Quality summary report: Stoma Care Service CLCH Quality Report Jan – Dec 2011 Service exact name Stoma Care Department Address line 1
Room 16, Outpatients, Lower Ground Floor,
Address line 2
Chelsea & Westminster Hospital, 369 Fulham Road,
Town/city
London
County Postcode
SW10 9NH
Website
www.clch.nhs.uk
Main telephone
020 8746 5911
Completed by
Claire Halkyard Service Manager
Approval
Joanne Jones Associate Director of Adults 2
CLCH Quality Report 2011 Summary report for Stoma Care Department Directorate
Adults 2
Service area
Stoma Care
Boroughs
Barnet ⌧
Kensington & Chelsea ⌧
Hammersmith & Fulham
Westminster⌧ ⌧
CQC statement of purpose for this service
The Stoma Care Service is a specialist service which provides a holistic care package to patients, families and professionals on stoma care management. The specialist nurses enable stoma care patients to achieve quality of life through education, support and guidance on practical issues and encouragement and counselling.
The service offers a range of interventions to both in-patient and out-patients and includes clinic, home–visits and telephone contact support within a multidisciplinary team. The service is available as a resource for all stoma care patients, their families/carers and Health Professionals working within Primary and Secondary care. This ability to provide seamless care has shown to increase patient satisfaction which has been evidenced in the Patient Reported Experience Measures (PREMs) and patient comments. The service is based within two hospital sites and provided by Central London Community Services. There are two Clinical Nurse Specialists (CNS) based at Chelsea and Westminster Hospital and one CNS at St Mary’s Hospital. Clinic sessions take place within the hospital Outpatients Departments and patients are formally reviewed at 6 weeks, 3 months, 6 months and annually following stoma formation, with further appointments made as necessary. Stoma formation often has a huge psychological impact on patients which is managed by the supportive nature of the CNS role. Quality of Life is assessed with a Questionnaire at 3 months post-operatively and if appropriate patients are screened for depression and anxiety using psychological assessment tools and
referred on to psychological services if necessary. As part of the role of the Clinical Nurse Specialist, educational programmes are undertaken to ensure all staff within primary and secondary care remain updated and confident in stoma care management. Regular teaching of medical students takes place, as well as teaching on specialist courses such as the gynaecological cancer course at The Royal Marsden Hospital. The Stoma Care Department also contributes to research undertaken by the Stoma Care companies into product improvement. The Stoma Care Departments are open Monday-Friday 8am-4pm. Referrals are accepted from any Health Professionals, patients or their carers. The service is provided to patients within the boroughs of Hammersmith and Fulham and Westminster. The Stoma Care Service in Barnet provides specialist stoma support and advice for adult patients in Barnet. The Specialist Nurse works in collaboration with the wider continence team, district nurses, GP, other health and social care professionals in the community and also with the teams in hospitals. Specialist training is provided to Community services and joint visits are carried out to ensure that the most appropriate care is provided to meet patient needs. Alongside specific care planning for stoma care and appliances, advice regarding diet, general health and lifestyle is given. Patients can be seen in an outpatient clinic setting or in their own home. Support and advice is given to manage the changes for those who have a new stoma and for those who have problematic needs. The Specialist Nurse has also worked in collaboration with the acute sector developing a pathway for patients that provides a seamless service through their journey. Overall
A number of measures were undertaken in 2011 to assess the quality of the
summary of
stoma care department’s performance:
quality performance
Safety
and next steps
•
Work has been undertaken on the assurance of safe discharge. There are processes in place to ensure direct communication between the StomaCare nurses with the surgical team as well as the community health
professionals to prevent delays on discharge. Thereby reducing the risk of incidents on the discharge process.
Effectiveness •
After collaborative work with psychological therapies and establishing evidence based practice the service instigated the use of GAD7 and PHQ9 depression and anxiety scores to enable better access for patients to appropriate professional support.
•
The team have undertaken a clinical audit against the Royal College of Nursing (RCN) standards that all patients having planned stoma surgery will be sited by a qualified professional prior to surgery. This Clinical Audit highlighted areas for improvement and the team has developed an action plan to address these areas.
Experience •
Quality has been measured for by a patient experience survey of the new stoma patients of 2010. This gained insight into the patient experiences whilst measuring their experiences against the department and RCN standards
•
Recording solicited and unsolicited comments and taking patient stories on patient experience. We aim to build on developing patient experience measures.
•
Piloted a Quality of Life Patient Reported Outcome Measure (PROM) of patients at 3 months post-operative.
Safety Overview
A robust system is in place across the Specialist Stoma-care service to ensure that our staff undertake annual mandatory training which includes safeguarding training. We also have a professional responsibility for continual professional
development and have regular appraisals to identify training needs and to encourage staff to report all clinical incidents and near misses through the Incident Reporting and Management Policy. The service has robust protocols in place to ensure that adverse risks are mitigated. Safety of patients is an integral aspect of stoma –care management both in terms of physical safety and mental health and well-being. Key achievements this year
Incident Reporting The stoma – care service has 0 reported incidents or near- misses between January – December 2011. The Stoma Care nursing service prioritises patient safety and works hard to continually reduce the risk of incidents occurring. Key initiatives this year improving patient safety involved: 1) Safe discharge. Work has been undertaken on the assurance of safe discharge. There are processes in place to ensure direct communication between the Stoma-Care nurses with the surgical team as well as the community health professionals to prevent delays on discharge. Thereby reducing the risk of incidents on the discharge process. 2) Skin integrity. In response to Best Practice guidelines the Stoma Care nurses teach patients to look after the vulnerable peristomal skin as well as supporting and educating ward staff and District Nurses in line with RCN Stoma-Care guidelines. 3) High output/dehydration. Ileostomist's are at risk of high output and dehydration. As part of the Stoma-care pathway, support and education is provided to ensure the patients know when to instigate treatment and seek help.
Key results
The stoma – care service has 0 reported incidents or near- misses between January – December 2011. To ensure that we are up to date on incident reporting the team will be inviting the Quality Assurance and Safety Team to provide Incident reporting training to the service.
Safety
Action
Expected
Named
Improvement
completion
lead
Actions for
date
2012
1. To organise and undertake incident reporting training
March 2012
MJ
from the Quality, Assurance and Safety Team
Effectiveness Overview
We aim to achieve the best possible outcomes for patients. To do this, we regularly monitor to see that we are delivering care and treatment according to best practice standards, and we increasingly look to measure and improve clinical and patient reported outcomes. This year we have focused on our clinical audit portfolio and measuring against both local and national standards to improve patient care. Key themes that have arisen from this year’s data was the need to develop better links with psychological therapies services to ensure that patients were receiving appropriate amount of psychological support if necessary. This has resulted in better access for patients to psychological care through collaborative working on the screening process. The stoma care nurses use GAD7 and PHQ9 depression and anxiety scores to enable better access for patients to appropriate professional support. The team have also undertaken a clinical audit against the Royal College of Nursing (RCN) standards that all patients having planned stoma surgery will be sited by a qualified professional prior to surgery. This Clinical Audit highlighted areas of good practice and areas for improvement and the team has developed an action plan to address these areas. The team have participated in the Trust wide Health Records Audit and have undertaken this across both sites. A Patient Reported Outcome Measure (PROM) in the form of a quality of life questionnaire has been piloted this year with the view to roll out during 2012. This will provide us with evidence on how our clinical outcomes are impacting on stoma patient’s quality of life.
Key
The following clinical effectiveness improvement actions have been undertaken
achievements this year: this year
1) Undertaking a pre-operative siting audit 2) Psychological Therapies collaborative working. 3) The Trust wide Record Keeping Audit
Key results
Patient Reported Outcome Measures (PROMs) In 2011 the stoma care service introduced the Quality of Life PROM which was piloted at the beginning of 2011 and will be launched in 2012. This will gather data from service- users about the impact of living with a Stoma and will assist in gaining an insight on how intervention from the Stoma care service has impacted on their quality of life. Clinical Audit Participation in Trust-wide audits during 2011
The stoma –care nursing service participated in the Trust Wide Health records audit. 1 borough was involved and audited the following number of records: 1) Barnet:
0
2) Kensington and Chelsea:
0
3) Hammersmith and Fulham:
0
4) Westminster:
11
The service achieved a mean compliance rating of 65.47%
Evidence based practice forms a staple part of the stoma-care service. This year our clinical audit plan has focused on the following audits: 1) The Pre-operative Siting Audit This audit was undertaken by the Stoma care nurses against RCN guidance that “all patients having planned stoma surgery will be sited by a qualified professional prior to surgery”. The audit has identified that of the planned stoma formations, 98% were sited. The patients that were not sited had not been referred. As a result of the audit the stomacare nurses have an action plan in place to ensure that the pre-operative
referrals are made by surgical teams. NICE compliance The following NICE guidance is either fully or partially relevant to this service: •
CG2/1 Infection control
•
CG2/2 Hand hygiene
•
CG/3 use of personal protective equipment
•
GG2/5 Sharps disposals
•
CG2/6 Education of patients, their carers and healthcare personnel
•
CG22 Anxiety
•
CG23 Depression
•
CG91 Depression with a chronic physical health problem
To ensure that we are complying with these best practice guidance, we have carried out the following actions in 2011: NICE guidance baseline assessment conducted and guidance implemented. The above NICE guidance are all partially relevant to the Stoma Care Nursing Service. These are all fully implemented as they relate to the Service and rated compliant on the NICE Dashboard. The following specific actions have been taken to ensure compliance is on-going: a. Guidelines CG22, CG23, CG91. The service has met with Nicola Bell, Head of Psychological Services to develop a protocol for a referral pathway for patients with moderate to severe depression / anxiety. The protocol been agreed and is currently in progress. Target date: April 2012. b. Guideline CG2/6. The Stoma Care Service has several educational initiatives for doctors, nurses, patients and their carers. Patients and their carers receive on-going education and information in relation to stoma care, both pre and post operatively. The Service has also provided 2 study days for district nurses and ward nurses. In addition 2 colorectal cancer study days are being held imminently for patient groups and GPs (50 participants in each group). These study days have generated wide interest and are oversubscribed. Training and liaison with hospital
doctors at all levels is a regular feature of the Service’s education and training programme. c. All guidance. The service provides all required information regarding NICE implementation to the Quality Assurance Department and full compliance has been recorded. No barriers to the implementation of NICE Guidance are noted.
What the patients say about the outcomes of their care and treatment
The comments below are taken from the Stoma Care Nursing Patient Experience Questionnaire; “As my stoma was unplanned it was very much a shock and distressing waking in ICU to learn of my situation. But with the excellent care, understanding and professionalism of Mel and Mandy it was so much easier to face. They were, and continue to be a source of strength to me both in my recovery and to the future. Their dedication to patient needs excels and their attitude to patient care is more than 100%. They are a credit to stoma care nursing and NHS specialist nursing. Thank you.”
“The care help and support I had from the stoma care nurses at the Chelsea and Westminster Hospital was amazing. They went out of their way to help me and never made me feel I was wasting their time or being a nuisance. Without their support I don’t think I could have coped so well. They were wonderful.” Clinical
Action
Expected
Named
Effectiveness
completion
lead
improvement
date
actions To develop new PROMS in relation to patients’
May 2012
MJ/AG
independent care on discharge
Experience Overview
We care about treating everybody with kindness, dignity and respect at all times. Stoma-care patients require specialist support both physically for their stoma and
to return to a good quality of life. Having a stoma is a major life event and in addition to the medical complications that may arise, patients may become anxious and depressed.
Quality of life may also deteriorate and it has been
shown that the first few weeks post-stoma is the most important period for successful long-term post-operative outcomes for stoma patients (Brown and Randle 2005). Written information and verbal explanation around stoma management are vital at an early stage in the recovery process.
Each patient undergoing surgery that will result in a stoma is entitled to the highest-quality, comprehensive, specialist nursing services that can be provided (Coleman and Waller 2000). They maintain that patients' physical, psychological, social and spiritual needs should be acknowledged and appropriate information, advice and support provided to them and their families or carers, in order to enable patients to achieve an optimal rehabilitation. It is for this reason establishing a more robust assessment and referral pathway into the psychological therapies was established Key achievements this year
In 2011 we undertook a local PREM asking for the experiences of the patients who had a new stoma formed in 2010 at Chelsea and Westminster Hospital. This is to be repeated in 2012 and to include St Mary's Hospital. In addition to the local PREM, the standard Fr3dom Health PREM will be undertaken as of Dec 2012. The following points summarise the Service’s key achievements during 2011: Development of local PREM (see below). Development of referral pathway, with Psychological Health Services, for patients with moderate/severe depression and anxiety. A wide range of educational initiatives with Patients, Carers, Hospital Doctors, GPs, District and Ward Nurses (see also below). Piloting of Quality of Life (QoL) Questionnaire. Development of comments for patients and carers. Engagement with CLCH Quality Assurance Department to ensure the delivery of evidence for a wide-range of current and future quality initiatives, including NICE compliance.
Patient survey
Patient surveys (known as Patient Reported Experience Measures – PREMs)
results
Summary of results for core patient experience measures (Aug-Dec 2011) Stoma Nurses were not involved in the Fr3dom Health PREM until December 2011 although are now fully engaged. Therefore there is only 1 result, mapped from the local PREM, which is relevant to this Table.
Question
% patients/carers rating overall experience good or
Result for
Trust-wide
this service
average
97%
93%
excellent % patients saying they were definitely involved in planning their treatment % patients saying they were always treated with dignity & respect % patients saying they definitely understood explanation % patients satisfied with waiting time
Interpretation of PREM results This information relates to a locally developed PREM which was provided to patients (n=32) during 2011. •
Overall responses (including comments) suggest a positive patient experience with the CLCH Stoma Care Nursing Service.
•
94% of patients who responded rated the overall service of the stoma nurses as ‘Excellent’.
•
Compliance to standards (where applicable) from the patients perspective was also high. For example: a. 100% of patients waiting for elective surgery were seen on the ward by a stoma nurse. b. 100% of patients were provided with written information. c. 100% patients were visited on the ward postoperatively (both emergency and planned). All patients were seen 2 or more times with 28% receiving 10 or more ward visits.
d. 89% of patients found home visits ‘Very helpful’; and 11% ‘Fairly helpful’. e. 100% of patients responded that they were able to contact a stoma nurse if they needed to. f.
92% of patients found the telephone advice ‘Very helpful’; and 8% ‘Fairly helpful’.
1) In addition, there was substantial evidence from both qualitative and quantitative responses that the stoma nursing team provided significant psychological / emotional support to their patients.
For example:
g. 90% of patients ‘Strongly’ agreed’ or ‘Agreed’ that meeting the stoma nurse helped them to feel less anxious about the procedure. h. 84% felt ‘Confident’ or ‘Fairly confident’ about their stoma care on leaving hospital. i.
Qualitative patient feedback from the survey showed that patients placed a high value on the psychological and practical support provided by the stoma nurses (see patient comments).
2) The overall conclusion, from patients’ responses and comments, is that the Stoma Care Nursing Service provides an exceptionally high quality, professional and essential service to patients and their carers.
PREM methodology The Stoma Care Nursing Service was not involved in the Fr3dom Health PREM initiative until December and therefore the following Table cannot be completed.
PREM volume targets
Total (Aug-Dec 2011)
Number of patients who responded to a PREM Total new referrals % of new referrals who responded to a PREM Target % of respondents Target achieved?
. Compliments Compliments and Complaints and
•
Complaints
Number of compliments Jan 2011 – Dec 2011: [14] letters of thanks received to the department [6] unsolicited compliments recorded
•
Number of complaints Jan 2011 – Dec 2011: 0
Patient user
The service receives many compliments and letters from previous patients and
groups and
formalising this process will enable the department to make use of the
focus groups compliments received by patients. Other
Many patients wish to tell their story and below is a patient’s story in their own
qualitative
words;
feedback
Julie (a former patient – name anonymised) had a stoma formed and reversed in 2011 and wanted to tell her patient story and has kindly allowed us to share her journey.
“I have suffered from diverticulitis for a number of years and was admitted to hospital twice during the early part of 2011. It was decided that I needed surgery and I was admitted to The Chelsea & Westminster Hospital on August 3, 2011 for an Sigmoid Colectomy and I also a Loop Ileostomy. Prior to the operation I had an appointment with Mandy Gunning, one of the specialist stoma nurses, who gave me all the practical information I needed in dealing with a stoma and how to manage after the operation. I did find the realisation that I would probably have to live with a stoma a bit of a shock as the surgeon had said I had only had a 50/50 chance of needing to have one. The meeting was, however, extremely useful as I was then able to come to terms with it prior to surgery and I was also able to practice empting the bag. On the day after my operation Melanie Jerome came to see me and to help me prepare and empty the bags and then visited me daily. Her kindness, extraordinary patience and support were invaluable and I returned home confident that I could cope with my ileostomy.
The week after I got home either Mandy or Melanie contacted me every day to ensure I was OK. They also visited me on two occasions to check I was managing the stoma care until I was well enough to attend their clinic. In hospital I developed an infection in my operation scar which continued after I arrived home. I needed to have the wound dressed every day and this was done firstly by the district nurses and then by the practice nurses at the surgery. After a few weeks I think that the wound dressings might have interfered with the ileostomy bag as the bags began to leak at the top which was rather alarming. This made me feel very insecure so I contacted the stoma nurses and Melanie saw me the next day and suggested a different type of bag, which was fine and I didn’t experience any more problems. I then continued to visit the stoma nurses regularly at the Chelsea & Westminster who made sure that my stoma template was regularly corrected and that everything else was OK. They were also extremely helpful regarding diet and other general lifestyle advice. It was so reassuring to be able to talk to them regularly and their help and advice was invaluable. I found that I experienced few problems in dealing with the bag, except the leakage, during the first few weeks as I was pretty much housebound and only went out for short periods. As I got back to normal life and started going out more, e.g. going to the office, visiting friends and the theatre etc., I did find I was constantly anxious about emptying the bag as however prepared you are, you worry about finding a toilet and also about the smell which isn’t very pleasant but the odour elimination sprays did help quash some of my anxieties. I found that I needed to empty the bag 6 – 10 times in a 24 hour period which was quite restrictive and I was constantly checking to see if it needed empting. I was very lucky, as after only 3 months I was able to have the reversal operation but the stoma nurses were still there to pack and dress my wound every few days. I am now completely healed and back to normal. During this whole process I felt fully supported by the stoma care nurses and think that the fact that they knew me throughout the process, from before the first operation into my home and afterwards, made such a difference to my recovery process, both physically and psychologically.
I can’t thank Mandy and Melanie enough for their tremendous support and care. I really don’t know how I would have coped without them.”
What the
Below are some patient comments we have received via our local PREM
patients say “I would like to thank the stoma nurses for all their support over the last 10 months. They have always been there for me and I could genuinely not have got through it without them. They are both brilliant at their jobs and lovely caring ladies. I’m so glad I met them and had the privilege of them looking after me.” “The level of care I received from Mandy and Melanie at C&W hospital far exceeded my expectations both from a surgical and emotional point of view. I honestly don’t think I could have got through this terrible time without them. They both went above and beyond to assist me and I will forever be grateful to them both.” “I just wanted to make sure you know how grateful I am for all your support through my operation and getting used to my stoma. You both do a fantastic job and it made the world of difference having such friendly and positive people to help me. Thank you so much. God bless.” Patient
Expected
Named
experience
completion
lead
Improvement
date
Actions
Action
To develop protocol and pathway for the referral of non-
April 2012
AG
April 2012
AG
Dec 2011
MJ
cancer patients with moderate to severe depression and/or anxiety to appropriate psychological services. Review ways of ensuring that patients with no/little verbal or written English skills are included in the in the sample of patients contacted for the next survey. To liaise with the Quality Assurance and Safety Department to make a qualitative analysis of the patient comments (now complete).
