Sep 122019

David Wastell is a Registered Nurse and Service Improvement Manager within the Acute Deterioration team in 1000 Lives Improvement.

We spoke to him about the ongoing roll out of Community NEWS in Wales –  a key part of the  *1000 Lives Improvement response to the challenge included in the ‘A Healthier Wales’ plan to improve management of acute illness across the whole system pathway.

Tell us a bit about your background

I qualified in Sydney Australia 21 years ago. My background has predominately been working in Intensive Care Units, I was fortunate to be involved in the ‘Between the Flags’ Programme in New South Wales and the implementation of colour coded charts in the health board in Northern Sydney. This was my first exposure to a chart that aided staff at the front line in identifying Acute Deterioration (AD).

How are charts being used in Wales?

I returned to Wales in 2014 and was amazed to find that colour coded, scoring observation charts were being widely used in the acute care sector and were a key element in identifying patients with Sepsis.   NHS Wales has since been internationally recognised through the ‘Global Alliance Award’ (2016) for embedding a standardised approach to identifying Sepsis in acute settings through NEWS.

Until 2017, the primary focus for the Acute Deterioration team was working within acute settings. However, the emphasis has recently shifted in line with the ‘Healthier Wales’ agenda, and we are now focussed on working with staff in community settings to embed NEWS in practice. This is with the aim of making NEWS the single language for identifying patients at risk of acute deterioration across all parts of the health and social care system together.  Through the implementation of NEWS and the early warning scoring system for Acute Deterioration, discussions around ceiling of treatment, escalation of care and Advanced Care Planning can be at the forefront of the individuals needs thus potentially providing care closer to home.

What’s the scale of this work in the community?

It’s huge – there are over 170 teams across Wales and together that totals over 1500 district nurses alone.  We are also working with GPs, and Acute Response Teams across every health board as well as First Responders (Welsh Ambulance Services Ambulance and St John’s Wales). My role is to assist individuals and teams to look at their systems and processes in relation to acute deterioration and implement standardised improvement measures and tools across their teams to improve the identification of patients at risk of acute deterioration (including Sepsis).

What improvement measures and tools do you mean? 

Working within the new Improvement framework we have supported community teams with the Model for Improvement, stakeholder engagement and forcefield analysis and using data collection and analysis tools. Utilising interactive maps of Wales we are able to plot the progress of the teams with a traffic light system. As the various teams have become NEWS Ready (Amber) to NEWS Active (Green), it is a visual representation of the improvements teams and health are making. Vitally important has been the monthly Programme Leads days, it has provided the opportunity for shared learning, in a supportive and non-judgemental environment. We have also developed  tools such as NEWS charts, sepsis screening tools and Acute Kidney Injury bundles.  You can download these from the 1000 Lives Improvement website or request copies from any members of our national team.

Why did the focus shift to community settings?

The success of NEWS in acute settings shows that it provided the basis for a unified and systematic approach to the first assessment and triage of acutely ill patients. It is a simple track-and-trigger system for monitoring clinical progress for all patients – reflected by its use today in 60 hospitals in Wales, as well as by the Welsh Ambulance Service (WAST).

However, there appeared to be a gap between what was happening in the Acute Care Sector and that of the Community. I had the opportunity in 2017 to undertake some work with Eve Lightfoot (RCN Nurse of the year 2018), to get involved with District Nurse training around Sepsis awareness and acute deterioration. I quickly realised that teams had obvious enthusiasm and desire to utilise NEWS but appropriate education around AD and Sepsis recognition was missing. At the same time, teams had limited resources yet their workload and complexity of patients’ needs was increasing dramatically.

I spent a lot of initial time shadowing District Nursing Leads and teams across Wales where I observed varied cases; from daily visits to check blood ketones and catheter flushes, to complex leg dressings and abdominal wound packing.

The focus was to observe the number of patients having a full set of observations and from that having a baseline NEWS score.  This was not happening regularly.

The need to provide care closer to home for the people of Wales was fully supported by the Welsh Government and in particular the “Healthier Wales” strategy document made it a priority. In March 2019 the Chief Nursing Officer (CNO) mandated that NEWS should be rolled out and be implemented by all district nursing teams across Wales.

 What difference would NEWS have made to changing outcomes in the cases observed?

If NEWS had been available in many of the cases that I observed, it would have provided a subjective measure of any deterioration and perhaps trigger the question around possible Sepsis.  It also became very evident that staff did not have all the necessary equipment to provide a NEWS assessment. Training was needed to be provided around the recognition and response to Acute Deterioration in the community, and at an-all-Wales level.   That became our programme focus.

How do you think improvement knowledge and training will make a difference to staff and patients?

Personally, I have seen in two continents the impact of embedding a systematic approach in identifying an unwell patient, underpinned by an improvement mind- set and desire to change. NEWS in the Community Sector in Wales will have a massive impact on how we communicate to patients and families. I believe NEWS will greatly improve the care we give, putting the person at the centre of everything we do.

For professionals, in particular more junior staff members, it will offer them the skills, tools and training resources they need to make changes that give them a greater sense of personal and team achievement.  On that level, NEWS is an empowering tool.

For the first time we now have a common sickness language that connects all parts of the health and social care system together in Wales. Through NEWS, everyone is speaking the same language for identifying Acute Deterioration and sepsis, and at the earliest point in time which we know makes a huge difference. This is exciting for everyone, most of all our patients!

*1000 Lives Improvement is re-launching as Improvement Cymru – the new all-Wales improvement service for health and social care.  Join us at the launch In November. Read about it and sign up here

Apr 032019

We catch up with Evie Lightfoot, District Nurse from Hywel Dda University Health Board on winning the RCN in Wales Nurse of the Year 2018 and the role Quality Improvement has played in her work.

Evie has developed training to help community nursing staff recognise sepsis in patients.

What does this award accolade mean to you personally and professionally?

I am so privileged to have won this award. At times I felt like giving up as it was quite a lonely journey, juggling the role of being a working single mum of 3 children with a District Nursing caseload and a research internship!

Receiving the award and recognition for my passion and dedication has made it all worthwhile and will hopefully encourage others to get involved in a project that they are passionate about.

The purpose and drive was to improve patient safety and recognition of sepsis and appropriate escalation in the community, by doing this it has enhanced the nursing teams’ knowledge, and skills, and helps to empower them to escalate appropriately.

I hope it has also raised the profile of District Nursing, improving the understanding of the important and often complex role that we have in delivering home based care, highlighting how the role of the District Nurse has evolved into a multi-faceted job caring for patients and their families with often unpredictable and complex health care needs.

On a personal note, winning the RCN in Wales Nurse of the year award 2018 and the RCN Community Nurse of the year award has been very exciting and a great honour. It has given me a platform from which to work with others to promote the role of Community Nurses in the quest to improve patient care. It has brought new opportunities and experiences which will broaden my knowledge and increase my confidence, helping to open up new possibilities for my future career. I am very privileged to have been given this opportunity.

Where did your journey begin?

My journey began almost 7 years ago when I started working as a community nurse. I had previously been employed as a junior sister in A&E and had ITU experience, so was used to assessing unwell patients using NEWS – National Early Warning Scoring System and Sepsis screening.

It was apparent to me straight away that community nurses did not have the appropriate training / education to recognise a deteriorating patient.  NEWS observations were not performed in the community and staff had not had any Sepsis education training. Nor did they have the correct equipment to carry out a full set of observations.

I tried to voice my concerns which wasn’t easy, as at this time it wasn’t recognised that Sepsis was a problem in the community or that there was a need for community nurses to perform NEWS observations. This left me feeling frustrated.

I completed my SPQ District nursing degree and went on to do a research internship where my project was to establish District Nurses current knowledge of sepsis and appropriate escalation. I wrote a bespoke community sepsis education package which I delivered with the help of a colleague from the 1000 lives team. We delivered the training to over 100 nurses across Carmarthenshire, the plan was to then re questionnaire them 3 months later.

This initial project was a catalyst and it uncovered lots of issues that needed to be addressed in order to improve patient safety.

What were some of the challenges along the way and how did you overcome them?

It has been a constant challenge and still is!

There were initial concerns that if I delivered sepsis awareness education and NEWS observations to community nurses that they would suddenly escalate inappropriately and that here would be a large queue of people outside GP surgeries and A&E.  It was also suggested that you didn’t need a score to know if someone was sick.

So I have had to reassure and explain that although NEWS is a valuable tool to detect deterioration and possible sepsis, it does not replace a practitioner’s clinical judgement it, is there to support and enhance it.

The NEWS system is also a common communication language used by the Welsh ambulance service and secondary care. This means that for Community and Primary care if you need to escalate a patient who is deteriorating the use of NEWS will help the process.

Even at an early stage there were practical obstacles such as finding venues to teach, to try and get staff to attend due to staffing problems and even down to the equipment and having to transport and carry a heavy TV and trolley to venues!.

I have worked closely with Chris Hancock and the 1000 lives acute deterioration team for many years involved in the National Out of Acute Hospital RRAILS group as well as Health board Out of acute hospital work.

The support that I have received from 1000 lives has been pivotal to the success of my work, they have been a fantastic team to be involved with and to help drive my initiative.

They continue to be a team that I liaise and meet with frequently to help drive forward the acute deterioration work in the community and I am excited and proud to be involved with the official launch of NEWS into Community nursing this March.

Would you recommend the Quality Improvement approach to others looking to make a change? And what do you think is key to sustaining improvement?

Yes using a QI approach allows a structured system, it prompts you to collect data and see what is working or not, and what needs to be changed. I only wish I had done this from the beginning of the project more diligently, but It’s all a learning process I guess.

I have learnt that with the best will in the world giving education and tools isn’t enough. You have to evaluate what change has taken place to inform future practice.

For it to succeed you can’t be precious, It’s imperative to share ideas and get other people on board so that the change can be embraced by others to ensure that it gains ownership and sustainability to be embedded into practice.

Do you have a plan for building on your success?

I am still collecting data, so currently success for me is measured by the feedback that I am receiving from staff and patients. The Community SBAR tool is going to be launched officially, this will then allow me to measure the outcomes of when patients care is escalated in the community. To evidence the good work that is being done by community nurses.

I am also hoping that with the launch of NEWS nationally on March 21st this will further help to embed best practice within the community nursing teams in HDUHB and nationally.

I am hoping that NEWS and the SBAR approach will be embraced into Primary Care with many interested already from care homes and GP practices.

I have recently set up a task and finish group to redesign our transfer of care document so that it contains more pertinent information that is needed, such as NEWS score, if a DNA CPR is in place etc. This will hopefully improve communication between secondary and community care. The plan is for the document could be used on transfer from hospital or from a care setting or form community, rather than just a discharge letter.

I am also very interested in doing a project in the future to look at post sepsis care and support of patients in the community.

I am currently undertaking further Quality Improvement work to establish how well the NEWS is being embraced by the community nursing teams and to be able to measure the outcomes.

What words of encouragement would you offer to others starting on an improvement journey?

I believe that it’s important to have a strong defined aim of what you are trying to achieve and why, you must keep this in mind throughout the process, to help keep your motivation up and to prevent you deviating.

If your idea to implement change is backed with integrity and a strong desire to improve patient care and the practice then you are on the right track.

Make sure your idea is evidence based and that it is something you are passionate about. You have to gain thick skin and broad shoulders, not everyone will like or agree with your ideas, it’s about developing coping strategies and enhancing communication skills to deal with it!

Learn from the hurdles and obstacles, celebrate the successes even when they small, keep knocking on doors as networking with others is the key to success.


Apr 032019

Rydym ni’n dal i fyny gydag Evie Lightfoot, Prif Nyrs Iau Tîm Ymateb Acíwt (ART) yn Sir Gâr, Bwrdd Iechyd Prifysgol Hywel Dda, ar ôl ennill Nyrs y Flwyddyn RCN yng Nghymru 2018, a’r rôl y mae Gwella Ansawdd wedi’i chwarae yn ei gwaith.

Mae Evie wedi datblygu hyfforddiant i helpu staff nyrsio cymunedol i adnabod sepsis mewn cleifion.

Beth mae’r wobr yn hon yn ei olygu i chi yn bersonol ac yn broffesiynol?  

Mae’n fraint fawr ennill y wobr hon. Ar adegau, roeddwn i’n teimlo fel rhoi’r gorau iddi, oherwydd yr oedd hi’n daith eithaf unig, yn jyglo’r rôl o fod yn fam sengl i dri o blant sy’n gweithio, gyda baich achosion Nyrsio Ardal ac interniaeth ymchwil!

Roedd derbyn y wobr a’r gydnabyddiaeth am fy mrwdfrydedd a’m hymroddiad wedi gwneud y cyfan yn werth chweil, a gobeithio bydd hyn yn annog pobl eraill i gymryd rhan mewn prosiect y maent yn frwdfrydig amdano.

Y diben a’r nod oedd gwella diogelwch cleifion ac adnabod sepsis, a chynnydd priodol yn y gymuned, trwy wneud hyn, mae wedi gwella gwybodaeth a sgiliau timau nyrsio, ac mae’n helpu i’w grymuso nhw i ddatblygu’n briodol.

Rwyf hefyd yn gobeithio ei fod wedi codi proffil Nyrsio Ardal, gan wella dealltwriaeth o’r rôl bwysig, a chymhleth yn aml, sydd gennym o ran cyflwyno gofal yn y cartref, ac amlygu sut mae rôl y Nyrs Ardal wedi datblygu i fod yn swydd aml-ffasedog yn gofalu am gleifion a’u teuluoedd, gydag anghenion gofal iechyd cymhleth ac anrhagweladwy yn aml.

Yn bersonol, mae ennill Gwobr Nyrs y Flwyddyn RCN yng Nghymru 2018, a Nyrs Gymunedol y Flwyddyn RCN, wedi bod yn gyffrous iawn, ac yn anrhydedd mawr. Mae wedi rhoi llwyfan i mi weithio gyda phobl eraill i hyrwyddo rôl Nyrsys Cymunedol yn y cwest i wella gofal cleifion. Mae wedi arwain at gyfleoedd a phrofiadau newydd, a fydd yn ehangu fy ngwybodaeth a chynyddu fy hyder, a helpu i gyflwyno posibiliadau newydd ar gyfer fy ngyrfa yn y dyfodol. Mae wedi bod yn fraint fawr cael y cyfle hwn.

Ble ddechreuodd eich taith?

Dechreuodd fy nhaith bron i 7 mlynedd yn ôl, pan ddechreuais weithio fel nyrs gymunedol. Roeddwn i wedi cael fy nghyflogi’n flaenorol fel prif nyrs iau yn yr adran damweiniau ac achosion brys, ac roedd gen i brofiad yn yr uned triniaeth ddwys, felly roeddwn i’n gyfarwydd ag asesu cleifion anhwylus gan ddefnyddio NEWS – System Sgôr Rhybudd Cynnar Cenedlaethol, a sgrinio Sepsis.

Roedd yn amlwg i mi ar unwaith nad oedd gan nyrsys cymunedol yr hyfforddiant / addysg briodol i adnabod claf sy’n dirywio. Ni chafodd arsylwadau NEWS eu cyflawniad yn y gymuned, ac nid oedd staff wedi cael unrhyw hyfforddiant addysg sepsis. Ac nid oedd ganddynt yr offer cywir i gyflawni set lawn o arsylwadau chwaith.

Ceisiais leisio fy mhryderon, nad oedd yn hawdd iawn oherwydd, ar y pryd, nid oedd sepsis yn cael ei gydnabod fel problem yn y gymuned, a bod angen i nyrsys cymunedol gyflawni arsylwadau NEWS. Roedd hyn yn gwneud i mi deimlo’n rhwystredig iawn.

Fe wnes i gwblhau fy Ngradd Nyrsio Ardal SPQ, a mynd ymlaen i wneud interniaeth ymchwil, lle sefydlwyd fy mhrosiect i sefydlu gwybodaeth Nyrsys Ardal presennol am a chynnydd priodol. Ysgrifennais becyn addysg sepsis cymunedol pwrpasol, a chyflwynais hwn gyda help cydweithiwr o dîm 1000 o Fywydau. Fe gyflwynom yr hyfforddiant i dros 100 o nyrsys ledled Sir Gâr, a’r cynllun wedyn oedd eu holi nhw eto 3 mis yn ddiweddarach.

Roedd y prosiect cychwynnol hwn yn gatalydd, ac fe wnaeth ddadorchuddio llawer o broblemau yr oedd angen mynd i’r afael â nhw er mwyn gwella diogelwch cleifion.

Beth oedd rhai o’r heriau ar hyd y ffordd, a sut gwnaethoch chi eu goresgyn?

Mae wedi bod yn her gyson, ac mae’n parhau i fod!

Roedd pryderon i ddechrau, petawn i’n cyflwyno addysg ymwybyddiaeth o sepsis ac arsylwadau NEWS i nyrsys cymunedol, y byddent yn cynyddu’n amhriodol yn sydyn, ac y byddai ciw mawr o bobl y tu allan i feddygfeydd ac adrannau damweiniau ac achosion brys. Awgrymwyd hefyd nad oedd angen sgôr i wybod a oedd rhywun yn sâl.

Felly, rydw i wedi gorfod tawelu meddwl ac esbonio, er bod NEWS yn offeryn gwerthfawr i ganfod dirywiad a sepsis posibl, nid yw’n amnewid dyfarniad clinigol ymarferydd, mae yno i’w ategu a’i wella.

Mae NEWS hefyd yn iaith gyfathrebu gyffredin a ddefnyddir gan Wasanaethau Ambiwlans Cymru a gofal eilaidd. Mae hyn yn golygu, ar gyfer gofal cymunedol a sylfaenol, os oes angen i chi uwchgyfeirio claf sy’n dirywio, a bydd defnyddio NEWS yn helpu’r broses.

Yn gynnar, hyd yn oed, roedd rhwystrau ymarferol, fel dod o hyd i leoliadau i addysgu, i geisio cael staff i fynychu oherwydd problemau staffio, a hyd yn oed yr offer a gorfod cludo a chario teledu trwm a throli i leoliadau!

Rwyf wedi gweithio’n agos â Chris Hancock a thîm dirywio acíwt 1000 o Fywydau ers nifer o flynyddoedd, bod yn gysylltiedig â grŵp RRAILS Allan o Ysbyty Acíwt Cenedlaethol, yn ogystal â gwaith Allan o Ysbyty Acíwt Byrddau Iechyd.

Mae’r gefnogaeth rydw i wedi’i derbyn gan 1000 o Fywydau wedi bod yn ganolog i lwyddiant fy ngwaith, maen nhw wedi bod yn dîm gwych i fod yn gysylltiedig â nhw, ac i helpu hybu fy menter.

Maen nhw’n parhau i fod yn dîm rydw i’n cysylltu â nhw ac yn cyfarfod â nhw’n aml i helpu hybu’r gwaith dirywio acíwt yn y gymuned, ac rwy’n gyffrous ac yn falch o fod yn gysylltiedig â lansiad swyddogol NEWS mewn nyrsio cymunedol ym mis Mawrth.

A fyddech chi’n argymell yr ymagwedd Gwella Ansawdd i bobl eraill sydd eisiau gwneud newid? A beth ydych chi’n meddwl sy’n allweddol i gynnal gwelliannau?

Mae defnyddio ymagwedd gwella ansawdd yn caniatáu system strwythuredig, mae’n eich hybu chi i gasglu data a gweld beth sy’n gweithio ai peidio, a beth sydd angen ei newid. Pe bawn i ond wedi gwneud hyn o ddechrau’r prosiect yn fwy dyfal, ond mae’r cyfan yn broses ddysgu, am wn i.

Rydw i wedi dysgu, hyd yn oed â’r ewyllys gorau yn y byd, nad yw rhoi addysg ac offer yn ddigon. Rhaid i chi werthuso’r newid sydd wedi digwydd i lywio ymarfer yn y dyfodol.

Er mwyn sicrhau ei fod yn llwyddo, ni allwch fod yn fursennaidd. Rhaid rhannu syniadau a chael pobl eraill yn gysylltiedig er mwyn i bobl eraill allu derbyn y newid i sicrhau ei fod yn cael ei ddefnyddio a’i fod yn gynalidawy, er mwyn ei ymgorffori mewn ymarfer.

A oes gennych chi gynllun i adeiladu ar eich llwyddiant?

Rwy’n dal i gasglu data, felly ar hyn o bryd, caiff y llwyddiant ei fesur yn ôl yr adborth rwy’n ei dderbyn gan staff a chleifion. Bydd yr offeryn SBAR cymunedol yn cael ei lansio’n swyddogol, a bydd hyn wedyn yn caniatáu i mi fesur y canlyniadau pan fydd gofal cleifion yn cael ei uwchgyfeirio yn y gymuned, i dystio’r gwaith da sy’n cael ei wneud gan nyrsys cymunedol.

Rwyf hefyd yn gobeithio, ar ôl lansio NEWS yn genedlaethol ar 21 Mawrth, bydd hyn yn helpu ymhellach i ymgorffori ymarfer gorau mewn timau nyrsio cymunedol ym Mwrdd Iechyd Prifysgol Hywel Dda, ac yn genedlaethol.

Rwy’n gobeithio y bydd NEWS ac ymagwedd SBAR yn cael eu defnyddio mewn gofal sylfaenol, gyda nifer o gartrefi gofal a meddygfeydd eisoes â diddordeb.

Yn ddiweddar, sefydlais grŵp gorchwyl a gorffen i ail-ddylunio ein dogfen trosglwyddo gofal, er mwyn iddi gynnwys gwybodaeth fwy perthnasol sydd ei hangen, fel sgôr NEWS, a oes gorchymyn DNA CPR ar waith, ac ati. Gobeithio y bydd hyn yn gwella cyfathrebu rhwng gofal eilaidd a chymunedol. Y bwriad yw i’r ddogfen gael ei defnyddio wrth drosglwyddo o ysbyty neu o leoliad gofal, neu o’r gymuned, yn hytrach na llythyr rhyddhau’n unig.

Mae gen i ddiddordeb hefyd mewn gwneud prosiect yn y dyfodol a fydd yn edrych ar ofal ar ôl sepsis, a chefnogi cleifion yn y gymuned.

Rydw i ar hyn o bryd yn cyflawni gwaith Gwella Ansawdd i sefydlu pa mor dda y mae timau nyrsio cymunedol yn defnyddio NEWS, a gallu mesur y canlyniadau.

Pa eiriau o anogaeth fyddech chi’n eu cynnig i bobl eraill sy’n dechrau ar daith wella?

Rwy’n credu ei bod hi’n bwysig cael nod diffiniedig cryf o beth rydych chi’n ceisio ei gyflawni a pham. Rhaid i chi gadw hyn mewn golwg trwy gydol y broses i helpu i sicrhau eich bod chi’n parhau’n frwdfrydig a’ch atal rhag gwyro.

Os yw’ch syniad i weithredu newid yn cael ei ategu gan onestrwydd a dyhead cryf i wella gofal cleifion a’r ymarfer, yna rydych chi ar y trywydd cywir.

Gwnewch yn siŵr bod eich syniad ar sail tystiolaeth a’i fod yn rhywbeth rydych chi’n frwdfrydig amdano. Rhaid i chi fod yn groendew a bod gennych chi ysgwyddau llydan. Ni fydd pawb yn hoffi nac yn cytuno â’ch syniadau. Mae’n ymwneud â datblygu strategaethau ymdopi a gwella sgiliau cyfathrebu i fynd i’r afael â hyn!

Dysgwch o’r rhwystrau, dathlwch y llwyddiannau, hyd yn oed pan eu bod nhw’n fach, parhewch i gnocio ar ddrysau gan fod rhwydweithio ag eraill yn allweddol i lwyddiant.