Professor Jean White Chief Nursing Officer/Nurse Director NHS Wales

1. MANAGING PERIOPERATIVE CARE WITHIN CHANGING ENVIRONMENTS Professor Jean White Chief Nursing Officer/Nurse Director NHS Wales

2. Daisy Ayris – a true leader 'After attending the International meeting of the Royal College of Surgeons at Harrogate in the mid-fifties I had a vision. What would it be like if theatre nurses could belong to such an organisation? This vision became a fixed idea. I must do some thing about it so that all theatre nurses could have some common ground for meeting to discuss problems and standardise procedures for the benefit of patients, nurses and medical staff'. (Daisy Ayris)

3. My Theatre Nursing Experience • Clinical practice was as a theatre nurse • I did the ENB 176 in UCH London in 1983/84 • I was a member of NATN for nearly 20 years • Chair of the South Wales Region • Teacher of perioperative care

4. This presentation • What are the challenges and changes facing the NHS? • What does this mean for perioperative staff and the patients they care for? • What can be done to drive up quality and patient safety? • Look at examples from Wales in how staff have risen to the challenge • Transforming Theatres

5. Demographic changes - Wales • Improving life expectancy at birth: 77.2 years for males and 81.6 years for females – but widening gap between rich and poor • Many public health challenges: • 23% of adults currently smoke • 57% of adults classified as overweight or obese, including 22% obese. • 1 in 3 children overweight or obese, including 16% obese • Excessive alcohol consumption – leading to social problems as well as disease • Rapidly ageing population – more over 65 yrs than 0-15 years old – resulting in more chronic conditions and dementia

6. Dementia • Currently estimated 35.6 million sufferers world wide; 6 million in Europe • Numbers will double by 2030 and triple by 2050 • Increasing risk with age: • 65-69 – 1 : 25 • 70-79 – 1 : 10 • 80+ - 1 : 6

7. Future challenges - money International recognition that current financial models for healthcare worldwide are unsustainable – more must be spent on prevention (4% only in EU at present) • Need to make every penny count • Service delivery under the spotlight – must be efficient and effective – and may affect where services are provided • May affect who delivers care – changes in professional and support roles • Wales – emphasis is on reducing waste, harm and variation to improve quality and safety of care

8. Workforce issues • Medical workforce shortages • EWTD • Difficulty to recruit in some specialities • Feminisation of workforce resulting in changing working patterns • Emerging advanced roles, eg Surgical Care Practitioners • Support staff roles expanding • Changes in retirement and pension arrangements

9. Future changes in care New drugs, technologies and approaches – some surgical interventions will stop as other techniques replace it More minimal invasive surgery Increased day surgery and quicker discharge from hospital, eg enhanced recovery from surgery programmes for joints and bowel surgery Improved patient pathways for specific conditions

10. Infection – still an issue Evidence from prevalence surveys indicates that surgical site infections (SSI) are still a problem – is the largest proportion of HCAI Wales 2006 – 18% of HCAI 2011 – 24.3% of HCAI [adjusted] While attention on specific infections, eg C.difficle and MRSA are showing huge improvements nationally – re-focussed attention is needed on SSI

11. Devolution and health policy

13. Action areas Together for Health • Service modernisation, including more care provided closer to home and specialist ‘centres of excellence’ • Addressing health inequalities • Better IT systems and an information strategy ensuring improved care for patients • Improving quality of care • Workforce development • Instigating a ‘compact with the public’ • A changed financial regime

14. 1000 Lives Plus national patient safety programme http://www.1000livesplus.wales.nhs.uk/home

15. Methodology • 1000 Lives Plus uses specific methodology to engage staff to bring about improvement: PDSA cycles [Plan, Do, Study, Act]. Principles are to start small and local, test results, spread good practice • It uses ‘care bundles’ to standardise improvements, Examples: • Peripheral venous cannulae care bundle • SKIN bundle (pressure ulcer prevention) • Stroke bundle • New in 2012: • – Oral care bundle – Fundamentals of Care national audit finding • – Learning Disability bundle for acute care – Ombudsman case

16. Transforming Theatres(part of 1000 Lives) • Four key areas for all theatres in Wales: • Patient experience and outcomes • Safety reliability of care • Team performance and staff well-being • Value and efficiency • Supported by national programme leads but driven by local Health Board facilitators. • Staff have access to the Productive Operating Theatre box set of guides designed to help staff deliver improved care.

17. Highlights of activities • WHO surgical safety checklist implemented • Pre and post-list briefings held – whole team communication and improved safety • Theatre environments de-cluttered & stock reduced • Recycling and procurement of cheaper alternatives – cost reduction • Glitches identified, recorded and addressed • KPIs Theatre utilisation – start and finish times, list management • Surgical site bundle implemented – reduced infections • Patients’ temperature monitored and problems addressed • Patient satisfaction gauged and feedback acted upon

18. Example area covered by 1000 Lives:Skin Integrity

19. SKIN [Integrity] BUNDLE – widely adopted in clinical areas across in Wales Is the patient on right mattress? Repositioning? Skin to be kept dry, avoid moisture Keep patient hydrated and well nourished SURFACE KEEP MOVING INCONTINENCE NUTRITION

20. Aneurin Bevan Health Board • Waterlow score done on ward and recorded on pre-op assessment; SKIN bundle applied • Theatre SKIN bundle applied in all phases of care – specific forms used to report care • Part of handover between recovery and ward staff • SKIN bundle applied in post-op care on ward.

21. Cost saving Aneurin Bevan Health Board Examples that have led to cost savings: • Unused supplementary items removed reducing HSDU costs. 1/3rd items removed. • In 2009/10 and 2010/11 had been increase 1000 items/year for sterilisation – 2011/12 no increase • 6000 obsolete items worth £250,000 scraped/recycled • Stock control identified £1.2 million reduction; now a truer baseline • Recycling waste cost £15 less per tonne than orange bag disposal. In Nevill Hall Hospital this is a saving of £2093/year. Recycling glass paracetamol bottles saves £13,000/year compared to sharps container disposal. • Overall cost saving last year £180,000

22. Prince Charles Hospital, Cwm Taf Health Board • No more portering - Patients encouraged to walk to theatre when appropriate or a theatre assistant collects them – 24% reduction in late starts as a consequence • Standardisation of stock items held; reduction of items held; common manufacturer used for laparoscopic equipment – net savings £64,470 this financial year • Weekly run chart of theatre usage and briefing meetings with compliance by medical staff. Consultants are changing this practices as they don’t like poor comparisons with their colleagues.

23. Theatre Procurement TeamCwm Taf Health Board • Theatre Procurement Staffare based within the department, this helps with their ongoing relationships with the theatre staff, surgeons and anaesthetists. Alongside the Senior Nurse, they take the lead with any new service developments scoping out equipment, stock, safe usage and impact assessing proposed clinical service changes. • It has changed the culture where the surgeons used to approach outside representatives or companies; they along with the Team Leaders now liaise with the Theatre Procurement Team regarding equipment issues. • This leaves the Team Leaders more time to concentrate on their theatres and primarily the patient and the environment, which will aid to improve the quality of the patient’s experience

24. The Patient Experience – as important as safety • Dignity and respect a tier 1 performance area monitored by Welsh Government – key care metric • Fundamentals of Care audit • Older People’s Commissioner review and ongoing monitoring of action plans • Use of Patient Stories at board and team level

25. DIGNITY PLEDGE TO OUR PATIENTS[Cwm Taf Health Board]We believe that staff should treat patients the way they would wish to be treated • We will greet patients and visitors in a welcoming and sincere manner. • All interventions will be explained to patients while in our care and staff will offer opportunities for further questioning. • Patients will be given privacy during treatments or when receiving personal care. “Care in Progress” signs will be used when interventions are being carried out. • Patients/relatives will be given privacy during consultation/breaking bad news. • We will ensure patients remain properly covered when in our care or when transferred to other areas. • We will prevent patient information from being shared inappropriately e.g. stopping telephone conversations being overheard, computer screens being viewed and that white boards have non identifiable patient information upon them. • We will appropriately and sensitively communicate with patients.

26. Conclusion • Evidence from Wales shows that major savings can be made while driving improvements in safety and quality of care. • Time to take a hard look at what we are doing – see what you can change for the better!