Poster Group H - Patient Safety Audit- BPSC2023

Background/Problem/Issue

• Failure to clear the spine, in particular the c-spine, can potentially risk secondary spinal cord injury.

• Extensive nursing resources are required for moving and handling spinal injury patients. Once the spine is radiologically cleared a documented plan should be formulated to ensure immobilisation and stabilisation, and relayed to the nursing staff

Aim

• To assess whether a Trauma CT scan was done and reported by a consultant radiologist for all Level 1 trauma patients admitted to Neuro ICU over a 6 month period.

• To assess whether the first part of the spinal management form was completed by a Neuro ICU consultant.

• To assess whether a plan was made in the event of weaning sedation in all patients.

Guidelines used

The Guidelines for initial spinal management of sedated and ventilated trauma patients are part of adult major trauma guidelines. The spinal management form is based on them.

https://qrco.de/bdtCSE

Images/Charts

Conclusions/Lessons Learned

• Ideally, in all level 1 trauma patients, a trauma CT needs to be done. This was not being done in 17% of our patients.

• This audit found that we were quite good at completing the first part of the spinal form on time. However, the second part of the spinal form was not completed for 70.32% of our patients. This needs to be brought into the attention of our consultants.

Results/Data

• Total number of patients surveyed: 64

• Number of patients in whom a trauma CT scan was done and reported: 53 (82.81%)

• The first part of the spinal form was completed in case of all 64 patients (100%)

• Number of patients in whom a final plan was made: 52

• Number of patients in whom a plan was made in the event of weaning sedation= 19 (29.68%)

Assessing the compliance with filling spinal management forms in major trauma patients

Dr Mehak Malhotra, Junior Fellow, Southmead hospital Bristol, Jesus Romero Munoz, ACCP, Southampton General Hospital

An analysis of rejected MRCP requests for quality improvement in a tertiary referral centre for HPB surgery

Dr Rickesh Shah, Dr Rishi Chavda

• Inappropriate scan requests place a substantial strain on radiological services.

• This has considerable cost implications for the NHS and more significantly the potential to expose patients to unnecessary harmful ionising radiation

• Magnetic resonance cholangiopancreatography (MRCP) is an invaluable imaging modality that is utilised in the assessment of patients presenting with jaundice, abdominal pain and deranged liver function tests.

• However, MRCP requires specialist interpretation thereby limiting the number of scans that can be performed daily

• Within our centre the protocolling of MRCP requests requires obstructive liver function tests, a preceding abdominal ultrasound scan (USS) along with explicitly documented approval from a consultant general surgeon or gastroenterologist, within the request.

• We analysed rejected MRCP requests with the aim to reduce the number of inappropriate requests.

Background Method

• Prospective data was collected over 2 cycles each spanning 6 weeks in duration.

• Rejected MRCP requests were identified and analysed, noting the reason for rejection.

• Patient data was collected to ensure blood results and a preceding USS warranted the request

• Data was also collected pertaining to date/time of request, date/time if re-requested and the date/time the investigation was performed

• For comparison, data was collected on the date/time from request to investigation in non-rejected scans

• Following analysis of the data from cycle 1, change was implemented by means of educating junior doctors responsible for requesting scans on the protocolling requirements for MRCP. This was achieved through both verbal explanation and the dissemination of the information in the form of posters distributed in clinical areas, with a subsequent reaudit of data

Results

• The median time from original request to MRCP being performed in patients without a rejection was 920 minutes in comparison to 2376 minutes when the original request was rejected, thus representing a delay of over 24 hours.

• Cycle 1 showed 20/67 MRCP requests rejected, for which 4 patients did not have a prior USS and 16 did not have approval from a consultant documented in the request. This demonstrated an overall rejection rate of 30%.

• Cycle 2 showed 6/71 MRCP requests rejected, for which all 6 patients did not have approval from a consultant documented in the request. This demonstrated an overall rejection rate of 8%

Conclusion and next steps

• The median time from original request to MRCP being performed in patients without a rejection was 920 minutes in comparison to 2376 minutes when the original request was rejected, thus representing a delay of over 24 hours.

• Cycle 1 showed 20/67 MRCP requests rejected, for which 4 patients did not have a prior USS and 16 did not have approval from a consultant documented in the request. This demonstrated an overall rejection rate of 30%.

• Cycle 2 showed 6/71 MRCP requests rejected, for which all 6 patients did not have approval from a consultant documented in the request. This demonstrated an overall rejection rate of 8%.

• The 3rd cycle of our project will include a change to the request form to ensure a consultant's name is not missed from the request.

Figure 1: The median time taken from initial MRCP request to the scan taking place depending upon whether the initial scan request was rejected or not rejected.

Figure 2: The outcome of the initial MRCP request in each cycle.

Drinking, Eating And Mobilising (DrEaMing) Within 24 h Of Abdominal Surgery

Dr M Skelac Torbay and South Devon NHS Foundation Trust

RESULTS

INTRODUCTION

Post-operative complications may include blood clots, infections, bleeding and poor wound healing. NHS England and NHS Improvement determined quality indicators for surgical services being delivered - DrEaMing within 24 h of surgery for 60-70% of eligible patients. This is a simplified programme of care and is included into Perioperative Quality Improvement Programme, supported by Royal Colleges.

AIMS

Only 33% of patients for whom DrEaMing was applicable were given fluids, food and mobilised 24h within the surgery.

This increased to 40% after the first intervention, but there was little change after the second intervention (38%). Only after the third intervention, the percentage changed to 82%.

DrEaMing is now a part of intensive care MDT checklist. Nursing and physiotherapy notes became more consistent and informative.

METHODS

Data collection 1: Electronic data about elective abdominal surgeries was collected during 6 weeks. Each case was given a pass only if all 3 conditions were met.

Intervention 1 - presentation at the intensive care consultant meeting

Data collection 2

Intervention 2 - presentation during a surgical meeting

Data collection 3

Intervention 3 - introducing DrEaMing in the MDT checklist

Data collection 4

DISCUSSION

Communication between the teams was the main limiting factor to reaching the standards of care.

Intervention 1 showed that targeting only one part of the MDT can achieve limiting results, despite the best efforts. The second intervention did not yield any results. This might be because surgeons record their plans on the operation notes and later have limited exposure to their patients.

Intervention 3 showed that clinical teams should work together in order to achieve positive results for their patients.

FUTURE CHALLENGES

•Communication and coordination between the MDT

•Regular multidisciplinary assessment of a patient’s DrEaMing status and the setting of individualised targets

•Could review of DrEaMing be part of the routine daily clinical assessment?

•Could we protocolise or prescribe postoperative DrEaMing?

•Early engagement from the patient (introduce the concept at pre-operative assessment and in patient information leaflets)

•Effective postoperative analgesia

•Limiting unnecessary attachments

Figure 1: Audit tool used for data collection

Figure 3: Future interventions

Figure 2: The impact of interventions on the percentage of surgical patients achieving DrEaMing within 24 h of surgery

Prehospital birth in the South West: measuring and managing neonatal hypothermia

Background:

Neonatal hypothermia (<36.5°C) is an important risk factor for babies born before arrival at hospital (BBA); in low birth weight infants, mortality increases by 28% per 1°C decrease in admission temperature below 36.5°C.

In the prehospital setting babies can become hypothermic within minutes. Research from the UK and abroad suggests that paramedics do not routinely record neonatal temperature following BBA.

Methods:

We conducted two service evaluations in the South West of England to examine which groups of women are most likely to experience BBA, what proportion of BBA babies have a neonatal temperature recorded by the ambulance service, what proportion of BBA babies are hypothermic on arrival at hospital, and what barriers exist for prehospital neonatal temperature measurement/management.

1) Service Evaluation One: Ambulance service data

Anonymised extracts from electronic patient care records were provided by the South Western Ambulance Service NHS Foundation Trust (SWASFT) for a three-year period (January 2017-January 2020) to determine the percentage of BBAs where a neonatal temperature was recorded, and how many of these were hypothermic.

Interviews were carried out with 20 operational paramedics from the same Trust to explore experiences of prehospital neonatal temperature measurement/management.

Data were analysed using simple descriptive statistics and thematic analysis.

2) Service Evaluation Two: Hospital data

Anonymised extracts from hospital neonatal records were provided by six South West NHS Hospital Trusts for a three-year period (January 2018-January 2021). Demographic characteristics of the mothers and characteristics of the birth were analysed and presented using descriptive statistics.

Findings:

Ambulance service data:

• Neonatal temperatures were recorded in 2.7% (43/1582) of BBAs attended by paramedics

• 72% (31/43) of recorded neonatal temperatures were below 36.5°C (hypothermic)

• Barriers to prehospital temperature measurement of newborns included unavailable equipment, prioritisation of other care activities, and a lack of exposure to births.

Hospital data:

• 35% (64/184) of babies arriving at hospital from the ambulance service were hypothermic on arrival and 25% of these were classed as “moderately” or “severely” hypothermic, with warming needed urgently to prevent poor outcomes (Table 1).

• Some babies were more likely to be hypothermic on arrival at hospital, including pre-term babies and those whose mothers reported a disability at the booking appointment.

• Some women in the South West were more likely to have a BBA than others, including those with safeguarding concerns, late booked pregnancies, and those who have had babies before.

WHO Temperature Proportion of Implication classifcation range those hypothermic for outcomes/ on arrival care (WHO)

Cold stress 36 - 36.4°C 48/64 (75%) Cause for concern (mild hypothermia)

Moderate 32 - 35.9°C 14/64 (22%) Danger, warm baby hypothermia

Severe <32°C 2/64 (3%) Outlook grave, skilled hypothermia care urgently needed

Impact:

As a result of this work, the South Western Ambulance Service NHS Foundation Trust set up a series of Quality Improvement meetings which led to:

• An audit of axillary thermometers on all frontline vehicles, resulting in new orders for equipment

• A staff-facing winter campaign to raise the awareness of neonatal hypothermia (including posters detailing what crews are able to do in order to keep babies warm)

• Amendment of the electronic patient care system to encourage neonatal temperature measurement/management

The fndings from this work also contributed to the Prehospital Newborn Life Support course held at South West AHSN which has received endorsement from the Resuscitation Council UK and will be disseminated to healthcare professionals throughout the UK.

Authors: Dr Laura Goodwin, on behalf of the project team: Katie McNee, Roisin McKeon-Carter, Emily Beach, Adam Bedson, Sarah Black, Toity Deave, Kim Kirby, Helen McAdam, Graham McClelland, Nick Miller, Ria Osborne, Hazel Taylor, Sarah Voss, Jonathan Benger.

Table 1: Neonatal temperature on arrival at hospital

Service Evaluation One was funded by a UWE Bristol Vice Chancellor’s Early Career Researcher Development Award. Service Evaluation Two was funded by the South West AHSN as part of its Perinatal Health Equity programme.

Preventing Iatrogenic Inpatient Hyperkalaemia

Samantha James, Chris Michie

Introduction

Electrolyte disturbances are common amongst hospitalised patients, they can lead to significant complications and prolonged hospital admissions. Hypokalaemia and its treatment is an essential part of medical practice, however, inaccurate and incomplete prescriptions can lead to over-replacement and hyperkalaemia, which can lead to arrhythmia and death. (1)

The aim of this project was to improve the accuracy of potassium replacement prescriptions in order to reduce the number of patient harm events as well as ensuring prescriptions were in keeping with best practice guidelines.

Results

Methods

The first part of the project analysed the electronic prescription of all inpatients prescribed ‘Sando -K’ over one month across all wards. Data was collected to assess; if course duration was documented, if repeat serum potassium levels were taken and the length of potassium replacement treatment that was dispensed. Inappropriate prescriptions were defined as prolonged prescriptions (beyond the recommended length) where Sando -k was continually prescribed despite normokalaemia or hyperkalaemia.

Analysis of the first data set revealed that 2483 doses were prescribed for 358 patients. Of these no course length was docum ented on any of the prescriptions. Of 358 patients 14 received an inappropriately long course duration with 3 of these going on to become hyperkalemic, requirin g medical intervention.

Intervention

After this data was collected the main intervention of the project was to alter the electronic prescription system to auto-fill the course length to 3 days, as per national guidelines (Fig 3). A series of educational events and talks were also delivered to prescribing professionals.

Post - Intervention Results

Post-intervention out of 262 patients, course length was documented on all prescriptions, 97% had their serum K re -checked and no patients developed hyperkalaemia (Fig 4 & 5).

Conclusion

The results showed that this simple intervention ultimately prevented patient harm and improved accuracy of prescriptions. This audit demonstrated as electronic prescribing becomes more common, systems must be integrated to enhance safety and minimise errors. Of note the second cycle data found 2 patients to have duplicate prescriptions of potassium replacement. Fortunately these were not administered, however going forward we will be looking into how this too can be improved.

Figure 3. Screenshot of ePMA prescription

Figure 5. Cycle 2 - Inappropriate

Improving patient safety by analysis of PRN medication usage

Dr Emmeline Gee Manchester University NHS Foundation Trust

Background

• Trust guidelines state “PRN medications should be reviewed weekly, ideally as part of an MDT review".

• There was concern that these guidelines were not being adhered to on the female psychiatric inpatient ward.

• This could be negatively impacting patients' physical and mental health.

Aims

1) To assess guideline adherence of reviewing PRN medications and medication optimisation.

2) To implement measures to improve adherence, if indicated.

Cycle 1

P - Ascertained if guidelines were being adhered to

D - Collected data from electronic patient notes system from weekly MDT documentation and MAR charts

S - Calculated percentage of patients with medication reviews

A - Created a reminder poster and placed it in the MDT room for 6 weeks

Results

Intervention

Cycle 2

P - Ascertained if there were improvement in number of weekly medication reviews

D - Collected identical data from electronic patient notes system from weekly MDT documentation and MAR charts

S - Re-calculated percentage of patients with medication reviews

A - Laminated the reminder poster and printed a duplicate to place in the staff room

Conclusion and Learning Points

• A simple reminder poster can have a significant impact on patient safety.

• Completing a further PDSA cycle will ensure the positive change is sustained.

• Overuse of certain medications can indicate other underlying physical or mental health issues.

Audit looking into the management of stroke mimics presenting to MKUH as possible strokes

Dr A. Venkatesh, Dr V Gupta Milton Keynes University Hospitals NHS Foundation Trust Introduction

On average, stroke mimics account for 25% of patients presenting to hospital with possible strokes. There are two main categories of mimics-

• Medical mimics 80%

• Functional 20%

The commonest diagnoses presenting as stroke mimics according to existing literature are- recrudescence, functional disorders, migraines and seizures.

Why this audit?

Identifying stroke mimics accurately could avoid potential misdiagnosis and side effects associated with use of acute stroke and/or preventative management including thrombolysis or long term antiplatelets.

Standards

All those presenting with stroke or stroke like symptoms should have a ‘stroke call’ put out so that the on-call stroke team at MKUH are notified to assess the patient. Local results were compared with data from the SSNAP Stroke Mimic Audit 2021

Methods

All patients presenting to MKUH with symptoms of a possible stroke between July 2022 and October 2022 were identified, including:

• Community stroke calls

• Inpatient stroke calls

• Repatriations of confirmed strokes

Results

50 7% of stroke calls at MKUH were diagnosed as mimics as compared to the national average of 52 8% as identified in the SSNAP Audit 55 2% of stroke mimics nationally are female, 52 8% of our cohort of mimics were female

Though the above figures appear similar, SSNAP categorizes TIAs as mimics accounting for nearly 20% of mimic diagnoses, whereas TIAs were categorized as strokes in our Audit The graph to the left illustrates the percentages of mimic diagnoses in MKUH, the graph below is from the SSNAP Mimic Audit 2021

Thrombolysis, if administered within the recommended time window (4 5 hours from symptom onset once haemorrhage has been excluded) offers benefits of likely reperfusion to those who have had an ischaemic stroke, however administering this to someone who has not had a stroke comes with increased risks of bleeding with none of the reperfusion benefits

10% of strokes and 0 7% of mimics are thrombolysed on average nationally, at MKUH only 4 8% of strokes were thrombolysed despite door to needle (DTN) time being well below (29 minutes) national standards (60 minutes) However, NO mimics were thrombolysed

The table below shows the strokes and mimics that presented within the thrombolysis window in our cohort

Conclusion and Recommendations

In conclusion, we have identified that elderly patients with delirium form a large proportion of those presenting to MKUH as suspected strokes. In someone who is delirious and possibly septic, time is of the essence in starting appropriate treatment. Appropriate recognition of delirium vs stroke is also helpful in utilizing the stroke team’s resources in a more efficient manner and to reduce the risk of inadvertent thrombolysis. There is scope for improvement as we have noted a significantly smaller proportion of stroke mimics presenting and being diagnosed with delirium nationally.

Recommendations

• The CT team are now being involved in stroke calls that are put out in order to minimize DTN time and possibly aid in ruling in/out strokes rapidly.

• A review of assessments and subsequent referrals to the stroke team for suspected strokes from ambulance crew/ED/wards to identify areas of learning and examination amongst clinical staff to reduce the proportion of mimics being treated as stroke calls/strokes.

• To consider looking into the prevalence of risk factors in those with confirmed strokes vs mimics could be considered to investigate any correlation between certain risk factors and neurological presentations of stroke mimics

A 5 - year review of the care of women with HIV in Pregnancy at Lister Hospital, Stevenage, East and North Hertfordshire NHS Trust

Dr Datchayini Babu, Dr Priyatha Babychan , Dr Rabia Zill- e- Huma, Dr Sarah Edwards, Dr Gail Crowe

Introduction

HIV remains a global concern and poses maternal and fetal risks in pregnancy. Vertical transmission rate in the UK has significantly reduced from 2.1% in 2000 to 0.22% in 2018 with adherence to local and national guidelines

Method

24 cases were identified and reviewed from June 2017 to June 2022. Data collection included a review of all paper and electronic records from maternity, safeguarding team, neonatal and GUM clinics

Objective

Review the care of women with HIV in pregnancy against local and national British HIV Association (BHIVA) guidelines

Results

• 75% of women were known HIV positive prepregnancy

• Socio-economic, confidentiality, visa and financial issues existed in most cases, with 12% requiring children's social care involvement

• 42% of women had fetal growth concerns

• Contraception discussion was poorly documented, only noted in 17% of cases

• 29% of women had C-sections due to obstetrics concerns, 100% of women had undetectable viral load at delivery

• 16.7% of infants were born pre -term

• All infants received post -exposure prophylaxis (PEP) post -delivery and remained HIV -free on follow -up

• All women bottle-fed their babies

Conclusion

• Importance of pre-pregnancy counselling and contraception advice to avoid unintended pregnancies. Availability of revised documented birth plans electronically.

• Need for holistic, peer, charitable and mental health support because of their complex needs

• Individualised care plans and the importance of a multidisciplinary approach to gauge adherence to antenatal care for continued better maternal and fetal outcomes.

Dr Thomas Hardman, Dr Carmen Mallet, Dr Carl Sullivan

Introduction

Contrast induced nephropathy (CIN) and acute kidney injury (AKI) are controversial complications following administration of iodinated contrast media They are associated with increased morbidity and mortality

The standard used the development of AKI post contrast is 10-20% (RCR2013)

The incidence after Endovascular Aneurysm Repair (EVAR) is thought to be higher than other angiographic procedures due to the higher volume of contrast used and proximity to the renal arteries

This is a reaudit of a project aiming to identify the incidence of patients who develop AKI post EVAR, and to establish appropriate future pathways

Methods

• Data was collected from Welsh Clinical Portal and Radiology Information System (RADIS)

• First audit cycle patients underwent EVAR between 2009 and 2015 Second audit cycle patients underwent EVAR between 2018 and February 2023. The results were presented in the radiology educational meeting

• Baseline creatinine (<7 days pre-op) and maximum post EVAR creatinine (<48 hours) was compared and staged according to KDIGO criteria.

• Patient demographics, type and volume of contrast used and mortality was recorded

Results

References

1. Lee, J et al (2017) Occurrences and results of acute kidney injury after endovascular aortic abdominal repair?, Vascular specialist international U S National Library of Medicine Available at: https://www ncbi nlm nih gov/pmc/articles/PMC5754070/ (Accessed: March 18, 2023)

2. Saratzis A, Melas N, Mahmood A, Sarafidis P Incidence of Acute Kidney Injury (AKI) after Endovascular Abdominal Aortic Aneurysm Repair (EVAR) and Impact on Outcome Eur J Vasc Endovasc Surg 2015 May;49(5):534-40 doi: 10 1016/j ejvs 2015 01 002 Epub 2015 Feb 27 PMID: 25736516

3. Pichel, A C and 9WL, M M (2023) Acute kidney injury after evar, The BMJ Available at: https://www bmj com/rapid-response/2011/11/02/acute-kidney-injury-after-evar (Accessed: March 18, 2023)

4. Health Professionals & Consumers (no date) RANZCR Available at: https://www ranzcr com/search/ranzcr-iodinated-contrast-guidelines (Accessed: April 16, 2023)

5. Oderich Gustavo & Tenorio, Emanuel (2019) Optimizing Outcomes of Endovascular Aneurysm Repair in Patients With CKD

• In

• Of this, 4 (13%) had developed an AKI.

• Mortality was greater in the AKI group:

Ø 36 1% patients (26/72) in the non AKI group had died

Ø 44% patients (4/9) in the AKI group died

• NB - In those patients who had died the mean length of survival was longer in those with AKI and the average age at EVAR was higher

• The sample size of AKI group is small and multiple factors impact mortality and so no statistically significant associations could be made.

Conclusions

There was a 3% increase in proportion of patients with AKI between the 2 audit cycles Overall, the average creatinine rise reduced from 9% to 8%

Although, at our institute, we have demonstrated a lower reported incidence of AKI Post EVAR then previous studies (14 1 %1 , 18 8%2 and 16%3), it remains a recognized risk factor for patients undergoing EVAR and should be one of the parameters routinely monitored post operatively

We demonstrated no association between contrast volume and creatinine rise.

The small number of patients that were excluded did not have routine sCr levels checked post operatively which may impact the results

There was small increase in mortality post EVAR in the AKI group but the AKI group were older and survived longer so difficult to draw conclusions.

The study agrees with RCR endorsed guidelines that iodinated contrast should be given to patients regardless of renal function if the diagnostic benefit to the patient justifies this administration 4

Limitations and future work

1. There are multiple causes of AKI therefore it is difficult to state the exact incidence of contrast induced nephropathy post EVAR

2. Multiple patients had imaging or procedures requiring contrast pre-and post operatively, making it difficult to identify the EVAR procedure as a sole contributor to AKI.

3. Multiple factors impact mortality, and the patients undergoing EVAR often have multiple life-limiting co-morbidities

4. Ensuring accurate data collection of patients eGFR pre-and post-EVAR is required to assess if creatinine rise is proportional to stage of CKD and considering preprocedural hydration.4

5. Anaesthetic performance status was not extracted from the available data – this may be helpful in future studies

6. Although not performed at our institute, patients undergoing fenestrated EVAR and multibranched stents have been shown to be at greater risk of AKI Studies have shown despite the involvement of renal vessels there is no greater risk when compared to infrarenal EVAR 5