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Sepsis care, vacancy rates, resus team: how a matron transformed her ED

Stella Davey responded to concerns about her hospital emergency department by forming a resus team that has transformed patient care and staff morale
Stella Davey

Stella Davey responded to concerns about her hospital emergency department by forming a resus team that has transformed patient care and staff morale

  • Team of senior nurses and paramedics is permanently deployed to ensure stability
  • Team training includes leadership, advanced life support and rotation in intensive treatment unit
  • Sepsis care has improved and the units vacancy rate has fallen

The emergency department (ED) at Kingston Hospital had a serious problem with morale in 2016. The Care Quality Commission (CQC) had identified high numbers of new and inexperienced staff at the Kingston Hospital NHS Foundation Trust in London and felt it was creating unsustainable pressures.

Nurses felt that managers did not appreciate these challenges

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Stella Davey responded to concerns about her hospital emergency department by forming a resus team that has transformed patient care and staff morale

  • Team of senior nurses and paramedics is permanently deployed to ensure stability
  • Team training includes leadership, advanced life support and rotation in intensive treatment unit
  • Sepsis care has improved and the unit’s vacancy rate has fallen
Picture of matron Stella Davey, who responded to concerns about her hospital emergency department by forming a resus team that has transformed patient care and staff morale.
Matron Stella Davey Picture: David Gee

The emergency department (ED) at Kingston Hospital had a serious problem with morale in 2016. The Care Quality Commission (CQC) had identified high numbers of new and inexperienced staff at the Kingston Hospital NHS Foundation Trust in London and felt it was creating unsustainable pressures.

Nurses felt that managers did not appreciate these challenges and their effect on the quality of care delivered to patients.

That same year an NHS England report said there was poor morale, most senior nurses were looking for other jobs and band 5 nurses were being allocated to resus with little experience of looking after the sickest patients. Unsurprisingly, there were patient safety incidents.

Emergency department resus team permanently deployed to ensure stability and safety

In response, matron Stella Davey developed an ED resus team, in which three senior nurses and three paramedics – three at band 7 and three at band 6 – would be permanently deployed in the area to ensure stability and safety.

The effect on morale, leadership and staff development throughout the ED has been huge. Staff retention and satisfaction has increased, with the vacancy rate for bands 6 and 7 reduced from 40% to zero.

Ms Davey says: ‘We felt that paramedics had skills that would benefit the team and would be able to provide immediate, safe and consistent care to critically ill patients. Importantly, they are fully integrated into the team, so those skills have been shared.’

The dedicated resus staff are joined each shift by one or two members of the wider team, ensuring more junior staff are supported and developed.

Senior nurses now have an opportunity to develop their clinical career while continuing to nurse

‘The ED has ownership of the sickest patients, which has reduced our reliance on critical care outreach staff and the hospital cardiac arrest team, allowing them to focus on sick ward patients,’ says Ms Davey. ‘It has given our senior nurses an opportunity to develop their clinical career while continuing to nurse.

‘Nurses are using their clinical leadership skills. There is a designated nursing team leader for trauma or cardiac arrest calls.’

Training opportunities for the resus team have included leadership, advanced life support, a rotation in the intensive treatment unit (ITU), clinical assessment, arterial blood gas sampling and interpretation, EZIO (intraosseous) and airway management and European paediatric life support.

The wider team has also benefited from an extensive training programme including weekly simulation, a trauma immediate life support course, clinical supervision, airway management and advanced patient group directives.

(L-R) Amelia Harris, Stella Davey and Alice Dixon during judging at last year's RCNi Nurse Awards.
(L-R) Resus team members Amelia Harris, Stella Davey and Alice Dixon during judging
at the 2019 RCNi Nurse Awards Picture: David Gee

There were challenges. The initiative was launched in January, a particularly busy time for EDs, and the team struggled to develop a presence in the hospital and have their skills acknowledged by other teams.

This was addressed by hospital-wide teaching and increasing awareness of the team. ‘The ITU placement helped with this – as well as giving the team skills,’ says Ms Davey.

The CQC inspected again in 2018 and noted improvements in staff numbers, skill mix, and staff knowledge and experience at delivering effective care and treatment.

Patients have timely, safe and dignified treatment

Resus was rated outstanding in the caring category. ‘Most important has been its impact on our patients,’ says Ms Davey. ‘They have timely, safe, dignified treatment.

‘There is a focus on supporting families and end of life care, with early end of life care decisions with the family’s involvement. There is family-witnessed resuscitation.

‘We have implemented critical checklists to improve safety and standardised resus bays, including difficult airway trolleys for adults and children, supported by standardised training for airway management.’

Nurse leadership behind the impressive service transformation

Care of patients with suspected sepsis has also improved hugely since the team was established. ‘Treatment is timely, with monthly figures showing 90-100% of sepsis patients receive antibiotics within an hour, up from 46%,’ says Ms Davey.

The resus team were finalists in the Emergency Nurse category of last year’s RCNi Nurse Awards.

From shocking figures to sepsis champions

SInce 2016, the emergency department at Kingston Hospital has been on a sepsis journey that has seen the team treble the number of patients who receive antibiotics within an hour.

‘Our figures were pretty shocking,’ says matron Stella Davey. ‘At that time, only 30% of patients arriving at A&E were screened and 30% given antibiotics within the hour. We have worked hard to empower the whole team to recognise sepsis early.’

The range of measures, including raising awareness and staff development, have been a great success. The department has consistently scored 90% or above on both measures for the past year. For three months the audit showed 100%.

Senior nurses now deliver every stage of Sepsis 6 pathway

There has been a comprehensive programme of ongoing sepsis teaching sessions and in-house simulation, a sepsis champions scheme in the department, and awareness raising, including embracing World Sepsis Day in mid-September, and staff feedback and celebration when staff recognise sepsis early and treat it in a timely manner.

One crucial initiative has been enabling senior nurses to deliver every stage of the Sepsis 6 pathway under patient group directives (PGDs).

‘Previously, the nurse at triage would have to wait for the doctor to see the patient or see the doctor and ask them to prescribe antibiotics,’ says Ms Davey.

RCNi Sepsis resource collection

The department had been advised by the Care Quality Commission in 2018 that it should ensure PGDs were used more. An audit and improvement plan and training for every nurse around analgesics brought PGDs effectively back into use. Ms Davey used this as a platform to bring in PGDs, enabling nurses to prescribe antibiotics too.

Ms Davey explains: ‘Different levels of PGDs have been developed for staff of appropriate experience and training, and ongoing clinical supervision is key to support nurses in administering them.’

Level 2 PGDs allowing nurses to prescribe and administer antibiotics were approved in March 2019, and level 3, empowering nurses to prescribe and administer more advanced medication such as IV morphine and nebulisers, in June 2019.

A lot of work done to address concerns among senior clinicians

There are clear rules on who can use the PGDs. For example, level 2 nurses must be two years post registration, have completed level 1 (governing analgesics) for three months and passed in-house ED training and assessment. They also must have completed an anaphylaxis and intermediate life support study day.

While it has been an undisputed success, there were challenges. ‘There was a lot of work to do to address concerns among senior clinicians over whether it was an appropriate thing for nurses to do and safe for patients,’ Ms Davey says.

‘We had to convince them that those administering the medication were the right staff with the right skills and training. The guidelines and governance are tight. There is a clear chart setting out what each level can do and strict criteria over who you can give it to and who you can’t.’

Nurses needed reassurance that they were competent and skilled to perform what was previously a medical role. The team had already surveyed its nurses to find out what prevented them from using PGDs in the ED.

‘We did it anonymously, which was important,’ says Ms Davey. ‘My team knew I was passionate about this and I wanted them to tell me their feelings honestly and not just tell me what I wanted to hear.

‘The general feedback on the barriers they faced was time – sometimes they had a queue of patients to see – and confidence, especially among the more junior staff.

‘We were asking them to do something new, something they felt was a doctor’s job. It surprised me. In my view it felt much safer for me to prescribe/administer the drugs as I had been with the patient and assessed them.’

High level of clinical supervision

The ED matrons spend a lot of time in clinical practice, on the floor, ensuring a high level of clinical supervision. ‘This is reassuring for the senior managers and gives the nurses confidence.’

For Ms Davey it is a win-win situation. ‘Our sepsis improvement speaks for itself,’ she says. ‘And our patients have a better experience. They like that the person doing the initial assessment is also giving them what they need by prescribing and administering their medication.’

It has been good for the nursing team’s morale too. ‘It has been a way that they can develop as nurses, but still be a clinical nurse, rather than taking a manager role or an advanced nurse practitioner role, which is more medical,’ says Ms Davey. ‘I am passionate about enabling that.’

 

Consultant Anna Forest Hay credits nurse leadership for the impressive transformation. ‘These dynamic nurses were empowered to research, combine their experiences and design the way it was to run. Having experienced many top-down diktats for change over the recent past, it felt a strangely novel idea but rapidly revealed itself to be the most impressive departmental change.’

‘As ED nurses, the ability to deliver timely, effective and compassionate care is the whole purpose of our job’

Amelia Harris, resus team’s nurse lead

Ms Forest Hay adds: ‘We will never return to the days where resus was not run by a dedicated team of highly qualified and experienced, dynamic nurses and paramedics who have organised the area to enable themselves to use their skills and serve patients with optimum efficiency.’

Amelia Harris, the team’s nurse lead, says: ‘The resus team is ensuring the sickest patients receive the best possible care and outcomes, and this is largely because of Stella Davey’s leadership. She inspires us all.’

She adds that nursing care in the whole ED has improved, not just in resus. ‘We are so proud of the difference our team is making and the excellent care we deliver.’

The difference this has made to morale is huge, Ms Harris says. ‘As ED nurses, the ability to deliver timely, effective and compassionate care is the whole purpose of our job.’


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Sepsis Resource Collection


Find out more

National Institute for Health and Care Excellence (2020) Sepsis Overview

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