Archives: Case studies

Case study

PreciSSIon (Preventing Surgical Site Infection across a region)

PreciSSIon (Preventing Surgical Site Infection across a region) is a double award-winning collaborative involving all hospitals in the West of England. The aim was to reduce incidence of surgical site infection after elective colorectal surgery by implementing a four-point evidence-based bundle of care developed at North Bristol NHS Trust in February 2013.

This became a Health Innovation West of England project in November 2019 and we supported adoption and spread to other hospital trusts (Royal United Hospital Bath, University Hospitals Bristol and Weston, Gloucestershire Hospitals Foundation Trust and Great Western Hospital Swindon) through project management, provision of resources, and funding of collaborative events.

The project almost halved SSI with a reduction of 47 % by March 2021. It is estimated that the project saved 115 patients from developing an SSI, with an associated cost saving of £566,720. This result was achieved despite the COVID response causing major disruption in hospitals.

Watch our PreciSSIon bundle video.

The challenge

Surgical site infection (SSI) refers to wound infections following invasive surgical procedures. SSI arises from contamination of the wound site during or after surgery. The development of SSI is complex with many contributing factors.

SSI is the third most common hospital acquired infection in the UK accounting for 14.5% of all HC AI affecting 250 000 people a year in England with an estimated 34-226% increase in associated costs.

SSI causes pain for patients, can increase hospital stay and readmission and increase antibiotic use. When severe it can lead to intensive care admission and rarely, death.

SSI is more common after colorectal surgery where wounds can be contaminated by bowel content, but most hospitals do not know their SSI rates. Rates of between 8-30% have been reported based on in-hospital SSI and readmissions. However, the prevalence is likely to be underestimated because SSI frequently presents after the patient has been discharged from hospital.

View the PreciSSIon implementation toolkit.

Our approach

The PreciSSIon project had 2 clear aims:
1. To establish reliable SSI measurement after elective colorectal surgery using a validated patient reported outcome questionnaire at 30 days.
2. To implement an evidence-based 4-point care bundle. The PreciSSIon bundle, includes: 2% chlorhexidine skin preparation; a second dose of antibiotics after 4 hours operating; use of dual ring wound protectors; antibacterial sutures for wound closure.

Health Innovation West of England supported the PreciSSIon collaborative using the IHI Breakthrough Collaborative model. We produced resources and materials to aid data collection and implementation of the PreciSSIon bundle. These included QI (quality improvement) resources, an implementation toolkit, posters, and videos. We also ran ‘learning and sharing’ events for the collaborative which were an opportunity to meet and share successes, challenges, and discuss data collection. One face to face meeting occurred before the pandemic but then all subsequent events were virtual.

“The collaborative element enabled staff and trusts to support each other during the difficulties of the COVID-19 pandemic and engagement was high, with theatre teams in particular being empowered to make a difference.

“We had our challenges, including standardising measurement, procurement of antibacterial sutures and sustaining measurement during the pandemic, when staff were redeployed to other roles, but despite this we have demonstrated that a care bundle developed in a single hospital can be adopted and spread. Also that the original outcome of a 50% reduction in SSI after elective colorectal surgery can be replicated in other hospitals and deliver results within just 18 months.”

Dr Lesley Jordan, Consultant Anaesthetist and Patient Safety Lead, Royal United Hospitals Bath NHS Foundation Trust

Impacts to date

The regional average baseline SSI rate was 18%. Implementation of the bundle in all trusts between November 2019 and May 2020 resulted in a 47% improvement in SSI rate, leading to a regional average of 9.5% by March 2021. This equates to saving 115 patients from an SSI, a significant improvement in patient experience. Compliance with bundle was 87% for chlorhexidine, 79% for antibacterial sutures, 68% for wound protectors and 92% for antibiotics.

A UK study demonstrated that the cost of a SSI after elective colorectal surgery is £4,928 equating to a regional cost saving of £566,720. 3 hospitals also implemented the bundle after emergency abdominal surgery leading to a reduction in SSI from 22.5% to 12.5%.

PreciSSIon was shortlisted for two 2021 HSJ Patient Safety Awards, winning the Infection Prevention and Control Award. PreciSSIon also won Quality Improvement Team of the Year at the BMJ Awards, both in September 2021.

In March 2022, the Journal of Hospital Infection published a study by surgeons and trainees who formed part of the PreciSSIon project team. This evidenced the value of SSI bundles to patients and the NHS. Read the journal article.

In September 2022 the Journal of Hospital Infection published PreciSSIon – a collaborative initiative to reduce surgical site infection after elective colorectal surgery. This concluded a care bundle developed in a single hospital can be adopted and spread and the reduction in SSI after elective colorectal surgery can be replicated in other hospitals and deliver results within 18 months.

Next steps

In October 2022 we launched a new PreCiSSIon collaborative – focused on reducing SSI after caesarean birth – in six local acute hospital maternity units across the region. Read more in our launch blog.

The project results have been shared with the Royal College of Surgeons and the results have been presented at the Association of Surgeons of Great Britain and Ireland with the aim of sharing more widely.

The project launched in November 2019 and is ongoing, although Health Innovation West of England project management has ended.

Project leads:
Anne Pullyblank, Medical Director, Health Innovation West of England
Dr Lesley Jordan, Consultant Anaesthetist and Patient Safety Lead, Royal United Hospitals Bath NHS Foundation Trust

Find out more about PreciSSIon.

 

The West of England Learning Disabilities Collaborative

We established the West of England Learning Disabilities Collaborative (LDC) in early 2019 bringing together individuals and organisations from across the region interested in the care of people with a learning disability and experts by experience, with a focus on three priority areas:

  • Improving recognition of deterioration through use of soft-signs and National Early Warning Score (NEWS2).
  • Promoting the uptake of flu vaccinations (for both care staff and patients) and the use of reasonable adjustments such as the nasal vaccine.
  • Supporting increased uptake and quality of Annual Health Checks (AHC).

The LDC provides a space for collaboration, cross-system working and sharing of good practice in a way that did not previously exist in the region.

The overarching aim of the collaborative is to reduce the inequity in care for people with a learning disability that has been identified nationally through the LeDeR (Learning Disabilities Mortality Review) programme.

Read our blog on how the LDC was formed.

In October 2021 the LDC team presented to the West of England Patient Safety Collaborative Board. Watch their short presentation which gives an overview of the LDC’s work and why co-creation is vital to its effectiveness:

The challenge

It is estimated that approximately 2% of the adult population has a learning disability. On average, people with a learning disability die 20 years younger than their peers. Many of these deaths continue to be from avoidable causes, such as pneumonia and sepsis.

Whilst the healthcare needs of people with a learning disability have been considered throughout our project cycles at the Health Innovation West of England, we had never before undertaken a specific project for people with a learning disability. The collaborative aims to put people with a learning disability, their carers and the healthcare staff that support them at the centre of our work. Read our blog on the importance of co-creation to the LDC.

The LDC advocates use of NEWS2 and soft-signs tools including RESTORE2 to support early identification of physical deterioration in patients. “Soft signs” training (including RESTORE2 and RESTORE2 Mini) is particularly valuable in the management of deterioration where individuals have difficulties in communicating when they are feeling unwell or in pain including in care homes for people with a learning disability or developmental needs.

Our approach

The collaborative’s first priority is to build on the work across the region to implement NEWS2 and expand into the learning disability sector, incorporating the use of soft signs through RESTORE2 training. Based on the recommendation from the LeDeR programme to empower carers, and the success of our RESTORE2 training for care homes (including learning disability settings), and in collaboration with Wessex Patient Safety Collaborative (PSC), we were commissioned by NHS England to train 120 ‘Super Trainers’ to deliver training remotely to paid and unpaid carers across the UK. The training and resources were co-created with people with a learning disability, carers, and supporting organisations, and this has created the potential for the training to be delivered by people with lived experience. To accompany this training, we worked with partner organisations to develop a series of short, bitesize videos in plain English. These include measuring heart rate, oxygen levels, temperature, how to recognise soft signs, and how to tell someone if you are worried.

To support our second priority during the 2019 flu vaccination season we collaborated with NHS England to produce a flu vaccination communications toolkit, including easy read information about the flu vaccine, for providers to use to promote uptake for people with a learning disability and their carers. We also had the NHSE website updated so that people with a learning disability were explicitly mentioned as being at risk. The toolkit is now updated and re-released each year. We also contributed to a letter for care workers to give to their GPs to obtain the vaccination for free, based on feedback from our members that they were being told they were not eligible for a flu vaccination and turned away.

Improving the uptake of annual health checks is the third aim of the collaborative and remains a high priority for systems and NHS England. Initially we were commissioned to increase the uptake of annual health checks through meetings and workshops. We were subsequently commissioned by NHS England South West to produce a series of videos that encouraged greater uptake of annual health checks for people with a learning disability. The videos were co-created and produced with Misfits who are a theatre and social group led by people with learning difficulties. We also collaborated with a number of experts by experience to produce these videos. The videos were published in October 2021 and cover a range of audiences including health professionals working in primary care, with a second playlist focusing on people with a learning disability and those that care for them. This project was selected by NHS England as an exemplar case study for the LeDeR 2021-22 Action from Learning Report (see pages 25 and 45).

In addition, we established a community of practice with over 300 members including representation from NHS England, our member organisations, Public Health England, Royal College of GPs, community learning disability providers, the local LeDer team and experts by experience. This is a hub for sharing best practice and information. A wide range of webinars have been held and members are sent a quarterly newsletter. We have also co-created videos and resources to support, amongst other campaigns, the uptake of covid boosters and oral healthcare.

Since March 2022, through Blue Stream Academy, RESTORE2 Mini is available as a free e-learning module to all carers (paid or unpaid).

Impact to date

  • In February 2021 we delivered the ‘Super Trainer’ RESTORE2 model to 167 experienced trainers, who by the end of May 2021 had trained over 7000 paid and unpaid carers, with training continuing to be delivered across the country.
  • The bitesize deterioration videos have had over 44,000 views and were 2021 finalists as part of a wider series on deterioration for a HSJ Patient Safety Award.
  • Our work was highlighted in the LeDeR Action from Learning report on sepsis
  • NHS England reported a 57% uptake of flu vaccinations in our region in November 2021 which is higher than the national average of 50%.
  • We campaigned for COVID vaccinations for people with a learning disability when this vulnerable group were not initially included on the priority list for vaccination. We contributed to a letter to the House of Lords which resulted in the list being updated in February 2021.
  • We presented our work to support the uptake of annual health checks at the September 2021 HSJ Patient Safety Congress with Andrew Bright, Head of Development for Thera Trust, an expert by experience.
  • Most recent data shows that 72% of people with a learning disability in the West of England accessed an annual health check.
  • We produce a regular newsletter to share best practice and resources which is sent to our collaborative of nearly 400 members.
  • We have run a series of seven webinars on topics such as advanced care planning, physical health, and mental capacity during Covid-19 which had more than 560 attendees.
  • To March 2022, over 2240 care staff have been trained in use of RESTORE2 or RESTORE2 Mini with 417 West of England care providers participating.

To illustrate how RESTORE2 training has improved patient outcomes and care staff confidence in communicating at the handovers of care a series of ‘in our words’ case studies have been collated. These illustrate the positive personal impact training has had on care staff, their patients and teams.

Key to developing the LDC’s soft signs videos and super-trainer model was co-creation, and working with us was one of our experts-by-experience Andrew Bright, who is Head of Development at Thera Trust:

“RESTORE2 will make such a difference and save lives. From my own personal experience of taking part in the training and watching the videos; I feel like they will make a huge difference, and from my own point of view I felt included in the work”.

Next Steps

The West of England collaborative ceased in its current format in March 2022. The collaborative has been relaunched to cover the entire South West region, and is funded and delivered in partnership with NHS England South West.

The reformed collaborative aims to share learning and best practice across the South West and focus on the adoption and spread of tested diagnostics, products and technology that supports both people with, and those who care for people with, a learning disability.

Find out more

Visit the South West Learning Disabilities Collaborative web page or email us at healthinnowest.swldc@nhs.net.

Electronic health records in care homes

With our support, Bath and North East Somerset, Swindon and Wiltshire (BSW) CCG built on a recent trial using an early ‘mobile’ version of TPP’s SystmOne electronic health record, by introducing a new care home module across a small number of care homes.

Early feedback is indicating demonstrable benefits in improved communication between care homes and primary care, as well as efficiencies around access to patient clinical records.

In October 2020 BSW CCG successfully bid for NHS England funding, aimed at projects supporting accelerated use of digital technologies during the Covid-19 pandemic to enable the ‘virtual’ care of patients across primary, community and acute care settings. This allowed the project to extend its scope, with the aim of spreading the use of SystmOne into 20 care homes during 2021.

“Our team thoroughly enjoyed working with our colleagues at Health Innovation West of England, who played a crucial role in securing regional funding from NHS England to scale up our work programme. They also helped us to shape our approach to the planning and delivery of the project, which has made a real difference in releasing clinical time to care for patients within the care homes who have adopted the new system.”

Jason Young, Assistant Director of Digital Transformation at BSW CCG

The challenge

Prior to using SystmOne in care homes, the registration of a new care home resident could take on average three to four hours, as information to complete paperwork needs to be pulled from multiple sources. It can be difficult to obtain a full medical history for individuals new to a care home, particularly when coming from another care setting or if they have few family members.

Care home staff also spent significant time contacting local GPs to discuss resident health problems, reorder prescriptions, arrange consultations – or just seek advice. The Covid-19 pandemic increased pressure on these services and demonstrated the relevance for potential online consultations.

The approach

Health Innovation West of England provided programme management support to the BSW team, as well as local experience of delivering digital transformation projects.

We also part-funded an external technical specialist to assist implementation and was also instrumental in securing additional funding from NHS England as part of the Covid-19 response.

The project team approached 67 care homes to establish their interest in having access to SystmOne.

Where there was a positive response from a care home, the team also engaged with the local GP practice and provided a product demonstration to both.

This formed stage one of the four-phase approach:

  1. Engagement and demonstration of SystmOne.
  2. Information governance training, covering the Data Protection Security Toolkit (DSPT)
  3. Technical implementation and system training for SystmOne
  4. Transformation – design of processes and procedures between the care home and local GP practice.

Later, an additional stage was included to make contact with the care home two to four weeks after implementation to check progress and offer additional support where needed. This provided a useful opportunity for an informal conversation to start to understand the initial impacts being experienced, and whether these matched the original hypothesised benefits.

As of 30 November 2021, 18 of the projected 20 homes had fully implemented SystmOne, with a total capacity of 738 beds. Further care homes are now interested in the technology.

“SystmOne has saved us time and having access to information allows us to feel less of a hinderance to the GP, where we would otherwise have to call the surgery.”

“Getting to know a resident and their medical history much faster, this includes all open referrals to other services. Easier to plan the future care for residents, used to wait one to two weeks for GP summary, but now have immediate access.”

Feedback from care home staff

The impact

Data on the usage of SystmOne for the eight months to 31 October 2021, when 17 care homes were using the technology, reveals varying use of the system. Two homes had been using it significantly and consistently for several months, while another six are considered regular users.

Further analysis suggests usage levels may reflect uptake by specific members of staff in particular homes, with a number of users ‘dropping off’ the data, possibly reflecting the transient nature of the workforce in the care home sector.

Overall, 50 different staff members across 14 of the 17 care homes were using SystmOne in this eight-month period, viewing 4,085 patient records in the period.

It is estimated that up to 2,820 hours of time was saved during registration of new patients into care homes. This is based on it previously taking an average of three to four hours to register a new resident, pulling the information needed to complete paperwork from multiple sources. Whilst these numbers are not validated, a former care home manager confirmed, “the documentation when registering someone new in a care home is immense.”

Further feedback captured:

  • All the participating care homes say they believe they are delivering better care by using SystmOne.
  • The access to GP notes and medicines history via SystmOne are seen as particularly helpful.
  • The care homes report clinical time saving due to improved communication channels with GPs (less telephone queueing for example).
  • They get quicker responses from GPs – less ‘telephone tag’.
  • Significant time saving is being reported in registering new residents, due to accessing patient records more quickly, giving the ability to plan for care immediately, rather than having to wait for paper records to arrive.
  • Some reports of quicker access to test results (bloods, pathology/radiology, etc), with a couple of examples of this leading to earlier prescribing and receipt of medication for a resident – reducing pain.
  • Care homes using SystmOne report quicker and more confident clinical decision making – leading to better care.
  • Three care homes say they have avoided ambulance call outs or ED visits as a result of using SystmOne.
  • Three care homes are using the GP tasking facility.
  • Four care homes are keen to record information into patient records (such as test results) – involving a potential upgrade of service.
  • Care homes are keen to use the medicines ordering facility once a planned enhancement is released later this year by TPP.

Whilst from a relatively small selection of care homes, the feedback gained to date supports the original aims to improve to patient care and create internal efficiencies through implementation of the TPP Systm One solution.

“Overall SystmOne has helped our residents.’’

“We are finding it really useful, especially if we have queries about GP consultations, allergies, lists of meds and medical history and resus status for new people.”

“We avoided having to send a resident to hospital where they may have continued to suffer by being resuscitated/treated against their will.’’

Feedback from care home staff

Key learnings

Care homes were at the forefront of the challenges encountered during the Covid-19 pandemic, which meant engagement was difficult as staff had different priorities to contend with. These were exacerbated by:

  • Outbreaks of Covid-19
  • Covid vaccination programme
  • Restricted visiting for relatives.

Additionally, agile project delivery was negatively impacted by:

  • Relatively high turnover of staff
  • Low digital literacy levels
  • Limited Wi-Fi capacity
  • Care homes’ IT incompatibility with SystmOne.

It is important to understand that staff in care homes work under very different pressures to many staff in the NHS and other industries. Homes range in size and in the services they offer. Many are small, family-owned business, whilst others are chains within larger corporate organisations. But each has its own culture, systems and processes that need to be accommodated when collaborating with the care home teams to implement new ways of working – particularly when introducing a new technology.

The majority of homes contacted, regardless of their structure, didn’t have capacity to see implementation through to fully embed the use of SystmOne. Those that had the perseverance to be able to do so are now seeing efficiency benefits, but the capacity to engage and transform should be a consideration for any future care home projects.

Next steps

The project has now transitioned to ‘business as usual’ for BSW CCG, so more homes can benefit from the implementation of TPP SystmOne.

BSW CCG have also shared their approach and learnings with Gloucestershire CCG who are ‘fast following’ with some early successes.

Find out more

Find out more about Health Innovation West of England’s digitial transformation work or email dave.evans5@nhs.net.

 

PReCePT – preventing cerebral palsy in preterm babies

Every year around 4,000 women in the UK give birth very early because of complications with their pregnancy. Being born too early is the leading cause of cerebral palsy, which has a lifelong impact on children and families.

Magnesium sulphate (MgSO4) given during preterm labour reduces the relative risk of cerebral palsy in very preterm infants by 30% and costs from just £1 a dose.

To increase uptake of MgSO4, the PReCePT programme was developed by the Health Innovation West of England with University Hospitals Bristol and Weston. As a result of its regional impact, PReCePT was selected as national adoption and spread programme from 2018 to 2020 by the Health Innovation Network (formerly the AHSN Network).

PReCePT was the first ever perinatal quality improvement (QI) programme delivered at scale across the whole country, bringing together midwives, obstetricians and neonatologists.

By March 2020 all 152 maternity units in England had adopted PReCePT, significantly reducing variation in administration rates of MgSO4 and achieving the national target of 85% uptake.

An estimated 48 cases of cerebral palsy were avoided as a result of PReCePT, saving around £38.4 million in lifetime health and social care costs.

“Patient safety has always been at the centre of my work. PReCePT allowed me to take some new evidence, some new research, to put that into practice, to disseminate that to the staff, and to see the benefits and outcomes improving for these women, their babies and their families.”

Claire Edward-Few, Practice Development Midwife, Stoke Mandeville Hospital

PReCePT: ingredients for success: In this short film, members of the PReCePT team from around the country share their experiences and learning as part of the national adoption and spread programme.

The challenge

Around one in ten babies of very low birth weight develop a form of cerebral palsy. The lifetime cost per patient with cerebral palsy, including health care, productivity and social costs, is estimated to be around €830,000 (1).

In 2015 NICE (NG25) recommended administration of magnesium sulphate (MgSO4) in very preterm births as a core part of maternity care to substantially reduce the risk of cerebral palsy by 30%, based on accumulating evidence in support of its brain protective potential (2).

For every 37 mothers below 30 weeks gestation who receive magnesium sulphate, one case of cerebral palsy is prevented.

However, the uptake of MgSO4 in the UK remained relatively low, compared with the rest of the developed world. The National Neonatal Audit Programmes report demonstrated an uptake of 44% for eligible babies in England in 2016, and 60% in 2017 (3).

Sources: 

  1. Kruse M, Michelsen SI, Flachs EM, Bronnum-Hansen H, Madsen M, Uldall P. Lifetime costs of cerebral palsy. Developmental Medicine and Child Neurology. 2009;51(8):622-8.
  2. 2015 NICE Guideline 25: Preterm labour and birth. National Institute for Health and Care Excellence (Available from: https://www.nice.org.uk/Guidance/NG25)
  3. National Neonatal Audit programme (NNAP) 2017 and 2018 [Available from: http://www.rcpch.ac.uk/improving-child-health/quality-improvement-and-clinicalaudit/national-neonatal-audit-programme-nn-3)

Our approach

Health Innovation West of England developed PReCePT with University Hospitals Bristol and Weston NHS Foundation Trust to help reduce cerebral palsy in preterm babies by optimising administration of MgSO4 to eligible women in preterm labour (less than 30 weeks), using a quality improvement (QI) approach.

Following successful rollout of PReCePT across all five maternity units in the West of England in 2014-15, PReCePT was selected as one of the Health Innovation Network’s seven national adoption and spread programmes during 2018-2020, funded by NHS England. Health Innovation West of England led on this programme.

Delivered through the 15 innovation networks, the PReCePT programme used standardised QI resources such as toolkits, implementation guides and dashboards. Midwife champions were funded to deliver PReCePT in each maternity unit and regional clinical leads supported delivery across each geographical area.

PReCePT also benefitted from £0.5 million in ‘Scaling Up’ funding from the Health Foundation to run a cluster randomized trial nested within the national programme. Known as the PReCePT Study, this aimed to assess whether an enhanced QI intervention improved the uptake of MgSO4 in preterm births over and above the national PReCePT programme.

“As a mother who has gone through pregnancy and preterm birth, it is inconceivable to me that there wouldn’t be a joined-up approach across the whole perinatal team. It’s any mother’s expectation that the care she receives during her pregnancy and preterm birth and the subsequent care of her baby are delivered seamlessly.”

Monica Bridge, Parent Partner

Impacts to date

PReCePT has led to improved compliance with NICE guidance, increasing awareness of the use of MgSO4 as a neuroprotector, developing care pathways and support through a range of QI tools and training.

By the end of the Health Innovation Network’s national programme in March 2020, all 152 maternity units in England had adopted PReCePT. The programme achieved its aim of 85% uptake and variation in administration was significantly reduced.

An estimated 48 cases of cerebral palsy were avoided as a result of PReCePT, saving an estimated £38.4 million in lifetime health and social care costs (figures from 2018-2021).

Feedback from midwives in lead or champion roles demonstrated that PReCePT enabled them to develop their units, themselves and each other in QI skills and thinking, supporting greater collaboration.

An important outcome of the programme was increased accuracy in reporting and collection of MgSO4 administration data, data monitoring, and follow-up of missed cases.

Published in January 2023, an evaluation of the national programme, led by NIHR ARC West, found that PReCePT was both effective and cost-effective.

“I was fortunate and privileged to partner first with the Health Innovation West of England and then the national network to scale up PReCePT into every maternity unit in England. I was tasked with leading the clinical leadership for the national programme. There was no blueprint or roadmap for this sort of intervention, and we had to come up with an innovative model. I believe that a key ingredient in our success was enabling clinicians to lead. It was about enabling perinatal team leadership, bringing together obstetricians, neonatologists and midwives. Leadership is about creating more leaders, rather than followers.”

Dr Karen Luyt, Neonatologist, University Hospitals Bristol and Weston NHS Foundation Trust

Next steps

The administration of MgSO4 as a neuroprotector has been included in the NHS Long Term Plan, the national Patient Safety Strategy as well as Saving Babies Lives v2. It is a key component of the national Maternity and Neonatal Safety Improvement Programme’s Optimisation and Stabilisation of the Preterm Infant primary driver.

“I believe strongly that every woman who goes into labour under 30 weeks should have the chance to have this medicine because it’s a no-brainer really. It’s easy to do and it doesn’t cost a lot and you can just see that it can transform lives for both children and all of their families.”

Elly Salisbury, Parent Partner

The information in this case study is based on these time periods:

  • West of England: March 2014 – March 2015
  • Health Innovation Network national adoption and spread programme: April 2018 – March 2020
  • Health Foundation PReCePT Study / ‘Scaling Up’ project: April 2018 – November 2020

For more information email healthinnowest.transformation@nhs.net. 

Health Innovation Programme

We have run the Health Innovation Programme (HIP) as an innovation business development course to help healthcare entrepreneurs test the validity of their business models and understand how to pitch their propositions to the NHS, amid a very complex NHS business landscape.

The programme was developed as a collaboration between four AHSNs (West of England, Kent Surrey & Sussex, Wessex and South West) and the global no. 1 university business incubator, SETsquared.

We worked in partnership with SETsquared to deliver the Health Innovation Programme (HIP) locally once a year.

Innovations that have benefitted from our local HIP include:

  • A pain self-management app
  • A breastfeeding support app
  • A rehabilitation solution for patients with neurological conditions
  • An app for self-measurement of vision
  • A virtual support provider for vulnerable people
  • A staff engagement tool

“I learned a huge amount in the HIP bootcamp training and was able to share my business ideas with fellow innovators, present my business proposition to a panel of experts and start building relationships with a network of experts and fellow entrepreneurs. Since then, I have continued to receive ongoing support from the AHSN with regards to funding opportunities, application reviews, pilot evaluations and connecting me to NHS maternity services and commissioners.”

Dr Chen Mao Davies, Founder/CEO of Anya and HIP graduate 2018

The challenge

Innovation is critical to enabling the NHS to achieve its ambitions, but it will not meet its financial or capacity challenges by relying purely on innovation from within. It needs to work creatively with industry to meet the efficiency challenges facing the healthcare system, in order to improve quality of services and deliver better outcomes for patients.

Many commercial industries, such as shopping, holidays, insurance and journalism have benefited from adapting new technologies and new ways of working, and so too must the healthcare sector – discovering innovations with promise that can be developed, adapted and adopted.

However, most start-up businesses fail within two years – and often this is due to poor business planning, misunderstanding the market, or failing to clearly identify and express the value proposition to investors or customers.

Add to that the complexity of the NHS as a marketplace and the high hurdles that need to be cleared for regulatory approval, and the NHS becomes a particularly difficult market to succeed in.

The Health Innovation Programme (HIP) helped to bridge this gap, by helping healthcare entrepreneurs to fully understand their marketplace and develop a business proposition with real potential to transform healthcare.

Our approach

We worked works in partnership with SETsquared to deliver the Health Innovation Programme (HIP) locally once a year.

  • An intensive fully funded health innovation business development course, the Health Innovation Programme (HIP) targets people with innovative business propositions with genuine potential to transform health and care.
  • Historically run face-to-face over four full days, the course has been delivered virtually over five half days since 2020, with optional afternoon networking and 1:1 mentoring.
  • The programme has run every year since 2015.
  • While covering core skills in entrepreneurship, HIP also provides delegates the opportunity to make a compelling pitch to an experienced panel, to network with like-minded innovators, and the chance to get continuing support from their local AHSN to further develop their proposition.

“The HIP provided us with a good introduction to business and operating in the NHS. It supported us to improve ideas and our business case and provided insight to improve strategy. It started a thought process that ultimately led us to pivot our business model to be more NHS focussed and integrated. We continue to work with the West of England AHSN, which has supported us throughout our innovation journey; connecting us with appropriate organisations, helping us to write bids for funding and it is with their support that we have now moved onto a very different phase of our journey – from business development to NHS deployment and scale.”

Carey McClellan, Founder/CEO of getUBetter and HIP graduate 2015

Impact to date

The West of England’s HIP has supported 134 healthcare entrepreneurs across the region to develop businesses that improve patient care, generate savings for the NHS, create jobs and economic growth. Our business support has included helping them to refine their propositions, take their businesses forward, launch new products, secure investments and widen business networks.

New products and services
HIP graduates have been supported in the development of a number of new healthcare products and services. These include:

  • getUBetter – a pain self-management app

Carey McClellan is the Founder/CEO of getUBetter – a physiotherapy self-management digital therapy platform that integrates with local musculoskeletal (msk) pathways, to aid the recovery and prevention of minor injuries. He is also a graduate of the 2015 Healthcare Innovation Programme.  The app, which launched in 2016, is now deployed in the NHS and occupational health sectors across South London and South West England and is prescribed by clinicians (GP, physiotherapist, occupational health) during patient consultation. Visit the getUBetter website for more information or watch this video.

  • Anya – a pregnancy, parenting and breastfeeding support app

Dr Chen Mao Davies is the Founder/CEO of Anya – a parenting support app using 3D interactive technology – and a graduate of the 2018 Health Innovation Programme. To date, Dr Davies has won over £250,000 grant funding from Innovate UK, EU, UnLtd and the NHS, partnered with 12 NHS trusts across the UK, as well as Virgin Care, to pilot the technology and, in 2021, won the prestigious Innovate UK’s ‘Women in Innovation Award’. The app is now available on NHS prescription in select regions. Find out more about Anya here.

  • SoleSense – a digital rehabilitation platform for patients with neurological conditions

Caz Icke is a specialist neurophysiotherapist and the developer/Director of SoleSense – a digital rehabilitation platform for patients with neurological conditions affecting balance and walking. Her innovation, SoleSense utilises sensory insoles to provide biofeedback that helps patients perform better independent exercise. She graduated from the Health Innovation Programme in 2019, which has, to date, led to a partnership with a Senior Research and Innovation Director in the NHS and a ‘Women in Innovation Award’ from Innovate UK IN 2021. Visit the SoleSense website to find out more.

“The Health Innovation Programme gave me a crash course in business and taught me how to pitch into the NHS. Since graduating they have helped me in writing grant applications to source funding (something I used to very difficult) and with their help, I was successful in winning the Innovate UK Women in Innovation Award, which has been a huge catalyst for my business!”

Caz Icke, Director of SoleSense and HIP graduate 2019

Next steps

We continue to support the graduates of the programme through our HIP Alumni.

 

The information in this case study is based on the period from 2015 to March 2023.

NEWS – National Early Warning Score

Prior to use of the National Early Warning Score (NEWS) across healthcare systems there was no standardised response to deterioration or common ‘language’ used at all handovers of care for acutely unwell patients.

The Royal College of Physicians (RCP) developed NEWS and the updated NEWS2 as an aggregate scoring system of physiological observations that act as a ‘track and trigger’ for deterioration, providing a common language across settings.

Supported by Health Innovation West of England, NEWS was adopted across all elements of the region’s healthcare system, bringing together healthcare staff to work collaboratively, share ideas, experiences and data around implementation.

The use of NEWS across the West of England demonstrated improved outcomes compared to the rest of the country and NEWS2 was subsequently rolled out nationally through Health Innovation West of England’s Patient Safety Collaboratives in 2018-20.

NEWS2 continues to be used in all health and community care settings and has been advocated, alongside clinical judgement, as a tool to support monitoring of patients with COVID-19.

Further work around managing patient deterioration in the West of England has evolved from the success of our adoption and spread of NEWS, including the Emergency Department (ED) Safety Checklist and use of ReSPECT (Recommended Summary Plan for Emergency Care and Treatment).

“The Early Warning Score empowered us to explain the necessity for immediate referral to the acute sector. The good news is that thanks to NEWS and the sepsis screening tool, the right response was received at the right place enabling the patient’s life to be saved”.

North Somerset Community Partnership Rapid Response

You can also watch our National Early Warning Score (NEWS): Supporting clinical judgement and patient safety video here.

The challenge

Prior to the use of NEWS, health care settings did not use the same common language or set of measurements at the handovers of care.  This resulted in a lack of consistency in identification and response to acute illness.

NEWS is a simple scoring system, based on the six physiological measurements that make up the routine vital signs of an adult patient. By monitoring scores over time, NEWS can demonstrate a positive response to treatment, or more importantly, allow early detection of patient deterioration. Early recognition and management of deterioration leads to improved outcomes for patients.

In 2015, NEWS was only used in some hospitals in the West of England and was not used at all in pre-hospital care.

Our approach

In March 2015, the West of England Patient Safety Collaborative became the first region to implement NEWS.  In the West of England 26 organisations – including all acute trusts, out-of-hours GP services, mental health trusts, community service providers and three clinical commissioning groups – agreed to support the adoption and spread of NEWS and to communicate the score at handovers of care across the system. We produced a suite of resources, including a NEWS2 toolkit, to support implementation.

We used an IHI Breakthrough collaborative model to bring people together every six months, with local task groups meeting more frequently. Health Innovation West of England facilitated the introduction of NEWS into the South Western Ambulance Service Foundation Trust’s electronic Patient Care Record and supported implementation and spread.

Health Innovation West of England also created Primary Care, ED and Community Collaboratives to enable sectors to meet and share best practice on patient safety including NEWS and the ED Safety Checklist . Work was also undertaken with the sepsis cluster. In addition, band 4 healthcare providers in the community were trained on human factors and SBAR communication.

During the pandemic, and in line with the British Geriatrics Society paper offering key recommendations to help care home staff support residents through the pandemic, we focused on training care home staff in the use of NEWS2 as part of RESTORE2 training. Free training on RESTORE2 mini is also provided for residential and domiciliary care workers to spot, and act on, the soft signs of deterioration.

Impact to date

To illustrate where NEWS has improved patient outcomes by use of consistent assessment and triggering of responses across patient pathways a number of patient stories have been collated from across the region. The stories include a patient in North Somerset, who made a quick and full recovery from sepsis as a result of his NEWS being communicated at every handover of care.

From 2018 to 2020, NEWS2 was rolled out nationally through the our Patient Safety programme, commissioned by NHS Improvement. Prior to the programme’s selection for national adoption and spread the Health Innovation West of England produced an explainer video to showcase use of NEWS.

In collaboration with ARC West, a systematic review demonstrated that there was no published study where NEWS had been implemented across a healthcare system but that early warning scores were good at predicting short term outcome [1].

A qualitative study demonstrated that NEWS was useful as an adjunct to decision making [2].

We demonstrated distribution of NEWS across pre-hospital settings and showed that a NEWS of 5 was a reasonable trigger for escalation in pre-hospital care [3] and that by using a system approach, patients with higher NEWS reached hospital quicker and were seen more quickly[4].

Health Innovation West of England also demonstrated that NEWS could predict outcomes in patients seen in non-hospital settings and that our system approach led to the West of England having the lowest mortality in England in patients with suspicion of sepsis [5].

The National Confidential Enquiry into Patient Outcome and Death report argued that NEWS has increasingly become part of the lexicon for communication about physiology between all health care providers, enhancing and focusing the handover of technical information about patients, especially those at risk of deterioration.

In 2020, the Health Innovation West of England and NIHR ARC West examined the impact of COVID-19 on NEWS2 across four acute hospital trusts in the West of England region. It found using NEWS2 can help identify those COVID-19 patients who are sickest and at risk of dying. The study was published in Emergency Medicine Journal.

In December 2022, to celebrate the tenth anniversary of NEWS, Clinical Medicine Journal published a special celebratory edition. This featured two papers authored by Health Innovation West of England colleagues:

Next steps

While this Health Innovation West of England programme has now ended, the ongoing impact of our adoption of NEWS, and related collaboratives, continues to be felt today in the work of the AHSN and our Patient Safety Collaborative, particularly around managing patient deterioration.

For instance, our NEWS roll-out led to the training of thousands of care home staff and carers to detect and communicate the soft signs of deterioration. Free videos, produced by Health Innovation West of England and partners, to help staff working in care homes spot and respond to the soft signs of deterioration, have been viewed more than 700,000 times and were shortlisted for a 2021 HSJ Patient Safety Award.

Our Learning Disabilities Collaborative continues to advocate use of NEWS2 and soft-signs tools to support early identification of physical deterioration in patients who may be less able to communicate feeling unwell.

Our programme to support the use of ReSPECT (Recommended Summary Plan for Emergency Care and Treatment), also evolved from insights gained through the ED Collaborative and NEWS project around inappropriate end of life ED attendance and conveyance, alongside our wider work around Structured Mortality Reviews.

Find out more by visiting safer care through NEWS or email: healthinnowest.transformation@nhs.net

 References:

  1. Can early warning scores identify deteriorating patients in pre-hospital settings? A systematic review.  Rita Patel, Manjula D. Nugawela, Hannah B. Edwards, Alison Richards, Hein Le Roux, Anne Pullyblank, Penny Whiting.  Resuscitation 132 (2018) 101-111
  2. Using the National Early Warning Score (NEWS) outside acute hospital settings: a qualitative study of staff experiences in the West of England.  Emer Brangan, Jonathan Banks, Heather Brant, Anne Pullyblank, Hein Le Roux, Sabi Redwood. BMJ Open2018;8:e022528. doi:10.1136/bmjopen-2018-022528
  3. Distribution of the National Early Warning Score (NEWS) across a healthcare system following a large scale roll-out. Lauren J Scott, Niamh M Redmond, Joanna Garrett, Penny Whiting, Kate Northstone, Anne Pullyblank 10.1136/emermed-2018-208140 March 6 2019
  4. Scott LJ, Redmond NM, Tavare A, et al. Association between National Early Warning Scores in primary care and clinical outcomes: an observational study in UK primary and secondary care. Br J Gen Pract. 2020;70(695):e374-e80.
  5. Pullyblank, A., Tavaré, A., Little, H., Redfern, E., le Roux, H., Inada-Kim, M., Cheema, K. and Cook, A.on behalf of the West of England Patient Safety Collaborative. Implementation of the National Early Warning Score in patients with suspicion of sepsis: evaluation of a system-wide quality improvement project.  British Journal of General Practice 8 April 2020; bjgp20X709349. DOI: https://doi.org/10.3399/bjgp20X709349

Emergency Department (ED) Safety Checklist

Patient crowding in Emergency Departments (EDs) makes it difficult for staff to monitor all patients for signs of clinical deterioration. University Hospitals Bristol and Weston developed an innovative ED Safety Checklist to respond to these challenges.

Supported by Health Innovation West of England, the checklist was adopted by all seven EDs and the ambulance service in the region through the formation of an ED Collaborative, bringing together staff to work collaboratively, sharing ideas, experiences and data around implementation.

Following NHS Improvement’s recommendation for the checklist to be used in all EDs, it was rolled out nationally through our Patient Safety Collaboratives in 2018-20.

Further work around managing patient deterioration in the West of England has evolved from the success of our ED Collaborative and the development of the checklist, including adoption of the National Early Warning Score (NEWS2) in urgent care and use of ReSPECT (Recommended Summary Plan for Emergency Care and Treatment).

“International evidence, highlighted in the ‘Keogh Review’ of Urgent and Emergency Care clearly demonstrates the risks that crowded EDs pose to patient safety and outcome. This intervention is designed to directly address these challenges and has already been shown to be effective: it is entirely consistent with national policy in emergency care.”
Professor Jonathan Benger CBE, National Clinical Director for Urgent Care, NHS England

 

You can also catch our Emergency Department (ED) Safety Checklist video here.

The challenge

The UK and other countries have seen an unprecedented increase in demand for ED services in recent years.

Crowding in the ED has a profound impact on staff’s ability to deliver safe and high-quality care. This can lead to delay in recognition and treatment of patients with severe conditions, such as stroke, heart attack and sepsis with associated poor outcomes.

Staffing problems in the ED workforce can lead to reliance on agency and non-ED-trained staff. As demand and workload rise, staff can become overwhelmed by the tasks they need to complete in a timely fashion, whilst managing frequent interruption, and the risk of undetected patient deterioration increases.

Patients sometimes have to wait several hours in the ED for diagnostic tests and inpatient beds, as well as in the ambulance at peak times. The number of healthcare staff who interact with a patient increases and so does the risk of communication errors.

Sources: Paper published in the Journal of Clinical Nursing 

Our approach

Designed to address the challenge of ensuring patient safety during periods of crowding, University Hospitals Bristol and Weston NHS Foundation Trust, led by ED Consultant Dr Emma Redfern, developed and tested an innovative ED Safety Checklist in 2014, initially with support from the Health Foundation and then subsequently the Health Innovation West of England through its Patient Safety Collaborative.

The checklist helps to standardise and improve the delivery of basic care in EDs, systemising the observations, tests and treatments that need to be completed in a certain order. It also addresses quality of care issues, such as provision of pain relief, nutrition and hydration. It serves as an aide-memoire for busy staff, and any doctor, nurse, bank or agency staff can join the department and provide the right care by following the time-based framework of tasks.

Following the success of the initiative at University Hospitals Bristol and Weston, the West of England Patient Safety Collaborative supported all seven EDs and the ambulance service in the region to successfully adopt, adapt and refine the checklist through the formation of an ED Collaborative in 2016, using the IHI breakthrough collaborative model and quality improvement methodology.

The ED Collaborative brought together clinical and non-clinical representatives from all the trusts to work collaboratively, sharing ideas, experiences and data around implementation.

Health Innovation West of England developed a suite of resources, including a toolkit to support adoption. The toolkit includes a project plan, educational/promotional material, data collection tools, role specifications and a generic dashboard.

Impact to date

In July 2017, the ED Safety Checklist won the HSJ Patient Safety Award for ‘Best Patient Safety Initiative in A&E’. The judges felt the checklist had achieved a significant impact on patient safety and, having already spread across multiple organisations, could see the potential for wider adoption across the country.

There was a rapid move towards national adoption when NHS Improvement wrote to all trusts in England in October 2017 to recommend implementation of the ED Safety Checklist, unless they already had an equivalent evidence-based system in place.

From 2018 to 2020, the ED Safety Checklist was rolled out nationally through our Patient Safety Collaborative adoption and spread programme, commissioned by NHS Improvement. In 2019/20 the we found that the number of trusts using the checklist was 76%, a site adoption increase of 50%.

ARC West evaluated implementation and use of the ED Safety Checklist in the West of England during 2017. The evaluation found that dedicated training time and full integration with existing clinical documentation led to the best outcomes.

As a result of adoption of the checklist across the region, the number of majors / resus patients having their NEWS calculated within an hour of admission to ED had improved from an average of 55% to 84% in the first year, while those having their pain score calculated had increased from 59% to 93%. The number of ECGs requested within 10 minutes of arrival increased from 36% to 71% in appropriate patients. There was an increase of 5% in CT scanning within an hour for patients with a suspected stroke.

In February 2020 ARC West published a paper evaluating the Emergency Department Checklist to enhance patient safety. This resulted in updates to Health Innovation West of England’s toolkit.

Use of the checklist (or an equivalent) is now supported and endorsed by NHS England and NHS Improvement, the Royal College of Emergency Medicine, the Royal College of Nursing, and the Care Quality Commission.

“We are delighted to have been involved – the checklist has been a great tool to help us improve both safety and patient experience in the ED. Led by our clinical staff, a multidisciplinary team has been involved in making this checklist work at its best in both our emergency departments.”
Quality Improvement & Safety Director, Gloucestershire Hospitals NHS Foundation Trust

Next steps

While this Health Innovation West of England programme has now ended, the ongoing impact of our ED Collaborative continues to be felt today in the work of the Health Innovation West of England and our Patient Safety Collaborative, particularly around managing patient deterioration.

For instance, the establishment of the ED Collaborative marked the start of our work in urgent care with the National Early Warning Score (NEWS). Our programme to support the use of ReSPECT (Recommended Summary Plan for Emergency Care and Treatment), also evolved from insights gained through the ED Collaborative around inappropriate end of life ED attendance and conveyance, alongside our wider work around NEWS and Structured Mortality Reviews.

Our work on the ED Safety Checklist began in April 2016 and ended in March 2020.

Find out more about the ED Safety Checklist here or email us: healthinnowest.transformation@nhs.net.