Poster Group J - Full QI Project- BPSC2023

Optimising vaccinations in patients with chronic lymphocytic leukaemia

A Quality Improvement Project (QiP) in the Haematology Department, Royal Cornwall Hospital Trust (RCHT)

Authors: Dr Rebecca Wood and Dr Ziad Zeidan (presenter)

Background

Chronic Lymphocytic Leukaemia (CLL) is a largely indolent lymphoproliferative disorder that can be managed in its early stages in primary care. Hypogammaglobulinemia and immune paraesis occur in 20-70% of patients with CLL, with infective complications accounting for up to 50% of all CLL related deaths1. Measures to reduce infection risk include vaccination, prophylactic antibiotics and Ig replacement therapy. The British Society of Haematology advises that all patients newly diagnosed with CLL should receive vaccinations for Seasonal Influenza, Pneumococcus & Hib2

Issues Identified

• Documentation of vaccination advice in outpatient clinic correspondence for patients newly diagnosed with CLL

• Deficiency in patients’ knowledge and uptake of required vaccinations

Aims

• Optimise resilience to infection in patients newly diagnosed with CLL by improving vaccine uptake

• Create a sustainable change in the long-term management of new patients with CLL at the Royal Cornwall Hospital

Methodology

1. The clinic letters of the 14 most recent diagnoses of CLL in the department and 9 most recently commenced on acalabrutinib were reviewed for vaccination advice. In addition, patients were interviewed via telephone regarding their knowledge of required vaccinations

2. The data was presented at the Haematology Department Governance Meeting, along with guidance on documentation of vaccination advice

3. The data was remeasured for the most recent diagnoses of CLL, following which patient vaccine cards were implemented

4. The data was remeasured for the most recent diagnoses of CLL, following which GP information sheets were sent to primary care with each new diagnosis

5. The data was then remeasured following implementation of the GP information sheets, following which, the overall data of the project was analysed

PDSA Cycle

Act: Departmental presentation, patient vaccination card distributed & professional educational resource in primary care employed

Results

Plan: Optimise resilience to infective complications in patients with CLL

Uptake of Pneuomococcal vaccine (Cycle 3)

Documentation of vaccine advice (Cycle 3)

Uptake of pneuomococcal vaccine (Cycle 2)

of vaccine advice (Cycle 2)

Analysis of Documentation of Vaccination Advice in Clinic Letters and Uptake of Pneumococcal Vaccine Following Implementation of QI Cycles Yes No

• Initially, 78% of clinic letters did not document the vaccination guidance, this was reflected with a 50% uptake of the pneumococcal vaccine amongst patients

• Following the first cycle, the documentation improved to 80% of clinic letters, with a 40% uptake of the pneumococcal vaccine

Study: Reduced vaccine uptake amongst patients with CLL and need for further education identified

Do: Investigate vaccination advice, patient knowledge & primary care knowledge

CLL VACCINATION CARD

I have recently been diagnosed with CLL and require the following vaccines:

Vaccines at diagnosis:

Prevnar (pneumococcal conjugate)

Haemophilus influenza type b conjugate vaccine

Fluvax

• Meningitis ACWY

Pneumovax II (pneumococcal polysaccharide) 2 months after Prevnar

Boosters:

Pneumovax II every 5 years

• Fluvax annually

• Following the second cycle, the implementation of the vaccine cards improved the uptake of the pneumococcal vaccine to 75% of patients; however, only 50% of clinic letters documented the vaccination guidance

• Following the third cycle, the uptake of the pneumococcal vaccine was noted to be 89%, with 78% of clinic letters accurately documenting the vaccination guidance

• Interestingly, following the third cycle the uptake of the Hib vaccine improved to 50%, whereas previous cycles had demonstrated a 0% uptake of this vaccine

Discussion & Conclusion

• The main limitation encountered during this project was the presence of low patient numbers during the first two cycles, which was likely secondary to reduced capacity during the COVID pandemic

• Nevertheless, it was noted in the final cycle that a significant number of patients were able to be included in the data analysis

• Patients initially reflected difficulties in accessing primary care during this period, which may have affected vaccine uptake; however, it was noted that the vaccine cards empowered them to follow it up

• Distribution of the vaccine cards and primary care resource is now standard practice for all patients newly diagnosed with CLL

• In order to confirm the long term sustainability of this project, a re-audit is planned to take place in the latter part of 2023 with a potential to audit pneumococcal antibody titres as a marker for resilience to infection

Figure 1: Bar chart displaying documentation of vaccination advice, patient knowledge of required vaccines and uptake of the pneumococcal vaccine amongst the initial patient analysis.

Figure 2: Bar chart displaying results of all three cycles focusing on documentation of vaccine advice and uptake of the pneumococcal vaccine amongst patients newly diagnosed with CLL.

Improving the Quality of Cardiac Surgery Discharge Summaries

Sachin Patel, Alice Copperwheat, Marios Patronis

Background

• Cardiac surgery is complex with medication changes common.

• General practitioners need to be aware of any cardiac surgery operation and the patient’s post operative inpatient stay.

• Discharge summaries are completed by juniors and should match the guidance outlined within our departmental handbook.

Aims Aims

• To assess adherence of cardiac surgery discharge summaries to departmental guidelines

• To improve upon adherence of cardiac surgery discharge summaries to departmental guidelines.

Methods

• 1st audit cycle of discharge summaries between 2/9/22 and 28/9/22.

• Intervention: A lecture was given to juniors informing them of the baseline audit results and reaffirming what should be included within the discharge summary.

• 2nd audit cycle of discharge summaries between 6/10/22 and 3/11/22.

Results

Discussion

• Aim of 100% compliance across all domains not met.

• Operative details improved across most domains.

• Lecture was not given to thoracic and vascular juniors who may cross cover on weekends.

• Possibility of having a specific cardiac surgery template on the discharge summary system to improve compliance?

1st Audit Cycle (n=74)

Lecture

2nd Audit Cycle (n=72)

Improving patient referral pathways in ENT patients

Dr. George Williams, Dr. Tabitha Unsworth-White &

Miss. Hannah Light

1 Introduction

The SHO led ENT emergency clinic is a format used throughout NHS trusts to triage individuals with conditions needing to be seen in a timely manner. Conditions range from severe otitis externa, which needs to be seen within a week, fractured nasal bones needing manipulation after 7 but before 14 days, and foreign bodies in ears, which can be left for weeks in certain circumstances. The authors aim to implement a list of conditions to be booked into this clinic, highlighting those which need to be seen as an emergency on-call and ensuring conditions needing consultant-led specialist outpatient clinic review are referred appropriately.

2 Method

To investigate whether a patient had been referred to the SHO led clinic appropriately we looked at the clinic diary, the patient’s booked and the ailment they were referred for. We compared this to the list of conditions that should be seen in the clinic and those that should be seen elsewhere. We collated the data for one week before cycle 1 and after every cycle from there on.

The first cycle was the creation of a poster of conditions that should be seen in the clinic, and those that should be seen via other pathways.

The second cycle was to alter this poster to inform SHO colleagues of particular time frames that some conditions should be seen within.

The third cycle was an educational element of teaching incoming SHOs about the poster and which conditions should be seen in the clinic.

A driver diagram highlighted where in the referral chain changes could be introduced:

1) A poster detailing where different conditions should be seen.

2) Addition of the time frame that these conditions need to be reviewed in.

3) Teaching SHOs regarding the use of this poster and the common conditions seen.

3 Results and Analysis

Data was collected from the ENT emergency clinic diary booking system over three separate five-day periods. Weekends were not included due to reduced staffing. 44 patients were seen during the first cycle, 32 (72.7%) patients were deemed to have been booked correctly. Following implementation of the poster and education of the ENT team responsible for booking appointments, 41 (89.1%) patients were booked correctly in the second cycle. This increased to 100% (26) in the third cycle, this cycle included fewer patients due to the inclusion of a bank-holiday. The most common conditions seen were Otitis externa with 31 cases, recurrent epistaxis (19) and manipulation of nasal fracture under anaesthesia (12).

4 Conclusions & Going Forward

The creation of a clinic poster established a clear referral pathway ensuring patients were seen in a timely manner and were reviewed in the appropriate clinical setting. The results collected demonstrate that by the third cycle, all patients were being triaged to the correct service and the emergency clinic was not being overbooked with inappropriate referrals. Further cycles should include the change to new SHOs to ensure they are aware of the poster and continuing to follow its guidance. Going forward we are aiming to audit emergency clinic telephone calls to ensure that these are also appropriately dealt with.

Maximising our ‘peak flow’: how QI supported a redesign of community pulmonary rehab services in Milton Keynes

Alison Stirton-Croft, Lisa Pitam, Kiaya Watson, Jennifer Hammond, Susan Gaynard, Home 1st Therapies, Community Health Services Milton Keynes

Introduction

CNWL provides community based Pulmonary Rehab services in Milton Keynes. The service was suspended during 2020 due to the pandemic, and when it restarted in April 2021 it faced large waiting lists with long waiting times for patients.

Aims

In addition to our stated improvement aim, we wanted to:

• Ensure we provided a safe service for all patients referred for community based pulmonary rehab.

• As well as seeing patients within 90 days, we needed to ensure that all venues were Covid safe and that patients felt safe enough to take part in group sessions.

V. Kopanitsa1, S. Flavell2, J. Ashby 2, I. Ghosh2, S. Candfield2, U. Srirangalingm2, L. Waters2

• Strengthen relationships with partners across the whole system to support patients with respiratory conditions.

1. University College London (UCL) Medical School;

We faced the dual challenge of clearing our historic waiting list, and ensuring we had capacity to manage ongoing referrals into the service. Even before the pandemic the service was struggling to see patients within 90 days from referral, as per British Thoracic Society guidance. 1 High demand also affected partners providing support for pulmonary rehab and respiratory issues across the system. We agreed we would need to rethink the way in which we provided our service across Milton Keynes. QI provided a structure for us to work through ideas for change.

2. Central and North West London NHS Foundation Trust

Methods

Starting in June 2021, we set an aim to clear our historic waiting lists and to ensure that:

By the end of 2022, all patients referred for Pulmonary Rehab services would be seen within 90 days of referral.

• We used QI methodology (Model for Improvement)2 to structure our work around changes to processes, pathway for patients and accessibility to the service.

• 5 PDSA ramps and a total of 14 cycles allowed us to test and establish changes.

• We gathered feedback from patients, staff and partners throughout our work to inform next steps.

Discussion and Results

A Driver Diagram helped us to see our system and identify where we needed to make changes.

PDSA cycles allowed us to test a number of ideas. We have now worked through 5 key ideas which are reflected in these PDSA ramps.

One of our ramps shown in more detail. Starting small, we worked up until we were sure things worked. We’ve now made this part of our business as usual operating model.

As we tested a number of ideas, we started to see our waiting lists come down. Recent rises have been in line with increases in referrals (e.g. when we took on hospital patients) and have been managed in a timely way.

We wanted to see all patients in under 90 days from referral. You can see that our new approach means we are now seeing patients faster than before the pandemic. (our Service was suspended from Apr 2020 – Mar 2021 so there is no data for this period in the graph).

The Patient Perspective

The team have been so friendly and have always e staff been there for any problem you have, not just breathing related.

I’d like to thank the team for their work. I attended a rehab course before covid, and the new programme is much better. Having experts in to do the talks was a highlight, and I also really liked the new exercises and format. I feel so much better having finished the course. 0

Examples of our revised processes – they underpin our clinical activity and make the journey smoother and safer for patients.

Lessons Learnt

• We have established a new way of supporting patients across the system and have been able to demonstrate this to patients

• There have been unintended consequences which have been really significant:

* we have identified a number of patients at assessment who needed to be referred back to their GP for medical optimisation. In at least one case this enabled early identification of serious issues which could be treated in primary care rather than requiring an admission to hospital following a crisis.

* As we managed to clear our backlog and release capacity to see patients we were able to work with the hospital to support them with their waiting list. This has helped a wider redesign of the whole system pathway for patients needing pulmonary rehab services.

• We’ve learnt a lot about data – including data quality issues associated with the configuration of our patient management system. This is being addressed separately.

• We know that improvement is a continuous journey! Further work needs to be done to upskill more staff on management of the My COPD app and to explore why patients drop out of classes. Could we increase completion rates?

References

1. British Thoracic Society, QualityStandardsforPulmonaryRehabilitationinAdults , 2014, Quality Statement 1, p.8. 2. Langley et al, TheImprovementGuide , 2009, pp23-25

Huddle Up! In Critical Care

Background

Whilst working on a busy Critical Care until we noticed we were asked to review airway problems despite not being airway trained clinicians We identified that staff did not always know who was airway trained, or the names and roles of different members of the MDT

The WHO Surgical Safety Checklist is a national mandatory requirement before all surgeries and is a simple communication tool shown to reduced adverse outcomes and improve communication There is currently no mandatory requirement in Critical Care for such checklist despite many similar safety challenges

SMART Aims

To increase team awareness of airway trained clinicians for the shift to 90% by the end of October 2022.

Additional safety features: names and roles, unwell/at risk patients, limitations of treatment planned procedures/transfers, and admissions/discharges

Methods

Pre-huddle self-assessment questionnaires (11 questions) were distributed amongst staff to collect baseline data

Staff members were encouraged to join a new Critical Care MDT Safety Huddle based on the WHO Surgical Checklist for a few minutes each day and complete a safety huddle checklist form (fig 1) Outcome measures were determined using data from post-huddle questionnaires and analysed via run charts

Process measure data was collected from completed safety huddle checklists

A total of 9 PDSA cycles were carried out (fig 2) After the SMART aim was achieved in October 2022, the next PDSA cycles focused on improving the process measure

The timeline of methods using Model for Improvement methodology is outlined in figure 3

Results

In addition to the results shown above our analysis showed the following:

The huddle resulted in a positive shift in staff feedback towards feeling part of the team and effective communication

The majority of respondents said the MDT safety huddle increased their knowledge of staff patients and plans

The level of knowledge regarding sickest patients remained consistently high after huddle introduction

The huddle increased knowledge of patients with DNACPR/ceilings of treatment

The huddle increased knowledge of expected procedures and transfers

The huddle increased knowledge of expected admissions and discharges

The comfort levels experienced by staff when raising concerns remained consistently high after huddle introduction

Process measure

if I ve been away, helps me prioritise which patients to see first" Good to meet new people and find our their roles

"Helpful as someone new to ICU which patient have DNACPR and which are airway trained" Feel it s made a definite difference "Really good especially for airway trained"

Recommendations

The MDT safety huddle increases trained clinicians and other safet names/roles, expected/planned care

There was already high awarenes area, and staff felt comfortable r intervention

The MDT safety huddle has recei team

is room to improve the fre embed the practice further (inclu

Figure 2: Diagram of PDSA cycles

Figure 1: Safety Huddle Checklist

Figure 3: Methodology timeline

Dr Amy Ma, Dr Maneesha Aruketty, Dr Zeeshan Malik, Dr Carl Oakden, Royal Bolton Hospital

C o l d w e a t h e r a n d l o w s o c i o e c o n o m i c s t a t u s d i s p r o p o r t i o n a t e l y a f f e c t p e o p l e w i t h c h r o n i c R e s p i r a t o r y d i s e a s e ( M a r n o e t a l , 2 0 0 6 ) W i n t e r 2 0 2 2 / 2 3 w a s o n e o f t h e w o r s t w i n t e r c r i s e s i n h i s t o r y ( N H S C o n f e d e r a t i o n , 2 0 2 3 ) a s h e a t i n g c o s t s t r i p l e d a g a i n s t a b a c k d r o p o f r e c o r d - h i g h i n f l a t i o n m a k i n g i t i m p o s s i b l e f o r p e o p l e t o h e a t t h e i r h o m e s e n o u g h t o m a i n t a i n t h e i r h e a l t h T h e r e i s a n e c d o t a l e v i d e n c e a n d s i g n i f i c a n t c o n c e r n t h a t p a t i e n t s a r e n o t u s i n g r e s p i r a t o r y d e v i c e s s u c h a s o x y g e n c o n c e n t r a t o r s a n d C P A P m a c h i n e s a s p r e s c r i b e d d u e t o f u e l p o v e r t y ( G u a r d i a n , 2 0 2 3 ) P a t i e n t s a r e o f t e n e n t i t l e d t o g r a n t s , o r r e i m b u r s e m e n t s f o r e n e r g y c o s t s b u t m a y n o t b e a w a r e o f a l l s o u r c e s o f s u p p o r t a s e a c h h a s d i f f e r e n t q u a l i f y i n g c r i t e r i a a n d m e t h o d s o f a c c e s s A q u e s t i o n n a i r e w a s u s e d t o c h a r a c t e r i s e t h e p a t i e n t p o p u l a t i o n a n d t h e i r n e e d s F i s h b o n e d i a g r a m a n d N I C E g u i d e l i n e s i n f o r m e d i n t e r v e n t i o n d e s i g n . A f u r t h e r q u e s t i o n n a i r e w a s d e s i g n e d t o c a p t u r e o u t c o m e s p o s t - i n t e r v e n t i o n .

of patients spoke with a HCP about Cost of Living crisis/utility affordability.

Some doctors felt the work was beyond the scope of their job so we decided to target patients directly A leaflet targeting patients that clinicians could distribute was a compromise

Patients surveyed probably did not correspond to patients reached by leaflets due to infrequency of appointments Next intervention designed to target same patients before and after help

25% of patients aware of available financial resources (32% at baseline)

33% of patients spoke with a HCP regarding the CoL crisis (0% at baseline)

of patients receive one or more government benefit payment

patients stayed in bed longer to stay warm in the past year of patients could not keep their living room warm in the past year

of patients did not know how to find information about financial support

of patients had difficulties meeting heating costs in the past year

of patients would like support from the respiratory team on the Cost-of-Living crisis

Aims

W e a i m e d t o i n c r e a s e t h e p e r c e n t a g e o f p a t i e n t s :

A w a r e o f a v a i l a b l e f i n a n c i a l r e s o u r c e s . T a r g e t : 5 0 % o f a l l p a t i e n t s

C o n t i n u i n

Lessons Learnt

a t i e n t s

Analysis by run charts yielded no significant trends. Only the target for continuing medication was met Significant weekly variation persisted Resource scarcity made data collection and therefore interpretation difficult

Subpar results could be due to infrequent outpatient appointments, reducing the likelihood of patients impacted by interventions being captured during the time period of study

Barriers to success included logistical and manpower limitations, low number of patients surveyed, lack of clinician capacity for non-clinical work over winter

Sustainability

75% of patients continuing medication despite financial difficulties (68.75% at baseline).

Clinicians were up-skilled on CoL-related issues. Further data is needed to justify upscaling our interventions. A sustainable relationship between KCH and Green Doctors was established, laying the ground work for ongoing change

Green Doctors also provides training sessions for clinical staff for which our study identified a significant appetite for among certain staff.

There are aspirations to plan an intervention with greater reach next year, building on the learning from this project

Figure 3: Percentage of patients meeting measured outcomes by data collection point

Figure 2: Percentage of patients meeting measured outcomes by on average

Figure 1: Key statistics from baseline questionnaire:

Improving Same Day Emergency Care Capacity

D. Lokko, C. Valeriano, E. Diaz, H. Raybould, D.Quinn, and C. Wild

Introduction

SDEC is the provision of same day care for emergency patients who would otherwise be admitted to hospital. The national SDEC model builds on previous improvement work in Ambulatory Care services across the NHS, with the aim of providing a consistent approach to patient pathways. 1 National data suggests that SDEC patients account for approximately 22% of the acute medical take, who would have otherwise been considered for emergency admission. By assessing, diagnosing and treating these cohort of patients within the same day, we avoid unnecessary hospital admissions which have implications on patient outcomes and healthcare costs. 2 An increase in the number of returning patients impact on the ability of SDEC to manage the workload and capacity for new patients of that day, therefore BTH SDEC policy states that there should be no more than 6 returns per day. 3

Results

By process mapping SDEC returns, unnecessary patients waits to be taken to and from the different hospital departments for scans have been identified. A new return process was piloted for patients returning for Doppler ultrasound scans. Patients were given a request card on discharge, with instructions to present directly to the Vascular Unit in a given appointment date and time. If their Doppler scan is negative they are discharged directly from Vascular Unit and followed-up by an SDEC doctor or ACP via Virtual clinic. Seven PDSA cycles were undertaken. A total of 23 patients went directly to Vascular Unit and 73% (17) of those were discharged home direct from Vascular Unit and followed-up virtually, bypassing the need to physically return to SDEC. Since the start of the PDSA cycles the team have saved a total of 440 Care Minutes , which over a year, this could save a week in care time.

Lessons Learned

To utilise 100% of SDEC daily capacity for patient reviews (n=35) at Blackpool Teaching Hospitals by July 2022.

Initial Assessment

The variation in the number of return patients consequently impacted on capacity for new attendances, as they require same resources for space and clinician time. However, the option of having the patient return to SDEC for further imaging or review, provided a safe and effective alternative to admission to a hospital bed. Limiting number of returns to at most 6 provided a balance between the impact on capacity and the patient benefit.

Change ideas

§ Important to start small, manageable, easier and once you start seeing the changes it is motivation to continue

§ Celebrating the small wins

§ Collaborating as a team and with other departments

§ The importance of stakeholder involvement and the impact it has on the patient journey

Next steps

§ Sustain process for patients to go direct to Vascular unit

§ Identify the next cohort of return patients to test change on

§ Ensure all changed processes implemented on new unit

Telephone clinic

Programme Theory Patient Story

It’s not just about the numbers – patient story

scan QR code or use this short URL : https://qrco.de/bdA7nI

References

Expanding roles of advanced clinical practitioners (ACP) to improve lumbar puncture (LP) practice and patient waiting times in acute medicine

Mary Erica Diaz-Santos, Dr Alaoye Foy- Yamah, Dr Nilu Bhadra

Introduction

Lumbar punctures (LP) are crucial in diagnosing and managing acute headaches in secondary care.1 An audit was undertaken of all patients admitted to the acute medical unit (AMU) with a presenting complaint of acute headache (n=417) in a three-month period, which revealed that 12% (n=50) had an LP. These patients waited an average of 64 hours after brain imaging to rule out contraindications, for an urgent LP. There was also significant variation of LP practice against guidelines, particularly with use of cutting spinal needles and failure to give patient information leaflets. Previous research has highlighted that not following guidelines can lead to poor patient outcomes.2 Anecdotal feedback from AMU staff has suggested that prolonged waiting times have been worse recently due to significant operational pressures on senior doctors, who have traditionally been relied on for performing LPs. Evidence suggests that extending roles of permanent members of the multidisciplinary team such as advanced clinical practitioners (ACP) to include procedures such as LP was linked to better patient access and outcomes. 3

Aim

The main aim of this quality improvement project is to improve standards of LP practice

Discussion

Extending LP training to ACPs, ensured availability of staff to support senior doctors, leading to a reduction in waiting times. 3 Furthermore, expanding roles of ACPs to include LP was linked to better outcomes, thus providing basis for this change idea. By establishing expectations in LP practice through training, standards of care and patient safety improved. 4 However, the benefits of training depended on opportunities for clinical supervision, which required early engagement and availability of supervising senior doctors. By the 3rd PDSA Cycle, we noted an increase in LP waiting time because

I-chart to show average waiting time for lumbar puncture from Nov 2021- Oct 2022, between 1-37 occurrences

in the AMU by reducing waiting time for LPs and reducing variation in LP practice.

Method

The main change idea that was tested was the introduction of an LP training programme for ACPs and junior doctors. Three Plan-Do-Study-Act (PDSA) cycles were performed to develop and improve the programme and to monitor QI measures. Guidelines in LP practice were reviewed and addressed in the training programme and reinforced by the introduction of an LP trolley in the unit. 2 Outcome, process and balance measures were identified to monitor improvement. This was done through retrospective review of records of a random sample of patients who had LP during a specified time frame.

The main outcome measure identified was waiting time for LP, which was measured by the number of hours between a patient’s computerised tomography (CT) head scan being reported and the time cerebrospinal fluid(CSF) sample was received by the laboratory as indicated in their ‘CyberRad’ and ‘CyberLab’ records, respectively. CyberLab/Rad is the Trust’s electronic system used to order and view Pathology and Radiology investigations for all inpatients. Process measures used included: the percentage of patients who had LP who were given information leaflets, number of LP attempts, percentage of LPs performed with atraumatic needles and grade of staff performing the LP. Written feedback from patients and trainees were monitored as balancing measures.

Results

Data was gathered four-monthly, to allow ample time for trainees to gain competence with the procedure. This showed consistent improvement in aspects of LP practice. An initial decrease in percentage of successful 1st attempts was noted and associated with trainees gaining skill with LPs as seen in Figure 2 below. By the 3rd PDSA Cycle successful 1st attempts increased to over 90%. LP waiting time also showed marked decrease from baseline (M=64) by the 2nd PDSA cycle (M=19) as illustrated by the run chart (Figure 1). Overall reduction in LP waiting time (M= 38) was noted by 8 months.

of operational demands on senior doctors which impacted on their time to provide supervision. Buy-in and commitment from senior stakeholders to the benefits of training is key in this transition. As ACPs and junior doctors become competent in LPs, supervision roles can be assumed so that benefits of training are sustained.

References

1 BASH, National headache management system for adults, 2019.

2 Engelbohrs, et al., ‘Consensus guidelines for lumbar puncture in patients with neurological diseases’, Alzheimers & Dementia, vol. 8, 2017, pp. 111-126.

3 Ernst, et al., Expanding RN scope of practice to include lumbar puncture, AJN, vol. 118, no.3, 2018, pp. 54-60.

4 Lavery & Whitaker, Training advanced practitioners to perform lumbar puncture, Nursing Times, vol. 114, no.11, 2018, pp. 33-35.

Acknowledgements

Many thanks to all the technical help and guidance extended by the BTH QI Hub, with special mention to Parya Rostami and Sean Cross, as well as the unfailing support of the BTH Acute Medical Consultants and ACP/NP Team.

Figure 1. Run chart to show the waiting time and mean waiting times (M) per PDSA cycle for lumbar puncture from Nov 2021- October 2022, between 1-37 occurrences

Figure 2. Process measures by PDSA Cycle

Gestational Diabetes Follow-Up, QIP

Dr. Ziad A. Shaban, Dr. Mohammad Alfallal Kingsway Surgery, Swansea Bay University Health Board

I- Introduction

Advantages of adequate follow-up of women with GDM include the targeting of ongoing risk factors for the development of T optimise risk factors before any future pregnancies. It advised that women diagnosed with GDM should be followed up with either FBG test after by measuring HbA onwards (NICE

II- Objective

Boost the adherance percentage of GDM follow-up at Kingsway Surgery by at least %25 by the end of May months).

III- Analysis

Only 23 Patients were coded to have GDM out of around ( 0.023 %). The average UK prevalence is in 20 pregnancies.

• 9 patients were already diabetics (

• 12 didn't have their F/U (

• 2 were adequately followed-up (

So, 11 in total were getting appropriate F/U; Diabetics + Proper F/U after GDM Dx (

IV- Methodology & Changes

1 - We called the patients who missed/were not invited for the F/U and explained the risks of developing DM later in life .

2 - We sent letters with the discussed information, a blood form for HbA 1 c and instructions on how to book the phlebotomy appointment.

3 - We contacted the senior midwife in the hospital via email and explained the baseline results. It was important to insure the discharge summaries are inclusive of any pregnancy problems (especially GDM).

We also went through the importance of discussing the risks/complications of GDM with the patients and encouraging them to have the follow-up.

4 - We Discussed the findings with the team in the surgery, advised to keep the patient in the loop of F/U process.

5 - We presented the project results in the surgery clinical meeting to highlight the importance of proper coding for these patients, and ensuring they are added to the "pre-diabetes" list.

After running another cycle in 3 months, 24 patients were coded to have GDM. * 2 new registered patients, and 1 left the surgery *

V- Results

The GDM follow-up rate sharply rose by %39.5 (from %48 to %87.5 ) indicating the success of implemented measures.

• 12 were already diabetics ; three more discovered by HbA 1 c screening ( %50 )

• 9 were adequately followed-up ( %37.5 )

• 3 didn't have F/U despite prompting ( %12.5 )

- So, 21 in total were getting appropriate F/U; Diabetics + Proper F/U after GDM Dx ( %87.5 )