Published on 12 October 2023

EMA QUALITY & SAFETY NEWSLETTER October 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
    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 & Gastro)

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 could occur at any time. Please ensure you and your staff are familiar with our Best Care site and all information and resources related to accreditation. Our managers will be completing weekly readiness checklists in order to assess gaps and ensure we are prepared.
We continue to ensure improvement initiatives are ongoing in relation to ensuring timely access to care for our patients, as described in our Statement of Priorities. In September we have seen improvement in a number of these metrics compared to the month prior which means that patients are waiting less time for care in our community.

Patient Story

A 75yr old lady with multiple medical and legal complexities was admitted with bacterial epidural abscess and acute on chronic renal failure. Following a prolonged admission at Werribee and Footscray ICU, the patient was transferred to ward 2D for further management.
The patient advised the team that her listed Next Of Kin was claiming to be her Enduring Power Of Attorney against her wishes. The medical team sought legal advice and during her last weeks of life, the nursing team advocated for patient privacy and her wishes to not allow this person to visit. The multidisciplinary team worked collaboratively to ensure the patient’s long-time family friend was appointed Enduring Power Of Attorney, as per her wishes.
Prior to her deterioration, the patient instructed her friend to purchase thank-you gifts for all the staff (coffee, tea and chocolates) and made hand written thank you cards to individual staff who she felt provided very special care to her.
The patient unfortunately went into multiple organ failure and with the nursing team advocating for end-of-life care, the palliative care team was involved. This patient passed away with dignity and in comfort.

Kindness Corner

I took my daughter to Williamstown Hospital Emergency Department on 18/09/2023, she had cut her head open and required glue. Every single member of staff was so kind to her, the ladies on the front desk were extremely kind, the doctor and nurse were so wonderful. My daughter felt so comfortable and didn’t want to go home. Thank-you so much to all the team for working so hard and looking after everyone at the hospital. We are incredibly grateful for everything you do.

 

Improvement Initiatives

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

Removal of handover sheets across all of our EMA wards

General Internal Medicine Ward Round Standardisation project

Thunderstorm Asthma Preparation

DOS, Access and ED huddle changes

Regular simulation sessions at Williamstown ED and our Urgent Care Centres (supported by our Sunshine Education and Simulation team)

2G Staff wellbeing project– focusing on self-care activities prior to a shift

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…

  • Opening our new GIM Ward 2H at Sunshine Hospital, which includes a transit lounge.
  • 69 staff members within EMA to receive Length of Service Awards for 10-35 years of service (4 of these with 35 years of service).
  • Improved rates of inpatient falls and hospital acquired pressure injuries.
  • Improvements in timely access to care for our patients, including releasing ambulances to the community and our time to see patients in our EDs.
  • Improved rates of Mandatory Training and Performance & Development Plan (PDP) completion.

We are looking forward to…

  • Accreditation readiness
  • Mental Health and Wellbeing Act implementation & compliance
  • Sustaining and improving our timely access to care
  • SHED refurbishment
  • Review of General Internal Medicine model
  • EMR implementation at Bacchus Marsh and Melton
  • Endoscopy waitlist audit and access improvement initiatives.

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
  • Weighing our patients – both on admission and weekly
  • Completion of the required mandatory training for all our staff
  • Improving medical and nurse practitioner staffing (particularly across our EDs and Urgent Care Centres)
  • Improving waiting times for our patients requiring a Gastro-Intestinal Endoscopy procedure

What is the data telling us?

 

Data Analysis

  

Key Message
 

Hand Hygiene

 Overall Hand Hygiene compliance for the Division was 90% in September 2023, which is an improvement from last month. Some areas have yet to meet the audit numbers for the period. 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.
Healthcare Associated Infections Nil. Remove unnecessary cannulas as soon as possible.
 

Medication Errors
We saw 57 medication errors across the Division in September, with the majority being related to administration. APINCH medications were involved in 27 of these incidents (an improvement from last month).
 

Don’t forget the 5 Rights for medication safety

Standard 4: Medication Safety
 

 

Comprehensive Care—Falls, Pressure Injuries and nutrition
There were 66 falls across the Division in September, with nil resulting in fracture or head injury.

There were 16 hospital acquired pressure injuries recorded for EMA in September, review of incidents in Emergency Departments is underway.

Average weekly weight compliance across division is 86% and on admission is 72%. Both of these are an improvement on last week.

Average weekly weight compliance across division is 84% and on admission is 66%.
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 a reduction in the number of episodes of Mechanical Restraints over the past two months, however compliance with appropriate documentation remains low.

 

  

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

Ensure it is documented.
Communicating for Safety There were 20 incidents related to the Communicating for Safety standard and the majority (17) 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 one blood managements incident across our Division in September. Complete your mandatory training via WeLearn
Recognising and responding to Acute Deterioration There were 2 reported clinical incidents related to standard 8 in September, both in our EDs and Urgent Care Centres.  

See more about Standard 8: Deteriorating Patient
Incidents and Complaints
There was a total of 542 incidents across all standards for our division in September

We received 44 complaints in September, which is fewer than the previous month. The rate of responding to feedback improved in September.

 

 Standard 1 and Standard 2