Annual Report and Accounts - The Great Western Hospital

West conference call in August 2011 on pressure ulcers. The conference call was a success and the
pressure ulcer tools have made available for other SW NHS Trusts to use.
The community have commenced developing an EWS (Early Warning System) in the community
settings. It entails utilising the observation chart (currently used at GWH) for Wiltshire (to replace
their current Obs Chart).
The process is split into 3 phases: trailing chart on a community ward, roll out to inpatient areas and
roll out to neighbourhood teams.
Medicines Management –The team has worked across the Trust with omitting the abbreviations for
insulin prescribing. The prescribing will now be written as 'unit' rather than 'u, this will help to reduce
the number of errors associated with insulin prescribing.
Peri operative – The team has been working on improving compliance with normothermia to ensure
that the patient’s body temperature is normal throughout the operation. A traffic light system has
been introduced by the team to help identify patients who are at risk of becoming cold. The system
scores the patient and identifies what the risk is of the patient not being able to maintain a normal
body temperature. The theatre team is able to proactively provide interventional methods to keep the
patients warm.
Critical Care – The intensive care team is now successfully collating data and recording Ventilated
Acquired Pneumonia (VAP) rates in patients. A lot of hard work and effort has been invested in this
project (measure) and the team is now investigating specific trends in the VAP rates.
Institute Multi-Disciplinary Rounds where introduced during 2011 and are now embedded into
practice, there is regular attendance by the physio, pharmacy and dietician. Multi-disciplinary ward
rounds are taking place on a daily basis (Monday – Friday) and are helping to improve
communication between all team members, patients, carers and relatives.
As part of the SW SHA programme the Trust are involved a number of improvement projects which
includes, improving the use of the surgical safety check list, patient falls protocol, patient comfort
rounds, theatre pre list meetings, medication reconciliation and many more.
Effective Care
Priority 8: Compliance with best practice guidance (NICE) and Central Alert Bulletins
NICE: The National Institute for Health and Clinical Excellence (NICE) is an established organisation
that publishes evidence based guidelines and recommendations for patients and healthcare
organisations. Service providers are expected to consider and implement NICE guidelines where
relevant, when developing and delivering their services for their patients. Regulatory bodies such as
the Care Quality Commission (CQC) and the NHS Litigation Authority (NHSLA) can use these
standards as a monitoring tool to measure the quality and safety the organisation provides.
At the Great Western Hospital, the Clinical Audit & Effectiveness Department has been responsible
for the dissemination pathway for National Institute for Clinical Excellence (NICE) Guidance since
September 2007.
The NICE process includes identifying, disseminating, monitoring the implementation and reporting,
of all NICE published guidance and is managed by the NICE Lead, based in the Clinical Audit &
Effectiveness department.
NICE published 82 guidelines during 2011/12.
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