Published on 14 November 2023

EMA QUALITY & SAFETY NEWSLETTER November I 2023

  • Like to contribute?

    If you have a story or item that you’d like to contribute to your EMA Quality & Safety Newsletter, send it to EMAQuality&Safety@wh.org.au

  • EMA Key Contacts

    Divisional Director:
    Patriece Shelly

    Clinical Services Director:
    Garry Lane

    Director of Nursing & Midwifery:
    Nicole Davies

    Director of Operations:
    Lauren Davidson

    Director of Access & Flow:
    Fran Brockhus

    Operations Managers:
    Kylie Van Rooyen (Emergency Medicine Williamstown, Urgent Care Centres)
    Doriana Andreou (Emergency Medicine Sunshine and Footscray)
    Nicole Comito (Special Medicine)
    Joanne Kha (General Internal Medicine & Gastroenterology
    Coleen Scully (Operations Manager Access and Patient Flow Sunshine Hospital)
    Renie Lloyd (Operations Manager, Access and Patient Flow Footscray, Williamstown, Bacchus Marsh & Melton)

A message from the leadership team

Our current primary focus for the Division is preparation for accreditation. As you will all be aware, Western Health is scheduled for a short notice accreditation visit (WH will be notified 2 business days before the accreditation begins), which is likely to occur in November. Please ensure you and your staff are familiar with our Best Care site and all information and resources related to accreditation. Our managers are completing weekly readiness checklists in order to assess gaps and ensure we are prepared.
One of our primary focus areas for Quality and Safety across the Division is Comprehensive Care and there are a number of initiatives underway including an Improvement Project in our EDs and Urgent Care Centres; improving our utilisation of the Comprehensive Care iPOC for inpatients; and ensuring all risk assessments and strategies are in place.

Patient Story

“I just wanted to take this opportunity to give positive feedback on my recent visit to the Emergency Department at Western Hospital. I have a chronic condition, atrial fibrillation, that I am aware can be a bit of a pain for EDs as it’s usually non-life threatening yet can be quite unpleasant for the person experiencing it (albeit that at least some of that may be the result of anxiety associated with the condition) and does carry risks in the long term.
My condition has unexpectedly worsened recently, and I have found it hard to find the balance between avoiding burdening a busy ED, and being responsible about my health by getting timely help when things seem serious (due to the severity or duration of the AF episode). I have had two recent attendances at Western ED and really appreciated the attitude and care of the health care team. I felt like the dilemma I experienced was acknowledged and respected. Interestingly knowing that I would be taken seriously (after the first presentation), made the second presentation a far calmer and more orderly experience. I suspect this helped me to contain my symptoms. I await an operative procedure that I hope will be successful. However, in the meantime we arrived at a plan to avoid further ED attendances and to define more clearly when they might be needed.
I felt like this was something we worked out collaboratively and respectfully in the interests of both myself and the appropriate future use of the ED”.

Kindness Corner

Well done to the Footscray Hospital Emergency Department nursing team on their recent pulse check for Nurse Pool and Nurse Bank. The pulse check is coordinated through the Nursing and Midwifery workforce unit to gauge how pool and bank staff feel supported and valued in various wards and departments. The FHED team scored above organisational averages in the area of team work, staff satisfaction and meaningful work. Thank you FHED nursing team for making pool and bank nurses feel part of your team to provide best care to our patients.

 

Leadership Walk Arounds

You may have noticed the EMA leadership team in your areas undertaking leadership walk arounds. Leadership walk arounds are not new to EMA. The walk arounds provide us with an opportunity to connect with our teams, observe best care in action and also hear and act on your feedback. A recent systematic review published in BMJ Open Quality assessed the impact of leadership walkarounds on operational, cultural and clinical outcomes. The authors concluded that evidence exists to suggest a positive association of leadership walk-arounds on operational and cultural outcomes. The article can be found at: Impact of leadership walkarounds on operational, cultural and clinical outcomes: a systematic review | BMJ Open Quality

Improvement Initiatives

There are multiple improvement initiatives underway across EMA. Do you know about these? (If not, feel free to ask your manager).

Standardised Operating Processes for the Bed Coordinator teams to improve time to allocate beds from ED.

General Internal Medicine Ward Round Standardisation project.

Thunderstorm Asthma Preparation.

Code Crimson and Sepsis alert development in our EDs.

Ongoing access and flow initiatives across our EDs, including the use of Short Stay Units, AV offload, Front of Hours models, Category 2 time to be seen, use of Lower West Ward.

Improvements in utilisation of Transit Lounge.

Comprehensive Care Improvement project across our EDs and Urgent Care Centres, focusing on nursing leadership and risk assessment and tools.

Timely Emergency Care Collaborative (TECC) aiming to improve the timeliness of emergency care through improving system-wide patient flow – PDSA cycles continue within the ED & inpatient stream: Timely Emergency Care Collaborative – Home (sharepoint.com)

 

Achievements and Opportunities

We are proud of…

• Maintaining timely access to care for all of our patients.
• Our Footscray ED and Access team won a Best Care Awards for improved utilisation of SSU.
• Our Williamstown ED received a Bank Vic $5K innovation grant to purchase laptop on wheels.
• Dr Maninder Mundae (WH Rheumatology) was successful in a WH Shark Tank grant for Ultrasound Clinic.
• Our Medical Diagnostics Unit was Nominated for an Inspire Award.
• We have been managing our complaints well across the Division.

We are looking forward to…

  • Accreditation readiness
  • Mental Health and Wellbeing Act implementation & compliance and improving the use of our Sunshine BAU and Hub.
  • SHED refurbishment.
  • Review of General Internal Medicine model.
  • EMR implementation at Bacchus Marsh and Melton.
  • Improving patient access to our EMR outpatient clinics through the use of guidelines and other improvement initiatives.
  • Setting up a PDSA cycle with the ICU team to improve daily flow from ICU.

Our focus continues on…

  • Addressing our OVA incidents across the Division.
  • Falls & Pressure Injuries remain a key focus across the division.
  • Improved compliance with risk assessments and utilisation of iPOCS across our inpatient areas.
  • Completion of the required mandatory training and performance development plans for all our staff.
  • Improving medical and nurse practitioner staffing (particularly across our EDs and Urgent Care Centres).

What is the data telling us?

 

Data Analysis

  

Key Message
 

Hand Hygiene

 Overall Hand Hygiene compliance for the Division was 89% in October 2023, which is similar to last month. Don’t forget to replace the end of bed alcohol-based hand rub if empty. If you do not know where to get a new bottle from in the ward or department, please let the nurse in charge know.
 

Medication Errors
We saw 67 medication errors across the Division in October, with the majority being related to administration. APINCH medications were involved in 43 of these incidents.
 

Don’t forget the 5 Rights for medication safety

Standard 4: Medication Safety
 

 

Comprehensive Care—Falls, Pressure Injuries and nutrition
There were 80 falls across the Division in October, with four resulting in fracture or head injury.

There were 13 hospital acquired pressure injuries recorded for EMA in October.

Average weekly weight compliance across division is 86% and on admission is 86%. Both of these are an improvement on last week.

 
Supervise patients at risk of falling in bathrooms and toilets.

Complete risk assessments and implement appropriate prevention strategies as soon as possible.

 

Standard 5: Comprehensive Care
 

 

Mechanical Restraint

 There has been an increase in the number of episodes of Mechanical Restraints in October, however we have seen improved compliance with appropriate care and documentation.

 

  

Use least restrictive practice, review and remove as soon as possible.

Ensure it is documented.
Communicating for Safety There were 13 incidents related to the Communicating for Safety standard and the majority (8) of these were in our Emergency Departments and Urgent Care Centres. Please visit our Best Care website for more information about Standard 6
Blood Management There was six blood managements incident across our Division in October- all of these were in our EDs/SSU. Complete your mandatory training via WeLearn
Recognising and responding to Acute Deterioration There were 9 reported clinical incidents related to standard 8 in October, 7 of which were in our EDs and Urgent Care Centres.  

See more about Standard 8: Deteriorating Patient
Incidents and Complaints
There was a total of 622 incidents across all standards for our division in October.

We received 30 complaints and 10 compliments in October, which is an improvement on last month. We have significantly improved our response rates to complaints across the division.

 

 Standard 1 and Standard 2