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2019 3 SOAR analysis feedback from Facilitated WorkshopThis document is quite long, but may be of value as a resource to refer back to when actions are undertaken locally. It may also support individuals who attended with reflection around the event for the benefit of appraisal etc.The facilitated workshop in the afternoon used an ‘Appreciative Inquiry’ methodology with the aim of focusing on what we do well and sharing that knowledge.NELA records and locking.NELA case ascertainment and (early) locking is important to maximise the utility of the ELC ‘Run Chart Maker’ and ‘Dashboard’ in informing local teams on progress with QI initiatives as well as which areas to focus on next. It will also be an essential requirement for our Trusts to be successful in achieving the new Best Practice Tariff from April 2019. We heard from Simon Fallis (Consultant Colorectal Surgeon; Good Hope hospital), Andrew Claxton (Consultant Anaesthetist; New Cross Hospital), Jenny Wright (Consultant Anaesthetist; Russells Hall Hospital) and Ewen Griffiths (Consultant Upper GI Surgeon; QEH) about how NELA records are opened, completed and locked. All four Trusts were ‘in the green’ on the NELA report from the end of last yearThere was a mix of methods presented including the one person model (consistent interpretation of notes, but significant work load and vulnerable to data loss during any absence), through surgically led, anaesthetically led and with options around significant trainee input. We heard of paper based models and direct data input. Consistent to all the processes wereConsultant leadership withClinician input of data, ideally with Timely data entry using knowledge of Surgeons/Anaesthetist/Nurses in theatreIt was noted that although NELA started as a 3 year program ‘there is no sign of NELA ending soon’, indeed it has developed into an exemplar QI initiative and the focus on emergency laparotomy outcomes national means it will likely become more prominent. It is already a core part of CQC inspections. It was recognised that accurate data collection and input is fundamental to using NELA data for QI and achieving the BPT. As such NELA data entry should be a priority for the wider MDT at each hospital. How it is done should be decided locally, but important elements to consider include:Consultant ledTime in Consultant JP (Anaesthetic and Surgery); 0.5PA each for NELA lead roles seemed typicalNELA trainee leads; anaesthetics and surgeryClinician input of most data fieldsLogins for all consultantsLogins for all traineesLogins for theatre staff ‘NELA pause’ to go with ‘WHO sign out’ at end of NELA EmLap casesAt this point the ‘knowledge is in the room’ to answer nearly every question accurately.Real-time data entry in theatre: , for example it was suggested the surgical team could open the record and complete first few ‘tabs’ while patient in anaesthetic room, anaesthetics complete up to ‘tab 6’ towards end of surgery.Surgical leadership for post-operative data entry tab 7Direct email reminders (don’t let up)Surgical secretary (or other admin) time (3-5 hrs per week) to support ‘tab 7’ administrative data entry and locking. This was discussed on several occasions during the day and may be a fundamental part of timely locking of cases in preparation for BPTOther suggestions / examples includedAn identified General Manager with responsibility to support locally agreed method for clinically entered dataRegular NELA reports to Genral Mx governance meetings (including case ascertainment and locking) highlights importance of NELA data (BPT also)Logins for Care Of The Elderly (COTE) consultants: allow direct recording of their input Engage more with theatre teams to make it more multidisciplinary and share responsibilitiesNELA Participation certificatesNELA Newsletter; run by trainee leads under Consultant supervisionMonthly ‘NELA data entry award’ for clinician with most casesIn CEPOD theatre don’t send for next patient until data ‘complete’ to Tab 6 which equates to 87% of all data entryNELA logins and training as part of all new trainee and consultant inductions (including locums)Learn where info can be found on electronic record including PAS, radiology etcThe rest of the facilitated workshop used the SOAR methodology (Strengths, Opportunities, Aspirations, and Results/Resources) to explore 3 other key elements of developing a robust Acute Abdomen and EmLap pathway. The written outcomes were captured on paper and summarised below.Establishing a Trust NELA / EmLap teamStrengths‘What is currently best about how your site has developed a NELA / EmLap MDT’Most sites confirmed the presence of both a surgical and anaesthetic consultant lead, with good engagementSeveral sites confirmed some elements of a wider MDT already existed, including examples of engagement from one or more of Theatre and ward staff, trainees, Elderly care, General Mx, Execs, Radiology, ED, etcOthers reported ‘noticeably diminished reluctance from anaesthetic and surgical colleagues’ to engage in generalOther more isolated examples of strengths included an established reporting structure, increasing awareness around the Trust of the pathway for these high risk patients, a trained and engaged theatre team.OpportunitiesWhat do you see as main opportunities to improve’Most sites saw the building of a broader MDT as opportunity to gain momentum and traction to ensure ideas and solutions were tested and embedded. Several sites identified an opportunity to build awareness and engagement with colleagues across their departmentsThe MDT to coordinate QI projects with colleague and trainee involvement, with view to publication of posters, abstracts and papersSetting up a specific NELA Theatres MDT was identified as an opportunityComprehensive surgical and anaesthetic trainee involvement (joint projects) Aspirations‘What would you like to have achieved in 4 months time’Universal ‘buy-in’ from clinical colleagues, with ‘change in mind set’ to a proactive philosophyStrong MDT continuously monitoring and improving pathway, example given ‘ more GM visibility of cases, potential delays and need for escalation’Integrated EmLap pathway across multiple sitesMake CEPOD theatre a better place to work with ‘reduced turnover of staff’All induction programs (Consultants, Trainees, Locums, Theatre staff) include NELA / EmLapContract with OOH Radiology provider include same standards as local Acute Abdo / EmLap pathway; better communication between surgery and radiologyResults / Resources‘Where would you like to be once project is complete’ and ‘what resources will you need to achieve this’Fully functioning NELA / EmLap MDTCo-ordinated working across sites and across the regionBetter learning from cases and sharing of information (eg outcomes of RCAs)Admin support to MDTRequest for local ‘facilitated session’ to establish NELA / EmLap MDTReferral to and review by, a senior surgeonSenior surgeon in this context is MRCP or aboveStrengths‘What is currently best about how your site delivers this’Most sites mentioned senior review of patients. Examples included surgical review within 1 hour of referral two registrars available (peak times), twice daily consultant ward roundsSurgical consultants freed up of all other workConsultant surgeon on site 8am – 8pmConsultant surgeon on-site 8am -6pmConsultant review in EDSome sites mentioned CT scaning process: CT scans with actionable findings discussed over phoneRadiology document who the scan was discussed with in written report1 site had a specific referral mechanism for patients with suspected acute abdomen2222-EmLap voice bleep to surgical registrar on-callUniversal adoption of EWS, with escalationUse of screen savers and posters highlighting referral mechanismOpportunities (Referral and Review)‘What do you see as main opportunities to improve’Many sites identified a need for ‘better documentation of surgical review’Date and timeFindings, recommendations and outcomesFace to face review of patientAwareness campaign in hospital to highlight how critical this patient population is and need for prompt referralInclude pathway in induction for locumsConsultant to consultant discussionsAspirations (Referral and Review)‘What would you like to have achieved in 4 months time’Consistently delivered senior review 24/7Formalised evening ward roundsEstablish a referral pathway involving ED consultantsSenior review prior to CT scanRecruitment drive for more senior surgeonsAwareness of IR (Interventional Radiology) options available at different times.Results / Resources (Referral and Review)‘Where would you like to be once project is complete’ and ‘what resources will you need to achieve this’New consultant surgical rotaExtra senior / MRCS surgeons available at peak times when surgery happeningConsultant surgical bleep and inclusion in referrals when on-siteRisk AssessmentStrengths‘What is currently best about how your site delivers this’Most sites felt a formal risk assessment was an essential part of the assessment and consent process‘marker of good care, helps make decisions and informs consent’‘Gives consistency between clinicians when ascribing risk’‘Raises awareness with theatre team of high risk nature and need for extra preparation/equipment’Half of hospitals said they regularly use a formal RA tool, and two commented they used the NELA smart phone app for this purposeIt’s a useful prompt to open the NELA recordMove to NELA RS ‘is a good development’Opportunities‘What do you see as main opportunities to improve’To have NELA RS incorporated into booking processUse risk tool to highlight high risk cases to deploy resources appropriatelyEscalation / urgency / priorityTheatre team (size and staffing level)Consultant presenceCritical care referral and bed‘extra care’Improve completeness of discussions /consent betweenSurgeon and patient / familyClinical teamsIdentify need for wider MDT involvement in decision making; esp Crit Care and COTEData AccuracyTraining around use of ASA scale (fundamental for NELA RS) and other aspects of NELA RSDevelop app related to data entryOthers:Use ‘magnets’ on ward boards to highlight EmLap cases and where risk score neededUse appraisals system to raise awareness of importance of Risk AssessmentAspirations‘What would you like to have achieved in 4 months time’To be part of our normal practiceUse in all discussions with family and patientUse when discussing with colleagues and in making ceiling of care decisions / avoid over treatmentUse during handover for every acute abdomen / EmLap caseRecord NELA RS on Consent form and in notesResources allocated based on need (risk)Lactate checked pre-op for all casesSwitch from P-POSSUM to NELA RSResults / Resources‘Where would you like to be once project is complete’ and ‘what resources will you need to achieve this’Incorporate Risk score into WHO brief and WHO checklistStaff trained in using NELA RSUsed at Handover‘Pathway’ paper work updated to include NELA RSReview of codingMore support from IT and information / analyticsWe understand from feedback that more detailed explanation of the methodology used on the day with stronger facilitation would have been useful and we will work to achieving this for future meetings ................
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