Poster Group G - Patient Safety Audit- BPSC2023

Identifying Resilience: A System Safety Review of Trauma and Orthopaedic Theatres

Victoria Collins, Kayzia Bertman & Andrew Seaton

Background

Between March 2019 and April 2021, Gloucestershire Hospitals NHS Foundation Trust (GHNHSFT) reported 6 never events, within the Trauma and Orthopaedic (T&O) specialty. Never events are defined as “Serious Incidents that are wholly preventable because guidance or safety recommendations that provide strong systematic barriers are available.”1

Never events are investigated to identify the factors that contributed to the undesired outcomes, with the aim of making reco mmendations for improvements. Within GHNHSFT, the traditional investigation approach had not, however, led to the desired improvement. With the publication of the Patient Safety Incident Response Framework (PSIRF)2 poised to introduce system-based analysis, a system safety review was designed (Figure 1) and carried out to analyse ‘work as done’, rather than ‘work as imagined’3 within trauma and orthopaedic theatres, as an alternative method of identifying improvement needs. The analysis identified opportunities to build system resilience, which were developed and tested through a multidisciplinary Quality Improvement (QI) collaborative.

Method

1. Process maps (Figure 2) were created with key staff, to describe the intended process from patient identification to patient recovery for T&O surgical procedures.

2. A Systems Engineering Initiative for Patient Safety (SEIPS)4 analysis (Figure 3) was conducted during a workshop with approximately 40 multidisciplinary staff from theatres.

3. The CARe QI handbook5 was used to conduct observational studies of the theatres processes, enabling 'work as done’ to be described and resilience indicators (Figure 4) identified. From this analysis, improvement opportunities were determined

4. A QI collaborative was established, supporting approximately 20 multidisciplinary staff to use a QI approach, to test and learn from potential interventions.

The systems analysis, identified 11 potential areas for intervention. These consisted of five QI projects, four management actions and two recommended audits.

Results

By the 13th April 2023, 486 days had elapsed since the last never event in theatres.

References

Conclusion & Lessons Learnt

The system safety review took more time than a traditional investigation in exchange for a wider scope of review. This lead to the identification of latent factors and improvement needs in areas that may not have been evident through a traditional investigation process. The approach encouraged and enabled staff participation in the diagnostic and improvement processes, recognising their essential involvement in the identification of ‘work as done’ and the value of their engagement.

There was a necessary trade off between theory and practicality and a locally based coordinator within theatres was essential to managing the logistics of implementing the approach

The learning from this application of systems analysis, resilience engineering and QI, will be used to inform the development of the Gloucestershire Hospitals Patient Safety Incident Response Plan (PSIRP).

1 NHS Improvement. (2018). Never events policy & framework. https://www.england.nhs.uk/publication/never-events/ 2 NHS England. (2022). Patient safety incident response framework. https://www.england.nhs.uk/patient -safety/incident-response-framework/ 3 Hollnagel, E., Wears, R. L. & Braithwaite, J. (2015). From Safety-I to Safety-II [White Paper]. University of Southern Denmark, University of Florida, USA, and Macquarie University, Australia. https://www.england.nhs.uk/signuptosafety/wp -content/uploads/sites/16/2015/10/safety -1-safety-2-whte-papr.pdf

4 Holden, R.J., Carayon, P., Gurses, A.P., Hoonakker, P., Schoofs Hundt, A., Ozok, A.A. and RiveraRodriguez, A,J. (2013) SEIPS 2.0: a human factors framework for studying and improving the work of healthcare professionals and patients. Ergonomics, 56(11), 1669-1686 http:/dx.doi.org/10.1080/00140139.2013.838643 Holden, R.J., Carayon, P. (2021). SEIPS 101 and seven simple SEIPS tools. BMJ Quality & Safety, 0, 1 -10. http://dx.doi.org/10.1136/bmjqs -2020-012538

5 Centre for Applied Resilience in Healthcare. (2020) CARe QI: A handbook for improving quality through resilient systems. https://resiliencecentre.org.uk/care-qi-handbook

Audit of endoscopy safety in a District General hospital rated ‘inadequate’ by the CQC

Dr A. Crawford, Dr E. Connor, Dr Z Carter Tai . Supervisors: Dr C.Rossi, Mr N.Chandratreya

In June 2021 the overall CQC rating of Weston General Hospital (WGH) was ‘inadequate’. Changes over the past couple of years, including th e merger of Bristol and Weston -Super-Mare trusts, has aimed to improve services across the board. The endoscopy service at WGH offers inpatient and outpatient investigations to thousands of patients every year. We aimed to evaluate the safety of the service offered over a 12 month period. We used measures set out by the Joint Advisory Group on GI Endoscopy and other published statistics.

Background

For identifying, reviewing and reporting deaths and unplanned admissions related to endoscopy the Joint Advisory Group on GI Endoscopy: Global Rating Scale (2021) is used.

STATISTICS FOR PERI-ENDOSCOPIC COMPLICATIONS AND MORTALITY

Cardio-pulmonary complications account for approximately 50% of all procedure -related deaths associated with GI Endoscopy (1)

ERCP:

Mortality <1%, perforation <0.5% (1,6)

Pancreatitis rates ~5% (data obtained during ERCP safety audits)

Bleeding rate post-sphincterotomy ~2% (data obtained during ERCP safety audits)

Upper GI endoscopy:

There is an overall complication rate (including mucosal biopsy) of 0 13% and an associated mortality of 0.004%(2) Acutely bleeding oesophageal varices: overall mortality remains ~20% (2); mostly due to underlying liver disease

Colonoscopies and flexible sigmoidoscopies.

Frequency of perforation varies; related to case -mix and experience of endoscopist. Perforation rate of 1/1000 and post-polypectomy bleeding rate <1/200 (3,5,6)

Results

Total number endoscopic procedures June 2021 to May 2022: 3428

Readmissions:

Of these 3428 there were 58 re admissions within 8 days of the procedure, 6 of which were deemed to be related to the original endoscopic procedure. Re-admissions were split between procedures, ERCP – 1, OGD – 1, Colonoscopy – 4, nil related to flexi-sigmoidoscopy.

Mortality:

There were a total of 38 deaths identified within 30 days of the procedure, only one of which was related to the initial procedure

The death was related to ERCP: the patient presented initially with abdominal pain and choledocholithiasis ERCP found a 10mm stone in the CBD – extraction was not possible due to distal CBD stenosis

Following a sphincterotomy, a stent was placed in the distal CBD PostERCP, the patient developed jaundice and haematemasis Pancreatitis was confirmed on CT and cause of death recorded as post-ERCP

pancreatitis

One set of paper case notes was lost and therefore not analysed

Re admission rate for 2021-22: 0 18%, mortality rate: 0 029%

113 ERCP procedures were performed, with 1 death (0 88%) and 1 readmission (0 88%) with post-ERCP perforation (localised, contained around duodenal stent) There were no lower GI perforations, 2 cases of post-polypectomy bleeding (approximately ~0 25% incidence)

Methods & Materials

Inclusion Criteria: Readmission within 8 days of procedure. Mortality within 30 days of procedure. Included procedures:

OGD

ERCP

Flexible sigmoidoscopy

Colonoscopy

We acquired a list of all patients who underwent an endoscopic procedure in the 12 months between June 2021 and May 2022, including inpatient and outpatient procedures

All patients who met the inclusion criteria for readmission or mortality were identified and their case notes obtained

Patients’ paper case notes, Evolve and GP records were reviewed in order to evaluate whether the death or re admissions was related to the endoscopic procedure

The indications for endoscopy, outcome of procedures and reasons for readmissions or deaths were also noted

Discussion

Each case of mortality and readmission was analysed using electronic records, GP records, paper case notes, radiological reports clinical documentation to evaluate the clinical course, learning points and clinical outcomes for each patient

This data is not a representation of total complication rate: immediate complications when patient remains an inpatient have not been included Additionally, we only have information about readmissions to UHBW hospitals: patients may have been re-admitted to different hospital trusts for which we do not have easy access to records

BSG minimum standards for post polypectomy bleeding is <0 5% with aspirational target <0 1% We do not have exact data about number of procedures with polypectomies but approximate a postpolypectomy bleeding rate of ~0 25% More data/analysis of this would be useful

There is poor data to compare our rates of complications to the national average – much comes from diagnostic endoscopies, not treatment, and is from retrospective and older case studies, making comparison difficult(5,6)

Conclusions

It was concluded that the endoscopy service at WGH was safe and viable The number of readmissions and deaths related to endoscopy were similar to previous audits and well below the published rates of complications in literature

A review of individual cases for all complications, readmissions and deaths showed that issues were identified and treated appropriately in a timely manner

A retrospective review of periendoscopic complications in OGD, ERCP, flexible sigmoidoscopy and colonoscopy conducted during the period of June 2021- May 2022.

How effective is COMMUNICATION between Secondary Care and Primary Care in relation to MEDICATION CHANGES?

Jie Yee Tan1 , Kirsty Green1 , Dilani Perera1

1 Older Person’s Medicine, James Cook University Hospital, South Tees NHS Trust

Introduction

• General Practitioners are not often aware of medication changes during inpatient stays due to omission of information in discharge letters

• For patients this can lead to regular medications not being continued, or patients receiving wrong dosages

• For healthcare professionals it can result in confusion

• Therefore, communication with primary care is essential in older person's medicine (OPM) as these patients have multiple co-morbidities and are often affected by polypharmacy.

*Medication changes: Including medications stopped/ medications started/ medications altered)

Aim of Audit

1. Review and inform local OPM department regarding compliance with the local standards of discharge medication lists

2. Identify and implement ways to improve communication with primary care colleagues regarding medication changes during inpatient stays.

What Are We Doing To Improve

• The results highlight the importance of improving our communication with primary care when it comes to medication changes during inpatient stay.

To improve we are doing a number of things:

Methods

• A retrospective study.

• Data was collected from the electronic discharge summary system for discharges from the OPM ward in August 2022.

• Standards were identified from the local protocol (G148- Medicines Reconciliation for All Admitted Adult Patients), we looked at:

1. Accuracy of discharge medications lists with regards to the current prescribed medications which include patient’s regular medications and the medications started during inpatient stay

2. Documented dose alterations and rationale

3. Rationale for discontinuation of medication

4. Documented indications for newly prescribed medication

Results

• Standard was set at 100%

• No sub-category hit the target of 100%.

• Only 61% of discharge letters documented the reason why new medications had been started

• 75% documented why medications had been stopped.

• 91% documented the reason for dosage changes.

1. Informative posters are to be placed on the OPM ward to increase awareness of the importance of accurate medication paperwork on discharge

2. Present our findings at the OPM departmental meeting.

3. Work with the electronic prescribing system’s (ePMA) colleagues, pharmacist and GPs with interest in informatics to implement a way to automatically transfer the admission medications into the discharge letters, so that we can list whether they are new, stopped or changed in the newest version of the system.

Safe prescribing of thromboprophylaxis post-TURP

Dr Hazel Chon, Dr Piranavan Kirupananthan, Mr Manish Gupta

INTRODUCTION

- Trans-urethral resection of the prostate (TURP) is one of the most performed operations with over 45,000 undertaken in the UK every year

- TURP is the telescopic removal of the obstructing part of a prostate using diathermy.

- Post-TURP bleeding risk is the most notable complication potentially leading to reoperation and blood transfusions

METHODOLOGY

- Data collected

-> no. of high-risk patients

-> no. of pharmacological thromboprophylaxis prescribed

-> no. of mechanical

thromboprophylaxis prescribed

-> no. of patients with significant bleeding needing blood transfusion/reoperation

- Repeat audit performed subsequently to complete the audit cycle

STANDARD

According to the European Association of Urology (EAU), the use of pharmacological prophylaxis post-TURP is prohibited while those deemed high risk for venous thromboembolism (VTE) are recommended only mechanical prophylaxis until ambulation.

RESULTS

- A total of 328 patients were included

AIM

Our closed loop audit aimed to assess mechanical and pharmacological thromboprophylaxis prescribing in patients who underwent TURP

Lessons learnt included the importance of repeat audit to measure the effect of change and the continuous process of maintaining patient safety.

- 0.6% (1st cycle) vs 0% (2nd cycle) of patients required a blood transfusion due to significant post-op haemorrhage

Application and Appropriateness of IPC prescription on the stroke rehabilitation unit

By Dr Tan, Dr Lim, Dr El-Sayegh

Introduction

Incidence of deep vein thrombosis is the highest among patients who are immobile. In this project, we are interested in post-stroke patients. Deep vein thrombosis can lead to potentially fatal complications such as pulmonary embolism. The CLOT3 trial has shown that intermittent pneumatic compression (IPC) significantly reduced the risk of all DVTs. We measured if healthcare workers are compliant in prescribing and applying IPC to patients and the consistency of patients receiving this.

Methodology

This audit is based on National Clinical Guidelines for Stroke (2016) 3.13.1 recommendations where patients with immobility after acute stroke should be offered IPC within 3 days of admission and this treatment should be continuous for 30 days or until the patient is mobile or discharged. A crosssectional audit of 20 inpatients admitted to a stroke rehab unit was conducted, with the primary outcome as clarity of documentation of IPC prescription on the drug chart and reasons if omitted. The secondary outcome measured was the consistency of IPC application to patient if prescribed.

Result

Pre-intervention, there were 30% (6 out of 20) of inappropriate IPC prescription. As for secondary outcome, there were less than half of the IPCs were applied correctly, with the majority cause being post-physio and postmobilizing.

Interventions included posters as reminder to both prescribing doctors and nurses. We also held brief teaching sessions to healthcare workers to reinforce the importance of IPCs application.

Post-intervention, the percentage of inappropriate IPC prescription dropped to only 5% and the consistency of application increased to 76%.

Pre-Intervention

Appropriate

Discussion

Post-Intervention

Inappropriate

Appropriate

Inappropriate

Evidence has shown that IPCs application reduces the VTE risk, and are an inexpensive preventive management (30 pounds per pair). Education and aide-memoire for healthcare workers (healthcare assistant, nurses, doctors, pharmacist, and physiotherapist) should be provided, particularly during changeover period, to ensure optimal IPCs prescription and application. A pathway should be developed to mitigate harm should IPCs not be appropriately prescribed or applied.

Pre-School vaccination booster uptake in a semi-rural General Practice.

Flora Williams Burton Sherwood Forest Hospitals Trust; Larwood Health Partnership

1. Introduction

The childhood vaccination programme has been key for the protection from, and eradication of, many pathogens. This includes the now very rare smallpox and polio, but also diphtheria, tetanus, pertussis, polio, measles, mumps and rubella (1). These have been specified due to the current UK government vaccination schedule (2), according to which a pre-school booster vaccination of diphtheria, tetanus, pertussis, and polio (dTaP) and measles, mumps, and rubella (MMR) should be given at 3 years 4 months old or soon after.

However, uptake is variable within communities, and although Quality Outcomes Framework (QoF) guidance is set at 87% uptake, vaccination rates are often lower. There can be many reasons for this, though a significant one is due to the fact that they are so successful – high vaccination rates have made dangerous illnesses seem rare, and so the public no longer view them as a threat. When patients and parents believe the benefit of vaccination to be low, the perceived risks often outweigh these benefits, and so children are not vaccinated (1).

The focus of this audit is on patients who have, versus patients who have not, had their pre-school booster vaccination for diphtheria. This has been chosen as it forms part of the pre-school booster programme and has not had as much media coverage as other vaccinations (i.e., MMR), thus less misinformation is in the public domain. Diphtheria has a high transmission rate, and even with optimal treatment can be fatal in up to 10% of cases. Prior to vaccination, it killed approximately 35000 children per annum in the UK. Although cases are now exceedingly rare, there have been 2 fatalities in Europe since 2015 (3).

2. Criteria and standards

Patients included in this audit were those aged 3 years and 4 months to 5 years old at the time of data collection. The assessed outcome was that they must have a vaccination containing diphtheria within the previous 20 months. A vaccination containing diphtheria was set as the assessment marker for having received the dTaP vaccine, and the time limitations set excludes original vaccination as last dose given at 16 weeks (4 months).

The standard for patients vaccinated was set at 87%. This is based on the Quality and Outcomes framework for 2021/2022, which sets childhood vaccination targets at 87-95%(4). There has been no change for 2022/2023(5). This standard has been chosen due to its relevance in the context of a semi-rural General Practice (GP).

3. Methodology

Using the SystmOne clinical reporting, a report was created of all patients aged 3 years 4 months to 5 years, and all patients aged 3 years 4 months to 5 years with an entry of diphtheria containing vaccination within last 20 months (from feb1 2023). Microsoft excel was used to extrapolate data such as percentages and numbers not vaccinated.

4. Results

On 1st February 2023, there were 634 children aged 3 years 4 months to 5 years old registered with the practice. 489 (77%) had had a vaccine containing diphtheria in the preceding 20 months, and 145 (23%) had not (Figure 1). This falls below the QoF standard of 87% by 10%, or 64 children (Figure 2).

5. Discussion

Kaufman et al (6) conducted a systematic review in 2021 of barriers to childhood vaccination. They found six prominent recurring themesAccess, Clinic or Health System Barriers, Concerns or Beliefs, Health Perceptions and Experiences, Knowledge and Information, and Social or Family Influences.

Concerns and Beliefs encompassed the most barriers. Highlights from this category are concerns around the safety of vaccines, and a lack of trust in the healthcare system and/or government. This can be demonstrated by the MMR vaccination and autism scare in the late 1990s. Authored by Wakefield in 1998, a case study of 12 patients implied a correlation between the vaccine and a novel syndrome consisting of GI and developmental disease. The paper had no control category and relied heavily on parental recall. Godlee, Smith, and Marchovitch (7) argue that this was deliberate fraud in their 2011 editorial. The original paper was noticed by the media, and resulted in an all time low vaccination rate for MMR. Despite the paper now being declared as fraudulent and retracted, the damage remains in many communities.

Communication was the largest barrier in the Clinic or Health system category and covers problems such as vaccination not being explicitly recommended by healthcare practitioners. This is an important factor to consider when planning an intervention.

Access barriers highlights issues such as time and expense. Outside of the NHS, vaccinations can be expensive, but that would not be relevant to this audit. Other challenges under this heading that may apply to this patient population include waiting times and childcare for siblings.

Although the other categories may have points where an intervention would help uptake, the above are the easiest to target and therefore most relevant for this audit.

6.1

To attempt to increase vaccination uptake, a text message was sent to all (guardians of) patients who were due their vaccinations. There were two patients who were not sent this message, one due to no number on file and one who had not consented to being sent SMS. Additionally, a poster was put on the screens in the waiting room.

Data collection was completed 6 weeks after the initiation of intervention. I used the same search using SystmOne clinical reporting. This showed that in the current age group of 3 years 4 months to 5 years old, 534 out of 662 children had had their preschool vaccinations, which equates to 80.7% (Figure 3).

Using an online chi-squared calculator (8), the chi-square statistic is 3.5531. The p-value is 0.059434. This is not significant as p > 0.05. The chi-square statistic with Yates correction is 3.3039. The p -value is 0.069116. Again, this is not significant as p > 0.05.

These have different total population values as they are snapshots in time, however I also followed up my original data group. Of the original 648, 559 were now vaccinated. Using this data and the same chi-squared calculator (8), the chi-square statistic is 20.8118. The pvalue is < 0.00001, which is significant as p < 0.05. The chi-square statistic with Yates correction is 20.1665. The p -value is < 0.00001. This is again significant as p < 0.05.

8. Limitations

This method does not exclude patients with contraindications to vaccination, and does not confirm that they also had the MMR vaccine. This study was done within a single GP surgery at a single point in time, and the intervention period was limited to 6 weeks, due to rotation of staff.

9. References

1. Torracinta, L., Tanner, R., & Vanderslott, S. (2021). MMR vaccine attitude and uptake research in the United Kingdom: A critical review. Vaccines 9(4), 402. https://doi.org/10.3390/vaccines9040402

2. Gov.UK. (2022, February 17). Routine childhood immunisations from February 2022 (born on or after 1 January 2020). Retrieved January 28, 2023, from https://www.gov.uk/government/publications/routine-childhood-immunisation-schedule/routine-childhood-immunisationsfrom-february-2022-born-on-or-after-1-january-2020

3. Oxford Vaccine Group, The University of Oxford. (2018, May 31). Diphtheria. Vaccine Knowledge Project. Retrieved February 2, 2023, from https://vk.ovg.ox.ac.uk/diphtheria#Key-disease-facts

4. NHS. (2022, October 18). Quality and Outcomes Framework guidance for 2021/22. NHS choices. Retrieved January 28, 2023, from https://www.england.nhs.uk/publication/update-on-quality-outcomes-framework-changes-for-2021-22/

5. Gault, B. (2022, July 27). Qof 2022/23: What practices need to know. QOF 2022/23: What practices need to know. Retrieved February 2, 2023, from https://managementinpractice.com/practice-intelligence/finance/qof-2022-23-what-practices-need-to-know/

6. Kaufman, J., Tuckerman, J., Bonner, C., Durrheim, D. N., Costa, D., Trevena, L., Thomas, S., & Danchin, M. (2021). Parent-level barriers to uptake of childhood vaccination: A global overview of Systematic Reviews. BMJ Global Health 6(9). https://doi.org/10.1136/bmjgh-2021006860

7. Godlee, F., Smith, J., & Marcovitch, H. (2011). Wakefield's article linking MMR vaccine and autism was fraudulent. BMJ 342(jan0511), c7452–c7452. https://doi.org/10.1136/bmj.c7452

8. Stangroom, J. (2023). Chi-square calculator. Social Science Statistics. Retrieved April 19, 2023, from https://www.socscistatistics.com/tests/chisquare/default2.aspx

7. Discussion Part 2: Post-intervention

From the original population, even considering the passage of time we can see a large number of patients were vaccinated in the 6 week interval between the two sets of data collection. To ascertain whether this would have happened naturally with time, I would need to compare with historical data, but due to differences in coding over time, plus the covid-19 pandemic, this data is likely to be unreliable. Overall, this suggests that the individual texts sent were an efficient intervention at encouraging vaccination.

When compared to the data using the same search at a different time point, we see that there is much less of an increase in vaccination, although an increase still exists. Possible reasons for this include the fact that new patients coming in to the age bracket would not have received the SMS, or that the poster was not effective.

Within the population covered by this GP surgery, there is a large Polish community, some of whom have limited English. Something to consider is whether providing the poster or other resources in a different language would aid uptake. Additionally, texts were only send to those who were eligible for the vaccination, but would sending a message to those who are about to become eligible increase early uptake?

Intervention

6.2 Reaudit

Statin prescribing and cardiovascular events in stage 3-4 CKD patients at a tertiary teaching hospital following the publication of the 2017 NICE guidance on statins in CKD

Dr. G Gentile, Dr. E Khine, Dr. H Morgan, Dr. E Mcdermott, Dr. A Williamson, Dr. V Manfreda, Dr. M Fadlallah.

Background

CKD affects 700 million people worldwide and increases the risk of cardiovascular (CV) morbidity and mortality due to traditional and novel CV risk factors (albuminuria, mineral bone disease). Most people with CKD die for CV disease rather than progressing to stage 5. NICE 2017 guidelines recommended patients with eGFR <60ml/min/1.73m2 should be on a statin for CV disease prevention.

Results

Patients were mostly males with a median age of 73.4. Baseline prevalence of current/ex- smokers, previous CV events, diabetes, and hypertension was 28.4, 46.7, 50.1, and 78.7% respectively, suggesting a population at very high risk of CV events.

58% were on a statin at baseline, this raised to 62, 68.3 and 69.4% at 1, 2 and 3 years, respectively. However, most patients were on a statin for secondary prevention of CV disease. Adherence to NICE guidance in primary prevention was low (42.5%) and did not significantly improve during follow-up.

Methods

A retrospective observational study including 150 renal out-patients with stage 3-4 CKD at RCHT between July 2017 (date of NICE publication) and 2022. Data were extracted from electronic databases and GP summaries. Anagraphic, disease (diabetes, hypertension, etc.), laboratory, and drug data were extracted. Statin prescribing was recorded at baseline and 1, 2 and 3 years of specialist review.

Conclusions

Statin prescribing in CKD out-patients needs improvement, almost 60% didn’t receive a statin as per NICE guidance. A stronger collaboration with primary care is imperative to achieve the target, as nephrologists see the patient too late, at which time almost half of patients have already had a CV event.

Sarah J. Puthur1 , Haroon, Majeed2

Foundation Trust;

• High calibre post-operative notes are necessary in Trauma and Orthopaedics departments to facilitate effective communication between colleagues 1 .

• The guidelines provided by the Royal College of Surgeons of England (RCS Eng) is widely used for writing comprehensive post-operative notes 2

• The generic nature of the above guidelines omits specific post-operative information in operation notes such as weight bearing status, requirement for post-operative physiotherapy, requirement for antibiotic prophylaxis, venous thromboembolism (VTE) prophylaxis and appropriate follow-up plan which are crucial for delivering high quality care in Trauma and Orthopaedics 3 4

LESSONS LEARNT

Trust

To review quality of post-operative documentation in operation notes within the Trauma and Orthopedics department at a level 1 trauma center and assess if a standard proforma improved documentation

METHODS

RESULTS

Weightbearingstatus

Post-operativeinstructionsfor physiotherapy Appropriatefollowuporganized

Following introduction of standard proforma at the emergency site, statistically significant improvement in documentation of:

oRequirement for post-operative physiotherapy (P= 0.001)

Following introduction of standard proforma at the elective site, statistically significant improvement in documentation of:

oRequirement for post-operative antibiotic prophylaxis (P= 0 009)

oRequirement for VTE prophylaxis (P= 0 001)

oRequirement for post-operative physiotherapy (P= 0 001)

However, no statistically significant improvement in documentation of:

o Weight bearing status post operation

o Need for post operation follow up ANTICIPATED BENEFITS OF BETTER DOCUMENTATION IN ORTHOPEDICS

Customize the standard proforma currently in use to include specific post-instructions:

1. Requirement for antibiotic prophylaxis

2. Requirement for VTE prophylaxis

3. Weight bearing status and duration

4. Requirement for post-operative physiotherapy

5. Follow up

REFERENCES

Peri-operativecomplicationsApproximatebloodloss

Detailsoftissues,removed,addedoraltered

Detailsofmetalworkorimplantsadded,removedor…

Detailsofclosure

Requirementfor post-operativeantibioticprophylaxis

RequirementforVTEprophylaxis

Post-operativenursinginstructions

NEXT STEPS

Weightbearingstatus

Post-operativeinstructionsfor physiotherapy

Appropriatefollowuporganized

Standard proformas- an effective tool for documenting postoperative information in Trauma and Orthopedics Surgery at a level 1 Trauma center.

1 North Manchester General Hospital, Manchester University NHS

2 Manchester Royal Infirmary, Manchester University NHS Foundation

A CLOSED LOOP AUIDT OF K-WIRE POSITION AND FIXATION FAILURE RATE IN PAEDIATRIC SUPRACONDYLAR FRACTURES OVER AN 8-YEAR PERIOD IN A DGH SETTING

Erin Jones & Nicole Corin, Royal United Hospital Bath

INTRODUCTION AND AIMS

Supracondylar fractures are common paediatric elbow fractures. There may be associated neurovascular injury and most require surgical fixation. A 2014 audit demonstrated most fixations were with lateral wires but loss of fracture reduction was common Following a change in departmental consensus we hoped that all paediatric supracondylar fractures would be managed with at least two crossed K-wires and with no loss of reduction post operatively

STANDARDS

BOAST supracondylar guideline: surgical stabilisation should be with at least two K-wires

Crossed wires are associated with a lower risk of loss of fracture reduction, whereas divergent lateral wires reduce the risk of injury to the ulnar nerve

Departmental consensus: supracondylar fracture should be fixed with at least 2 crossed wires

METHODS

All paediatric supracondylar fractures from May 2021 to May 2022 were identified from daily trauma sheets and theatre lists There were 20 supracondylar fractures within this audit period. Operation notes, intra-operative imaging were used to determine number, size and positioning of K wires Post operative imaging and clinic letters were used to ensure satisfactory reduction was maintained. The 2021-2022 data was compared to similar data collected in 2014, 2016 and 2019 to assess practise over time

RESULTS & DISCUSSION

In our audit period 18/20 supracondylar fractures were managed with crossed K-wires and 2/20 managed with lateral K-wires All used at least 2 wires Fracture reduction was lost in 1 patient with lateral wires There were no iatrogenic ulnar nerve injuries.

This demonstrates a significant change since 2014 when 6/16 patients had crossed wires, 10/16 had lateral wires and 8/10 had loss of reduction. Sequential audit cycles have demonstrated a sustained change in practise from lateral only wires to crossed wires for supracondylar fractures

LESSONS

A change in surgical practise has led to fewer patients experiencing loss of fracture reduction avoiding future morbidity and need for reintervention This has been achieved without any increase in iatrogenic ulnar nerve injuries.

FUTURE WORK

Ongoing audit of surgical practise for supracondylar fractures within our department to ensure practise maintained, including presentation at local audit meetings and to new members of department, Audit of departmental practise against remaining BOAST supracondylar standards underway

COVID-19 and Myocardial Injury

Introduction

Covid-19 has hit the world causing significant mortality, economic burden and global panic. Covid-19 is principally a lung pathogen but has extra pulmonary manifestations particularly affecting the cardiovascular system. Acute myocardial injury is defined by presence of raised troponins and mainly is a result of systemic inflammatory response which leads to worse prognosis especially in the presence of pre-existing cardiac conditions.

We conducted a study at Russells hall hospital, Dudley after receiving a large volume of inappropriate referrals to the cardiac department. We aimed to establish the guidance given in NICE guidelines about covid 19 and acute myocardial injury to help the healthcare professional who are not cardiac specialists to identify and treat acute myocardial injury and its complications in covid-19 patients

Methodology

We conducted a retrospective study from Nov 2020 to April 2021 looking at 50 patients who had raised troponins and were either diagnosed with or were suspected to have Covid-19. Parameters listed in NICE guidelines regarding diagnosis and management were investigated and included

1.Diagnosis or suspected diagnosis of covid-19 and acute myocardial injury

2.Diagnostic tests for myocardial injury including high sensitivity troponin, NT-proBNP levels and an ECG

3.Documented evidence of monitoring for cardiac or respiratory deterioration

4.Documented evidence of monitoring for parameters such as continuous ECG, blood pressure ,heart rate and fluid balance

5.Critical care treatment required

Results

The results of the study against parameters listed in the NICE guidelines showed

80% of the patients admitted had a diagnosis of the covid 19, of these none had a clear diagnosis of acute myocardial injury and only 20% were suspected to have acute myocardial injury

95% of the total patients had hs trop levels done, ECG was done in 66% of the patients however, NTpro BNP levels were measured in only 20% of the patients

5% patients had documented evidence of monitoring for cardiac or respiratory deterioration

Similarly, only 5% patients had ecg monitoring, blood pressure and heart rate monitoring, and fluid balance charting

Critical care treatment was required in 20% of the patient

Conclusion

As a result of this audit, it was suggested that there was a lack of knowledge among healthcare professionals regarding the diagnosis and monitoring of the myocardial injury in Covid -19 patients

It was recommended that proper guidance about the diagnosis, monitoring and treatment be carried out and for the purpose, flow charts and care pathways containing various steps of the process and when to seek cardiology advice were devised and distributed throughout the medical units.

It was also suggested to carry out a re-audit after the proposed interventions to look for any improvements

Dr Khush Bakht ,M.B.B.S; Russells Hall Hospital , Dudley Group NHS foundation trust .