patients are taken directly into the resuscitation room) Patients who are declared life extinct before arrival at hospital

8. Score3210123 BP sys<7071-8081-100101-199>200 CRT> 2 H.R<4041-5051-100101-110111-129>130 R.R<912-1718-2021-29>30 O2 TherapyYes CNS AGGRESSIVE NEW CONFUSION AWAKEVERBALPAINUNRESP PAINNONE Pain but coping. No analgesia. Had analgesia. Coping Had analgesia Not coping AGE70 + TEMP<3535-37.737.8 + Pre Hospital Early Warning Score (PHEWS) PCR No: Incident No: Date: Call Sign: Peripheral Venous CannulaYESNOTime inserted:ANTTYES NO

9. Pre Hospital Early Warning Score (PHEWS) This scoring system should be used each time a set of vital sign observations are recorded. The total score should be documented on the observation chart in the appropriate place. If the total score is an isolated 3 or a combined 3 to 5, the observations will need to be repeated within 15min. You will also need to notify the duty officer and/or the ED Triage Nurse. Observation of vital signs should be continued frequently until PHEWS reaches 3 or below with clinical intervention e.g. Oxygen or fluids. VSO=Vital Signs Observations ANNT= Aseptic No Touch Technique used VSOTime BP sys CRT HR RR O2 CNS Pain Age Temp Total

10. RRAILS – Pre Hospital Early Warning Scoring (PhEWS) Tool Quality work done over a period of time developing a trigger tool specifically for Ambulance Crews facing long delays gaining entry to Emergency Departments. Developed tool was ‘fit for purpose’ for the original specified use however, with evolving circumstances and demands on the service, the tool needed to be adapted. The introduction of NEWS across all organisations is pivotal to current developments within WAST. Although NEWS will not suffice the needs of WAST in its current format, there are intentions to work alongside national experts in this field to modify NEWS specifically for use by ambulance staff on patient contact.

11. RRAILS – Pre Hospital Early Warning Scoring (PhEWS) Tool Ambulance crews in North Wales Wrexham Locality were part of the pilot of PHEWS. Many lessons can be learnt from the staff involved. Their contribution and findings from developing this tool will be easily applied to adopting a new Early Warning Score specifically for ambulance staff. Use of SBAR utilised by all North Wales staff during the data collection period was exemplary. It made the collection of information easy.

12. GP Enhanced Multidisciplinary Team Clinical Contact Centre (MDT) PDSA The Welsh Ambulance Services NHS Trust is undertaking a Plan Do Study Act (PDSA) Cycle to identify whether a GP enhanced multidisciplinary team (MDT), in the Clinical Contact Centre (CCC) at Vantage Point House, will increase the number of patients that are directed to the most appropriate point of Health and Social Care, thus reducing inappropriate conveyances and ultimately assessment/admissions at the local Emergency Departments. The team consists of a doctor, paramedic and nurse The primary role of the Multidisciplinary Team in the CCC at VPH is to support the ‘on-scene’ Ambulance Crew via the telephone. This will be achieved by; –Assisting in the development of a differential/ working diagnosis. –Providing critical thinking and support to ambulance crews –Advising on optimal pathway –Facilitating access to pathways

13. GP Enhanced Multidisciplinary Team Clinical Contact Centre (MDT) PDSA The scope of the PDSA includes all patients who call 999 within the South East Wales Region. The parties participating in the change are; The Welsh Ambulance Trust NHS Services(WAST) Aneurin Bevan Local Health Board(ABHB) Cardiff and Vale Local Health Board(C&V) Cwm Taf Health Board The PDSA commenced 17 th October 2011. The Primary Exclusion criteria for the trial are all patients with immediately life- threatening conditions, serious injury and/or at risk of short term deterioration will be transferred direct to definitive care.

15. GP Enhanced Multidisciplinary Team Clinical Contact Centre (MDT) PDSA An electronic Clinical Reporter has been developed linked to the ambulance call stack to enable clinical records to be selected and automatically populated ahead of any intervention from the multi- disciplinary team. This process enables data capture and reporting. Next Steps The PDSA will run for a 4 to 6 month period Monthly reports on outcome data will be made available Full evaluation will take place and recommendations made

16. Breakdown of referrals to alternative pathways by MDT from 17 October 2011 – 30 April 2012

18. Breakdown of conveyances saved by MDT from 17 October 2011 – 30 April 2012

19. Cumulative number of conveyances saved by MDT since commencement of PDSA

20. Acute Coronary Syndrome Primary PCI has been identified as more efficacious for the treatment of STEMI compared to thrombolysis and is associated with reduced mortality rates and better patient outcomes. From 31 st October the primary PCI service has been extended in the Mid and West Region from the Cardiac Centre at Morriston Hospital and is available for patients that can be transported by the Trust within 90 minutes of recognition of symptoms to door. A clinical pathway has been developed to ensure that patients benefit from the service which includes pre-alert to Morriston to prepare for the patients arrival.

21. Falls prevention in the community Older people who fall account for approximately 10% of all 999 calls to the Welsh Ambulance Services NHS Trust and many patients transported to A&E are subsequently discharged without further intervention There is a risk that patients who do not require conveyance managed at home, without referral into a falls pathway, may re-access the Trust following subsequent falls The Trust has continued to work with colleagues across Wales to further develop referral processes Work is continuing to progress to facilitate referrals into Pembs with target now set for end of June 2012.

22. Referral pathways in place

23. Falls prevention in the community Next steps Enhanced skills training to be provided to paramedics which will support increased numbers of fall referrals into alternative care pathways, treat & refer. Outcome measures will include increased falls referrals and reduction in conveyance to A&E.

24. Falls pathway for nurse triage Patients who had fallen and subsequently assessed by NHS Direct nurses had not been previously been referred into any falls prevention/ assessment teams across Wales. Discussion with falls teams in the Neath/Port Talbot and Bridgend areas held and referral criteria agreed. The Community Intermediate Integrated Services (CIIS) offers maximum meaningful independence at home by supporting and complimenting Health and Social Care mainstream services. Its overall aim is to prevent or stop progressive deterioration in a person’s physical condition or level of independence and to prevent avoidable acute hospital admissions. A falls screening tool was developed for use by NHSDW nurses and a small scale PDSA undertaken during May/June 2011 in one locality to refer to the CIIS team. No referrals were made.

25. Falls pathway for nurse triage The referral criteria was reviewed and widened and another PDSA cycle undertaken in July/August. No referrals were made. During the initial phase a number of referrals who may have been suitable for referral to the CIIS team were identified who were not referred on. These calls were fed back to the respective call takers via their line managers in order to raise awareness and promote learning. A Falls Champion was identified in each of the clinical contact centres to raise awareness and encourage referrals and each site had a dedicated communications board which outlined the campaign and the benefits to patients and their families/carers.

26. Nurse falls referrals

27. Falls pathway for nurse triage – Next Steps Awaiting software change which will ‘prompt’ staff to “Consider referring patient into relevant falls team/ pathway within patient’s locality, if pre determined inclusion criteria have been met” Operational staff and ‘falls champions’ continue to monitor types of calls in ‘real time’ advising onward referral where appropriate. Continue to explore referral opportunities with other falls teams across Wales, early discussions held with ABHB

28. Nurse Falls Referrals Patient Story Information relating to a repeat service user was identified. 35 occasions between 1 st June 2011- 21 st December 2011 when caller had accessed 999, from these contacts there had been 3 admissions to hospital. Of the total number of 999 contacts, the patient had been passed for nurse triage on 19 occasions. All contacts related to a fall from within the home in particular when transferring from bed to commode. Nurse recognised need for falls referral and referral made. Assessment by a CIIS nurse and Occupational Therapist (OT) on the day of referral. CIIS homecare support was provided with immediate effect three times daily.

29. Nurse Falls Referrals Patient Story The OT ordered equipment such as a hospital bed and hoist. Patient assessed and examined by the CIIS Nurse Practitioner on the following day and as a result investigations were conducted, bloods, MSU,ECG, etc. CIIS continued to support the family until a long term care package of care was started. Since referral into CIIS there have been no further contacts via 999. This powerful ‘story’ was presented to Executive Trust Board in March 2012.

30. Leadership  Trust Target – To undertake 2 Executive Patient Safety Walkrounds each month in different locations and service areas.  Issues and action plans from WalkRounds presented to Patient Safety & Safeguarding Group for monitoring and to escalate unresolved issues  Recent changes following WalkRounds include improved access to cleaning materials for crews at A&E departments, improved communication between health colleagues and Patient Transport Services and a decision to move to disposable laryngoscopes. A Walkround calendar has been produced and is posted on the Trust Intranet for access by all staff. A Walkround tracker has also been developed to monitor the progression of the action plans.

31. Patient Stories Patient stories continue to influence service improvements and continue to open each session of the Trust Board Improving Communication – A Medical Information Card The Trust has produced in conjunction with deaf communities a handy pocket sized ‘Medical Information Card’ to aid communication between deaf service users and health care professionals. Internal awareness raising with staff has been undertaken to encourage paramedics to look for the card which provides important information including the individual’s medical history, communication needs, etc. Over 10,000 cards have been distributed within first stage to various venues and key contacts to raise awareness of the cards. Through our ongoing work with deaf communities we have identified a member of the public who signed up to the card and used it on numerous occasions in healthcare settings.

32. Often Paramedics will be first on the scene in the event of an emergency and improving communication in a pre hospital environment is essential. The card will help to give important information to Paramedics and other emergency staff if there is an accident or emergency. The information inside the card can include name; demographics, medicines taken and allergies.

33. Patient Stories Have your Say In development (to replace existing feedback mechanisms) is the ‘Have your Say’ model. This will bring together all feedback channels under one framework and enable a more coordinated approach to monitoring and acting on patient/service user feedback. A large part of this will be to review our archiving system for capturing and recording feedback to ensure a robust administrative system that is more widely available of embedded across the Trust and its associated activities.

34. The ‘Have your Say’ online element of this facility will be hosted on the Welsh Ambulance website. When feedback is submitted an alert is raised with the patient experience administrators. The ‘Have your Say’ brand will be the umbrella for all feedback submitted to the Trust. Face to face contact Putting Things Right Consultation and engagement Patient targeted approach Online Storytelling

35. Contact details Chris Powell Nursing Quality & Clinical Practice Lead/1000 Lives Plus Key Contact Welsh Ambulance Services NHS Trust Chris.Powell2@wales.nhs.uk Tel: 07872415430