Poster Group A - Full QI Project - BPSC2023 by munglani

17th May 2023 Poster

Competition Group A Full QI Project

Drug Round Interruptions, Prince Philip Hospital

Sister Amber Bolt, Manager Ward 1, Sharon Jones QIST Practitioner & Eleanor Pearce QIST Facilitator

Background, Aims and Objectives

Ward 1 nurses were frequently being disturbed during medication rounds resulting in an increased risk of errors and patient harm. Our Improvement Project ran from 11/01/22 until 09/06/22. Our AIM was to reduce the amount of interruptions and errors. A data collection tool was designed to analyse the main causes and themes, 12 PDSA cycles were carried out and a wider culture change was embedded to help people refrain from making unimportant interruptions, give the nursing staff the confidence to say “no” when being interrupted unnecessarily and identify other members of staff who can be interrupted.

PDSA 2/ 10/02/22

Doctors to change the time of their morning ward round so as to not clash with the medication round. At the request of the ward manager doctors have changed their morning ward rounds to 9.30am from 10/02/22

Outcome Measures

Process Measures

Balance Measures

PDSA 3/ 14/02/22

Creation of posters and door handle signs agreed and developed

Delivered to the ward on week commencing 14/02/2022.

Avoid harm to patients by working together on the ward

Identify interruptions during medication rounds

Staff feedback regarding interruption reasons

PDSA 5/ 28/02/22

HCSW to begin observing medication rounds with new audit form.

The view ultimately is to give them a role as Safety Links.

PDSA 12/ 20/05/22

Ward manager meeting with staff to discuss the implementation of reminding staff members and patients that they are on a drug round when disturbed with the assurance that they will speak to them on completion. Also, ward manager to support staff in embedding new culture.

Reflection

The fact that it is the registered nurses responsibility to focus on medication rounds doesn’t mean that other members of staff don’t need to play their part. We learned that it is important for everybody to understand that medication rounds are protected time. This made the nurses feel less stressed and created a better team atmosphere.

We are embedding the cultural changes throughout the Health Board. by spreading and scaling this project across all wards in Prince Philip Hospital. We are also providing training to Newly qualified nurses, Junior Doctors and recently we have been recognised by Swansea University who now use our learning and presentation in their Business School & Nursing school as part of their Medication Safety lectures

Its ok to say “no” to drug round interruptions

Changing the Culture Together

QI Project Improves Safer Psychiatric Physical Health and Informed Prescribing

Dr Bjørn Varder (CT1 Psychiatry), Emma Livesey (Advance Clinical Practitioner), Dr Sally Arnold (Consultant Perinatal Psychiatrist).

Further improvements to the physical health board to make it more comprehensive with colour coding to improve physical health investigations further. .

Re-audit and review

Physical health review should be undertaken within 24 hours

Pre-intervention: 75% had a physical assessment within 6 hours of admission, 10% within 24 hours, and 15% with no assessment. Post implementation: All but 1 had a physical health assessment done within 6 hours of admission and the remaining 1 had an assessment done with 24 hours.

Recognising the importance of physical health and how we needed to improve.

Pre-audit, and implementation of a physical health board to recognise what interventions are needed.

ECG investigation

Pre-implementation: 15 patients had an ECG completed, 3 not completed and 1 patient who declined.

Post implementation: All patients had an ECG completed.

Blood monitoring for patients on antipsychotics.

Antipsychotic monitoring ensures safe prescribing. Data post intervention showed further scope for improvement, and now on the board there is a list of which blood tests required for antipsychotic monitoring

Contraception

All patient should have contraception discussed before discharge.

Pre-implementation 55% had a discussion regarding contraception.

Post-implementation: 85% had a discussion around contraception. Reason for not discussing was due to the patient being too psychiatrically unwell to engage. The board then changed to reflect discussions and contraception being in place.

Green (on contraception)

Yellow (discussion about contraception has taken place, but not on contraception yet)

Red (contraception discussion needed).

Contraception

Discussed During Admission? (PreIntervention)

Time Taken for Physical Health Assessments to be Done (PreIntervention ) Done within 6h Done within 24h Not Done Time Taken for Physical Health Assessments to be Done (Post Intervention ) Done within 6h Done within 24h Not Done

0 2 4 6 8 10 FBC U&E Prolactin Fasting blood glucose HbA1C Lipid levels LFT Antipsychotic blood monitoring pre-intervention completed not completed 0 0.5 1 1.5 2 2.5 FBC U&E Prolactin Fasting blood glucose HbA1C Lipid levels LFT Antipsychotic blood monitoring post intervention

0 5 10 15 20 Done Not Done Refused

ECG Done During Admission? (Pre-Intervention)

Done Not Done

Contraception

Done Not Done

Discussed During Admission? (Post Intervention)

A closed-loop audit on venous thromboprophylaxis prescriptions in an acute general hospital

Jun Yu Chen, Mustafa Kareem and Danujan

INTRODUCTION:

Venous thromboembolism (VTE) occurs secondary to deep vein thromboses within the leg. It classically presents as acute leg swelling, pain and breathlessness and is the leading cause of preventable deaths in hospitals.(1) COVID-19 infections are associated with an increase in VTE underlying the increased importance of VTE risk assessment.(2)

AIM:

To objectively review the adherence to venous thromboembolism prophylaxis prescriptions in an acute general hospital.

METHODS:

Following two previous plan, do, study and act (PDSA) cycles conducted in July and December 2021, two further cycles were conducted in March 2022 (Cycle 3) and April 2022 (Cycle 4).

Act:

Cycle 3 - presented findings at departmental meeting and displayed posters

Cycle 4 - added a section on VTE into induction handbook and discuss assessment and reassessment at departmental induction

hospitalisation

VTE is the #1 cause of preventable

Every 37 seconds, someone in the VTE risk assessment is quick and

VTE risk assessment is a quick and effective tool to reduce

Regular VTE reminders are essential to ensure consistent

References: (1) Thrombosis UK | The Thrombosis Charity wishes to increase Retrieved January 17, 2023, from https://thrombosisuk org/thrombosis-statistics Research, 213 138–144 https://doi org/10 1016/J THROMRES 2022 03 017 (3

Figure 1: Plan, do, study and cycle.(3)

UHMB Cross-Bay VTE Audit 2022

Background and Aims

Methodology and Standards

first dose administered within 14 hours of admission

100% of patients had VTE prophylaxis/management reviewed on the first consultant review Additional areas were reviewed after discussion in audit meetings in previous cycles: Patent's’ receipt of verbal and written information about thromboprophyalxis If patients were to be discharged on extended VTE prophylaxis with low molecular weight heparin, was appropriate information and training given? If the patient was SARS-CoV-2 positive, was the modified regimen for thromboprophylaxis given?

Results (October 2022 cycle)

65% compliance of

Action Plan

Conclusions

Clear improvement has been demonstrated in compliance against NICE and local guidelines.

However we have room for improvement in administration of enoxaparin within 14 hours of admission, PTWR/consultant review of VTE prophylaxis, and provision of verbal and written patient information regarding VTE

General Surgery

On call / Colorectal ward round: Clinical narrative: History: Examination: • Fluid

Obs/EWS: •

Checklist

considerations

ward round): VTE prophylaxis Regular meds prescribed?

NBM status/nutrition Review anti-biotic Ceiling of care/DNACPR status Diagnosis: Plan

balance:

• Key blood/urine/radiology results: • •

(important

to be reviewed on

•

Every 37 seconds someone in the western world dies from a venous thromboembolism (VTE). 55%-60% of these cases occur during or following hospitalisation Thrombosis UK, 2018) VTE is the number 1 cause of preventable deaths in hospital. The cost of treating DVTs and PEs in the emergency setting is estimated to be around £1427 and £3618 each. As per our trust’s policy, every VTE that occurs within 1 month of hospitalisation is considered during our bi-annual VTE compliance audit. Our aims for this audit is as follows: To reduce patient VTE risk by meeting/exceeding the National Quality Requirement of performing a VTE risk assessment in 95% of patients Reviewing the efficacy of our online VTE pro-forma on the Lorenzo system Ensuring up-to-date knowledge around VTE and appropriate prophylaxis prescriptions Ensure that VTE risk assessment and VTE prophylaxis is done in accordance with NICE guidance Anticipated benefits to patients are: Reduced risk of direct and indirect mortality and morbidity due to VTE Increased patient education surrounding VTE Increased quality of inpatient care

We created a proforma using NICE NG89 and local trust guidelines. We then conducted three 6-monthly cycles audit between 2021 - 2023 where we used plan-do-study-act cycle to retrospectively review 200-220 patients across 3 sites of UHMB trust: Royal Lancaster Infirmary (RLI), Furness General Hospital (FGH) and Westmorland General Hospital (WGH). Patients have been selected from the following departments: ED, AMU, Medicine, Surgery and O&G. Random sampling was used across a 6 month window selecting 20 patients per specialty, per hospital (Only 20 in total taken from WGH as its few inpatients are elective surgery). Our audit standards were: 95% of patients to have a VTE risk assessment completed on admission 100% of patients to have a correct thromboprophylaxis prescription based on their VTE assessment 100% of patients to have thromboprophylaxis administered as prescribed 100% of patients who had enoxaparin prescribed, had the

administering enoxaparin within 14 hours of admission. Delays in administration and the Lorenzo EPR automatically scheduling administration for the next day can account for this discrepancy 61% of remaining inpatients had their VTE prophylaxis checked on their first consultant review. Explicit documentation of a review is sometimes missed, especially if no VTE prophylaxis is required 27% of patients received information around VTE prophylaxis, at least verbal in form • 13% of patients received written information 30% of patients had VTE prophylaxis prescribed according to the correct dosing regimen when they were COVID positive • 95% of patients who required extended prophylaxis on discharge had an appropriate discharge prescription *of these patients, all but 1 had appropriate training before discharge the single patient who didn’t was frail and required district nurse input 83% accuracy in VTE prophylaxis prescription (including no prescription) • 3% of patients requiring LMWH had an incorrect prescription. Possible reasons include human error, systemic pressures, awaiting patient weights and blood results Patients discharged on the same day were excluded from this assessment • 91% of patients had a formal VTE risk assessment completed on admission • Patients discharged on the same day were excluded from this analysis • 94% of patients had VTE prophylaxis administered as prescribed Those that didn’t likely were discharged before the dose could be given

Audit standard Desired compliance Compliance Achieved 2019 audit Compliance Achieved March 2021 Audit Compliance Achieved Oct 2021 Audit Compliance Achieved March 2022 Audit Compliance Achieved October 2022 Audit 95% of patients to have a VTE risk assessment completed on admission 95% 95% 89% 90% 77% 91% 100% of patients had a VTE prescription correct, given the outcome of the assessment 100% 92% 76.5% 93.3% (without N/A) 79% 72% 83% 100% of patients had thromboprophylaxis administered as prescribed 100% 99% 78% 93.4% (without N/A) 77% 88.5% 94% 100% of patients who had enoxaparin used, had the first dose administered within 14 hours of admission 100% 87% 53.8% 55% 65.5% 65% 100% of patients had VTE management reviewed on the PTWR or first consultant wardround 100% 70% 45% 69% 60.5% 61% 0 50 100 150 200 No Yes Was the VTE risk assessment completed on admission? Yes No Home 183 18 19 Yes No None Required 118 25 58 0 30 60 90 120 150 No Yes Was the VTE prescription correct, given the outcome of the assessment? Yes No 135 8 0 35 70 105 140 175 No Yes Was VTE prophylaxis administered as prescribed? Yes No 62 35 0 18 35 53 70 No Yes If enoxaparin used, was the first dose administered within 14 hours of admission? 0 30 60 90 120 150 No Yes Was the patients VTE management reviewed on the PTWR or first consultant ward round? Yes No Discharged 118 77 6 0 45 90 135 180 225 Written No Written - Yes Verbal - No Verbal - Yes Did the patient receive oral or verbal information about VTE Prophylaxis? V - Yes V - No W - Y W - N 54 147 27 174 0 2 4 5 7 9 No Yes If Covid +ve was VTE prescribed correctly? 0 8 15 23 No Yes If extended prophylaxis was indicated, was this prescribed correctly on the discharge prescription? Yes No 21 1 This table shows UHMBT’s compliance with national standards on a biannual basis (there is a notable gap between 2019 and 2021 due to a pause in data collection due to the COVID-19 pandemic) The new surgical ward round pro forma that aims to mitigate the disadvantages of the supplementary recording on the Lorenzo EPR system by having a VTE checklist item (bold and underlined) Aim Action Needed By Who? By When? Appoint new VTE Champions for both RLI and FGH Decide on who will take over in role VTE Team The next Audit meeting Better use of patient education aids Encourage staff to provide VTE Leaflet booklets to new inpatients VTE Steering Group Ward VTE champions D/c at Next VTE Meeting Sharing of VTE Data more widely among doctors Regular review of clinical indicators Monthly bulletin Ward managers All junior doctors The next VTE audit meeting Increase VTE compliance on the wards that have the poorest performance Bulletin to all staff with compliance percentages by ward monthly VTE Steering Group Trust data scientists Next month Improve compliance with 14hr rule Raise awareness amongst both doctors and nurses VTE champions Next audit cycle Improve compliance with VTE review on post-take ward round/consultant review Use the standardised ward round pro-forma that includes the VTE review on the checklist All junior medical staff Next audit cycle This table shows our action plan over the cycles. An example highlighted on the left is our new ward round pro-forma encouraging VTE review

Acknowledgments

References: Thrombosis UK (2018) Thrombosis Statistics, Thrombosis UK Thrombosis statistics. Available at: https://thrombosisuk.org/thrombosis-statistics.php (Accessed: April 22, 2023). Dr Angus Rosie, Dr Bilal Ali, Dr Saira Nawaz, Dr Aerandee Kannangara, Dr Ovin Jayawardena, Dr Namratha Kaur, Dr Rohan Cheerala (FY1 – Contributors to Audit Cycle) Dr Srinivasapakshirajan Parthasarathy, Dr Gautam Talawadekar (VTE Trust Leads)

Dr Md Sakir Mahmood, Dr Tricia Tay, Dr Nicholas Rossi

Audit of Medicines Reconciliation timings for General Surgery admissions

Robert Hwang, Scott Crosbie, Marianne Gazet, Suzana Anjum, Charlotte Allan

Introduction

• Medicines reconciliation is the process of recording and prescribing patients’ regular medications upon a change in care setting such as hospital admission (1). NICE states that this should be completed within 24 hours of admission.

• Timely completion of medicines reconciliation allows the healthcare professional to continue the patient’s regular treatments while applying any modifications made necessary by the acute presentation, such as preventing any interactions with newly prescribed medications.

Aims

• To evaluate Royal London Hospital General Surgical department compliance with the NICE guideline of completion of medicines reconciliation within 24 hours of admission.

Methods

Intervention:

• Written correspondence to all members of the team emphasising medicines reconciliation

• Tickbox column added to handover sheet

• First cycle: Patients on the General Surgical take list between 05/12/22 and 18/12/22 (n=61).

• Exclusion: <18 years old, <24 hours admission.

Re audit:

• Performed using the same methodology between 20/02/23 and 03/02/23 (n= 46).

Results

• First-cycle : 62.3% meeting the target

• Second-cycle results: 74.0% meeting the target

• Overall improvement of 18.7%

Conclusion

• Visual reminders and increased awareness enhance the team’s ability to meet National targets for Medicines Reconciliations.

References & Acknowledgements

1) National Institute for Health and Care Excellence (NICE), Medicines optimisation: the safe and effective use of medicines to enable the best possible outcomes. 4th March 2015.

2) World Health Organization (WHO). Standard Operating Protocol for Medication Reconciliation. Version 3. Many thanks to the Royal London Hospital General Surgery department for their support in this project.

Improving documentation and teamwork in an oncological emergency

Polly Outram Hillingdon Hospital

| qiclearn.com | @qiclearn

Minutes Matter: the case of the empty red box

BACKGROUND DIAGNOSTICS AIM & MEASUREMENT DEFINITION CHANGE IDEAS

cycles

PDSA

RUN CHART REFLECTIONS & LEARNING | londonpaediatrics.co.uk | @LondonPaeds Acknowledgements: Dr Richa Ajitsaria Hillingdon POSCU and ward nurses -10 20 30 60 70 Minutes to Antibiotc administration Patient Admissions Time taken from arrival to antibiotics administration Guideline –“Summary of the emergency management of neutropenic sepsis” “Start intravenous antibiotics within 1 hour” Children with cancer are at risk of life threatening infection. They need antibiotics fast to prevent deterioration and death. 6 in 10 of them don’t have accurate documentation of time-toantibiotics. When minutes matter, how do we know we are keeping them safe? Majority of admissions had no exact time of antibiotics documented Parent calls to say they are coming in Patient arrives Doctor bleeped Obs taken Patient weighed Notes collected Proforma found Line accessed Bloods taken Swabs taken Document in notes that abx given within one hour. Antibiotics taken to given Antibiotics prepared and checked with 2 Antibiotics prescribed by doctor “The box to document the time is hidden at the back of the proforma. We didn’t know it was there, or that we could write there. It seemed like the doctor’s part of the notes.” “We write information on the frontsheet of the proforma, but the rest of it is for the doctors to write in.” Lightbulb moment This is a whole team process, so it is a whole team problem! I need to understand the nursing side of things! Nursing High level Process Map 0 1 1 2 4 5 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 Patient admissions Documentation of time to antibiotics Series2 Median Line Winter 2021 (baseline median from audit) 1 – documented 0 – not documented 1 2.1 2.2 3.1 3.2 3.3 2.3 4 Winter 2022 onwards

Authors: Bonnett, MH; Bacon, S; Mullins, J; Westcott, C

Clinical Transformation of an adult VTE Risk Assessment form

Why?

NICE and the VTE Exemplar Centres guidelines advises:

• 95% of patients should be risk assessed for:

• Venous thromboembolism (VTE) risk

• Bleeding risk

Internal Trust audits of VTE Risk Assessment compliance shows a range of completion as low as 70%.

Aim

1. Create a single standardised digital VTE Risk Assessment

2. Provide safe up to date clinical decision support (Fig 2.)

3. Improve completion compliance to meet national 4. improve patient choice faith and non 5. Improve patient 6. Support clinical teams to decommission paper forms

7. Future proof for future changes

Clinically led Transformation

Audit

Clinically led transformation:

The informatics team followed a cycle of transformation (Fig 1.) to design and implement a solution within the constraints of the system

Collaboration and engagement with:

• key stakeholders

• users

• Patients

Project Results

75% of the paper forms do not follow BNF & Trust guidance for pharmacological thromboprophylaxis. 0% of forms mention Fondaparinux as an alternative not containing animal

Feedback gathered & reviewed Collaboratively design the next iteration of the form. Roll out to more trust areas - Target compliance 95%

Launch digital VTE Risk assessment form, and flow board compliance indicator. Target compliance of 95%. Results Compliance of 88-91% (baseline improvement 18%).

Current and future state process maps (Fig. 3). A draft VTE Risk Assessment form was collaboratively designed

Review of all paper VTE Risk Assessments in use. Analyse the findings (Fig. 4,5,6). Make recommendation for change

Start No FSJ-1 CF Narrative FSJ-5 Review relevant Various FSJ-6.2 Prescribe in Drug card Paper FSJ-2 Step 2: CF Narrative FSJ-3 Step 3: Bleeding CF Narrative FSJ-4 VTE Prophylaxis CF Narrative FSJ-6 For Mechanical Rx FSJ-7 For Pharm. Rx FSJ-7.2 Prescribe in Drug card Paper FSJ-6.1 Document reasoning CF Narrative Yes Go to FST 7 No FSJ-7.1 Document reasoning CF Narrative Go to FST 8 Yes FSJLaunch VTE Risk CF Narrative

Process Mapping PDSA 1 PDSA 2 0.00% 5.00% 10.00% 15.00% 20.00% 25.00% 30.00% 35.00% 40.00% <20 <30 <15 none percentage with Heparin eGFR Guidance Heparin dosing eGFR Range Variation between Heparin dosing guidance based on eGFR

Fig 3. Future state Process Map Fig 1. Cycle of Transformation

Enoxaparin Weight dosing range none 50-140 50-100 Fig 4. Baseline Audit Data None 50 –100kg 50 – 140kg

Fig 2. Clinical decision support Fig 5. Terminology used to describe mechanical prophylaxis