One Step Ahead

Minutes of the EOC Clinical Governance Committee

08:00OnWednesday 22nd October 2014;Boardroom

Present:

David Ward / DAW / Catherine Flower (notes) / CF
Anwar Hussein / AH
Sophie Bevan / SB
Naj Bhaskaran / NB
No / Item / Who / Documents
1.0 / Minutes
1.1 / Apologies for Absence and welcome
Philip Mitchell, Sue King / DAW
1.2 / Minutes of Previous Meeting
The minutes of the previous CGC meeting of the 22nd September were agreed with no amendments made. / All
1.3 / Previous Matters Arising
AJ Report:
The group discussed the final AJ report and the action plan developed from the recommendations. It was agreed that:
Anaesthetic governance is required with agreed techniques & an overall pre intra operative pathway. Anaesthetic Department to write a document responding to the recommendations of the AJ report for Medical Council & CGC.
AH raised concern that there are no guidelines / protocols with regard to monitoring patients with spinal opioids on the ward. Royal Utd Hospital Bath has good guidelines.
Review of the nursing structure /man powerto look after patients with spinal opioids – SKing & SB.
The Pain Audit Nurse position has gone out to advert. CGC were concerned that no clinician input has been sought for this position.
AJ report to remain as a standing agenda item. / DAW
2 / Cases for Discussion / Who
2.1 / CS
DAW presented this patient on behalf of PM.
Issues:
  1. Vascular damage
  2. Fracture
PM to discuss surgical technique with surgeon if not already.
Potential vascular injury was managed well, however CGC concerned that accessing the vascular surgeon at particular times of day could be tricky.
Action: Vascular cover arrangement requires reassessing. Obtain the document detailing vascular agreement – ?SLA. / DAW
2.2 / AC
NB presented this patient who had a cardiac arrest on the table in theatres.
This patient has a history of fibroid ?cause. Operation abandoned.
The quality of support of ODP’s was excellent and the system worked well. CGC agree excellent management. / NB
2.3 / SG
DAW presented this patientwho was diagnosed with periprosthetic fracture 48 hours post op:
Issues:
Osteopenic rheumatoid patient in late 70’s – case for Consultant not Registrar.
Choice of implant / fixation.
Why revise cup.
Poor discharge summaries
Outcome?
PM & DAW to discuss the case with the surgeon.
SB confirmed that advice will need to be sought from the Trust – can this happen or did we cause harm to the patient. (All patients who are exposed to moderate harm must be informed as part of being open and honest). SB to confirm & provide a document describing the terms of reference for moderate harm incidents. Clarity required of what the Trust report. / DAW
SB
2.4 / JV
DAW presented this patient who reported a lump in the wound 8 weeks post op. Deep infection confirmed. Second stage revision scheduled in November & will use antibiotic loaded cement.
The only possible risk factor was ‘infected’ scalp scratches. / DAW
2.5 / Provision of Hickman Lines
AH discussed his concerns that the insertion of Hickman lines are relied upon the good will of the x-ray team, theatre team and AH & NB. They are scheduled in an adhoc manner at present & are not very frequent.
It was stressed that if a surgeon thinks a Hickman line is required, early recognition and communication with NB / AH as soon as possible is necessary.
The group agree that there are no mechanisms in place for patient to go back to base hospital for this and that the EOC would be best option for the insertion of Hickman lines.
No solution. / AH
3 / CGC Dashboard / Who
3.1 / DAW went through the figures provided for the CGC Dashboard.
Further tweaking of the scorecard required:
Remove all reasons for patients return to PACU as AH will go through individually.
NB to present the 24 patients LOS > 10 days at the next meeting.
Only document average LOS > 10 days and LOS 5-10 days also.
Clinical cancellations – 9 cases in September cancelled due to surgery no longer required. Unacceptable and the importance of assessing carefully in clinic needsreiterating.
Falls – SB to liaise with anaesthetic department.
DAW to liaise with Jocey Buly regarding reporting quarterly complication reports.
1 patient returned to theatre. Pt fell and dislocated. POA identified as unsteady on feet. SB mentioned we should falls assess all patients over 65 24 hours post op. Three categories – low, medium and high risk (criteria to follow). SB will meet with the Leads on 19th November to implement. CGC agreed. Discuss this case at next CGC.
SB informed CGC that the Trust require all investigations undertaken signed off at CGC. (Moderate harm incidents to stand on agenda). / DAW
4 / Items for Information or Circulation / Who
4.1 / NB discussed the consent form for shoulder patients on behalf of Mr Patel. Mr Patel would like the risks of complications typed on the consent form rather than hand written in order to tighten clinical governance within his team. No changes to the actual content of consent form. CGC agreed. / NB
5 / AOB / Who
5.1 / AH – Croydon will not accept warfarin referrals from us for patients who are newly prescribed warfarin therefore Croydon patients have to be discharged on dalteparin. This is not in the best interest of the patient.
Agreed: DAW to write a letter to Croydon CEO.
AH – Consider bringing a high risk patient in to the EOC from the private sector. Discussed with NB & SKidd. AH to engage the surgeon, anaesthetist, PACU & wards to discuss and plan well in advance.
SB – 12 x moderate harm incidents.
In May incident whereby ICD did not turn up. Statement outstanding – NB will chase and discussion for next meeting.
September - wound catheter needle left in patient whilst the other knee was being operated on. Fortunately this was retrieved before the patient left theatre. Paula Cox is writing up the investigation. SB to report at next meeting. / All
Dates of next Meeting
Wednesday 19th November at 08:00 – 10:00 /