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Axford misleads Axford. She is the chief of nursing services at Hey Myers Hospital. Um, and she has been involved in planting, um, tests within, uh, within her hospital. We have lease, and we have her slides. Is this your first slide lease? Just wondering. You know, that's, um, actually my last slide. And for some reason, it's not allowing me to move back, but I'm just so there we are. Apologies, everybody. Well, there's your title slide. So, um, we'll set you up and you're ready to go again. If people have questions, put them in the chat box, and I can put them to these afterwards. Thank you. So thank you again for inviting me, and it's a pleasure to be here, so I really want to focus on the practicalities of making this routine practice. Um, well, I just want to talk about the different approaches that we're taking. Um, University Hospital here. Myers. So we've talked about a lot about the competing pressures on staff and the need to make it easy. Um, we also need to highlight certain situations and prompts, and we need to make it everyone's business and really following on from Jane and obviously we haven't had a I have not met Jane, but actually it follows on nicely, Um uh, conversations today in terms of asking if the test is in place. It should be common language and not seen as a challenging question, because I think sometimes it still is seen as that. And, as Jane says, we've all experienced that that situation often out of ours at 3 p.m. Three am, even when we've got a frail patient who is deteriorating, know, tap in place and no clear plan. Often we've got two nurses responsible on the ward for the 30 patient, and a doctor is called Who's Not met the patient and then is being asked to make very, very difficult decisions in a time pressured situation. That's often the time where my over treat, because everyone is compromised the nursing staff you know the patient might try to guide, but it's really not the time. Is it to have those detailed, complex conversations and decision making at that time? So for me, um, it's about nurses taking a greater responsibility for tips, and I was interested that one of the questions was asking about other people um, completing text. I think his nurses and his HPVs we have an obligation to sure that to ensure that plans were in place for our patients, we need to promote optimum care. And we need to ensure that this is being provided, whether it's by absolute, active and robust treatment or active support in end of life care. We also have an obligation to our colleagues because, as Jane says, these stressful situations out of ours are really complex for all. So these conversations should we have in the cold light of day, so to speak? We want calm, informed conversations that promote patient safety. So I think nurses, um, with patients have a really input here. They as nurses. We spend a lot of time with our patients. We have intimate conversations. We're meeting relatives, loved ones. A lot of our advanced nurse practitioners are taking collateral histories, and they're involved in detailed assessment. So are a piece, and our specialist nurses were in an ideal position to initiate conversations and discuss patients in relation to their tap On site. We have what we call advanced care of the elderly specialist nurses. These we, we phrase them as a snack. Nurses. So there, routinely completing Tepes. So they're having in depth conversations with the patients, and they prepare the TEP. And on our in our hospital, obviously we have to have a clinic, a consultant that signs that off. But the nurses and our advanced practitioners are taking time with the patients, discussing with the family and the patient and having those, um, conversations. This then gives a seamless approach. The consultants, well, then pick up the conversation, and we've heard about what the barriers are to completion of tips. And often we hear that time is one of the barriers, Um, so nurses have that time we are then reducing the consultant time spent with the ongoing discussion. But we've laid the foundations. So it's a dual process and its dual working, um, to really have this seamless approach. The feedback from patients, uh, medical staff and and this is has been really, really positive, joining everyone together. So we're really rolling that format out to other a PS and specialists and actually encouraging all team members to be involved in conversations and documenting because, as Jane says, it's about the who is appropriate that at that time patients might initiate the conversations themselves and often do. And we as, um, non medical workforce need to take this forward. So what else are we doing on site? So some of our charge nurses are really taking the lead. We recognize how important it is to make it easy for medical staff to implement a tap. So again, as Jane says, making it easy in terms of having a supply of tips ready in the case, no trolley or putting a step into each case Note one ward. I've just, uh, put this on the screen because I just wanted to say, show you how simple that we're trying to make things. This is one of the senior charge this is taking this forward. So they're using it as a visual prompt. After the war drowned, they're coming to do a board round. So down on the left hand side, Um, obviously some patient names there that I've, uh I have not shared with you, but you can see here I've highlighted a couple of things. So the the initial focus on the ward was to make sure that everyone that had a d. N r c e p r in place also had a tip. So you can see that for a couple of patients there. Also moving on to the goal is for every patient on this ward. Tha have a tips in place, and you can see here, um, that we've got a couple of patients without a d n r. But they've got a tips in place. Um, so you can see that they're making progress there, um, lots to do, but really good initial steps. And that's really led by the senior charge nurse. And this is about the visuals for all the mg t two to see. Um, and really, again prompting those conversations. The other thing that we're doing in the hospital is, um, we have patient track, Um, and for those of the union know about patient track, and it's really an electronic platform for recording. Um, various information we've rolled out across the hospital at the moment for electronic observations. We will be, um, rolling it out to other things as well. And other assessments. So each morning, we have a director of huddles, so we have medical care of the elderly surgical, an emergency medical huddles. Um, the nurse is is in charge or senior charge. Nurses attend these, and they're led by the senior nurses. So we bring up patient track and we look at every patient with the news or five or more. So initially, our focus is on. Obviously, how is the patient and what is the plan for that patient? So again, you can see that we can add flags to to, um, the patient track system. So wanting to see if a patient has got a tap in place, If they've got a D in our in place, we need, uh and we prompt this conversation. Um, at these huddles, obviously, after this, we just don't leave it. Then the senior nurse goes back to the wards and speak to the nurse is in charge to see how the patient is. If the temp wasn't in place, has it been put in place? And how is the patient? And this is working in two ways. Um, we are looking at for the deteriorating patient that we need to escalate and make sure that we've got a robust treatments in place. But also the other end of the scale is are we treating the patient appropriately are the approaching end of life, but it's really bringing everything together in terms of the treatment escalation plan. So the senior nurses are there also to support the nurses on the ward's to have conversations with medical staff. So it's really just sort of working collaboratively. We've probably got quite a long way to go in our patient track. Um, but you know, it's a good start. We're also What I'm wanting to do is making sure that the medical staff in there they have a hand over huddle at night and day, and so we're trying to to bring that together. So what are our next steps? Um, we've talked about that the medical huddles and, uh, collaborating with with our nursing huddles. We're setting up a site deteriorating patient group on site, and that's really recognize, really wanting to focus on the recognition of the deterioration, pace, deteriorating patient planning, treatment and a folk focus on implementations of tips. We really want a tip, as Chain says, for every patient, Um, all of us should have a tip also. I mean, it's fantastic to to be involved in this webinar today, but I think in terms of national communication. People just still don't understand what the tip is. Um, and we've seen it on the news. There's still a lack of understanding sometimes about D N r. CPR, but really be good to see that sort of spread of communication in terms of what is a tip on what we're using it for in terms of, um, why we've we've talked about why, but I don't think this is Blue Sky thinking in our first wave of cove ID at University hospital hair Myers. Um, every patient that died had a tap in place. 85% of all of our patients with Covic had a tip so we could do that. But that was a clear focus. A real pressing need wasn't there during Cove it for, um, rationale and decision making. Unfortunately, this has really dropped down. And our last audit. There was some patients, some words with no patients with a tip, others up to 60%. So we know that we've got a long way to go. So finally, for me, we all know that that the phrase that safety does not happen by accident, but neither does quality, So treatment escalation. Planning to me is essential to main safety care for our patients That is focused on actually the quality of patient centered care. Thank you. Great talk. Well, to hear how you're implementing things in my ears. Um, there isn't, uh, that many questions in the chat box, and maybe some more will pop up. Um, there's one from Kerry, which I think I will come back, too. But there's been you've done a lot of work about the visibility of treatment escalation plans across the words across the hospital and really good to see it highlighted as one of the important things on the board. Um, this was done there in the huddles. How important is to have that flexibility and to to have that constant conversation about tips? I think it's it's it's absolutely essential that the ward that are using the board, um, it's obviously from after a consultant ward around. Everyone comes to the board, but I think it's it's the learning and the education from our junior staff as well, to to have that visibility, um, and just have the conversations that just to make it just the norm, Um, and I think we're we're We've got a long way, as I said to go about that, but I think it's just having those conversations to to for all of us to be saying, Well, what is that? What is the plan? Um, and that's for every member of the team. And if every member of the team can see that that it is on a board or that we're we're we we we've got the step in place. I think it's prompting those conversations. Um, And I think the the other thing that that I spoke about Steven in terms of, uh, advanced practice or race nurses, um, they are prompting the conversations and and having that with junior staff as well. So, um, it's just raising the profile, isn't it? There is a question, um, from a very low, um, about 80 p s again. And so, from from your experience, how has, um, you know, discussions that have been had in the community feed discussions in the more acute setting. So, uh, good question. Um, again, we are trying to have those conversations with patients. Is an A C. P in place. Obviously, we can, um, go onto the ecosystem. Um to see if there is an a C. P in place. And it's really joining that together, isn't it? Because, um, we're the same. Our tests are in place for the patient's journey. For the for this hospital admission only. Um, but but we need to to take into account. Often, patients have spent a long time, um, with other health care professionals, um, completing a C. P. S. So it's it's joining up those conversations, but also moving on from it. If if If we know that an A C P is in place, then that's a fantastic platform to to launch a conversation. So it's just joining them together and making sure that we're listening to our patients and and they they have a voice. Uh, Fiona Findlay has asked about patients with news greater than five and and how that works in practice when the nurse takes that back to the ward so so mixed at the moment. Um so, obviously, in terms of our escalation protocol in terms of observations, it triggers, um, and use of five to, um, contact medical staff and get a review of the, uh, ask for a review of the patient so we're following on from that escalation, So I think it is mixed. But what we're trying to do is ensuring that, um that a patient with a high news we're not just saying Well, yes, the news is, is high at six o'clock, and it's still high at 10 o'clock in the morning. If that news isn't changing, then whatever we're doing for the patient isn't working. So we need to review the plan, and I think that's what we're so So it's two things. It's not necessarily review the treatment escalation plan because that might be in place and robust. But that's actually what are we doing for that individual patient? Do we need to be more aggressive in the treatment as in Do they need to, you know, various higher level of care? Or is the patient changing their status? They're they're changing, and things are moving to a different trajectory so often it's a, uh, senior charge. Nurses and deputy charge nurses that that that do attend the huddles, but they take that back. But I think it's having that support of the senior nurse and our hospital emergency care team to follow that up. Um and make sure that that that that there is a plan in place and what we need to do is have more specific times in the day. So we have another huddle at three o'clock, and the plan is to bring that back at three o'clock and then again at nine o'clock so that we're reviewing all of these patients so that we all know across the the whole hospital, um, what our concerns are And if they if all of our patients have an appropriate plan. So again, a very good question, isn't it? And I think again, like Jane, I think often are Patients want to talk? Um, often are patients initiate conversations and there can be conflict. I think, Um, sometimes as relative's, we want our loved ones to to go on forever, don't we, um, but actually, uh, as an individual, you have different feelings. So I think it's really just exploring that, because in terms of the d n are, there is still, um, uh, some people that think that actually that means that we're not doing anything for that patient. And we've all heard that, haven't we? And that's that's terrible. None of us want to hear that because for every patient we want to to be supportive in their care. So I think it's just about explaining what a treatment escalation plan is. And actually, that's rarely. I mean, there's always going to be some situations where there where there's a difference opinion from relatives and the patients. But our patients are the ones that if they have the capacity that we need to listen to, and it is their choice going forward. And when clinicians are explaining what whatever is actually you see the sort of relief from some patients to say, right? Actually, thank you. Thank you for taking the time to actually explain what you're going to do, what I want you to do, and I'm working together. So actually I feel it. It's really, really positive. And the conversations that I've had personally with patients have been, uh, that can be very, very heartwarming because people want to talk. They wanted to talk, and they want to know what treatment, and they want to know what will happen If so. On the whole, I think it's really, really warmly received. Yeah, I think there's the fear that something might change, But we know that everybody that that works, and then it just never stops caring. And so the snoring continues no matter what. Um, thank you very much. I'm not going to choose to many more questions, but you're going to return to your group discussion at the end as well. Um, that was another really good presentation. It's really good to hear, like, um on the words.