ED nurse leads huge improvement at Kent trust
Man on a mission Cliff Evans was sent on a secondment to work at Medway Maritime hospital in Kent in a bid to tackle high mortality rates and low staff morale.
‘I have never worked anywhere that was so unsafe for patients,’ says emergency department (ED) nurse consultant Cliff Evans of Medway Maritime Hospital in Kent. He was seconded there in 2015 by NHS England to address its high mortality rates.
‘There were three to five incidents a week. People were dying.’
The nurse vacancy rate was 65%. ‘You can’t run a service on those levels. Staff were working in horrible circumstances having been in special measures for three years,’ Mr Evans says.
The staff who were able to had left, and those who remained or who were new were ‘all hands on deck’, leaving no time for mandatory training or appraisals. Only four nurses had emergency care qualifications that were relevant to their posts.
Three years on, Medway NHS Foundation Trust has been lifted out of special measures and has a below-average mortality rate.
‘This is such a great improvement,’ says Mr Evans. ‘Medway had a mortality rate 26% above the national average four years ago – it was the reason it was inspected by the Care Quality Commission and went into special measures.’
Addressing patient safety was his first priority.
‘Patients were arriving and being put in a corridor without an assessment,’ he says. ‘With a 65% vacancy rate you are not going to have an adequate number of nurses anywhere.’
Mr Evans describes it as a perfect storm. ‘Patients were not prioritised so doctors saw them in the order they had come in. The most basic things were not happening.’
He undertook an audit of the 24 patients waiting in the corridor on one day. ‘One person had a stroke, one an acute heart attack and four were septic. The trust board’s belief that the patients were low risk was completely unfounded. There was one nurse and a support worker.’
His report to the board and senior managers ‘sent shock waves.'
‘They wanted action to resolve it,’ Mr Evans added.
After an extensive review of literature and existing practice at Medway, Mr Evans, supported by the senior ED team, developed a bespoke initial assessment tool based on early warning scores.
‘Introducing a new triage system anywhere is worrying and this was in a challenged unit’
This system ensures patients are seen earlier by a clinician and referred promptly to specialties or admitted. There is clear evidence that it can lead to a marked reduction in episodes of harm, including death.
According to the trust’s audit, National Early Warning Scores (NEWS), which measure clinical deterioration, were being used on 90% of patients. ‘It was my belief that they were being used on zero patients so I undertook a retro audit of patient notes. It took about 34 patients before I found one with a NEWS score and the 35th had been calculated incorrectly.’
Once the new tool had been created, a training programme began. Every member of staff attended a two-day course and had to pass an OSCE – an objective structured clinical assessment.
‘Introducing a new triage system anywhere is worrying and this was in a challenged unit,’ says Mr Evans. ‘I didn’t sleep for days. We monitored it daily and I was on call 24 hours a day. We had a logbook for any incidents, but quickly noticed a level of safety that we had never had before.’
In just six months there was a 50% reduction in mortality, a 70% reduction in harm to patients, and incidents resulting in long-term harm to people were halved.
‘We kept showing the staff the audit results and what they were achieving,’ says Mr Evans. ‘And we launched it just in time.
'Shortly afterwards we saw a dramatic increase to 350 patients a day in March and April. If they had attended before the tool was implemented it would have been total bedlam. But our patients are so much safer, even with that increase.’
'Ready for change'
Lead clinician Ashike Choudhury says: ‘As a consultant, you would not know where the sick patients were. We had to use a sixth sense to find them. It was a stressful and difficult environment to work in. In the middle of the worst time, it was hard to see where the problem was.
‘We as a department were ready to change and Cliff came along with knowledge and experience of what we could do.
‘He, with his senior team, helped us ask the difficult questions and helped us go back to basics. Now the assessment is more effective and joined up, and I have the nurses coming to me identifying patients I should see or need to consider.’
Emergency programme general manager John Ferguson says the initial assessment tool was central to the reduction in mortality rates: ‘Triage is such a vital component of the patient’s assessment and treatment and Cliff’s model makes patients safer.
‘It has supported Medway to go from up to one thousand patients per month managed in a corridor to zero.’
Senior sister Emma Parkinson adds that the new triage system has encouraged nurses’ autonomy, creating a structured approach to assessment. ‘This has developed communication between the multidisciplinary team and the specialties,’ she says. ‘This means plans of care are commenced and initial tests and investigations implemented as soon as possible.’
‘Triage is such a vital component of the patient’s assessment and treatment and Cliff’s model makes patients safer'
She says that the development programme Mr Evans has put in place for nursing staff has been central to success and she has recently completed her BSc. ‘The programme highlighted gaps between our practice and updated guidelines. This has made a real difference in my role. The updated knowledge and practice improves standards of patient care.
‘The ED has improved immensely over the past 18 months. It feels a safer place to work, staff feel more appreciated and valued as they are being developed educationally and clinically.’
Mr Evans is full of praise for the nursing team. ‘There were excellent nurses working in a horrible environment,’ he says.
‘One of the key factors over the first eight months to a year was going back and revisiting the past in a non-blame way. Staff were part of those poor outcomes and had felt powerless at the time to challenge or do anything about it. We have had to put counselling in place and they break down regularly about the care given in the corridors.
‘A core part of my teaching is that if things ever start to slip they are the patients’ advocate and it is their responsibility to raise their concerns.’
Band 6 nurse Sharon Hemsworth-Smith says: ‘For 18 months patients were continually cared for in the corridor. Patients were never safe and I felt completely unsafe at work during that period.
‘The ED has changed dramatically for the better. It definitely has a bright future with happy staff and a safe environment – meaning patient care and safety is always put first.’
Cliff Evans's improvement strategy
Education and staff development are core components of consultant nurse Cliff Evans’s strategy to improve emergency departments.
At Medway, job descriptions had to be re-written as they had been watered down to try to get people in positions. Yet, impressively, Mr Evans reduced the 65% vacancy rate to just 16% through recruitment and retention.
It was essential to keep the staff already in post, he says, although senior nurses’ lack of specialist qualifications needed to be addressed.
Mr Evans says: ‘Morale was at rock bottom. Nurses were probably looking around for other posts or thinking of leaving the profession altogether.’
Having previously been an emergency care lecturer at North West London University, Mr Evans wrote a degree and master’s emergency nursing course for all senior and junior sisters at the trust that has been accredited by the University of Greenwich.
The first cohort, 11 of the most senior staff, has completed the course. In the future Mr Evans wants to run it every year and take up to 20 nurses.
‘By writing and delivering the degree course ourselves, with accreditation, the cost per student is about a tenth of what it would cost to send them to a university,’ Mr Evans says. ‘And that means ten times more people can have a specialist qualification.’
He also started working on improving the dire rate of appraisals at the trust. When he arrived, the Care Quality Commission had reported that only 16% of staff had appraisals. In the last report that had risen to 98%.
The local universities – Greenwich and Canterbury – had banned students from taking up placements at the trust in September 2015. ‘I don’t blame them – it was dangerous for students,’ he says. ‘But without students, how do you build your workforce of the future?’ By March 2016, he had persuaded the universities to allow students to return.
His recruitment plan includes a support package and 18-month development plan for newly qualified nurses, and providing them with a good working environment.
Staff nurses already in post were rolled on to a development programme so they could access the same opportunities available under the preceptorship, but in a less structured way.
Band 6 nurse Charlotte Weymouth-Hollywell says: ‘I have had my appraisal and completed the in-house ED course. It has made me a better clinician with more skills to complete assessments of patients and get them on the right pathway.
‘The ED has a bright future as long as we can maintain the momentum and continue the development programme for nurses.’