Nottingham University Hospitals – Think Drink Project

Case Study – May 2017    

 nottingham uni

Nottingham University Hospitals – Think Drink Project

About the Project

Think Drink initiative was established in 2015 at NUH. The cause and extent of the problem

was identified through audit data of fasting times for patients  waiting for surgery and valuable Patient Public Involvement feedback from patients about their experiences. The audit data indicated excessive fasting times for patients across the trust, an average of nine hours; this coupled with some negative feedback from patient, saying they were very thirsty and kept without fluid for long periods prior to their surgery. The overall aim of the initiative is to minimising fasting times for patients across the trust thus improving patient outcomes and experience, reducing dehydration and morbidity.

think drink

Think Drink is a very special project, it is not a difficult concept it is about a change in culture that has been longstanding across not only Nottingham University Hospitals but lots of hospitals across the NHS. Such a simple idea has had such a positive and wide spread impact on improving our patients’ experience; the project has encompassed all wards and departments and really is Trust Wide. Changing the longstanding culture of ‘nil by mouth from midnight’ has had minimal cost implications for us as a Trust and makes such an immense difference to our patients experience and outcomes.

In terms of contributing to the project’s success, it would not have been made possible without increasing awareness of the benefits of shorter periods of fasting to both staff and patients. Improving communication between theatres and ward staff with the development of specific guidelines and algorithms to simplify the process of fasting.

The project is a simple but innovative project which aims to minimise fasting times for our patients to improve patient experience and outcomes. Complications of excessive fasting are a patient safety issue; minimising fasting times reduces dehydration, hypoglycaemia and potentially reduces the incidence of electrolyte imbalance and acute kidney injury.

Implementation has been made possible by the inclusivity of all staff, students and patients through education and training. This has been achieved by developing and adopting specific eating and drinking guidelines and an approved drinks list and incorporating ‘Think Drink’ moments in theatre briefings in order to enhance decision making and communication.

Education and training of staff, students and patients has been undertaken across the whole of the organisation by credible and enthusiastic champions to promote engagement. The success has been measured by improved feedback and audit data; fasting times have reduced from 9 hrs to 3.5 hrs.

More importantly for sustainability, there appears to have been a cultural shift. Wards are more aware of prolonged fasting, and theatres are more comfortable with shorter periods of fasting.

Other organisations across the NHS have shown interest in the project, challenging long held perceptions is not easy and requires persistence and credible champions.


How Did We Achieve It?

A Project Group was formed which was made up of various members of the multi-disciplinary team including nurses, dieticians, anaesthetists who analysed the feedback from patients and the audit data which was then disseminated to theatre and ward staff at team meetings along with an action plan. The reasons for excessive fasting were explored from both process (theatre list planning, clarity of information given to patients), cultural (the ritual of ‘nil by mouth from midnight’) and educational (what are the recommended fasting times) paradigms.

Innovative solutions were generated by on the ground staff aiming to improve both patient outcomes and experience. The interventions targeted staff and patient understanding of the rationale for limited fasting, and ways to facilitate safe fasting times within changing theatre schedules. Small scale rapid pilots were used to refine the guidelines before wider roll out.

Theatre briefings now include a ‘Think Drink’ moment where a named member of the team clarifies with the anaesthetist and surgeon which patients can drink and until what time, based on the expected duration of cases. This is done for all patients on the theatre list and repeated during the day, this is communicated to the ward and admission areas. Ward and admission areas are then able to offer patients drinks up to two hours prior to their procedure. Patients are able to choose from a specially formulated drinks list to further improve their experience this includes: tea and coffee with no more than one fifth of skimmed, semi or soya milk, dilute squash, still energy drinks or drinks part of the enhanced recovery after surgery. The project guidelines incorporate adult and paediatric patients and include elective and emergency patients.

In terms of delivering and embedding the project, a Project Lead was employed to work closely with theatre and ward areas throughout the hospital, disseminating the guidelines and providing education and training to all staff and patients in order to promote understanding and engagement.


What Have We Achieved?

The Projects efficacy has been measured by improved patient feedback; this has been collated in a number of ways. One of the ways in which this has been collated is in the form of PPI feedback, the feedback received thus far has been exceptionally positive. Another measure used to assess the impact of the project is audit data of fasting times for patients across the Trust. This has reduced from 9 hours to just 3.5 hours which is a huge improvement especially given the size of NUH and the enormous culture change required.

We continue to gather feedback and have seen a reduction in negative comments regarding excessive waits; however on-going comments have enabled us to focus on continuous improvement. As a Trust we have made huge inroads in changing the culture and ritualistic practice of ‘nil by mouth from midnight’. This has only been made possible by improving knowledge and communication and cohesion between staff and different specialities.

Moving forwards in order to sustain the fantastic success of the project, we aim to continue to carry out regular teaching sessions for staff by developing a video; this can be shown to students and staff at Trust induction days and mandatory training.

With the implementation of specific eating and drinking guidelines, think drink moments and algorithms we have made a sustained change in culture. New staff coming into the Trust perhaps unaware of the Project and guidelines will see it being championed and learn from the example set by other staff.

Nutrition link professionals continue to champion the project in individual ward areas. Furthermore, patient information will be made available on the intranet to reinforce the importance of remaining hydrated prior to surgery, not only in terms of patient experience but examining and explaining some of the complications which are attributable to dehydration and pre-operative fasting.

The initiative is extremely relevant to other trusts in the Country, the project has enabled us to greatly increase patient experience whilst at the same time improve patient outcomes.  Using the most up to date evidence for fasting showing that long periods of fasting are no longer beneficial and that shorter period of fasting have better outcomes for patients. NUH have recently been shortlisted for a Nursing Times Award for the Project and the Project has received positive recognition in NUH’s recent CQC report.

Learning Points

  • Challenging the long-held dogma (‘nil by mouth from midnight’) is not easy and requires persistence and credible champions.
  • When there are competing pressures (reducing starvation versus perceived risk of list delays/cancellations) these need to be discussed openly.
  • Focussing the project on the patient rather than the process allows staff to speak up as the patients’ advocate.
  • Small things, such as clarifying what fluids are allowed until what time can make a huge difference to our patients.

Cambridgeshire Community Services NHS Trust

Beads of Courage: Making a Difference for Each Child

General Summary

The Beads of Courage programme was introduced to the UK, from America, through the paediatric oncology units. The beads are a concrete visual representation of each intervention a child has undergone during their treatment, helping them talk about their condition, fears and hopes. As a Community Children’s Nursing team, the children and young people (CYP) we support with cancer started to receive the beads supplied to us by the Regional centre.

Mags Hirst, our play specialist, recognised the benefits of this scheme and was passionate about extending it locally to the many children we care for complex and life-limiting illnesses, but who do not have cancer.  As the beads are not funded by the NHS, as a team we identified funding streams to ensure sustainability and to ensure local CYP could continue to benefit from these. The Beads provide them with a unique approach to personalising care by working in partnership with CYP and their families, enabling them to understand and talk about the impact of their condition and treatment on their daily lives.

The beads and the story they tell are unique to each child, their siblings and their families. The beads build a picture and a memory for each family that they can keep and reflect on. It gives credibility to their journey in a concrete and understandable way that can be used to explain to a child, when they are  older, what had happened to them, or as memory for the family if their child is no longer with them.

We were the first team in the UK to introduce the beads for children and young people with a non- oncology diagnosis, and the celebration annually of the children and their beads is a spectacular, happy, exciting event. With the positive attitude and leadership demonstrated by Mags, a willingness to identify unique elements of each child’s journey, and our ability to  share a joint, team vision, keeping children and families at the centre of what we all do, we have been able to work together to truly benefit children.  These benefits are achieved at the most challenging time in a family’s life and through the most painful journeys they will ever have to face, providing a platform for them to express their own, unique stories and paths



As a service we aim to provide individualised, compassionate care and believe that the Beads of Courage, in a small way, can give credibility to the child and their family of the challenges they face on an almost daily basis for, what is often, a lifetime.

The Beads of Courage embrace and celebrate each child’s unique experience and personal journey with regards to their complex or life limiting condition.

The beads are a physical reminder of each child’s personal story; their treatments, every hospital attendance, every visit by a community nurse, every intervention they have to have, and gives CYP the opportunity to build a visual representation of their personal journey, supporting their emotional, social and spiritual needs.  The beads also provide a way to open and improve dialogue not only within families but with those around them, such as friends at school and other professionals who may not have the broad understanding of the challenges and achievements each CYP has on their journey

We also provide beads for siblings.  These recognise the challenges siblings face with having a brother or sister who is unwell and who is often away from home.  They also provide a way to celebrate and acknowledge the support siblings provide as carers and recognise the impact having a child with a life-limiting illness in the family can have on siblings, for example when parents are away from home with the poorly child or miss family and school activities.



Mags Hirst provided the leadership for introducing this innovation for children with life-limiting illnesses.  She contacted the programme lead, and explored the use of the beads in a wider context. We were informed that the licence was available for CYP with life-limiting, non-oncological conditions and complex health issues. We then sourced initial funding and became the 1st team in the UK to provide the beads outside the oncology world.

We identified a pilot group of CYP already known to the team, and in partnership with the children and their parents, discussed if this was an innovation they would welcome.  The feedback was incredibly positive with universal agreement that this was something to be rolled out and which would benefit their child, as well as the wider family and friends.

Our pilot consisted of 8 CYP and we provided families with ‘Bead diaries’ to help us understand and evaluate the benefits of the beads in terms of family memories and recall, as well as the costs involved in providing the beads retrospectively to the point of diagnosis. Without exception, each family enrolled on to the pilot programme was able to comprehensively complete their child’s diary, one family being able to recall 9 years of complex care.

Through our initial investment, Mags was able to purchase the beads required to commence the pilot and complete these CYP bead collections. Each family has reported back the positive benefits and the therapeutic value of threading the beads alongside their children.  The therapeutic value reported included enabling families to remember and talk together about the detail of the treatments received, including the pain experienced and courage shown by the children and the great pride parents had in their child’s ability to face these challenges.

Our electronic records incorporate a care plan which highlights the beads programme as an intervention in itself, so that we can ensure all children and their siblings, who are eligible for the beads, are considered for the programme and the beads offered


The positive impact of the beads cannot be emphasised enough. Children and young people now have a voice that they may not have had previously. They are able to discuss and articulate their own, individual, stories in words and language they understand. The children, and their families, are able to take their unique combination of beads to hospital and clinic appointments and express what has happened to them since they were previously seen.

The impact on professionals has been astounding, most have never contextualised what it means to be a child or young person with a complex or life limiting condition. To see the beads, threaded together, is a very humbling experience for both clinicians and non-clinicians and is a reminder of why we all work in the roles we do and that all of us are working together to ensure positive experiences of health care for our patients or client group

We wanted to give the CYP a voice, a way of talking through their experiences, fears and successes.  We have evidence of a young girl who was selectively mute, as a result of her fears and worries due to her ill health.   Using her beads as a platform to speak, she was able to explain to people what scared her and what she has endured and earlier this year she was supported by Mags to stand up in school assembly and talk about her journey

We are measuring the beads in terms of cost and report 1/4ly on this to our financial team and donors, to ensure effective and appropriate use and ongoing sustainability of the beads


The greatest measurement we have is qualitative from the feedback and engagement from the children and their families both in terms of engagement with the initiative, a positive expectation that the children will receive their beads from the nurses who visit them, the accumulation of retrospective beads for interventions by professionals outside of the team and increasing attendance at our annual tea party for children and families where we celebrate the immense courage and bravery the show each day.


Key Learning Points

  • Be open and honest when discussing the purpose of the beads with families and children before they start on the initiative
  • The reflection needed can be painful for families and this needs to be supported
  • The ongoing funding needs to be considered as this needs to be sustainable, families and children will discuss and compare, so there needs to be equal access
  • Storage….you will needs lots of storage!

Making the inaccessible, accessible

sign Solutions

sign solutions photo 1Deaf people have always struggled with access to the NHS. The barriers to access can take many forms, whether it be needing an interpreter to talk to a doctor, or just making sense of the NHS leaflets and website information.

The introduction of the Accessible Information Specification, has provided NHS trusts with guidelines on how to meet the needs of their local Deaf community. Targeted to meet the minimum standards of the specification by July 2016, trusts have already implemented vital changes to improve how patients access the NHS services. However, the specification details further measures such as ensuring all patient information is available in the patient’s first or preferred language and that they are empowered to communicate instantly, to cover any emergency communication requirements.

At last technology has the answer, through on demand video Interpreting technology.

For the NHS, the video interpreting system enables profoundly Deaf patients to have instant access to a clinician in person at the trust or over the phone, through a registered and qualified British Sign Language Interpreter. This allows vital information to be communicated simply, easily and on demand 24/7. The system essentially removes the communication barriers for Deaf people, by giving them the freedom and independence to communicate with and access the services provided by their local NHS trust.

sign solution sphot 2

The Accessible Information Specification is designed to take a specific yet consistent approach to identifying, recording, flagging, sharing and meeting the information and communication support needs of patients, service users, carers and parents. It is applied right across the NHS and the adult social care system and has required the organisation to make a number of changes to policy, procedure, human behaviour, and, where applicable, electronic systems.

The standard defines the steps that NHS organisations need to take in order to make ‘reasonable adjustments’ under the equality Act 2010. An effective implementation of the said standard will lead to a number of benefits, including improved outcomes, heightened experiences, and the provision of safer and more personalised care and services to those individuals who find themselves within the Standard’s scope.

InterpretersLive! provided by Sign Solutions, uses existing computers/tablets and can even make use of existing packages such as Microsoft Lync to obtain a qualified and registered BSL interpreter on demand or via the trusts website to enable patients to make calls from home 24/7/365.

We can also offer translation of leaflets and letters for Deaf patients as well as face to face provision of Interpreters for planned appointments.

We are dedicated to making the world accessible for Deaf people to ensure they are able to fully participate and possess all the knowledge needed to make informed decisions. We can assist trusts in developing their systems and staff knowledge through Deaf Awareness training.

The introduction of the aforementioned services brings the NHS closer to meeting the Accessible Information specification requirements and further increases the accessibility rating of their website

To find out more about Sign Solutions and their innovative InterpretersLive! service visit


Clare Vale

Managing Director

Sign Solutions

0843 178 0783

PENLetter December 2016

Welcome to the Patient Experience Network Newsletter
PENLetter December 2016
Issue 39
View this email in your browser
Merry Christmas from the PEN team!
Welcome to this month’s PENLetter. We have collated all the current and inspirational patient experience news into one place.
Welcome Note from Ruth Evans, PEN Founder
There is so much to be celebrated in the news over the last month or so, with some really interesting articles.Two of my favourites are simple ideas that really can make a big difference to a patients experience!
1. random Acts of Flowers who deliver encouragement to Stanford Hospital patients by collecting unsold flowers and re-distributing them, and

2. a children’s health service partners with a transportation service to enhance the experience – a thoughtful idea with so much potential.

This month the Beryl Institute have released 8  “Guiding Principles for Patient Experience Excellence”  We have included them in our Leadership News section as this must start with the leaders and are listed below:

  1. Identify and support accountable leadership with committed time and focused intent to shape and guide experience strategy
  2. Establish and reinforce a strong, vibrant and positive organizational culture and all it comprises
  3. Develop a formal definition for what experience is to their organization
  4. Implement a defined process for continuous patient and family input and engagement
  5. Engage all voices in driving comprehensive, systemic and lasting solutions
  6. Look beyond clinical experience of care to all interactions and touch points
  7. Focus on alignment across all segments of the continuum and the spaces in between
  8. Encompass both a focus on healing and a commitment to well-being

In Patient Experience News we have found four great items including another article about communication – this time focussing on empathy.   This was also covered in one of the sessions at the recent PROMs summit where Prof Simon Rogers led a conversation about the importance of empathy in the consultation.  It made me think about how we may think we are being empathetic but not fully understanding what it means – two brilliant resources to help better understand empathy are:  Its not about the nail and Brené Brown on Empathy

Board members taste test the patient food in an article included in the Local News section – fantastic!   And so much more in our other sections.

Finally Nicky Beecher is interested in hearing about anything you are doing to improve the carers’ experience – see Questions from our members for our members for full details.

Wishing you a wonderful festive season.

All the best


We would love to hear from you if you are interested in taking part in this year’s celebration of great work to improve the experience of patient care.


This is a very exciting month for us as not only is it Christmas, but we have also been receiving entries for PENNA2016.  We can already see the calibre of the entries is extremely high giving our judges a tough challenge!  All bodes well, however, for an incredible celebration on 21st March 2017!

In the period 9th December -19th December our judges are reviewing submissions so our shortlist will be announced on 23rd December 2016
21st March 2017 is the date for our AWARDS Conference and ceremony at the REP in Birmingham – please put this date in your diary!
If you have any questions please contact the team on 033 33 44 7060 or
OR to register to attend please use the following link:

This Month’s Case Study
South Tyneside NHS Foundation Trust
Bringing Patient Experience Closer to Home

The Introduction of Using Entonox in the Community for Children Facing Distressing and /or Painful Procedures

When children experience pain or discomfort, during nursing interventions, cause distress for all involved.  This may lead to fear, anxiety and potential long term problems. We sought to reduce these issues by introducing the use of 50% Nitrous Oxide 50% Oxygen (Entonox) when undertaking invasive nursing procedures in children in the community.  On investigation we found that this is not done by any other children’s community nursing team in the country.


PEN News

Ruth Evans at PEN

3,130 tweets
following 408 people

Latest Tweets

To keep in touch with our latest news follow us on @PEN_NEWS – this is where we share the good things going on in healthcare – or join our LinkedIn group PENFriends.
Leadership News
Guiding Principles for Patient Experience Excellence Shared by The Beryl Institute
Patient Experience News
A Simple Way to Measure Health Care Outcomes

Doctors need to replace sympathy and compassion with broader skill of empathy

Why Patient Satisfaction is More Than “Making Patients Happy”
What is Experience? The Moments That Patients Remember Most
Overseas News
Giving Patients an Active Role in Their Health Care
Hospital Companions Can Ease Isolation For Older People
How 1 nurse practices being present with patients

Health profession students collaborate to improve patient care

Hospitalists transform patient care at NYU Lutheran
Technology News
Westchester Medical Center Health Network to Deploy MediNav Across its Campuses
Other News
Healthcare Actors Are Always On Stage! (What are your patients hearing when you think they’re not listening?)
Something Different
Nemours Children’s Health System partners with RoundTrip to enhance patient transportation services
Random Acts of Flowers delivers encouragement to Stanford Hospital patients
Articles from our Members
Leadership programme GenerationQ is now open for applications
The Health Foundation are looking for 18 senior health care leaders from across the UK to join our leadership programme GenerationQ.

GenerationQ is a part time, fully-funded leadership and quality improvement programme for senior leaders from health care practice, policy and the charity sector. It is designed to equip its Fellows with the skills and techniques to drive forward and influence improvements across services and organisations.

The programme aims to create a network of skilled and effective leaders who are able to have an impact on improving quality of care beyond their immediate sphere of influence.

Fellows achieve a postgraduate Fellows achieve a postgraduate certificate in Leadership (Quality Improvement) from Ashridge Executive Education.

Deadline for applications is 12 noon, 23 January 2017. If you are interested in applying visit

Questions from our members for our members.
Dear Acute Trust Colleagues,

Do any of you do anything specifically around Carers experience? For example do you have a specific survey for Carers, do you run any Carer’s focus groups, do you have a Carer’s lead at your trust?

We are reviewing what support we offer and how we monitor the experience of Carers at UHB – anything you have that you could share would be much appreciated.

Happy to share what we come up with too, if any of you are interested in this?

Contact me via email: or Tel: 0121 371 4724

Kind Regards

Nicky Beecher

Patient Experience Manager – University Hospitals Birmingham NHSFT

Conference:  Priorities for improving patient safety in the NHS: regulation, transparency and whistleblowing


This conference will provide speakers and delegates with an opportunity to discuss priorities for improving patient safety within the NHS – including safeguarding whistleblowers.  Delegates will assess priorities for the newly formed Healthcare Safety Investigation Branch in dealing with patient safety violations, challenges for developing a standardised approach for reviewing cases of patient death, and the impact of the NHS Improvement’s targets requiring all NHS Trusts to develop a ‘Charter for Openness and Transparency’.

Speakers will discuss next steps for reducing the number of avoidable deaths, the impact of 7-day NHS services on patient experience, and prospects for achieving the Health Secretary’s goal of creating a ‘learning culture’ in the NHS.

To book your place contact: Follow us on Twitter @WFPEvents

Conference: Next steps for IT, data and patient records in the NHS: funding, commissioning and implementing the Wachter Review


Following the launch of NHS Digital and the discontinuation of, delegates at this seminar will consider the priorities for digital health and widening digital participation in the NHS, in line with the National Information Board’s ‘Personalised Health and Care 2020 Framework’.

Attendees will also assess the impact of the Wachter Review, which looks at how IT and electronic health records are used across the NHS, and issues for data security and confidentiality, in light of a recent review by the CQC and the new National Data Guardian.   Further sessions focus on challenges for commissioners and providers to achieve paperless care, including progress made since the submission of Local Digital Roadmaps and Digital Maturity Assessments, using big data to improve health outcomes and expanding the use of patient data in research and clinical trials.

To book your place contact: Follow us on Twitter @WFPEvents

Masterclass: Complaints Handling & Response Letters

Wednesday 8 February 2017
Doubletree, Hilton London, West End, London

This interactive and practical workshop will provide a structured approach to complaints handling and response writing.  Delegates will be taken through a methodology that will ensure that all complaints are properly investigated and that responses will stand up to scrutiny. There will be a complaint and letter writing case study during which delegates will receive feedback from the trainer.

For further information and to book your place visit or email


Conference: Hospital Mortality Annual Summit: Mortality Monitoring & Reducing Avoidable Deaths attributable to problems in care- where are we now?

Wednesday 22 February 2017
The Studio Conference Centre, Birmingham

This national Summit will focus on the question of mortality monitoring: where are we now? Through national updates and practical case studies the conference will look at how we can reduce and monitor avoidable deaths in hospitals through a range of measures which will replace the single hospital wide HSMR approach. The various approaches will aim to answer the question of whether a problem in care contributed to death, and how to identify which deaths attributable to problems in care are unavoidable.

For further information and to book your place visit or email

Follow the conference on Twitter #NHSMortality

Conference: Learning from Serious Incidents: Implementing the CQC Recommendations

Thursday 23 February 2017
The Studio Conference Centre, Birmingham

This conference focuses on learning from serious incidents: improving the quality of investigations and ensuring lessons are learned and embedded into practice. Through national updates, practical case studies and expert led extended sessions, the conference will provide a practical guide to implementing the five opportunities for improvement as identified through the Care Quality Commission review.

For further information and to book your place visit or email

Follow the conference on Twitter #NHSSeriousIncidents

Measuring & Monitoring Patient Safety: Patient Safety Surveillance in Real Time

Friday 10 March 2017
De Vere West One Conference Centre, London

This conference focuses on measuring and monitoring patient safety in your service, including real time surveillance of patient safety concerns. Through national updates and practical case studies the conference will support you to develop the systems, metrics and culture to monitor and improve patient safety.  The conference will have an extended focus on the patient role in monitoring safety, developing systems to capturing, and learning from Patient Reported Safety Concerns, and the use of patients in real time surveillance of patient safety issues. The afternoon will focus on real time patient safety monitoring around key safety domains such as falls, mortality, staffing and medication safety.

For further information and to book your place visit or email

Follow the conference on Twitter #patientsafetymonitoring

Our 20% discount is available by quoting ref: hcuk20pen  when booking.(*Cannot be used in conjunction with any other offer.  Full T&Cs available upon request.)

PEN National Awards Conference and Celebration

Tuesday 21 March 2017
The REP, Birmingham

Don’t forget to put this into your diaries….to register to enter or to attend please use the following link: or contact us on 01772 336639 or


Measuring, Understanding and Acting on Patient Experience Insight

Friday 24 March 2017
De Vere West One Conference Centre, London

This conference will focus on measuring, understanding and acting on patient experience insight, and demonstrating responsiveness to that insight to improve care.

Through national updates and case study presentations the conference will support you to measure, monitor and improve patient experience in your service, and demonstrate responsiveness to the feedback you receive.

For further information and to book your place visit
or email

Follow the conference on Twitter #PatientExp


In-depth legal masterclass: Informed Consent After Lanarkshire

Friday 12 May 2017
De Vere West One Conference Centre, London

This one-day course will cover all elements of informed consent as well as the law relating to treatment of those who lack capacity and who are unable to give informed consent.   All delegates will have the opportunity to discuss their own areas of concern with an experienced healthcare lawyer.

For further information and to book your place visit or email

Useful Resources
New report on whole system flow in health and social care  In all parts of the UK there is an increased emphasis on health and social care organisations working
together to tackle the quality and productivity challenges that all systems are facing, and to ensure that care is ‘genuinely coordinated around what people need and want’.

Improving the flow of patients, service users, information and resources within and between health and social care organisations can have a crucial role to play in coordinating care around the needs of patients and service users, and driving up service quality and productivity.

Poor flow is not only a source of significant waste and delay, but it can also be devastating for patients and service users and deeply frustrating for people working in health and social care.

The Health Foundation and AQuA’s new report, The challenge and potential of whole system flow, draws on over 20 examples from across the UK and internationally. It outlines an organising framework and tested methods that local health and social care leaders can use to improve whole system flow.

Read the report:

In case you missed it
Its not about the nail
Brené Brown on Empathy
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South Tyneside NHS Foundation Trust

Bringing Patient Experience Closer to Home

The Introduction of Using Entonox in the Community for Children Facing Distressing and /or Painful Procedures


When children experience pain or discomfort, during nursing interventions, cause distress for all involved.  This may lead to fear, anxiety and potential long term problems. We sought to reduce these issues by introducing the use of 50% Nitrous Oxide 50% Oxygen (Entonox) when undertaking invasive nursing procedures in children in the community.  On investigation we found that this is not done by any other children’s community nursing team in the country.

The initiatives objectives were therefore clearly identified from the start: Our aim was to find a solution which could be utilised in all invasive treatments, preventing pain, discomfort and distress for patients, families and team members. The outcome would be person centred, subjective and qualitative, with the experience of the child, family and team members determining if the initiative had been a success or not.  It is envisioned that the initiative would make a sustainable difference as Entonox could be used for many children with varying nursing requirements on a long term basis.  All competencies, and guidelines developed are easily transferable to other teams and organisations and can be easily disseminated.



The ‘Eureka’ moment in regards to the use of Entonox in the community was during the insertion of a nasogastric tube (NG) to one child known as Joe. Joe has undergone dialysis, he required twice weekly injections and found that the NG experience was one procedure too many. Joe is 5 years old.  Joe became so upset and distressed, he was inconsolable.  This caused mistrust towards the professional, breaking down an established relationship.

Following a staff supervision session we analysed the situation and sought potential solutions.  We considered sedation but felt this was too risky within the community.  We acknowledged we have the use of Entonox in the hospital therefore our initial plan was to meet Joe and his Mum in hospital.  He self-administered Entonox and was given distraction whilst the tube was inserted much more easily. Joe was given 10 minutes to play following the procedure and was then allowed to go home. His mum commented she wished that could be done at home where he could watch his TV and feel more comfortable. Hospitals still scare Joe. This became the challenge for our team.


Planning & Delivery

The process began by consulting the expertise of the pain control specialist nurse within the Trust. Through joint working and training we (the two teams) decided to look into the pros and cons of using Entonox on children in their own homes for any distressing procedure.

The use of Entonox is a universally established practice within community midwifery services and within our trust has been used for over 30 years.  It has been found to be a safe and effective method of pain relief with a low incidence of adverse effects and a quick recovery time (Kanagasundaram S, Lane L, Cavalletto B, Keneally J and Cooper M 2001).

We carried out a risk analysis and the team underwent training and completed competencies, whilst being supervised and supported by our specialist colleagues. We contacted, by post, the entire directory of Community children’s nurses in the United Kingdom to ask of their experiences, in this regard. 98% of respondents stated they did not routinely use Entonox in the Community, but were greatly interested to learn from our experiences.

Practical problems we envisaged included:

  • The cost of equipment
  • Storage of equipment
  • Car insurance & transportation
  • Prescribing, patient group directives and consent
  • Staff training
  • On-going costs

The cost of the equipment was £400 which included 2 cylinders, the release valve, a carry bag and a box of disposable masks. The child keeps their own mask and this can be reused, for on-going painful dressings or procedures. The cylinders are stored in our clean utility storage cupboard which is locked and accessed by the CCN team only.

All staff have business use for work on their car insurance and as long we notified our insurers of the potential of carriage of medical gases, no one incurred any additional cost. We were asked to display a sign in our cars when carrying medical gases.

The senior nurses within the team can all prescribe so this is prescribed as either a ‘once only’ or ‘as required’ dose; however, a Patient Group Directives (PGD) was also developed in collaboration with the pharmacy department to enable Staff Nurses to still use entonox on the rare occasion a nurse prescriber is unavailable. Staff training was completed through multiagency working with the pain nurse specialists and the use of the medical representative. Hand-outs, written materials and competency sheets were undertaken by all staff. Consent of the family and\ or child is documented within the nursing notes.

On-going costs will be monitored, but are felt to be minimal and cost effective in regards to patient comfort, compliance, prevention of re-admission/re-attendance at hospital and long term outcomes of trust for the child. On-going audit will be more of a comparison of the child’s previous experience and patient satisfaction is gauged both formally and informally. We observe comments made by the child and family and also issue patient satisfaction questionnaires on a rotational sequence. Since we have started this process we have discussed this with the tissue viability team and they are considering introducing this method of pain relief throughout their clinics and home calls for painful procedures. The population of CCN’s are interested in using our experiences to inform their practice. Our aim is for children not to ever experience pain, or distress!

The types of nursing action which will require consideration for the use of Entonox include but not exclusively limited to:

  • The insertion of nasogastric tubes or gastrostomy button
  • The insertion of a port-a-cath needle
  • Painful burns, or dressing changes
  • Injections or Venepuncture for a terrified child
  • Removal of clips or sutures

If the child has a good experience they are less likely to develop phobias or anxieties which can be carried through to adulthood.



Children do not have to experience any painful procedures without adequate pain relief and distraction.  This should make the parents more relaxed and in turn the children may not have preconceived fears when faced with a nursing intervention in the future.  The results are monitored formally by the use of patient and family satisfaction questionnaires and informally in verbal feedback from children and their families.  So far, families have been very positive about the use of Entonox and children seen to be a lot less anxious about nurses visiting them at home.

Key Learning Points

  • Collaborative working
  • Reflecting upon experiences and identifying areas for improvement within our practice
  • Identifying drawbacks
  • Risk assessment
  • Seeking solutions
  • Sharing experiences
  • Identifying a good practice
  • Problem solving