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The US observance of ’Groundhog Day‘ is more than just the annual emergence of Punxsutawney Phil – the rodent soothsayer who ceremoniously predicts the timing of the arrival of Spring. It is the name of a popular film that represents how the repetition of unwanted experiences can contribute to scepticism, callousness and burnout for the primary character – weatherman Phil. However, he emerges from the darkness by applying what he learns over time to arrive at a new brighter day. Patient safety leaders are apt to feel like weatherman Phil. Repetitiveness – the feeling that something been done over and over again without change – can decrease engagement but it can also lead to experiential knowledge that can be applied to future efforts. Community engagement is paramount to patient safety success but it can be challenging if people feel like they wake to the same problem every day despite efforts to make a difference. The Boston-based Betsy Lehman Center has developed Including the Patient Voice: A Guide to Engaging the Public in Programmes and Policy Development. The Guide shares a six-element approach to involving members of the public as partners to reduce reoccurrence of poor care. Strategies focus on enabling community members to succeed as partners and contribute as experts to designing health services that are evidence based and accessible to all. This includes leadership-led mini-workshops for staff to inform their engagement programmes and patient correspondence reviews to identify the right consumers to invite as participants. Similarly lessons have been shared by MedStar Health, a large regional healthcare system that sought to engage patients and design strategies that engage patients and families in safety improvement. Organisational structures such as Patient and Family Advisory Councils (PFAC) served as the focal point of the shared learning effort. The system developed a network of courses that shared best practices to foster innovation and sustain realised improvements in event reporting, disclosure (the CANDOR Toolkit), after-incident support and sepsis reduction. The tactics used include board and leadership activation activities, a mentorship programme for new community leaders and public awareness campaigns. For example, the system launched a collaborative to share information to improve early detection of sepsis. Patients who had contracted sepsis along with PFAC members and in-house quality experts were brought together to design an educational video to reduce sepsis that highlighted symptom identification and response. The programme contributed to marked sepsis treatment improvement. The City of Philadelphia recently launched a prescription monitoring strategy to curtail the overprescribing of opioids in their region. Because this programme identifies by name the 10% of physician that overprescribe, these individuals can be offered targeted training and, if necessary, legal interventions to address their behaviour. Home-grown programmes can also be proactive to prevent overprescribing. One Boston-based family medicine clinic described their five-year change management effort to reduce opioid overuse. The authors reported their focus on developing “shared general principles”; communication mechanisms to connect clinicians with in-house addiction experts, patient registries, targeted training, certification opportunities and centralised leadership were all instrumental in embedding improved prescribing practices throughout the organisation. Consistent unremitting workload pressure perpetuates stress and fatigue. Its presence degrades staff relations, performance and the safety of care delivery. It’s a common problem that medical residents are burnt out: no news there. What conveys great promise are programmes like what the Virginia Mason Medical Center in Kirkland Washington has done to address burnout by implementing workflow changes and fostering a culture of “collegiality, respect and innovation”. The Center changed workflow by standardising clinical tasks, defining staff roles and carving out protected time for staff to recharge, self-educate and participate in improvement efforts. The Center has enhanced its culture and improved staff morale through leadership efforts to lower hierarchy, welcome and respond to feedback, and address inefficiencies that can discourage staff and derail efforts. Ninety percent of staff at Kirkland reported in a 2018 internal survey feeling content and engaged about their work. Medical residents can also find support through programmes like the ACGME Aware initiative. This set of tools targets strategies that junior doctors can use to build resilience and embrace their professional community through a mobile phone app to find support as they need it. Personal tactics to protect against burnout for more experienced healthcare professionals are also in demand. A news story in Medical Economics highlights what doctors and hospital administrators can do to minimise burnout, such as making time to socialise with peers and using the opportunity to share stories, rethinking their roles to bring joy back to medicine, and to listen. For 2020, Phil has told us that Spring is due to arrive early. Will the application of the successes reviewed in this month’s Letter reduce the recurrence of opioid overprescribing and staff burntout? We need more than a rodent to speculate on that for us. But given efforts by patient safety champions in the US and UK, improvements optimism is in the air.

This powerpoint presentation from the Birmingham Women and Children's Hospital NHS Foundation Trust explains the data backing up this fantastic initiative.

It's midnight on the acute floor, just before Christmas. As I walk through the Emergency Department (ED), I can hear the ambulances reverse up to the door, people shouting, doors opening and closing, phones ringing and the general white noise of the department. You wouldn’t know it was night-time at all, the lights are beaming and it's as noisy now as it is in the day. I am a junior doctor. I’m on my fourth night shift of six. I have a patient on the acute medical admission unit that I need to check up on. I take the opportunity to seek some darkness and quiet away from the hustle and bustle of the ED. As I go into the unit, I spot a young man in his 20s. He has a carer at his bedside. I stop. I say "hi"’ to the carer and just take a quick glance at the saturation probe that is on the young man’s finger. It’s reading 94% (normal is >95%). "Is that number of 94% normal for Eddie*?" I ask the carer. "Yes" he confirms. "What about the heart rate, that’s reading 140?" I asked, but didn’t want to come across alarmed, as this is quite high. "No. It usually reads 90. I was worried, but assumed you were dealing with it". My time is limited, I should be checking on my patient I originally came in to see. I have now seen a vulnerable adult with an abnormally high heart rate. However, the nurses are here… they can act on it , can’t they? I need to see my patient. I have patients backing up in ED, what about the four-hour target? Those thoughts go through my head in a split second. I now find myself pulling up a chair alongside Eddie and his carer. I find out that he has been admitted as his feeding tube had fallen out; he is here to have it replaced in the morning in theatre. I find out that it had fallen out 18 hours ago. As Eddie is unable to swallow without the risk of choking, he relies on the tube for all his medication and fluids. I take a look at the observations. Respiratory rate 18, heart rate 140, blood pressure 89/48, aprexial, not confused. He has a NEWS2 Score of 6. I see a sepsis screening tool that has been completed. It has been deemed that Eddie has a high suspicion of sepsis. But... he’s only come in for a tube change? I use the expertise of the carer. I find out that Eddie hasn’t had any fluids all day and his pads have been dry. At this point he should have had 3 litres of fluid via his tube. He also has not had his medication for his seizures. This is vitally important as it is highly likely he will seize this admission. I put some fluids up. I need to be quite aggressive with replacing his fluids as he may go into acute kidney injury. I write up his epilepsy medication, this time via his cannular. I explain to the nurses to give hourly observations and to call me if there are any problems. I check on Eddie that morning. He’s bright as a button. Smiling and ready for his tube replacement. If I walked on by, what might have happened? Eddie would continue to be treated for sepsis when he wasn’t septic and received antibiotics he didn’t need. Eddie would become more dehydrated and possibly acquired an acute kidney injury. Eddie may have suffered a seizure that could have been prevented. Due to these complications, Eddie may not have been fit for his tube replacement. Eddie's length of stay may have been increased, therefore increasing his risk of contracting a hospital acquired infection. What stopped me from walking by? Eddie reminded me of my brother, *Sam. My brother has cerebral palsy and needs 24-hour care. He’s funny, he can wrap mum around his little finger, he can play pranks on you, he is still my annoying little brother but coming into hospital always poses such a huge stress on us as a family, not to mention Sam. He always has people around him that know him. So, coming into this environment is alien. Due to his physical problems, he doesn’t ‘fit the normal patient mould'. Will he get the right treatment? Will he get his medication on time? Will there be anywhere for the carer to stay? Will the nurses know how to re-position Sam? How will they communicate to Sam? Will they read his patient passport? Will they act on his patient passport? Or will they walk on by? *Names in this blog have been changed for confidentiality purposes.

In this video, the team talk about how they have transformed the way they approach sepsis care by using a clinical decision support tool called E-sepsis to increase screening for sepsis and subsequent antibiotic administration. E-Sepsis sees integration of a number of clinical parameters including patient observations and laboratory results. It automatically alerts clinicians when it detects a patient with sepsis. This removes the need for manual intervention and e-sepsis prompts clinical action by the member of staff treating the patient. Viewers will also learn how they can adopt what the team have done within their own organisation through the blueprint that has been created of this project. The GDE blueprints can be found on the FutureNHS platform. To register, email: gdeblueprints@nhsx.nhs.uk

In this first issue topics include: data interpretation pressure injuries allergy medication errors vascular access sepsis awareness patient stories.

The resources include peer-reviewed content on identifying and managing sepsis in the community, in older people and in children from Emergency Nurse, Nursing Children and Young People, Nursing Older People and Primary Health Care.

Key learning points Maternal sepsis remains a significant cause of morbidity and mortality in the UK. Improving prevention and care of sepsis is highlighted in the latest Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries in the UK (MBRRACE UK) report: Saving Lives, Improving Mothers’ Care 2017. One of the actions suggested is a ‘declaring sepsis’ alert as described below. Where sepsis is suspected a sepsis care bundle, applied in a structured and systematic way with urgency, can save lives.

What will I learn? History of sepsis guidance Oxford AHSN approach to implementation of the guidance Care bundles (resource) Regional pathway for sepsis How to measure surveillance Limitations of coding sepsis Patient outcomes

This page sets out the approach, methodology and conclusions into how the outcome was achieved and contact details for more information on the collaboratives.

This short video explains how CareFlow has made improvements in recording venous thromboembolism assessments and in recording sepsis screening assessments.