Archived: Papworth Hospital

Papworth Hospital is the UK’s largest specialist cardiothoracic hospital and the country’s main heart and lung transplant centre. The hospital offers a range of services for outpatients, including cardiac, thoracic, transplant, radiology and pathology services.

We carried out this inspection as part of our comprehensive inspection programme

We carried out an announced inspection of the hospital on 3, and 4 December 2014, and an unannounced inspection on 14 December. We looked at all the inpatient services, including the Progressive Care Unit, and the outpatients department.

Overall we found that the hospital provided highly effective care with outcomes comparable with or above expected standards. The service was delivered by highly skilled, committed, caring staff and patients were overwhelmingly positive about the care they received at the hospital. However, there were areas in which the hospital could improve.

Our key findings were:

Access and flow

• The outpatients department provided 124,066 outpatient appointments during 2013/14, of which 67% were follow-up appointments. The follow-up to new patient ratio was in the highest 25% in the country.
• Meeting the referral-to-treatment time of 18 weeks for cardiology patients in the outpatients department was 98.8% and most other referral-to-treatment times were also meeting the national targets.
• The trust had been failing to meet national referral-to-treatment times for cardiothoracic surgery. This had been rectified at the time of our inspection. There were also a significant number of cancelled operations and high theatre use, and a number of patients had not had their surgery 28 days after their operation was cancelled. This was due to a number of reasons, including late referrals to the hospital from other centres that meant referral-to-treatment time targets could not be met, changes in patients’ conditions that meant they were unfit for surgery and capacity issues because of increased demand for some services.
• There were also concerns that the surgical department had no designated emergency theatre, which meant that elective operations were sometimes cancelled or emergency cases waited until a theatre was free.
• There was increasing demand for a number of services provided at the hospital, but service expansion was constrained because of the physical environment and limited building space on the site.

Incident reporting

• There were systems in place for incident reporting, but incident reporting was not consistent across the hospital. There were occasions when incidents were not reported in a timely manner
• In addition, there was limited evidence of shared learning from incidents across some services. As a result there were missed opportunities for learning in relation to avoidable patient harm
• The trust had reported and investigated two Never Events (these are serious, largely preventable patient safety incidents that should not occur if the available preventative measures have been implemented) over the last 18 months. The quality of the investigation reports for these incidents varied.
• Additional incident investigation reports reviewed also varied in quality, rigour and depth.

Risk management

• The management of risk within individual wards and departments varied. Some local risk registers required review because not all risks were clearly articulated or understood; this was a particular issue in medical services.

Medicines management

• The hospital used a comprehensive prescription and medication administration record chart for patients that enabled the safe administration of medicines. Medicines interventions by a pharmacist were recorded on the prescription charts to help guide staff in the safe administration of medicines.
• Records confirmed that Pharmacists visited all wards each weekday. Pharmacists and pharmacy technicians completed the medicines management section on the prescription record for every patient to confirm medication reconciliation had occurred. (Medicines reconciliation is the process of identifying the most accurate list of all medications that the patient is taking, including name, dosage, frequency and route, by comparing the medical record with an external list of medications obtained from a patient, or GP).
• The pharmacy department was open six days a week, but with limited hours on Saturday and pharmacists on-call out of hours. There was a pharmacy top-up service for ward stock and other medicines were ordered on an individual basis. This meant that patients had access to medicines when they needed them.

• Medication errors are the highest error group in the trust. Missed doses are counted as an incident; this is considered good practice. Prescribing errors and medication errors are both audited and both show an upwards trend. However, harm rates are well below the national average and indicated good reporting in this area. Action plans were in place and completion timescales identified and monitored. Lessons learnt were shared through the trust’s intranet page, junior doctors’ newsletter, pharmacy fact sheets and the sisters’ network. Plans to set up medication safety champions were in place, with the first meeting scheduled for December 2014.

Safeguarding

• There were systems and processes in place for raising safeguarding concerns. Staff were aware of the process and could explain what was meant by abuse and neglect. The safeguarding process was supported by staff training and all relevant staff had received safeguarding training. Staff were confident and competent in raising and escalating safeguarding issues.

Nurse staffing

• Care and treatment were delivered by committed and caring staff who provided patients with good services. Nurse staffing levels had been reviewed throughout the hospital earlier in 2014 and were assessed using a validated acuity tool.
• However, we noted that the Progressive Care Unit did not appear to have selection criteria or pathways for patients admitted to the unit, and there were no regular acuity assessments of patients in the unit at the time of our inspection. Since our inspection the hospital has introduced regular reviews of patient acuity and nurse staffing levels on this unit.

Medical staffing

• Care and treatment were delivered by highly skilled and committed medical staff.
• There was a good consultant presence throughout the wards, providing care to patients seven days a week.
• A ‘consultant of the week’ system had recently been initiated in medicine and was working well. A comprehensive handover took place from one consultant to another.
• Junior medical staff we spoke with all felt well supported in their roles by senior medical staff and they did not feel their workload was excessive. Findings from the General Medical Council Survey 2014 supported this.
• In terms of the consultant/patient ratio in the Critical Care Area, up to 33 patients were cared for on the unit and one or two consultant intensivists on duty falls below the best current evidence ratios as set out in the Intensive Care Society standards.
• A review of the thoracic service commissioned in May 2014 highlighted that there was poor junior surgical support for the thoracic service and the emergency on-call rota was unsatisfactory because of the limited thoracic experience of some staff on the rota. These matters were being addressed through an action plan developed in response to the review findings.

Infection prevention and control

• Staff were aware of current infection prevention and control guidelines and we observed good practices such as hand-washing facilities and hand gel available throughout the hospital. Staff observed ‘bare below the elbow’ guidance and staff wore personal protective equipment, such as gloves and aprons, while delivering care. However, we found that not all staff followed hand hygiene routines consistently.
• Some aspects of infection prevention and control were not being managed effectively, including the routing of some outpatients through thoracic medicine.
• Suitable arrangements were in place for the handling, storage and disposal of clinical waste, including sharps.
• Cleaning schedules were in place and displayed throughout the wards and departments.
• There were clearly defined roles, responsibilities and processes for cleaning the environment and the decontamination of equipment.

Mandatory training

• Mandatory training levels were very good and records demonstrated that overall compliance with mandatory training was 91%.

Outcomes and evidence-based care

• Patients received care and treatment that was evidence-based and in accordance with national guidance.
• Clinical outcomes and mortality rates were comparable with, or better than, other trusts nationally.
• Multidisciplinary team working was well established and used effectively to manage patients’ care and treatment needs.
• Staff at the hospital participated in an extensive programme of local, national and internationally recognised research.

Environment and capacity

• The hospital consisted of multiple buildings spread across the site. Many of the outpatient areas had been refurbished but space was limited and the service was physically confined.
• Some of the ward layouts were not appropriate, such as Baron ward, where a corridor in the ward was used as a central thoroughfare for staff and visitors alike.
• The outpatients department had developed many nurse-led clinics with additional clinics being run in the evening and at the weekend. This was recognised as good practice and patients who travelled long distances appreciated this flexibility in their appointment times.

Nutrition and hydration

• Patients had a choice of food and an ample supply of drinks during their stay in hospital. Patients with specialist needs for eating and drinking were supported by dieticians and other professionals
• There was good support for patients who needed assistance with eating and drinking, who were offered appropriate and discreet support.

We saw several areas of outstanding practice including:

• The surgical division’s effectiveness and patient outcomes were outstanding and were among the best in the UK.
• The Critical Care Area had recently developed guidelines for the prevention, recognition and management of delirium. This was a multidisciplinary piece of work led by the unit’s matrons and also included members of the ALERT team and a consultant intensivist. The guidelines were about to be launched and plans were in place for the work to be shared through conference presentations.
• The hospital had direct access to electronic information held by community services, including GPs. This meant that hospital staff could access up-to-date information about patients, such as details of their current medicine.

However, there were also areas of poor practice where the trust needs to make improvements.

Importantly, the hospital must:

• Stop the practice of routinely preparing the one medicine (GTN) in advance of its immediate use in catheter labs, in contravention of the Nursing and Midwifery Council’s standards.
• Ensure that incidents are reported in a timely manner and that learning from incidents takes place.
• Ensure that all fire exits are clear.
• Have an effective system in place to ensure that drugs stored in resuscitation trolleys are in date.
• Address the breach of single-sex accommodation on Duchess ward.
• Improve the way in which risk is managed and reported.
• Develop and implement a strategy for patients with a diagnosis of dementia.

In addition the hospital should:

In the medical division:

• Review the routing of outpatients through Thoracic medicine.
• Review the management of risk within individual wards and departments.
• Ensure the reporting of incidents in a timely manner.
• Develop cross-directorate learning from incidents.
• Review risk assessments for the location of resuscitation trolleys and fire safety exits.
• Improve the audit process for the maintenance of drugs required for the resuscitation trolleys.
• Review the staffing levels for allied health professionals, particularly occupational therapy, to ensure that they are available as part of the multidisciplinary team.
• Review capacity issues in some of the services, particularly in bronchiectasis services.

In the surgical division:

• Address the lack of clarity in selection criteria or pathways for patients admitted to the Progressive Care Unit.
• Review the use of regular acuity assessments of patients in the unit.
• Review and address the reasons for the significant number of cancelled operations and high theatre use.
• Consider the provision of a dedicated emergency theatre.

In the critical care service:

• Review the availability of facilities for relatives in the Critical Care Area.
• Review the medical staffing. In terms of the consultant/patient ratio, with up to 33 patients on the unit and one or two consultant intensivists on duty, this falls below the best current evidence ratios as set out in the Intensive Care Society standards.

End of life care:

• Explore ways to share and highlight the expertise of the end of life team and encourage earlier referral and more open conversations as part of the patients journey, with greater cross-service working.

In outpatients and diagnostic services:

• Improve the contingency plans to respond to the introduction of the new electronic records system at the nearby acute centre that was providing the hospital with pathology services.
• Assess the suitability of the environment to maintain the expansion of outpatient services.

Professor Sir Mike Richards Chief Inspector of Hospitals