NSLHD’s Safety and Quality Newsletter provides information on new and upcoming activities, programs and initiatives within the district that aim to improve the safety of our patients and the quality of our care.
NOVEMBER 2022
EDITION 20
The 2022 NSLHD Safety and Quality Account (2021-22 Report and 2022-23 Future Priorities) was recently released. Produced annually, the NSLHD Safety and Quality Account (the Account) demonstrates our organisation's constant drive and commitment to deliver safe, effective, accessible and patient-centred care, aligned with the needs of our local population. This year’s Account showcases initiatives, projects and programs from across the district that have achieved improved outcomes in the safety and quality of care we provide. The Account also includes how consumers and clinical groups and consumers have been engaged in priorities that address the community's needs; our workplace culture that drives safe and quality care; and our safety and quality plans and priorities over this financial year. In addition, the Account provides our community with open and transparent information about our performance against safety and quality indicators for the 2020-2021 financial year. The safety and quality improvement activities outlined in the Account align with the priorities set out in the NSLHD Strategic Plan and are underpinned by the National Safety and Quality Healthcare Standards. We acknowledge the outstanding contribution from teams in our hospitals and services across the district, including important and valuable input of our Consumer Advisors in the development of this year’s NSLHD Safety and Quality Account. 2022 SAFETY AND QUALITY ACCOUNT
IN THIS EDITION:
2022 NSLHD Safety and Quality Account Comprehensive Care eMR enhancements Gathering of Kindness Week Stillbirth Clinical Care Standard Acute Anaphylaxis - upcoming changes in clinical practice Worldwide Stop Pressure Injury Day New look Policy, Procedures and Guidelines Intranet site
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Clinical Governance Standard
Contact: Catherine.Rosario@health.nsw.gov.au (Clinical Reliability Improvement Facilitator, NSLHD Clinical Governance)
Click the image above to view the 2022 NSLHD Safety and Quality Account
Comprehensive Care * New eMR Enhancements * 29 November 2022 You evaluated and we listened
The Comprehensive Care Risk Screening and Assessment Pathway in the electronic medical record is the streamlined pathway that supports clinicians in identifying key risks and issues, in order to offer comprehensive care to their patients. Since the initial rollout of the Pathway on 7 June 2022 across Northern Sydney and Central Coast Local Health Districts, new updates to the Comprehensive Care Risk Screening Assessment Pathway are being introduced this month. The updates can be found in the ‘section titles’, ‘content’, and ‘layout’. During implementation week there will be a support team out and about across the district to assist and answer any questions. Soon to come is a dashboard that will allow clinicians to monitor the completion of the Care Pathways. The dashboard is planned to be introduced next year. There are 5 important steps (A.S.O.D.A) in the Risk Screening Assessment Pathway
Why Assess? Continuous assessment throughout the patient journey starts as soon as they enter our doors. Why Save? Saving keeps all your completed answers and allows you to review the suggested Alerts, Orders and Tasks. Why Order? Ordering ensures the patients' risks are mitigated, and harm is reduced. Having an up- to-date record ensures all clinicians are aware of alerts, orders or treatment plans for that patient. Why Use the Document Button? Documenting creates a legal document that can be found within the patient's progress notes. NOTE: If no orders are placed – the information will need to be documented in the progress notes or the Additional Notes section of the
Always start a new pathway if one is not active. If active open to assess
Save the pathway as you go
Order the relevant treatment options, Nursing care tasks, referrals and or alerts
Document the Risk Screen Pathway with any additional comments
Risk Screen Pathway Note. Why Assess / Review?
Assess and review the care pathway at each handover, transfer of care or change in condition
Re-assessment & replanning of care is a continuous process throughout the patient’s journey to effectively reduce patient risk and mitigate harm in response to the patient’s changing needs or at the request of family or carer.
Visit NSCC Comprehensive Care sharepoint site or scan the QR code for further detailed information regarding the changes. Contact: Zoe.Howard@health.nsw.gov.au (Change Manager, Clinical Informatics NSLHD) Comprehensive Care Standard
NOVEMBER 2022
EDITION 20
Partnering with Consumers Standard
ACUTE ANAPHYLAXIS The Acute Anaphylaxis Clinical Care Standard released in 2021 by the Australian Commission on
GATHERING OF KINDNESS WEEK 7 - 13 NOV 2022 The Gathering of Kindness is celebrated annually during November, using World Kindness Day to continue a conversation about kindness and compassion in healthcare. This year, the focus is on human connections, how they shape us and how they are at the heart of our work. A smile, listening to worries, or a reassuring conversation are some of the small acts of kindness that make a big difference to the experience of our patients and their families, and our staff, across NSW Health. These moments of connection are key to elevating the human experience for everyone. The recordings of in-person and virtual events will be made available
Safety and Quality in Healthcare (ACSQHC)
describes the clinical care expected for patients with anaphylaxis who present to health organisations.
The group has developed the Emergency Management of Anaphylaxis – NSLHD Guidelines which will be published December 2022 and the Handling of Adrenaline Autoinjectors – NSLHD Procedure , with associated education, to be released early 2023. In response, NSLHD formed a multidisciplinary working group of clinicians from across the district to develop local practice guidelines and procedures which align with the clinical care standard When released, the procedure will enable patients and/or carers, assessed as capable to self-administer, to retain their adrenaline autoinjector on their person/at the bedside during an admission or healthcare encounter. Prompt recognition of anaphylaxis Immediate injection of intramuscular adrenaline Correct patient positioning Access to a personal adrenaline injector in all healthcare settings Observation time following anaphylaxis Discharge management and documentation The 6 quality statements are: 1. 2. 3. 4. 5. 6. The clinical care standard detail six quality statements and a set of indicators to improve the recognition, treatment and follow-up of anaphylaxis in acute care.
in the NSW Health Elevating the Human Experience Gathering of Kindness intranet page to catch up on panel discussions, keynote sessions and conversations on demand at a time convenient for you.
Contact: NSLHD Consumer and Patient Experience unit at NSLHD-ThePatientExperience@health.nsw.gov.au
STILLBIRTH CLINICAL CARE STANDARD The Stillbirth Clinical Care Standard supports best practice care for stillbirth prevention and investigation, and bereavement care following perinatal loss.The National Standard was released by the Australian Commission on Safety and Quality in Health Care (ACSQHC) on 4 November 2022. Stillbirth is a tragic and profound experience that affects more than 2,000 families in Australia every year. In Australia, of approximately 820 births, six babies are stillborn every day. Stillbirth is defined as the birth of a baby without signs of life, at 20 or more completed weeks of gestation or at a weight of 400 grams or more.
The Stillbirth Clinical Care Standard includes ten quality statements describing the care that should be provided and a set of indicators to support monitoring and quality improvement. Visit the ACSQHC website to view the Stillbirth Clinical Care Standard and access further information and resources including information for consumers, clinicians, and healthcare services.
Contact: Lauren.Connors@health.nsw.gov.au (Clinical Reliability Improvement Facilitator, NSLHD Clinical Governance)
Click on the image above to download
Clinical Governance Standard
NOVEMBER 2022
EDITION 20
Comprehensive Care Standard
WORLDWIDE STOP PRESSURE INJURY DAY 17 NOVEMBER 2022
This year, NSLHD is supporting Worldwide Stop Pressure Injury Day on Thursday, 17 November 2022.
Pressure injuries are multifactorial, with over 100 risk factors linked to pressure injury development. When someone develops a pressure injury, they can expect to have a prolonged hospital admission, impaired quality of life and increased morbidity and mortality (Ref 1). In fact, if an older adult develops a pressure injury, they are estimated to have a two times higher risk of mortality, compared to patients without a pressure injury (Ref 2). Worldwide Stop Pressure Injury Day aims to raise awareness of pressure injuries and educate people on how to prevent and appropriately treat pressure injuries.
Across the district this month, you will see members of the skin integrity team donning high-vis vests to undertake the Pressure Injury Point Prevalence Audit, providing skin checks and education to our consumers.
Visit the skin integrity intranet page to access useful resources or to find out more.
References: 1. Teo SP, Halim N. Pressure injury prevention and management – Hospital initiatives and interventions. J Gerontol Geriatr 2019;67:235–38. 2. Song, Y. P., Shen, H. W., Cai, J. Y., Zha, M. L., & Chen, H. L. (2019). The relationship between pressure injury complication and mortality risk of older patients in follow-up: A systematic review and meta-analysis. International wound journal, 16(6), 1533–1544. https://doi.org/10.1111/iwj.13243re injury prevention.
Contact: Lizanne.Dalgleish@health.nsw.gov.au (A/Skin Integrity Improvement Facilitator, NSLHD Clinical Governance)
QUALITY AND SAFETY IN THE LITERATURE
BMJ QUALITY AND SAFETY
FINE PRINT NEWSLETTER The Fine Print newsletter is prepared by the Ministry of Health that highlights recent legislative, regulatory and other governance developments. In this series, BMJ provides succinct summaries of selected relevant studies published in the last several months. Some articles will focus on a particular theme, whereas others will highlight unique publications from high-impact medical journals. Access the November article via the NSLHD Library Spring Board Admani M.U., Gupta A. and Houchens N. BMJ Quality & Safety (volume 31 issue 11 pages 839-844 November 2022. DOI: 10.1136/bmjqs-2022-015508
The Spring/Summer 2022 edition can be accessed here.
NOVEMBER 2022
EDITION 20
Clinical Governance Standard
NSLHD CLINICAL AUDIT SCHEDULE
The NSLHD Clinical Audit Schedule has been developed for all sites and services within NSLHD to support the monitoring and evaluation of clinical care processes and to provide support for clinical quality improvement activities across NSLHD. Download the complete 2022-23 NSLHD Clinical Audit Schedule. Note: The Schedule is divided into three categories (NSLHD acute, sub-acute, MHDA and PACH). Visit the clinical audit intranet page for more information.
Clinical audits required to be completed this month are listed below.
November 2022 QARS Audits (entry links)
NSLHD_03_Peripheral Intravenous Cannula (PIVC) Insertion & Management - NEW VERSION
St 3
NSLHD_4_Monthly Accountable Drug (S4D_S8) Register Audit (RNSH | HKH | Ryde | MVH | MHDA)
St 4
NSLHD_05_ Falls Audit Documentation and Observation_Inpatient (RNSH | HKH | Ryde | MVH | MHDA)
St 5
NSLHD_6_ ID Band Specifications Adult / Paediatric Inpatients NSLHD_6_ID Band Specifications for Newborns V2
St 6
NLSHD_08_Monthly inspection for resuscitation trolley/ Resuscitaire equipment checklists NSLHD_8_Standard Adult General Observation Chart (HKH | Ryde | MVH | MHDA | PACH) (RNSH | HKH | Ryde | MV | MHDA | PACH)
St 8
POLICIES, PROCEDURES AND GUIDELINES
New look PPG Intranet site
The NSLHD Policies, Procedures & Guidelines Intranet site has recently undergone a transformation to cater for a more user friendly experience. The new site provides staff and PPG Authors improved navigation with the PPG process and PROMPT, the portal that houses NSLHD's Policies, Procedures, Guidelines and Standing Orders.
You can access the new site here.
New, updated and recently published district-wide PPGs. Click on the links below to download documents from the Prompt document system. Refer to the NSLHD weekly bulletin in your inbox to access the most up-to-date list of PPGs
Care for People with an Intellectual Disability accessing NSLHD Services Fetal Blood Sampling for Lactate Analysis - NSLHD Grading and Re-grading Procedures - NSLHD MOSAIQ Downtime Procedure - NSLHD
SAFETY ALERTS New, updated and recently published
Safety Alert (SA) - Requires immediate attention and action Safety Notice (SN) - Requires risk assessment at the district level Safety Information (SI) - Ensuring that lessons learned from state-wide, national or international sources are shared actively across NSW health system SI:009/22: Increased universal screening for syphilis infection in pregnancy - Issued 7 November 2022 SN:020/22: Updated: New recommendations for anticancer drug dosing in kidney dysfunction – ADDIKD guideline - Issued 4 November 2022 SN:021/22: Updated: Breast implant associated-anaplastic large cell lymphoma (BIA-ALCL) - Issued 11 Nov 2022 SI:010/22: Essure contraceptive devices - Issued 10 November 2022
For more information, contact: NSLHD-SafetyAlert@health.nsw.gov.au
Medication Safety Updates Medication Safety Updates including medication shortages are available on the CEC website.
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