Royal United Hospitals Bath NHS Trust
NHS / Health Body
Action Taken
The Trust has drafted a standard operating procedure for handovers, added an SBAR tool to the Paediatric proforma, developed a tool to safely exclude brain injury in intoxicated patients, and created a training tool with the South West Ambulance Service on "Confirmation Bias". (AI summary)
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Dear Madam Mr Alexander Frederick Richard Green - Response to Regulation 28 Report
Please see the Royal United Hospitals Bath NHS Foundation Trust’s response to the Regulation 28 Report issued on 1st April 2019.
1) Handovers need to be considered across the whole of the Trust to ensure they are appropriate and effective. Consider the use of the SBAR tool.
The Medical Director has commissioned a working group with the Trust Medical Safety Lead to improve handovers through standardisation, education and training. This group reports into the Deteriorating Patient Steering Group, chaired by the Medical Director, with a focus on reducing avoidable harm. This is a Trust breakthrough Objective for 2019/20.
There has been a review of improvements already made in general medicine handovers to see how good practice can be built upon and spread throughout the hospital. A draft standard operating procedure that forms the core of all handovers has been approved. Paediatrics have made significant changes to standardise handovers and are piloting further improvements including use of a validated extended SBAR tool called ISOBAR. It is agreed that SBAR will be the core element for all patient level handovers across the hospital and an education and awareness campaign is about to be launched.
The Emergency Department have taken the following steps:
a) Patients who have not been referred to the Department will be allocated to an ED clinician who is anticipated (barring unforeseen circumstances) to be present in the Department for the entirety of the patient’s stay within ED. Thus minimising the number of occasions they will need to be handed over. b) An SBAR tool has been added to the Paediatric proforma used to facilitate safe handover between clinicians, specifically focusing on outstanding concerns and actions to be taken. HM Senior Coroner for Avon Coroner’s Court Old Weston Road Flax Bourton BS48 1UL Directors Office Royal United Hospital Combe Park Bath BA1 3NG
Tel:
… … c) The SBAR Tool has been incorporated into the verbal and written handover process between the nursing shift co-coordinator and ward staff. d) The SBAR Tool now forms part of the Observation Unit Passport completed for all patients transferred to the Observation Unit.
2) The NICE guideline for head injury was not considered appropriate for use when it is clearly designed for exactly this case – a depressed conscious level should only be ascribed to intoxication after a significant brain injury has been excluded.
We are developing a tool that will assist and guide staff in safely excluding a brain injury in those patients who are believed to be intoxicated, that will strike the right balance between CT scanning those patients who need a scan and avoiding scanning those patients where a CT scan is only likely to cause potentially avoidable harm through exposure to radiation. It is envisaged that this tool will set out specific findings on an examination that might indicate a brain injury as opposed to intoxication, including a detailed step by step guide on how to carry out a thorough physical examination of a patient’s head.
For those patients in whom a significant head injury has been excluded and are diagnosed as being intoxicated, the Trust has developed a pathway to ensure that patients who fail to recover within the anticipated timeframe are reviewed by a senior doctor. This is to consider the possibility of an alternative diagnosis such as injury or illness not detected on initial assessment and to allow appropriate further investigations to be completed.
3) Assumption of intoxication – consider the development of training in relation to bias.
Working with the South West Ambulance Service, a training tool has been created which includes “Confirmation Bias” and the need to challenge the working diagnosis in any patient who fails to follow the anticipated clinical course. This will be utilised in every ED junior doctor teaching programme and reiterated in department handovers.
We trust that this response offers you sufficient assurances in relation to our actions following the Inquest into this tragic case.
Please see the Royal United Hospitals Bath NHS Foundation Trust’s response to the Regulation 28 Report issued on 1st April 2019.
1) Handovers need to be considered across the whole of the Trust to ensure they are appropriate and effective. Consider the use of the SBAR tool.
The Medical Director has commissioned a working group with the Trust Medical Safety Lead to improve handovers through standardisation, education and training. This group reports into the Deteriorating Patient Steering Group, chaired by the Medical Director, with a focus on reducing avoidable harm. This is a Trust breakthrough Objective for 2019/20.
There has been a review of improvements already made in general medicine handovers to see how good practice can be built upon and spread throughout the hospital. A draft standard operating procedure that forms the core of all handovers has been approved. Paediatrics have made significant changes to standardise handovers and are piloting further improvements including use of a validated extended SBAR tool called ISOBAR. It is agreed that SBAR will be the core element for all patient level handovers across the hospital and an education and awareness campaign is about to be launched.
The Emergency Department have taken the following steps:
a) Patients who have not been referred to the Department will be allocated to an ED clinician who is anticipated (barring unforeseen circumstances) to be present in the Department for the entirety of the patient’s stay within ED. Thus minimising the number of occasions they will need to be handed over. b) An SBAR tool has been added to the Paediatric proforma used to facilitate safe handover between clinicians, specifically focusing on outstanding concerns and actions to be taken. HM Senior Coroner for Avon Coroner’s Court Old Weston Road Flax Bourton BS48 1UL Directors Office Royal United Hospital Combe Park Bath BA1 3NG
Tel:
… … c) The SBAR Tool has been incorporated into the verbal and written handover process between the nursing shift co-coordinator and ward staff. d) The SBAR Tool now forms part of the Observation Unit Passport completed for all patients transferred to the Observation Unit.
2) The NICE guideline for head injury was not considered appropriate for use when it is clearly designed for exactly this case – a depressed conscious level should only be ascribed to intoxication after a significant brain injury has been excluded.
We are developing a tool that will assist and guide staff in safely excluding a brain injury in those patients who are believed to be intoxicated, that will strike the right balance between CT scanning those patients who need a scan and avoiding scanning those patients where a CT scan is only likely to cause potentially avoidable harm through exposure to radiation. It is envisaged that this tool will set out specific findings on an examination that might indicate a brain injury as opposed to intoxication, including a detailed step by step guide on how to carry out a thorough physical examination of a patient’s head.
For those patients in whom a significant head injury has been excluded and are diagnosed as being intoxicated, the Trust has developed a pathway to ensure that patients who fail to recover within the anticipated timeframe are reviewed by a senior doctor. This is to consider the possibility of an alternative diagnosis such as injury or illness not detected on initial assessment and to allow appropriate further investigations to be completed.
3) Assumption of intoxication – consider the development of training in relation to bias.
Working with the South West Ambulance Service, a training tool has been created which includes “Confirmation Bias” and the need to challenge the working diagnosis in any patient who fails to follow the anticipated clinical course. This will be utilised in every ED junior doctor teaching programme and reiterated in department handovers.
We trust that this response offers you sufficient assurances in relation to our actions following the Inquest into this tragic case.