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St Luke’s General Hospital
Carlow-Kilkenny
Annual Report
2016
Pictured above is the first ambulance arriving at the newly opened Emergency
Department on the morning of the 25th
May 2016.
2 St Luke’s General Hospital Carlow-Kilkenny Annual Report 2016
Foreword
Yet again, 2016 proved to be a very busy year in St Luke’s General Hospital
Carlow-Kilkenny. As an organisation, we cared for 18,773 inpatients, with
an additional 9,527 patients being treated on a day case basis. The number of
people availing of our emergency services reached its highest at 48,105,
whilst we delivered 1,625 babies. We saw a further 45,606 outpatient
attendances.
Between November 2015 and May 2016, we were fortunate to open our €21
million hospital development, which consisted of a new Emergency
Department, an Acute Medical Assessment Unit, an Acute Surgical
Assessment Unit, a Hepatology Department, an Oncology Day Ward, the
Susie Long Day Services Unit (including Endoscopy), the Dr Jim Mahon
Library and Education Centre, our Porter/Security Hub and a new
concourse, complete with Admissions desk, Reception and Switch Board
and a Coffee Shop. 2016 also saw the opening of our first shop on site.
This development has greatly enhanced the way in which we deliver our
services. I wish to thank patients, staff and visitors for their co-operation
during the construction phase.
As you will see from this Annual Report, each department is working to
meet the increasing demands on our services, whilst also providing quality,
patient centred care, which meets the needs of the population we serve.
Anne Slattery
General Manager
3 St Luke’s General Hospital Carlow-Kilkenny Annual Report 2016
List of Contents
Item Page
Foreword 2
Introduction 4
Health and Safety 7
Freedom of Information/Data Protection/Patient Liaison
Office
9
Dr Jim Mahon Library and Education Centre 11
Supplies 14
Pharmacy 15
Dietetics 18
Cardiac Diagnostics 19
Laboratory 21
Physiotherapy 25
New Emergency Department Photos 28
Surgical Directorate 29
New AMAU and Oncology Department Photos 35
Medical Directorate 36
Maternity 38
Respiratory 39
Diabetes Nurse Department 41
Tissue Viability 42
Haemovigilance 43
Oncology Day Ward 45
Hepatology 48
Hygiene Services 49
Arts 54
Clinical Risk Management 55
The Year in Photos 57
4 St Luke’s General Hospital Carlow-Kilkenny Annual Report 2016
Introduction
St. Luke’s General Hospital Carlow-Kilkenny is the Acute General Hospital for Counties
Carlow and Kilkenny. Since January 2015, it is one of the 11 hospitals in the Ireland East
Hospital Group. The population of Kilkenny/Carlow Community Care area is 155,993
(Census 2016) which represents an overall increase of 4% since the 2011 census when
the population was 150,031. Due to its location in the heart of the South East, St. Luke’s
General Hospital in addition to the counties of Carlow and Kilkenny, also provides
services to its bordering counties: Tipperary North and South, Waterford, Wexford,
Kildare and Laois.
In addition to the acute services that are provided on site at St. Luke’s, outreach services
are also provided in Kilcreene, Carlow, Thomastown and Castlecomer. The hospital has
303 beds with a Net Expenditure in 2016 of €64.5 million
The Clinical Directorate model of governance has been in place in St. Luke’s Hospital
since 2003. It previously comprised of a Medical Directorate and a Surgical Directorate.
Since the commencement of the new Consultant Contract (2008), the sole Clinical
Director leads both directorates which consist of Nurse Manager representatives, Health
and Social Care Representatives and the Business Manager. The Quality and Safety
Executive Committee meets monthly and is chaired by Dr. Paul Cotter, Consultant
Geriatrician.
Net Expenditure 2015: St. Lukes General Hospital = €59.924 million
Net Expenditure 2016: St. Luke’s General Hospital = €64.476 million
In Patient Specialty
In Patient Bed Complement
Medical 1
Acute Stroke Unit
Medical 2
CCU
Surgical 1
SMU (Surgical Medical Unit)
Surgical 2
ICU
Surgical 3
22
5
31
6
29
14
31
4
14
Obstetrics 29
Acute Psychiatry 44
Paediatrics 19
SCBU 5
Total 253
5 St Luke’s General Hospital Carlow-Kilkenny Annual Report 2016
Specialty Day Beds
Oncology
10
Surg/Med Day beds 24(16 currently open)
Paediatrics 1
Obstetric Assessment 4
Total 39
Staffing at St. Luke’s (31st
December 2016)
Staff category 31/12/2016
Medical/ Dental 137.15
Nursing 390.37
Health & Social Care Professionals 86.72
Management/ Admin 125.09
General Support Staff 188.15
Other Patient & Client Care 62.13
Total 989.61
Hospital Activity Data 2016 Inpatient discharges 18,773
Day cases 9,527 ED Attendances 48,105 Births 1,625 OPD Attendances 45,606
6 St Luke’s General Hospital Carlow-Kilkenny Annual Report 2016
2015/2016 Developments:
The new ED/AMAU, Susie Long Day Services Unit (Surgical and Medical Day
Unit including colonoscopy etc,) Oncology Unit, Hepatology Unit, Education
Centre and Hospital Concourse
Approval of the MRI scanner (Design Team appointed)
Other recent service developments
Acute Stroke Thrombolysis Service
Early Pregnancy Assessment Unit and Paediatric Assessment Unit
NEWS and IMEWS and PEWS implemented
Purchase of 6 beds for palliative care patients by Susie Long Hospice Group
3000
3500
4000
4500
jan feb mar apr may jun jul aug sep oct nov dec
Emergency Presentations 2016 v 2015 v 2014
2016 2015 2014
7 St Luke’s General Hospital Carlow-Kilkenny Annual Report 2016
Corporate Services- Health and Safety
1. 2016 Objectives:
It is the policy of St Luke’s Hospital Kilkenny to ensure the safety, health and welfare at
work of all employees, so far as is reasonably practicable. The Hospital is also
committed to ensuring that service users, contractors and members of the public are not
exposed to risks to their safety health and welfare.
In the calendar year 2016 the Health and Safety Committee of the hospital which
oversees the Safety Management Programme on behalf of all staff and service users alike
focused on a number of key areas namely:
a) Overseeing the provision of training with particular focus on manual handling
and violence and aggression training.
b) Ongoing analysis and monitoring of trends associated with incident reporting
c) Development of a Health And Safety Risk Register
d) Updating Departmental Risk Assessments
2. Key achievements/activity for 2016
2016 saw continued improved in the safety management culture in the hospital notably:
i. A 21% increase in the number of reportable incidents (145) in
2016 when compared with 2015 (114). 60% increase in lost time
accidents. 213 days lost due to working time accidents in 2016
compared with 85 in 2014
ii. Only 5% of all incidents in 2016 (5) were in reportable to the
Health and Safety Authority compared to 3% (3) in 2015. A
reportable incident is one where an employee is absent from work
for more than three days due to a work related accident.
Greater awareness of the need to report Health And Safety Incidents has as attributed
significantly to this increase mainly due to an increase in the amount of in house Health
and Safety Training that was provided in 2016.
A comprehensive breakdown of incidents reported is included in detailed below.
3. Audit
St Luke’s Hospital Kilkenny is scheduled for a visit by the HSE Audit Team in 2017.
In preparation for this department have undertaken a comprehensive review of the
Risk assessment Process and updated local records to comply with existing HSE
Policies/Guidelines.
8 St Luke’s General Hospital Carlow-Kilkenny Annual Report 2016
4. Work Plan 2017
The Health and Safety Programme in 2017 will continue to focus on addressing the
on- going training needs of staff. There will be a greater emphasis on establishing the
root cause of accidents /incidents in response to advice offered by the Health and
Safety Inspectorate in 2015. With a likely Health and Safety Audit scheduled for
some time in 2017 the emphasis will be on ensuring that the necessary audit
requirements are met.
9 St Luke’s General Hospital Carlow-Kilkenny Annual Report 2016
Freedom of Information/Data Protection/Patient Liaison Office
HSE Your Service Your Say Compliments and Feedback/Complaints –Comparison 2015 - 2016
Received:
2015
Received:
2016
Compliments/Thanks
38
Compliments/Thanks
55
Complaints 134
complaints 165
Verbal 49 Verbal 43
Over 30 days:
2015: 21 responses took over 30 days to conclude - 13 contained clinical judgement/two were
finance.
2016: 146 responses(s) concluded within the 30 days
23 Feedback/complaint letters (s) took over the 30 days period and 20 of these contained
Clinical Judgment concerns. .
The feedback received in 2016 can be classified as having combinations of the following
categories within the correspondence/feedback received:
Categories of concerns raised in overall feedback:
Access Dignity
and
respect
Communica
tion and
information
Safe
effective
care
Clinical
judgement
Privacy Particip
ation
Finance Improv
ing
health
48 30 75 73 81 18 20 48 2
10 St Luke’s General Hospital Carlow-Kilkenny Annual Report 2016
Categorized Under the HIQA Standards:
1. Person-Centred Care and Support
2. Effective Care and Support
3. Safe Care and Support
4. Communication and Information
5. Leadership, Governance and Management
6. Workforce
7. Use of Resources
8. Use of Information
99 76 42 47 2 2 4 7
Recommendations:
51 recommendations from heads of Departments – 35 implemented
Training in HSE Comments Compliments and Complaints Policy 2017 :
Liam Quirke, Regional Manager Consumer Affairs, provided staff training in
November 2016 and February 2017, and further training will take place in May
2017.
FREEDOM OF INFORMATION/ADMIN ACCESS/MEDICO LEGAL/DATA
PROTECTION
COMPARISON 2015 AND 2016
ST LUKE’S GENERAL HOSPITAL KILKENNY
Requests received 2015 2016
Freedom of Information 90 89
Admin Access 119 125
Medico Legal 236 281
Data Protection 9 23
Total 454 518
11 St Luke’s General Hospital Carlow-Kilkenny Annual Report 2016
Dr. Jim Mahon Library and Education Centre
2016 Objectives:
a. Continuing development of the Dr. Jim Mahon Library and Education
Centre
b. Restructuring regional HSE library services into a consolidated national
structure
c. Continuing provision of core library services and resources to HSE staff
and students on clinical placement
The Library and Education Centre is located on level 3 of the new building and provides
library services and resources to all categories of hospital- and community-based staff.
The remit of our library service is to provide access for all healthcare practitioners to a
comprehensive range of evidence-based, up-to-date knowledge resources for the purposes
of:
research into specific clinical questions, conditions or treatments relevant to the
care of individual patients
keeping up to date with developments in a specific area of the health sciences, or
the professional literature of a given specialty
continuing professional education
Our services are intended to ensure that point-of-care decisions are informed by best
international evidence and that staff engaged in education or research have an available
knowledge resource, and assistance when they need it.
Library services are available to all HSE employees and to students on clinical
placement, and are easily accessible. The library website www.hselibrary.ie/southeast
is home to a comprehensive collection of online resources including e-journals, e-
books, databases, clinical practice guidelines, patient education handouts, and more.
Subject areas include: medicine and surgery; nursing and midwifery; allied health and
social care; health service administration and management. Resources may be accessed
24/7 via any Internet-enabled computer.
Core services available in the new library include:
Clinical Queries: our librarians are expertly trained in locating best quality
health information. We can carry out searches for you, or recommend how
best to find the information yourself. Click on the “Clinical Queries” tab at
www.hselibrary.ie/southeast to submit a question.
Training: we provide training on the use of all resources as well as a range
of printed help sheets and user guides, and online tutorials. Contact us for
assistance in getting the most out of the resources available to you.
Other Services: other services include access to a comprehensive range of
up-to-date and regularly reviewed clinical reference books; document
12 St Luke’s General Hospital Carlow-Kilkenny Annual Report 2016
supply from other Irish and international libraries; access to computer
facilities, to purchased electronic resources and the Internet; photocopying
and printing facilities; quiet study areas and research facilities.
The following resources are available:
Journals: 10,000 electronic journals available in HSE South East. Access to
current full-text content for many leading journals.
BioMed Central: Open access publisher of peer-reviewed medical research.
BMJ Journals: Online issues of BMJ and other journals by BMJ Publishing.
BMJ Learning: Short, interactive medical education modules to help build your
CME/CPD portfolio.
BNF and BNF for Children: Continually updated, practical guidance on
prescribing, dispensing and administering medicines.
Catalogue: HSE South East: Details of all books held in each of our libraries.
CINAHL: Core database: nursing, midwifery and 17 health and social care
disciplines.
Clinical Key: A medical e-library by Elsevier Science with all 500 Elsevier
medical journals, 1,000 medical reference books, 9,000 clinical procedure videos
… and more. Includes Lancet.
Cochrane Library: Core resource for evidence-based medicine with systematic
reviews of the effects of healthcare interventions.
eBooks Nursing Collection: 330 nursing ebooks: clinical guides, evidence-based
practice manuals and core reference texts.
Ebsco Discovery Service: A simple search box to search many of our online
resources simultaneously.
JAMA: Online issues of JAMA and other specialist journals by the American
Medical Association.
Lenus.ie: Online repository of Irish health research.
MEDLINE: Core database: medical sciences.
National Guideline Clearinghouse: Clinical practice guidelines from the US
Agency for Healthcare Research and Quality.
NICE: Clinical practice guidelines from the National Institute for Health and Care
Excellence in Britain.
NEJM: Online issues of NEJM.
Nursing Reference Centre: A point-of-care clinical reference tool: nursing and
midwifery.
Royal Marsden Manual: Clinical procedures relating to all aspects of nursing care.
SocINDEX: Core database: social sciences.
UpToDate: A point-of-care clinical reference tool to help answer clinical
questions and improve patient care.
Also available: several other large packages of ejournals, incl.: BioMedical Reference
Collection; Psychology and Behavioural Sciences Collection; and ejournals from Oxford
University Press, Sage, Taylor Francis and Wiley.
13 St Luke’s General Hospital Carlow-Kilkenny Annual Report 2016
Key achievements/activity for 2016
Continuing development of Dr. Jim Mahon Library and Education Centre,
September 2015. Installation of videoconferencing facilities and
infrastructure
Coordination of literature reviews to support the National Cancer Control
Programme’s clinical guidelines in breast cancer, prostate cancer and
gestational trophoblastic disease
Consolidation of all regional library services into the National Health
Library and Knowledge Service
Continuing provision of core library services and resources to HSE staff
and students on clinical placement
Health and Safety
Departmental safety statement and risk assessments completed and continually reviewed.
Service user feedback and links with external agencies/services
Links with other agencies include:
o National Health Library and Knowledge Service
o Library Association of Ireland
o National Cancer Control Programme (NCCP) Guidelines Steering
Group
o HSE Non-Core Task Allocation Steering Group
o Evidence-Based Practice (EBP) Group, South East
o Waterford Institute of Technology (WIT) MSc. Steering Group
5. 2017 Key performance indicators and achievement projections/proposed new
developments
a. Completion of national restructuring of library services (Q3 2017)
b. Design and launch of new service website: www.hselibrary.ie.
c. Procurement and implementation of national library management system.
d. Systematic literature reviews to support new NCCP clinical guidelines in
ovarian cancer, lung cancer and gastrointestinal cancer and other national
programmes.
14 St Luke’s General Hospital Carlow-Kilkenny Annual Report 2016
Supplies Department
Key Achievements and Activity for 2016
In 2016 we started the roll out in introducing Kan-Ban & also scanning the store rooms.
The areas that we completed in 2016 were:
ED/AMAU bulk store
Oncology
CCU
DAY SERVICES
SCBU
OPD up & down
Endoscopy theatre
CSSD bulk store
CIVU
All of these areas are now up and running with a two bin system and scanning. Our aim
is that usage over the year should reduce by 10%. Also the fill rate for these areas is over
90%.
A new staff uniform was also introduced which consists of black pants with black polo
shirts with a supplies logo on the shirts.
Plans for 2017
In 2017 the department will be looking at other areas to introduce kan-ban. Under the
national roll our plan funds were received to purchase more kan-ban to roll out and
introduce scanning of the stores. The areas which will be completed between June-Sept
are:
Winter Ward
Maternity
Cardiac Investigation
SMU
SUR 1 & 2
SUR 3
In introducing this, the stores room will be made more efficient and easier for the end
users to locate stock.
15 St Luke’s General Hospital Carlow-Kilkenny Annual Report 2016
Pharmacy Department
The Pharmacy department in St. Luke’s provides a comprehensive pharmacy service to
the HSE hospitals in Carlow and Kilkenny. There are many service developments which
we are currently engaged in. These are outlined below along with our plans for 2017:
Discharge Service/GEMS
The pharmacy discharge service is provided to medical patients. As part of the service,
medication reconciliation is performed on admission, the patient is followed throughout
their stay and a discharge prescription is prepared. Once reviewed by the medical team,
the prescription is sent to the GP and community pharmacy prior to discharge. This
increases patient safety, improves prescribing and enhances communication between all
health care professionals, across all interfaces. In 2017 we aim to extend this service by
combining it with the Geriatric Emergency Medicine Service (GEMS). We will set KPIs
and submit a business case for extra pharmacists to facilitate the extension of this service.
The Geriatric Emergency Medicine Service (GEMS) is being established in early 2017.
Activity data has shown that up to 66% of all patients over 75 attending the hospital are
being referred by the GEMS team for a pharmacy review. This service has been shown to
be very beneficial and as part of the service plan for 2017 the pharmacy dept will look to
merge the discharge project and the GEMS project to consolidate the expanding role of
the pharmacist.
As part of the GEMS project we have already demonstrated the need for pharmacy
resources to be put in place to facilitate pharmacist input into the Comprehensive
Geriatric Assessment, complete the medication reconciliation on admission and prepare
the discharge prescription.
eHealth
As part of the discharge prescription service, the eClincial Suite Medicines
Reconciliation App is used to generate a Meds Rec on admission form and a Discharge
prescription PDF. This discharge form is sent to the patients GP and community
pharmacy, via Health Mail prior to their discharge. The eClinical Software has
completed a full security evaluation by the HSE’s Office of the Chief Information Officer
and fully complies with all HSE Data Protection, Encryption and Password Polices.
Currently Pharmacists have access to laptops for use on wards providing the discharge
service, where they can record information and generate documentation to maximise
efficiencies within the discharge project. As part of the quality assurance process for the
discharge project, prescriptions have been measured against the HIQA standards National
Standards for Safer Better Healthcare (2012), National Standard for Patient Discharge
Summary Information (2013) and Guidance on medicines reconciliation (2014).
16 St Luke’s General Hospital Carlow-Kilkenny Annual Report 2016
Pharmacist generated prescriptions have been seen to be fully compliant with the
standards listed above.
Medication Safety and Quality
In preparation for the announced HIQA hospital pharmacy inspections, a review was
carried out of the medication information service provided by the pharmacy. IV drug
administration guidelines for drugs commonly used on wards were reviewed and updated.
These will be placed on the intranet, for clinical staff to access and will be maintained by
pharmacy. The Pharmacy intranet hub will also contain soft copy of all Pharmacy Memos
circulated to St Luke’s staff. These memos will still be circulated by email. High-risk
medication posters were distributed to all wards for use in treatment rooms. Education
sessions were provided to hospital staff on the use of the new medication Kardex.
Pharmacy will continue to be involved in revisions and updates to the Kardex.
We have identified a need for a Medication Risk Management Pharmacist.
Hep C
The Hepatology service has expanded in 2016 and, in line with icorn targets, aims to treat
70 patients in 2017 with new direct acting antiviral agents.
Oncology
The oncology day ward currently opens four days a week. It is planned to increase
capacity to treat patients five days a week. It will continue to have a clinic day on
Tuesdays when the oncologist sees oncology inpatients and out patients. This increase in
activity may necessitate more pharmacy resources.
The availability of the expanded access programme is significantly increasing with the
introduction of a new agent for the treatment of metastatic breast cancer. An increase in
both the number of patients being treated is anticipated in addition to the use of more
monoclonal antibodies.
The NCCP continue to request detailed reporting on expenditure and details of the agents
we are using. There will be an increase in the number of agents that qualify for
reimbursement under the ODMS system. This involves registering patients and providing
details of each dispensing.
Antimicrobial Governance
Our antimicrobial consumption increased dramatically in 2016. In order to improve
antimicrobial governance and appropriateness a Smartphone APP was introduced in 2016
and made available to HCPs. The antimicrobial guidelines and policies were reviewed
and updated based on evidenced based guidelines and resistance patterns. Education was
provided to staff on antimicrobial guidelines. We participated in the national annual
point prevalence survey. We continue to monitor the consumption of Meropenem in line
with national recommendations.
17 St Luke’s General Hospital Carlow-Kilkenny Annual Report 2016
IEHG Pharmacists Group
As the IEHG becomes more established, we are forging closer working relationships
between the hospital pharmacies and joint quality improvement projects across the
hospital group.
Maternity Medication Governance
We aim to introduce a clinical pharmacy presence into the Maternity unit. We hope to
have adequate pharmacy resources to provide the level of medication governance and
oversight required and to meet the inspection criteria of HIQA and the PSI. This is
required to improve and maintain the required level of medication safety in the maternity
unit.
18 St Luke’s General Hospital Carlow-Kilkenny Annual Report 2016
Dietetic Department
Key Achievements and Activity for 2016
The dietetics department accomodated it’s 1st post graduate students from UCD
FODMAP clinics ongoing – preparing an analysis on the nutritional content of
diet post FODAMP advice in conjunction with UCD
Our dietetic department provides support to the dialysis satellite unit in Kilkenny
City and implemented the Nutrition Care Process (NCP) including nutrition
diagnosis during 2016.
We also support St Patrick’s Centre, which provides disability services in
Kilkenny and during 2016 we established an Enteral Feed Training and Support
Group (EFTSG) and commenced gastrostomy replacement training of nurses in
St Patrick’s centre. Ongoing active involvement in the Support at End of Life
Team. Implementation of NCP including nutrition diagnosis in St Patrick’s
Centre.
Initiated links with community dietetic services to establish existing paediatric
services available in both acute and community settings and to improve
interdepartmental communication to prevent overlap, reduce waiting times for
those under the care paediatric dietetic services
Commenced CHOICE training for children with Type 1 Diabetes
The department received 5,885 inpatient referrals and 2,070 outpatient referrals
during 2016 (both adult and Paediatric)
A dietitian specialising in Paediatric Diabetes began in post during 2016.
All Dietitians now CORU registered.
We developed and submitted abstract to Healthy Ireland re weight management
clinic for staff
Plans for 2017
We aim to commence provision of 5 point Subjective Global Nutritional
Assessment on all renal patients in Satellite dialysis unit once a year and address
acute renal nutritional issues in haemodialysis patients.
Pilot “drop in” dietetic clinic for staff.
Improve compliance with uptake of MUST on ward
Complete an audit of snacks available through catering
Review and improve waiting list times for Paediatric OPD
Second CHOICE facilitator to be trained
More staff to become proficient with insulin pump therapy(the way forward)
Carry out nutritional analysis of paediatric ward menu
Develop closer links with Diabetes Ireland to facilitate relevant courses for
children and adolescents with diabetes (e.g. cookery course)
19 St Luke’s General Hospital Carlow-Kilkenny Annual Report 2016
Cardiac Diagnostics
Key Achievements and Activity for 2016 in our department
1. We continued to provide a range of Cardiac Diagnostics tests and maintain same in a
timely manner. However due to high demands from in-patient activity, resources are
prioritised to this area, and thus seen an increase in our out-patient waiting times.
2. Growth in Cardiac Rhythm Management continues and more complex devices for
follow –up has come on stream and staff continue to up- skill on same
3. Increase in activity for Transoesphageal Service due to the relocation of same to the
new day service unit has seen a 128% increase.
4. Planning of relocation of Cardiac Diagnostics service to a dedicated additional space
Plans for 2017
1. Moving of service to additional larger space
a) Cardiac Diagnostics (old AMAU)
b) Cardiac Echo Labs – Ultrasound (old Cardiac Dept) .
2. Continue monitoring of all activity and waiting list for our service .
3. Clinical Training – Ongoing
Staff attended Echo Course, Pacing updates, Mandatory training continues.
4. Additional Clerical hours to provide support two both locations .
5. Plan to commence new service with the Implant of Loop devices and follow-up
care of same .
20 St Luke’s General Hospital Carlow-Kilkenny Annual Report 2016
Activity Report for Year 2016 Cardiac Diagnostic Department
Diagnostic Total Outpatients Inpatients GP referrals (triaged by
consultant)
12 Lead ECG
303 111 185 6
24 Hour Holter
2342 2083 12 242
24 Hour Blood
Pressure
1273 1226 6 38
Cardiac Event Recorder
44 39 2 3
Exercise Stress Test
1260 700 219 320
ICD Check
137 126 11
Pacemaker Check
500 444 54 1
TOE
48 20 28
TTE (Echocardiogram
2947 1355 1406 174
Grand Total 8,854 6,104 1,923 784
21 St Luke’s General Hospital Carlow-Kilkenny Annual Report 2016
Laboratory
Key Achievements and Activity for 2016 in our department
Quality Improvements set for 2016 Current Status
Quality:
Procure electronic document
management system.
Continue to monitor QMS in BIO with
a view to achieving accreditation once
new analysers installed
Awaiting national tender.
PSR submitted for upgrade with current
supplier pending national tender.
Blood Transfusion:
Preventative action: change process of
authorising Groups
Procure separate interface for IH1000
PA implemented
Interface issue resolved with IH1000
software update – no longer require
separate interface
Haematology:
Ensure IQC schedule is maintained
Resolve errors in coagulation analysers
Validate D Dimer to 24 hrs
IQC audits show 96% compliance with
documenting IQC – the IQC was
performed 100% but not documented on 6
/162 occasions
Coagulation errors resolved-no re
occurrences
D Dimer testing extended to 24 hours
EQUIPMENT:
Replace Issue fridge
Blood Culture tender
Auto validation of results
Issue fridge replaced
Blood Culture tender currently being
evaluated
Auto validation deferred to 2017
Point of Care:
New Blood Gas in ED/AMAU
Implemented & working well
IT:
POC remote access to Blood Gas
Instruments
Commence scanning BT request forms
Remote access in place for BG
Scanning BT forms active since Jan 2017
22 St Luke’s General Hospital Carlow-Kilkenny Annual Report 2016
Improve process for Web Access set up
Leased AC’s working/ No additional users
to be added until installation of new server
in May 2017
Auto validation of results in Blood Science Not complete in 2016 due to staff shortages
& training. Possibility of roll out in BT in
2017 to begin with pending collaboration
with UHW lab.
Plans for 2017
23 St Luke’s General Hospital Carlow-Kilkenny Annual Report 2016
Activity Summary
24 St Luke’s General Hospital Carlow-Kilkenny Annual Report 2016
Test 2015 2016%
change
Total Biochemistry 838794 902726 7.6
Total Haem & Coag 129774 130783 0.8Overall Total No Tests 968568 1033509 6.7
Blood Science workload up 6.7% in 2016 over 2015Review of last 6 years shows a total increase of 32%, primarily driven by Biochemistry workload.The main source of increase in 2016 was SLH up 6.4% and AEH up 12%
0
200000
400000
600000
800000
1000000
1200000
2011 2012 2013 2014 2015 2016
Biochemistry
Haematology
Total
25 St Luke’s General Hospital Carlow-Kilkenny Annual Report 2016
Physiotherapy Department
Key achievements for 2016:
The Physiotherapy achievements for 2016 included many quality improvement objectives
aligned with the National Standards for Safer Better Healthcare (NSSBHC) and included:
Working collaboratively with key stakeholder to develop a Pulmonary
Rehabilitation Programme for those living with Chronic Obstructive Pulmonary
Disease (COPD) across both Carlow and Kilkenny. Referral pathways,
assessment procedures and operational plans were drafted in consultation with
multidisciplinary team members.
Preparatory work to align physiotherapy appointment scheduling and records with
the iPiMS
Pilot participation by a senior physiotherapist in review clinics in ED to provide
early intervention, advice on self management and appropriate onward referral for
MSK conditions
Provision of a weekly ‘drop in’ clinic to provide advice/managment strategies for
staff on work related/work affecting conditions
Development and implementation of a Critical Care Rehabilitaton Pathway
Implementation of a post operative Pulmonary Complication Risk Assessment
and Treatment Algorithm
Full roll out of Bariatric Handling Tool developed in 2015
Continuation of patient satisfaction surveys and actions based on findings
Focus on reflective practice, use of clinical reasoning and goal setting templates
and clinical audit in a drive to continuously improve the quality of care delivered.
Delivery of Bone Health and Falls Education Programmes in collaboration with
Community Services
Development of walking maps within/in close proximity to the hospital to
encourage physical activity amongst hospital staff.
Updating ddepartmental Safety Statement and Risk Aassessments
Development and implementation of CPD Plan for 2016 based on the assessed
needs of individual staff in line with the organisational objectives and service
demands
26 St Luke’s General Hospital Carlow-Kilkenny Annual Report 2016
Key activities during 2016
Key activities during the year included routine physiotherapy delivery Mon to Fri as well
as on-call physiotherapy at weekends and public holidays in the following areas:
Medical, Surgical, Paediatric, Obstetrics and Gynae Wards
ICU and CCU
Outpatient Physiotherapy Department
ED (Sept to Dec only)
Antenatal care for women and their partners
Cardiac Rehabilitaton
Pulmonary Rehabilitation
The following table summarise activity during the year:
Table 1 Summary Physiotherapy Activity 2016
Service Area New Patient
Seen
Carryove
rs from
2014
Total
Patients
Individu
al
Contacts
Group
Contacts
Group
Sessions
Inpatients 3,928 90 4,118 16,497 0 0
On Call 643 0 643 1,046 0 0
Outpatients 1,055 368 1,423 4,894 94 17
ED & Review
Clinics (Sept to Dec
only)
106 0 106 106 0 0
Cardiac
Rehabilitation 399 22 421 448 2,188 42
Pulmonary
Rehabilitation 64 0 64 105 722 119
Ante Natal 237 243 295 0 276 45
2. Plans for 2017
Refine operational guidelines on COPD Pulmonary Rehabilitation Programme in
Carlow Kilkenny and develop GP linkages into the programme
Assist in the setting up of a COPD patient support group in Carlow
Go ‘live’ with iPiMS
Play active role in the roll out of GEMS project in St Luke’s Hospital
Make every contact count (MeCC) by maximising opportunities in interventions
with service users:
o promote physical activity as part of healthy lifestyle
o encourage smoking cesation and direct service users to supports available
locally as required
o promote bone health and falls prevention
Maintain DNA rate at less than 10%
Esure no patient is waiting more than 12 weeks for first physiotherapy
appointment
Maintain/Increase activity with same level of resources
27 St Luke’s General Hospital Carlow-Kilkenny Annual Report 2016
Ccontinue with service user satisfaction surveys
Continue to actively promote best practice and ongoing professional development
in line with service requirements
Continue with reflective practice huddles, clinical audits and PRCs.
28 St Luke’s General Hospital Carlow-Kilkenny Annual Report 2016
Saying ‘Goodbye’ to the old and ‘Hello’ to the
new Emergency Department 25/05/16
29 St Luke’s General Hospital Carlow-Kilkenny Annual Report 2016
Surgical Directorate
Departments include: Emergency Department, Maternity Services, SCBU, Day
Services Unit, Endoscopy, Central Decontamination Unit, Operating Theatres, ICU,
Discharge Lounge, X-ray, Pre Admissions clinic & HCA’s.
2016 Objectives:
The key objectives for 2016 are summarised under the following headings:
Leadership, Governance and Management:
The aim was to provide effective leadership for staff, while managing the Surgical
Directorate Departments productively, through the use of all available resources and
through utilisation of an effective governance framework which was communicated to all
Clinical Nurse Managers in the department.
This was achieved through Department Governance meetings where all our clinical
incidents were discussed and action plans drawn up.
Safe Care and Support:
The Surgical Directorate aim is to provide safe effective care for patients and this was
achieved through working within policies, procedures and guidelines and delivering care
that is evidence based. All staff participates in as many education programmes as is
reasonably practical to ensure that staff are kept up to date with the latest developments in
the service.
Workforce:
Workforce Planning played an important role within the Directorate in 2016 as we
planned to open the new Emergency Department in Q2 2016. This involved extensive
communication with staff/senior management/networking with colleagues and utilising
reports on trying to find the right balance for appropriate staffing. I assessed data and
utilised reports such as NICE guidelines and the Tallaght report to guide staffing levels
going forward. National and local campaigns advertising for staff eventually secured the
appropriate amount of staff required to open the new departments.
Use of resources:
It was envisaged that all available resources would be used in the treatment of patients in
2016. There was a lot of redeployment and training undertaken to ensure efficient use of
resources. Resources were stretched beyond capacity but despite this all patients were
treated with dignity and respect in trying to achieve optimum standards, which is evident
by the limited number of complaints within the Directorate.
30 St Luke’s General Hospital Carlow-Kilkenny Annual Report 2016
Key achievements/activity for 2016
All the Surgical Directorate departments had increased activity in 2016 which is
evidenced in the directorate’s individual reports. All departments are >90% for hand
hygiene and the majority are >90% in hygiene audits. Those that are not are due to infra
structural issues which are being addressed.
Risk Registers in place and live for all departments. One risk escalated to Executive
Management.
Development of Discharge Lounge
Mental health safety initiative in ED (Volunteer Programme)
All departments involved in Audits.
Audit tool developed for the transfer of 4 tasks from NCHD’s
Metrics audits completed
Audit of HCA Qualifications
2016 Department key achievements
Department Key Achievements
Day Services Unit Introduction of a consultant led
hysteroscopy clinic and a GP led Mirena
Clinic.
Day Of Surgery Admission activity
increased
Introduction of Pre Emptive analgesia
under the guidance of Department of
Anaesthesia
Developed general surgery discharge
advice leaflet
Development of an ERCP nursing transfer
letter
Undertook a 4 week Pilot study “Make
every Contact Count”. Qualitative data
obtained and results expected from Health
Promotion team in Q2 2017.
Assisted Mr. Awan in completing his audit
on utilisation & productivity of the day
ward.
ICU 216 admissions – 85 ventilated (39%)
Nursing documentation updated
31 St Luke’s General Hospital Carlow-Kilkenny Annual Report 2016
Care bundles introduced
Aerogun nebuliser system introduced
Closed suction introduced as per SARI
guidelines
Theatre Staff survey
Departmental safety statement
Theatre tables procurement
Monthly Governance meetings
Business case submitted for opening of 3rd
theatre
CDU Quality control measures introduced to
guarantee that the system currently in place
for release of sterile items is robust
Change of wrap and supplier which will
yield significant yearly savings
All staff members of Irish Decontamination
Institute
Endoscopy Commencement of TOE procedures
Enhancement of Bronchoscopy service
All site specific validations and audits
achieved
RANP commenced surveillance clinic with
specific patient cohort
Pre Admissions Clinic Increased activity
Introduction of Anaesthetic clinic
Radiology - X-ray Attendance at departmental radiology
meeting with all stakeholders
Increased activity
Emergency Department Planning works for move to new ED- May
2016
Induction of 7 new staff
Appointment of 7 CNM1’s
Escort policy introduced
Education to all staff re Mental Health
volunteer programme
Minor injury unit commenced
ANP- Minor injuries appointed
Discharge Lounge Establishment of discharge lounge
Meet HSE targets for efficient bed
management
Education all disciplines of staff
Development of KPI’s
Maternity Services Site development for AMP
CMM2 to antenatal clinic service
Completion of patient surveys
Various posts ratified
32 St Luke’s General Hospital Carlow-Kilkenny Annual Report 2016
Guideline Development
Commence implementation of Maternity
Strategy recommendations
SCBU Increased activity
28% increase in CPAP use
Guideline development
Healthcare Assistants All HCA’s at required Level 5 QQI
qualification
Attendance at study days
Improved attendance
Job descriptions for HCA’s in Paeds, ED,
AMAU & Oncology
Planning for 2017
Department Objectives & Aims
Emergency Department Develop Patient Pathways
Meet KPI’s as set out in Emergency
Medicine Programme
Monitor and decrease PET and triage times
Full compliance with PDD
Expansion of roles in ED department in line
with ED Taskforce recommendations.
Develop CNM3 role to include AMAU
2nd
ANP Candidate
Patient Flow
Expand Trauma steering group
Develop CNM1 role in ED
Develop specific role for ED HCA’s
4 staff undertaking 3rd
level programmes
Day Services Unit Introduce nurse led discharge
Scheduling to maximize utilization
Fully open the department
Endoscopy Unit Introduction of new Procedures
Scheduling to maximize utilization
Fully open the unit
Develop nurse led discharge
Conversion of current CLO testing to a
more cost effective & rapid response by Q2
17
RANP liaising with OPD re rescheduling
returns
X-ray Department SOPs all up to date
ERCP – SOP’s etc.
Prepare for MRI scanner installation
-+
33 St Luke’s General Hospital Carlow-Kilkenny Annual Report 2016
Theatre Department TPOT – National Programme for Surgery –
Meet targets
Safe Site Surgery – meet targets
Monitoring out of hours activity
Opening of 3rd
theatre to increase service
provision
CNM2 post
Pre operative Asessment Clinic Adapt our service utilizing the Pre-
assessment model of care document,
More clients due to increased activity in
Day Services Unit.
Review of stats and staffing requirement
Anaesthetic involvement – new clinic
commenced
ICU Critical Care Governance Group quarterly
meetings
Pathway – admitting & discharge policy for
ICU
RANP development
Refurbishment of the department
Roll out of chest drain policy
Develop a policy re 5th
ventilated patient
Central Decontamination Uunit Increased activity
Statistics been monitored for increased staff
Plan for increased traceability of single
items
Plan to decrease costs with regard to
consumables in CDU
Education of ward staff regarding CDU
processed items and accountability for
traceability
Ward chart audits
Complete Contamination policy
Encourage technicians to undertake formal
college training
Discharge Lounge Increase numbers in discharge lounge
Conduct patient experience survey
Introduce QIP on wards for expediting
urgent bloods
To assist senior decision makers in early
discharge to lounge
Maternity Services Implement recommendations from the
National Maternity Strategy
Implement recommendations from System
Analysis Investigation report
Midwife community care pathway
34 St Luke’s General Hospital Carlow-Kilkenny Annual Report 2016
RAMP post
Post Natal Symposium
PROMPT train the trainer programmes
Ultrasonagraphy training for 2 staff
Continue to develop the service and staff as
per bereavement standards, HIQA
standards, BFHI standards and patient
feedback
SCBU Up skilling of NRP train the trainers
Refurbishment of unit
Business case for staffing to meet
Categories of Perinatal Care
recommendations
Healthcare Assistants Increase WTE to introduce a line system for
CNM2’s at ward level to ensure robust
governance of HCA’s.
Approval of more WTE for other areas-
HDU, S3, SMU night duty
Ongoing education
Development of specific role for
ED/AMAU HCA’s as part of the ENIG
Audits Patient Satisfaction Surveys been
completed in 66% of areas.
All departments audits are up to date with
no issues
Metrics for Surgical 2
Strategy Developed induction pack for HCA’s
Completing survey for HCA starters in the
past year
35 St Luke’s General Hospital Carlow-Kilkenny Annual Report 2016
Opening of new Acute Medical Assessment Unit
and Oncology Day Ward April/May 2016
36 St Luke’s General Hospital Carlow-Kilkenny Annual Report 2016
Medical Directorate 2016
Key Achievements and Activity for 2016
Unscheduled Care continued to drive the activity within the Medical Directorate during
2016, with over capacity on inpatient wards and in our emergency departments on a
continuous basis. As part of the ongoing Ireland East Hospital Group Unscheduled Care
Programme, a lot of process improvement work (utilising Lean methodologies) has
commenced and is ongoing. A number of staff have been involved in a number of Rapid
Improvement Events (RIE’s), ranging from an RIE on predicated dates of discharge to
the completion of a value stream analysis (VSA) on Complex Care. Late 2016 saw the
introduction of the daily Navigational Hub in the hospital, which has facilitated a focus
on early discharge’s and an improved PDD application rate for patients. All of these
initatives will assist in reducing our lengths of stay and in improving the quality of patient
care and experiences.
The introduction of the Discharge Lounge at the end of 2016 has also come from the
process improvement plans around Unscheduled Care.
Activity levels in our AMAU continues to rise year on year. On April 11th
2016, the
AMAU transferred to the new facility on the Acute Floor. The Acute Medicine
Programme’s KPI’s continue to be monitored with the aim of reaching National targets
monthly despite the ongoing overcapacity issue.
Admission rate to our CCU increased by 11% in 2016 with it functioning as a HDU (75%
of admissions meeting HDU category) and a business case has been sent to IEHG for
HDU staffing approval.
In line with increased inpatient workload, the demands on our phlebotomy services also
continued to increased. Some additional phlebotomy resources were put in place in the
last quarter of 2016. This coupled with the introduction of the new blood tracking device
has assisted in proving a more efficient service.
A new addition to our outpatient clinics during 2016 has been the introduction of the a
Respiratory ‘Xolair’ clinic under the stewardship of Dr. Brian Canavan.
Three members of our nursing staff from AMAU, commenced their Post Graduate in
Health Science/Acute Medicine.
CCU had 3 staff members under taking 3rd
level courses in the following areas, Higher
Diploma in Cardiovascular nursing, Higher Diploma in Respiratory nursing and
Tracheotomy nurse – Competent in replacement of long term tracheotomy’s.
The Community Infusion and Venesection Unit introduced ‘Biosimilar’ medications
37 St Luke’s General Hospital Carlow-Kilkenny Annual Report 2016
The Hepatology Unit introduced Interferon Free antiviral medications for the treatment of
Hepatitis C
Staff on the Surgical Medical Unit (SMU) continued to participate in the Pressure Ulcer
to Zero collaborative and collected data until November 2016. - A SKIN Bundle was
developed and education is being rolled out by the TVN prior to the introduction of the
SKIN Bundle care plan.
The Medical Directorate had 2 staff trained as Instructors in Break Away Techniques and
Manual Handling who continue to provide training to staff in SLKK.
Nursing Metric’s are monitored monthly and reported to IEHG via the monthly
performance meetings.
Plans for 2017
The provision of services within the Medical Directorate will continue to be driven by the
increasing demand/activity and the relevant key performance indicators.
All ward areas will continue to participate in process improvement plans to meet National
target and facilitate quality initiatives as they arise.
The overall aim will be to
Continue to improve on patient safety.
Continue to improve care bundles.
Continue to improve documentation/assessments.
Be proactive in the introduction of quality. Improvements when opportunity
arises.
Continue to manage staff absenteeism rate through the use of the managing
attendance policy,
100% of all staff trained in identified Mandatory Education.
Facilitation of staff in 3rd
level courses (staff nurse identified to partake in
European Certificate in Essential Palliative care.
100% Staff trained in venipuncture and cannulation.
Roll out of DVT pathway in AMAU. (due April 2017)
Identification of additional pathways for use in AMAU that will improve patient’s
experience. E.g. PE pathway.
Allocation of additional staff WTE to meet HDU need.
Provision of clean clinical treatment room in SMU.
Commence work with Medical 1 and Medical 2 in relation to plans for a sensory
garden for patients with Dementia who attend SLKK.
38 St Luke’s General Hospital Carlow-Kilkenny Annual Report 2016
Maternity Department
Key Achievements and Activity for 2016 in your Department
Continue to build on a culture of quality and safety – by ensuring safe services that are
evidenced based and responsive to the needs of individual women and their babies
Empowering and Supporting women in their choices in relation to antenatal care and
birth experience .
The first National Maternity Strategy ( 2016-2026) and the National Bereavement
Standards following Pregnancy Loss and Perinatal death and HIQA National Standards
for Safer Better Maternity Services ( Dec 2016) were introduced in 2016 . These
standards are key to our strategic direction. Review of relevant standards incorporated
into 2017 service planning. In carrying out the role of safety and quality improvement the
Maternity Patient Safety Statement is published on the HSE and hospital website each
month to provide public assurance that maternity services are delivered in an
environment that promotes open disclosure. Completed Service User Maternity Survey
positive feedback predominantly.
Plans for 2017
To complete a local /Ireland East Maternity gap analysis on the National Maternity
Strategy Implementation plan and set key objectives/ priorities for 2017, in collaboration
with the National Women and Infant Health Programme team . Currently (2017) we are
doing site preparation for Advanced Midwifery Practice to support the delivery of care
pathways based on risk and choice for women, in line with risk categorization and
community care as outlined in the Maternity strategy.
39 St Luke’s General Hospital Carlow-Kilkenny Annual Report 2016
Respiratory
Key Achievements and Activity for 2016
Fully operational Pulmonary Rehab Programme with the appointment of full time
physiotherapist
1 programme run in Carlow winter 2016
COPD support group Formed
Full time Respiratory Physiologist appointed this allows for full range of tests and
services including sleep studies and sleep clinic
Designated Bronchoscopy lists each week
Xolair clinic
Integrated care CNS appointed to service (GP based)
Plans for 2017
Source new equipment to extend the Pulmonary lab to include Cardio/Exercise
testing
Increase research
New specifically targeted treatment clinics for patient groups i.e. Interstitial
Pulmonary Fibrosis
Progress business case for funding for second Respiratory nurse and second
Respiratory Physiologist
Activity for Jan - Dec 2016
Key Achievements and
Activity for 2016
Clinical Focus
Total patients seen by Respiratory CNS in 2016:
815 (all outpatients)
Expansion of Respiratory services in 2016
2016 saw the commencement in post of a Respiratory
Physiologist, Integrated Care Respiratory Physiotherapist &
an Integrated Care Respiratory CNS.
As a result the expansion of respiratory services for patients
now includes a dedicated Sleep Studies clinic, a Pulmonary
Rehabilitation Programme established in both Kilkenny &
Carlow.
Clinics
Nurse led respiratory clinics are provided Monday to
Thursday. This enables the provision of a high standard of
clinical care for patients with respiratory illness and their
families using an evidence based care planning approach
including self-management & health promotion activities.
Patient referrals are accepted from Medical Consultants,
Emergency Department Consultants & their teams/ GP’s/ &
40 St Luke’s General Hospital Carlow-Kilkenny Annual Report 2016
from other healthcare professionals both in the hospital and
community setting, & triaged according to clinical urgency.
At the end of Dec 2016 there were 10 patients receiving
Xolair treatment for brittle asthma which is required to be
given in hospital settings only.
Telephone service
Provision of a telephone service to patient with respiratory
illnesses & their families following discharge/ GP’s/ PHN’s
and other healthcare professionals to offer information/
support & advice on applicable services & resources
available.
Promotion of evidence based practice
Implemented the use of research based respiratory
assessment tools in respiratory nurse led clinics and in the
ROPD clinic for example the COPD Assessment Test (CAT)
& the Asthma Control Test (ACT) to improve respiratory
patient assessment & care.
Presently in the process of developing Safe Administration
of Omalizumab (Xolair) guidelines in collaboration with the
Consultant Respiratory Physician & the Chief Pharmacist.
Plans for 2017
Carry out audit on the administration of Omalizumab
(Xolair), following implementation of the Safe
Administration of Omalizumab( Xolair) guidelines to
measure standards & promote improvement in patient care.
Devise a 16 Week Post-Xolair Assessment form to ensure
the effectiveness of the treatment is evaluated correctly prior
to continuation of patient’s treatment at that point.
Update Guidelines for the Administration of Oxygen
Therapy to Adults.
In collaboration with CCU nursing staff update the NIV
guidelines to promote evidence based practice and improve
patient care.
Facilitate an inhaler workshop for healthcare staff in St
Luke’s in February 2017
In association with CNE in UHW, we plan to assist in
facilitating the Management of Adult Respiratory Patient
study days in 2017
41 St Luke’s General Hospital Carlow-Kilkenny Annual Report 2016
Diabetes Nurse Department
Key Achievements and Activity for 2016
Education of staff (nurses/ doctors) through Medication Management/ Mandatory
training and Grand rounds and Community staff – organised through RCMNE
CHOICE Programme – structured education of kids launched.
Provision of 15 hours of Paediatric nurse specialist each week
New paediatric nurse clinics
Improvements made to Hba1c results with the additional investment into Paeds
services including insulin pumps.
Art therapy to paediatric patients both individually and in groups to address the
psychological needs of the patients
Plans for 2017
Continue to provide education to staff, hospital and community partners
Commencement of Community Diabetes CNS that will run clinics in the
community (GP surgery’s)
Plan to develop CNS Study Day to include diabetes
Pumps initiations for adults and Paediatrics
Develop pump care pathway and policies
Progression of Hypos in clinic and wards – hypo box
Commencement of Nurse Prescribing in clinic
Provision of 5:1 DAFNE education training for DNS and Dietitan.
Implementation of maternity strategy guidelines, in conjunction with consultant
endocrinologist.
42 St Luke’s General Hospital Carlow-Kilkenny Annual Report 2016
Tissue Viability
Key Achievements and Activity for 2016
Clinical focus/ patient care: We received 606 inpatient and outpatient referrals for wound management advice/care.
Consultancy Activities:
Collaboration and representation of patient interests with colleagues within St
Luke’s on patient care, equipment needs, invoicing for rentals/ purchases etc.
Liaison with community care regarding patient funding and discharges on Vac
therapy/ dressing regimes.
Receipt of phone calls from outside agencies for advice on wound management
issues.
Audit and Research:
Ongoing monitoring of hospital acquired pressure ulcer incident reports and
reporting of figures to SMT and Hospital group through SMT.
Opportunistic audits of mattresses within the hospital to determine if meeting
hygiene standards.
Monitoring of rental costs for pressure redistributing mattresses/Negative Therapy
devices.
Updating of documentation/ guidelines/SOPs commenced.
Completed the Pressure Ulcer to Zero Collaborative in the summer.
Education and Training:
Attended an educational conference in Lisbon in late February and the wounds
UK conference in October 2017.
Provided education to surgical colleagues on wound management at surgical
lunchtime meeting.
Provided educational sessions to intern nursing students and opportunity to
shadow TVN for student nurses as requested.
Provided opportunistic education to both staff and student nurses and provided
educational sessions on pressure ulcer prevention documentation and SSKIN
Bundle Care Plan.
Plans for 2017
Complete the updating of documentation/ guidelines/SOPs.
Introduce the SSKIN Bundle Care Plan into all the relevant ward areas with
supportive educational sessions for staff.
Collaborate with surgical colleagues regarding specific availability of Tissue
Viability Nurse hours to enhance OPD service/ patient follow up.
Commence review of incontinent patient skin care regimes within hospital with view
to developing evidence based algorithm/ care plan.
43 St Luke’s General Hospital Carlow-Kilkenny Annual Report 2016
Haemovigiliance Department
Key Achievements and Activity for 2016
Maintained 100% traceability as per EU Directive for all blood component/
products (3008 in total transfused during 2016)
Electronic Blood Track Implementation commenced in February 2016. This is a
national HSE project and will be mandatory for all HSE hospitals. It involves the
use of a handheld PDA to label pre transfusion samples by scanning a barcode on
the patient ID wristband. It is also used to complete pre transfusion checks at the
patient’s bedside to administer RCCs & platelets (by scanning the patient’s
wristband and the barcodes on the blood component). 15 clinical areas have gone
live up to end 2016, with 93% of RCCs transfused using the device in December
2016. Implementation of Phase 3 has been on a phased basis and will continue
during 2017
400 nursing and midwifery staff received the mandatory Haemovigilance training
during the year, incorporating Blood Track Phase 3. Education sessions have been
provided on the Mandatory Training days, IV Medication Management days,
Student Nurse Information days and also informal sessions have been provided on
the clinical areas. Talks have also been given at the NCHD Induction days and the
Medical & Surgical lunchtime meetings.
18 portering staff trained on the procedure for collection of blood from the
laboratory, including new members of staff. All portering staff are in date for 2
yearly training
A total of 21 Haemovigilance non conformances were investigated and closed out
(non conformances which occurred on clinical area in relation to sampling,
collection, or administration of blood). Corrective actions put in place where
appropriate.
Investigation of 13 Serious Adverse Reactions (SARs) and subsequent reporting
to National Haemovigilance Office & close out.
Register maintained for all Maternity blood usage – this register is discussed at
Maternity governance meetings.
Investigation of ABO Incompatible transfusion which occurred in March 2016. .
Full report completed by Haemovigilance & Laboratory Quality Team and report
sent to the CIS by Clinical Risk Manager. Corrective actions put in place.
Haemovigilance Report presented at quarterly Hospital Transfusion Committee
meetings and also at the laboratory Annual Quality Management Review
(AQMR) with the Hospital Manager/ Clinical Director.
Haemovigilance audits completed as per laboratory audit schedule. Audits
completed included (1) Patient Identification wristbands, (2)Management of
Serious Adverse Reactions, (3) Vertical audits in conjunction with laboratory staff
reviewing a blood component from IBTS delivery to transfusion (one in SLGH,
one in KROH and one in Aut Even) and (4) monthly Traceability audits.
Full participation in monthly quality meetings with the Chief Medical Scientist,
Consultant Haematologist and Laboratory Quality Officer.
44 St Luke’s General Hospital Carlow-Kilkenny Annual Report 2016
Irish National Accreditation Board (INAB) inspection took place in September-
all aspects of Haemovigilance documentation including training records and
procedures reviewed by inspectors. Accreditation passed.
Plans for 2017
Continue with Blood Track Phase 3 Implementation during 2017. Maternity &
Paediatrics scheduled for February/ March 2017 (areas remaining include Theatre
SLGH & KROH and DOSA clinic KROH)
Review of all blood transfusion procedures and documentation on clinical areas to
incorporate changes required following introduction of Blood Track Phase 3.
Provide ongoing training sessions for all nursing, midwifery and portering staff.
Maintain 100% traceability for all blood components and blood products
Complete 2017 audits as per laboratory audit schedule, including audits of blood
track implementation.
Continue to monitor and investigate all reported Serious Adverse Reactions &
Serious Adverse Events
Continue to monitor all blood transfusion practices in SLGH & KROH and
investigate non conformances as they arise
Poster presentation of the ABO Incompatible transfusion error has been accepted
for display at the Academy of Clinical Science and Laboratory Medicine
conference in Galway on 31st March. A PowerPoint presentation is also to be
given at the conference by the laboratory Quality Officer, Chief Medical Scientist
and Haemovigilance.
45 St Luke’s General Hospital Carlow-Kilkenny Annual Report 2016
Oncology Day Ward
Introduction
In April 2017 the Oncology day unit moved to its new 10 bedded unit with minimal
disruption to our service, which is a credit to all staff involved, not one chemotherapy
administration day was lost!. Due to staffing issues, only 6 of the 10 beds have been
commissioned to date.
2016 Oncology Activity
A total of 3,080 day patients were treated on the unit in 2016. These figures
include parental and oral chemotherapy, supportive treatments.
There has been an increase in complexity of patients cared for, for e.g. in 2016,
we transferred many of our less complex nursing interventions out to the CIT
team in the community. This enables the day ward team to give more time to
multi drug therapy regimes, which inevitably take longer to administer.
At our oncology outpatient clinic, we saw 149 new patients and 954 return
patients, total (1,095).
CNS Roles:
1) Clinical Focus
1.1 Direct contact with patient while they are on our unit
1.2 Indirect Contact.
We provide point of contact for our clients via phone support to encourage
reporting of symptoms in a timely manner and psychological support for
patients and their families.
2) Patient Advocacy
2.1 Group Advocacy
The CNS on the Day Ward continues to strive to improve the quality of the
service we deliver to our patients and liaise with all staff and management
stakeholders on ways to do this. A Clinical Governance group formed in 2015 and
meetings organised on a 3 monthly basis to discuss developing issues.
2.2 Individual Advocacy.
The CNS attends the outpatient clinic and advocates on behalf of the patient and
their family - any issues they may have difficulty verbalizing. Also we facilitate
scheduling of treatments follow up scanning and other interventions.
2) Education and Training
3.1 CNS Education.
46 St Luke’s General Hospital Carlow-Kilkenny Annual Report 2016
It is imperative we remain up to date on emerging developments and issues in the
area of oncology. We also have a weekly lunchtime journal club in our
department.
Regular updates and education are also provided to the unit, by the various drug
companies/our own pharmacy department, as licensing changes and new drugs
become available.
The CNS staff have been involved in developing new PPGs for circulation
throughout Oncology and the general hospital. This year we have developed a
PPG for treatment of chemotherapy induced Diarrhoea, Mucositis and care of the
CVAD.
3.2 Patient Education
We are responsible for educating our patients before they commence
chemotherapy on any expected side effects; we support this with written material
and reinforce any information at regular intervals during treatment. We tailor our
information based on the comprehension skills and desires of the patient.
3.3 Education of Staff
Education of staff in the hospital continues to be on an informal basis, as we do
not have sufficient resources provide formal education
Audit and Research
Clinical Audit
The CNS in the oncology unit submits Key Performance Indicators (KPIs) to the
NCCP on a monthly basis outlining clinic activity, treatment and delays in
receiving same.
Audit Role
Again, this is an area that we are not able to reach on at present, due to the need
for prioritising current resources for direct patient care
Consultancy
Interdisciplinary:
As a nurse led service, we work and liaise with our Consultant colleagues and
those in other Oncology units on a daily basis via email/telephone and meetings.
We ensure all instructions are carried out, investigations ordered and results
followed through. We meet and discuss shared issues with our colleagues across
the region on a 3 monthly basis.
Interdisciplinary:
We liaise with the entire Medical and surgical teams in the hospital and
channel all new referrals through the nursing staff to ensure timely
appointments and to help identify any urgent cases. This also ensures that
all necessary information is available when patients come to clinic and that
the diagnosis has been given to the patient/family.
47 St Luke’s General Hospital Carlow-Kilkenny Annual Report 2016
We visit inpatients on the ward as required who are admitted although this
has been becoming more difficult as our workload has increased and also
the complexity and duration of treatments. We offer phone advice to the
ward in instances where we cannot review patients.
During 2014 we commenced a weekly MDT in conjunction with the
Palliative care and Home Care teams. This provides a forum to discuss
patient care pathways with the multi disciplinary team members.
We liaise with our colleagues in the emergency department to provide a
timely and quality service to our service users.
Planning for 2017
We hope to extend our service to 5 days per week to facilitate increased
demand.
We hope to introduce the NCCP telephone Triage model.
We hope to introduction scalp cooling for our patients in Q2 2017. 2 scalp
coolers have been purchased at a total cost of €30,000. The Scalp Cooler
drops the patients scalp temperature to minus 22, so many patient comfort
measures need to be in place to help tolerability of device. This will be a
first in the South East and we are very proud to be able to offer this
intervention.
Continue to work to meet all recommendations set out by the NCCP post
the Medication safety audit along with our Medical and Pharmacy
colleagues.
We hope to be secure by additional nursing resources for staff education
within the hospital.
48 St Luke’s General Hospital Carlow-Kilkenny Annual Report 2016
Hepatology Department
Key Achievements and Activity for 2016
We moved to our new department on the second floor of the new building.
All staff attended updating on new DAA treatments
We began providing DAA treatment for Hepatitis C under National Guidelines.
The staff in the department are fortunate to hold the positions of chair and
secretary for Irish Hepatology Nurses Association, and organise bi-annual
meetings in conjunction with the Irish Society for Gastroenterology.
We developed a new Liver Elastography Service, in conjunction with our
Radiologist colleagues.
Plans for 2017
We will treat approximately 70 Hep C patients, as per guidelines from the
National ICORN group
We hope to create new data base for Liver Elastography
49 St Luke’s General Hospital Carlow-Kilkenny Annual Report 2016
Hygiene Services End of Year Report for 2016.
HIQA defines hygiene services as:
“Hygiene is the practice that serves to keep people and environment clean and
prevent infection. It involves the study of preserving ones health, preventing the
spread of disease, and recognizing, evaluating and controlling health hazards”
No. Key Performance Indicator Achieved/Result Comment
1. The hygiene services committee will
have at least meet 8 times in 2016
100% Achieved.( Jan, Feb, March,
April, June, July, Sept, Oct,
Nov & Dec)
Goal achieved
2 100% of Hospital workers will
participate in hand Hygiene training
by the end of the year
74% For 2016 of all hospital
employee.
3 Each Clinical department will
carry out internal hygiene audits on
a two monthly basis.
28 clinical areas
in total were
audited
4 areas completed 6 Audits
10 areas completed 5 Audits
7 areas completed 4 Audits
4 areas completed 3 Audits
1 area completed 2 Audit
2 area completed 1 Audit
(6audits is our target for
clinical areas)
4 Each clinical area will be audited as
per risk category status.
100%+achieved
(Revisits in
some areas)
eCat System introduced.
Goal achieved
5 Each non clinical area will carry out
at least one internal hygiene audit
every six months.
Not achieved Pharmacy Area submitted
only 1
Lab have not submitted any
audit to date
6. All non clinical will be audited at
least once by the end of 2016
100% Goal achieved
7 Cleaning schedules will be reviewed
for all departments
Not achieved IR issues persist in some areas
8 A Patient satisfaction Survey will be
carried out
Completed.
92% of patients
who were asked
to participate
had a very
positive
experience.
Very positive results.
9. The Hygiene Committee will help to
identify, develop and review policies
relating to hygiene
100% Cleaning of Wheelchair
policy,
SLKK Cleaning Manual,
Waste Management Policy,
50 St Luke’s General Hospital Carlow-Kilkenny Annual Report 2016
The Management of Broken
equipment.
Procedure for Improving
Hygiene Standards in
Clinical Areas
10. The Hygiene Committee will
participate in the HIQA Hygiene
Services Assessment Scheme and
progress the Quality Improvement
Plans as necessary.
√
QIPs revisited &
updated on a
regular basis on
hospital website
to reflect
ongoing
progress.
QIPs associated with HIQA
visit on December 15th
2015.
were developed and uploaded
to the hospital website.
11. A Risk Register will be developed
and populated during 2016
Populated at
dept level.
All departments have relevant
hygiene risk highlighted at
ward level & these are
escalated to the hospital risk
register.
Following review of the hygiene audit reports over the year, it has been noted in the
findings areas in need of ongoing intervention and monitoring.
Findings
Technical Services
Completion of the new hospital complex incorporating the new ED, AMAU,
Hepatology, Oncology, Day Services Unit as well as the New Hospital
Library/Education facility
Improvements have been noted in some areas, particularly with the introduction
of the Arantico System traceability is visible and there is evidence of status of
ongoing works.
Painting and floor covering is ongoing depending on Patient Flow and patient
capacity in clinical areas & the main corridors. The admin building has a floor
space inside the main door repaired.
Clutter has worsened along the Stores link corridor. (Broken equipment, empty
cardboard boxes etc)
All Hospital windows were cleaned
51 St Luke’s General Hospital Carlow-Kilkenny Annual Report 2016
Issues that are of ongoing concern each month in the majority of departments
include:
Some WHBs that are non compliant with H.I.Q.A. recommendations.
Loose ceiling tiles, holes in walls, chipped paint on walls, doors and cupboards.
Damaged/ dirty window blinds.
Rust on radiators.
Damaged/worn floor covering/ skirting
Departmental
Some improvements have been noted in clinical practice, eg: hand hygiene. PPE
Sharps bins are mostly in line with best practice with assembly, signature, temporary
closure etc.
Improvement noted in the cleaning of equipment between patient uses.
Problematic Issues
Poor compliance with correct medication management.
Poor compliance with mattress checking
Poor compliance with Laundry segregation policy
Poor compliance with waste Segregation.
Staff training records (Hand Hygiene, Standard precautions, & Sharps) needed
updating in many areas.
Unclear roles & responsibilities in relation to the cleaning of some equipment,
more problematic in some areas than others. Partnership group established to
address change in practices related to these activities. In now an IR Issue.
Housekeeping:
Improvements noted in the cleaning of Sticky tape residue, and Lime scale from taps.
Poor compliance in the cleaning of Gel dispensers and replacement of gel in
public area.
Closure of tasks on eCat
Housekeeping services need to establish records of evidence on cleaning radiators
and window blinds
All Chemicals to remain locked.
Sign off sheets not always up to date.
52 St Luke’s General Hospital Carlow-Kilkenny Annual Report 2016
Achievements.
Rolled out the eCat paperless auditing tool to all areas for audit in St Lukes
General Hospital.
Completion of wheelchair audit and progress made in relation to findings.
Quarterly newsletter
A hygiene awareness week took place in September, very positive feedback and
useful suggestions & comments were received.
Education / training and updates were available for all staff, on the paperless
hygiene audit system eCat early in the year. Ongoing training on request for new
staff.
Information leaflets on hygiene for all staff and patients have been update and
distributed to all departments.
Completion of patient satisfaction survey.(December 2016)
Hospital Cleaning Manual completed and distributed to all areas in the Hospital.
Conclusion:
It is the intention of the Hygiene services Committee to ensure that the best possible
standard of hygiene is achieved through education, audit, review, monitoring and
evaluation of the service in line with the HIQA Hygiene Services Standards and the
National Standards for the Prevention & Control of Healthcare Associated Infection. We
will endeavour to achieve this goal in 2017.
53 St Luke’s General Hospital Carlow-Kilkenny Annual Report 2016
Hygiene Audits 2016
54 St Luke’s General Hospital Carlow-Kilkenny Annual Report 2016
Arts Department
Key Achievements and Activity for 2016
Arts Therapy Student working with Diabetic teenagers and multi disciplinary
team
Oncology art donation
I’d like to tell her project
Exhibitions throughout the year
Music Arts festival during Kilkenny Arts Week (August)
Staff Choir – established in September 2016 and was very successful
Percent for Art installation for the new foyer area was commissioned
Drop-in Wellbeing meditations sessions for staff at lunchtime
Some of our plans for 2017
Percent for art to be completed, installed & launched during 2017
Display of Travellers Art project
Continued participation in Arts festival with own exhibition and performances
Provision of led cultural walking groups to promote arts and wellbeing
Continuation of drop in meditation sessions
55 St Luke’s General Hospital Carlow-Kilkenny Annual Report 2016
SLGH Clinical Risk Management Department
1. Reporting of patient safety events:
The reporting of patient safety events is an important part of the risk management
process and ensuring that the hospital has a positive safety culture. All staff,
regardless of grade are encouraged to report patient safety events. All patient
safety events reported, are reviewed by the Clinical Risk Manager and are logged
onto the National Incident Management System (NIMS) operated by Clinical
Indemnity Scheme (CIS).
The hospital has a good reporting culture and in 2016, 1,259 patient safety events
were logged onto the system pertaining to clinical care related incidents, birth
specific related incidents, medication related incidents, nutrition related incidents
and incidents associated with physical and biological hazards.
Incidents of serious harm (Serious Reportable Events) as per HSE 2015
definitions are reported to the HSE Quality Improvement Division and to IEHG.
Information relating to Maternity incidents are included on the hospital’s
Maternity Safety Statement which is published on the hospital’s intranet site.
2. Review of patient safety events:
All patient safety events reported, are reviewed with the relevant line manager and
patient’s medical team as required. Learning and recommendations from reviews
are brought to the attention of senior management and are implemented through
the relevant governance committees in the hospital.
3. Risk Registers
Risk management is also concerned with the identification of risks and the
implementation of controls to minimise the impact of a risk or to prevent a risk
occurring in the future. A risk register is a database of assessed risks that face any
organisation at any given time. Its purpose is to help Managers prioritise available
resources to minimise risk and target improvements to best effect. All wards /
departments in the hospital are required to maintain a risk register. The overall
hospital risk register is maintained by the Clinical Risk Manager and risks are
escalated to IEHG management team.
4. Education and Quality Improvement
The HSE Quality and Verification Division have recently updated the HSE Risk
Management / Incident Reporting Guidance and Policies and they can be found at
http://hse.ie/eng/about/QAVD/riskmanagement. The Clinical Risk Manager over
the coming months will provide education sessions in relation to these documents.
The Clinical Risk Manager organises education sessions for staff on topics which
in relation to themes identified following review of patient safety events.
The Clinical Risk Manager is a member of governance committees in the hospital
and quality improvement committees in the hospital. The clinical risk manager
56 St Luke’s General Hospital Carlow-Kilkenny Annual Report 2016
provides data on patient safety events to relevant quality improvement
committees.
57 St Luke’s General Hospital Carlow-Kilkenny Annual Report 2016
The Year in Photos
Eleanor Moore, Business Manager, presenting
the then Minister for Health, Mr Leo
Varadkar TD, with his t-shirt to mark the
launch of the St Luke’s Couch to 5k 2016
Michael Walshe, Housekeeping
Manager, pictured at the Long Puck
Challenge on Jersey Day in 2016.
Prof Garry Courtney, Clinical Director,
pictured with Kilkenny Rose Claire Walsh
and the Rose of Tralee, Elysha Brennan,
during their visit to St Luke’s in 2016
Participants from St Luke’s with IEHG
Service Improvement Leads and Cindy
Walton from Simpler at the Outbrief
from the first Rapid Improvement Event
and Value Stream Analysis in St Luke’s
in 2016