Poster Group K - QI in Progress - BPSC2023

Introduction

- Hyponatremia is the most common electrolyte abnormality encountered in clinical practice​

- It is associated with increased mortality and prolonged length of hospital stay ( 1 )

- Errors in establishing the etiology of hyponatremia can lead to inappropriate treatment with adverse outcomes​

- An accurate diagnosis requires a careful biochemical assessment

Standards

1 -100 % of the patients with hyponatremia < 125 mmol /l should have elicited drug history.

2 - 100 % of patients with hyponatremia < 125 mmol/l should have plasma osmolality , urine osmolality , urine Na and K checked within 48 hours.

3 - 100 % of patients with hyponatremia should have plasma cortisol and TSH checked within 48 hours.

- 4 - Assess the length of hospital stay .

- 5 - 100 % of patients with hyponatremia 125 mmol/l should have CXR .

Methodology

- Retrospective audit of all patients with moderate / severe hyponatremia (Na <125 mmol/L) admitted to the medical wards of Diana Princess of Wales Hospital (n=185 ) . -

- Time period: 1 st of April 20211 st of October 2021 .

- Selected a random sample of 31 patients (using random sample generator)​ -Collected the required data from WebV and patients case notes (if needed) .​

Does hyponatremia increase the length of hospital stay ?

Results

Outcome

Discussion & conclusion

1 - Apply Hyponatremia bundle on the investigation request tab including all the required work-up of hyponatremia.

2 - Sending communication and awareness of this audit outcome via work e -mail.

3 - Update the hospital policy guidelines.

4 - Clinical porforma of checklist to be added to the medical notes for people coming with hyponatremia.

5 - Re -auditing after ensure compliance.

The Implementation of an ICU Intrahospital Transfer Checklist

Background and Aims

Transport of critically ill patients1 increases risk of adverse events

To minimize this risk and Improve the quality of care, an Intra-hospital Transfer Checklist was implemented using QI methodology

Methodology

Three Plan Do Study Act Cycles

Information gathering and first ICU intra-hospital transfer checklist draft

Tea Trolley Training2 and feedback forms collected for various MDT members

Finalized checklist piloted by SpR and ACCP and deemed practicable for use. Approved for use by clinical governance

“

100% of MDT members agreed that an ICU Intrahospital Transfer Checklist would improve patient safety ”

Results

Overall, 100% of responders agreed that an IHTC would:

o Help prepare for a potential adverse event during transfer

o Improve safety during transfer

Feedback identified that:

o More IHT training for nursing staff was needed

o The team should ensure suitable ventilator setup at destination

Neonatal Central Venous Catheters: A successful triad of a traffic light system, an education guide and a new X-Ray project

• Background:

The use of central venous catheters (CVCs) is essential part of neonatal care allowing delivery of intravenous fluids and medication However, their utilisation is associated with severe complications such as infection and extravasation to a body cavity, which is potentially fatal 1 Critical events associated with neonatal CVCs triggered a thorough review into local practice, with the aim to disseminate findings and ensure sustained improvements to patient care and safety.

• Aims:

Reduction of the number of incorrectly positioned lines, with the secondary aim of reducing complications through a prescript ive education package. We restructured the process for assessing CVC position, securing the device and created a robust system of ongoing monitoring. A collaborative ‘Central Line Quality Improvement Group’ was initiated to address all the project objectives.

• Initiated a quality improvement project with the radiology department

• Aim to re -evaluate the outcome 2 months post change

Cycle 5 Cycles 1 & 2 Cycle 3 Cycle 4

• Reviewed images of 50 babies for artefacts, collimation and the correct positioning.

• We found that poor quality X-Rays impacted on decision making

• Results:

 1st audit found 29.7% (28/94) lines were in an unintentionally suboptimal position (with 2 cardiac tamponades)

• 94 lines in 72 patients who had a CVC inserted on our unit were reviewed (01/09/2021-06/12/2021)

• Implemented changes

• Re-evaluated practice. Reaudit of 103 lines in 62 patients (01/03/202230/04/2022)

• Collated feedback and created education package

• Continuous education of the multidisciplinary team

Summary of changes

 Created a ‘traffic light system’ to assess and monitor CVCs

 Educated the team on optimal securing of catheters to avoid migration

 Developed an education guide distributed to every new rotation of doctors since 01/05/2022

 Designed posters on preparation for XRay, positioning and securing lines

 Liaised with radiographers

 Created new educational material

 1st re-audit revealed a reduction of ‘red lines’ to 17.4% (18/103)

 Review of X-Rays found suboptimal body and limb positioning in 45% of cases and artefacts in 55%

 2nd re-audit revealed a further reduction in ‘red lines’ to 13.1% (8/61)

• What’s next?

 Decide on implementation of Point of Care USS to check line position

of

to re -audit practice

Dr Ourania Pappa, Dr Megan Lynn, Erin Frankel, Sydnie Harris-Campbell, Dr Nicola Mullins Leeds Centre for Newborn Care, Leeds Children's Hospital, Leeds Teaching Hospitals NHS Trust

Table 1: Red lines and causes

Fluid Review Tab

L Tikare and N West Problem

Fluid reviews are vital across medicine and surgery to manage admission diagnoses and prevent iatrogenic complications.1-3 Improper fluid management can result in significant morbidity or mortality, with as many as 1 in 5 on IV fluids suffering harm due to incorrect administration. 4 Responsibility to complete fluid reviews falls often on the most junior of doctors who lack experience and specific training on conducting these assessments. 4

Aim

To develop a tool which contains components recommended by NICE and our local cardiology team, to aid in the completion of a fluid review. 5

PDSA 1

• Plan - Identify if fluid reviews are an issue for junior doctors in our trust.

• Do - Short survey to junior doctors.

• Study - 66% of doctors felt unsure when doing fluid reviews. 63% reported reviews would take >10 minutes. Elements doctors considered included weight, observations, intake/output, diuretic therapy.

• Act- A need for a standardising fluid reviews, and initial components to consider.

PDSA 2

• Plan - Finalise elements needed for review.

• Do - Discussions with local cardiology team.

• Study - Consultants and specialist nurses agreed this would be useful in their daily practise. Additional recommended elements: Hb, ferritin, NT-pro BNP, and renal function.

• Act - Acquired content needed for tab development.

PDSA 3

• Plan - Develop the Fluid Review Tab.

• Do - Develop prototypes and consult cardiology team for feedback.

• StudyImprovementsadding the timeline function, allowing both numerical and graphical data for clearer trends.

• Act - Tab completed and now live!

Future development

• Advertising to healthcare professionals.

• Feedback to improve further.

• Reassess junior doctor confidence.

• Timing how long reviews take with and without the tab.

• Teaching sessions for junior colleagues.

Lessons learnt

• Importance of an accurate and thorough fluid review.

• Limitations to a good fluid review.

• Understanding that our tab cannot replace a physical exam.

• Leading and developing a QI project.

• Resource development – who to contact and when.

• Teamwork and involvement of MDT.

Figure 1: Snapshot of the Fluid Review Tab in action, including plotted blood results and weights against medication and an intake/output graph.

Review of Clinical Decision Support Tools for use in Electronic Patient

Records at Manchester University Foundation Trust.

At our institution, a new EPR system was introduced in September 2022 (Epic Healthcare Systems Limited) The software includes a highly configurable, clinical decision support tools(CDSTs) called “Best Practice Advisories” (BPAs) In the first 7 months, we observed that the BPAs configured in our system had generated > 25 million alerts to our user base of 28,000 staff

CDSTs have the intended purpose of improving healthcare delivery (1) It can reduce patient safety incidents, reduce errors, increase adherence to guidelines, streamline administrative processes and more However, there are also possible drawbacks, and alert fatigue is a commonly reported phenomenon (2,3)

This occurs when too many in-significant alerts are presented, and users may start to dismiss alerts regardless of importance One solution to combat this is to prioritise alerts of critical importance and tailor alerts to avoid overwhelming users with clinically insignificant alerts

We report on a QIP designed to evaluate and refine our configured BPAs to promote accurate, appropriate, and practical clinical decision support whilst minimising alarm fatigue

Since the introduction of the EPR system in our trust in September 2022, there have been more than 25 million BPA alerts Of these, only a minor proportion (7 4%) have been actioned, with the majority (92 6%) being dismissed (Figure

2) Given the sheer volume of alerts, the trend observed could be perpetuated by alarm fatigue, which can cause some significant alerts to be inappropriately dismissed

On reviewing individual BPAs, it is clear there is scope to refine these CDSTs The common themes highlighted, corresponding to the ‘CDS five rights’, are summarised in Figure 3 Some BPAs were incorrectly configured meaning that despite an acknowledgement option being selected, this registered as ‘no action taken’ Discrepancies such as this will need to be rectified before re-auditing to improve data quality and aid in future reviews As outlined in Figure 1, these suggestions will be proposed to the relevant governance boards (e g acute care/ pharmacy/ nursing boards) to gather further opinions before working with buildanalysts to make changes on the live platform

We adopted a similar methodology employed at Jurong Health campus, Singapore (existing EPIC users) (4) Data was collected on each BPA, focussing on the following parameters:

• Number of BPA alerts (% of total BPA alerts)

• Triggers for BPA alert

• End-users alerted

• Departments alerted

• Acknowledgement options

• % age Appropriate actions taken

The collected data allowed an MDT approach to evaluate each BPA against the Healthcare Information and Management Systems Society’s (HIMSS) “CDS five rights” framework: (5)

The right information

To the right people

In the right intervention formats

Through the right channels

• At the right points in workflow

Recommendations were presented at respective hospital governance boards, before being trialled in the live system with the help of the EPR programming team (Figure 1)

1) Sutton RT, Pincock D, Baumgart DC, Sadowski DC, Fedorak RN, Kroeker KI. An overview of clinical decision support systems: benefits, risks, and strategies for success. NPJ Digit Med. 2020 Feb 6;3:17. doi: 10.1038/s41746-020-0221-y.

PMID: 32047862; PMCID: PMC7005290.

2) Sirajuddin AM, Osheroff JA, Sittig DF, Chuo J, Velasco F, Collins DA. Implementation pearls from a new guidebook on improving medication use and outcomes with clinical decision support. Effective CDS is essential for addressing healthcare performance improvement imperatives. J Healthc Inf Manag. 2009 Fall;23(4):38-45. PMID: 19894486; PMCID: PMC3316472.

3) Scheepers-Hoeks AM, Grouls RJ, Neef C, Korsten HH. Strategy for implementation and first results of advanced clinical decision support in hospital pharmacy practice. Stud Health Technol Inform. 2009;148:142-8.

PMID: 19745244.

4) Taking a thoughtful approach to clinical decision support: The right information to the right person at the right time [Internet]. EpicShare. [cited 2023Apr13]. Available from: https://www.epicshare.org /share-andlearn/juronghealth-bpa-overhaul

5) CDS/Pi Collaborative: Getting better faster-together(sm) - CDS 5 rights [Internet]. [cited 2023Apr13]. Available from: https://sites.google.com/site/cdsforpiimperativespublic/cds

6) Khan S, Richardson S, Liu A, Mechery V, McCullagh L, Schachter A, et al. Improving provider adoption with Adaptive Clinical Decision Support

Surveillance: An observational study. JMIR Human Factors. 2019;6(1).

7) (Kawamoto K, Houlihan CA, Balas EA, Lobach DF. Improving clinical practice using clinical decision support systems: A systematic review of trials to identify features critical to success. BMJ. 2005;330(7494):765)

The process of reviewing a vast amount of BPAs required a standardised and reproducible approach, and thus a few core principles were identified This led to the development of a ‘Build Guide’, which was created to promote a rigorous approach to evaluating and creating BPAs

This includes several checkpoints, focussing on 5 main areas; user groups targeted, circumstances of triggering (e.g. location of encounter), build characteristics (e.g. jargon-free, acknowledgement options points in workflow), trigger, and inclusion/exclusion criteria (e.g. departments, patient age, deceased patients). This can be used as a checklist to standardise the process of building BPAs in future.

CDS five rights (5) Common themes

The right information

Some disparities in the wording and response options. Sometimes unclear in how responses would be interpreted (e.g. action vs no action taken).

To the right people Sometimes targeting inappropriate staff (prescribers vs non-prescribers, nurses vs clinicians).

In the right intervention formats

Through the right channels

At the right points in workflow

Acknowledgement options need refining- some BPAs are configured to register as ‘no action taken’ regardless of option selected (difficult to audit data unless resolved). Could include activity links to relevant pages e.g. sepsis screen order set/ safeguarding referral links on relevant BPAs.

Different types of BPAs- silent vs pop up vs banner BPAs. Some may be more appropriate than others depending on context.

Some BPAs alert at inappropriate times in workflow; e.g. when opening chart/ administering medicines / recording observations etc

Some lockout options need refining to prevent repeated burden of BPAs if already acknowledged.

The guiding principles for introducing BPAs into the trust were that they should provide harm free care, increase quality of care, and it should meet MFTs current standards of secondary care These principles defined the scope when reviewing BPAs

One of the key challenges to implementing CDSTs is the sheer volume of alerts which contribute to alarm fatigue To mitigate this, we propose that organisations limit the number of BPAs and undertake regular reviews to ensure their clinical relevance (1,6)

It is also important to note that individual trusts can vary; including in patient demographics, organisation culture, and local practices Therefore, evaluating CDSTs to ensure they reflect this is critical when introducing EPRs (1) Continuous evaluation of CDSTs identifies discrepancies which can be amended For example, we discovered BPAs that were alerting even in deceased patients and some which were configured to not recognise an ‘action’ regardless of what the user clicks Secondly, this iterative process of re-evaluation will provide feedback to build-analysts on how BPAs are impacting end-users and clinical outcomes (7)

The process of re-auditing after making changes is highlighted above in Figure 1

Throughout our process, we identified some key aspects to building effective BPAs This has fed into the creation of a ‘Build Guide’ that contains common concepts discussed across stakeholders such as clinicians and build-analysts for building and validating BPAs This guide can be used as a checklist to refine and standardise the process of building BPAs in the future

Moreover, clinicians being directly involved can increase engagement and foster a sense of ownership and trust in CDSTs, which can improve integration of changes (6)

Having input from a large team can come with challenges To overcome these, it is important to have a MDT approach of healthcare professionals and buildanalysts This combines insights to include expertise in multiple fields, including clinical decision making and information technology

With these principles in mind, the team can develop BPAs that are evidence-based, user-friendly and tailored to the needs of particular individuals/ trusts To complement this, a ‘Build Guide’ can provide a more standardised and rigorous approach when considering evaluating and building BPAs

C O N C L U S I O N

Our process illustrates that CDSTs need careful, iterative scrutiny by clinical staff working with analytics teams Such processes can lead to significant improvements in the clinical decision support burden experienced by end users

Clinical informatics teams should proactively plan for such QIPs as part of new EPR implementation programmes Furthermore, utilising a standardised checklist such as a ’Build Guide’ can help to validate CDSTs

Hemant Kumar1 , Elise Clarke1 , Emily Mulligan2 , Christopher Dixon3 , Anthony Wilson3

1 Wythenshawe Hospital, Manchester University NHS Foundation Trust.

2. North Manchester General Hospital, Manchester University NHS Foundation Trust.

3. Manchester Royal Infirmary, Manchester University NHS Foundation Trust

Figure 1- our process of reviewing CDSTs

Figure 3 - Common findings from reviewing BPAs.

Figure 2- The number of total alerts, and proportion of appropriate actions taken.

Emergency Overdose Management in a Working age Adult Inpatient Psychiatric Hospital

Introduction

Dr Amber Broekhuizen

Methodology

Drug overdoses occur frequently among psychiatric inpatients, however the incidence of this across the country is not known. NICE guidelines (1) recommend TOXBASE advice pages (2) for common overdoses, which provide algorithms for optimal management. This project focused on paracetamol overdoses as these are common overdoses seen in this hospital and one of the most common overdoses presenting to emergency care services in the UK (3). TOXBASE guidelines recommend the following parameters with regards to paracetamol overdoses:

ü Patients should be referred for medical assessment if they have ingested over 75mg/kg of paracetamol, or if they are symptomatic

ü Activated charcoal may be of benefit if given within an hour of ingestion of 150mg/kg of paracetamol

From observation of the treatment overdoses at one inpatient psychiatric hospital, it was noted that management does not often align with these guidelines due to multiple factors such as delayed A&E presentation for multiple reasons, and lack of stock of recommended medications, namely activated charcoal.

This project aims to ensure that the vulnerable and often marginalised population of psychiatric inpatients have equal and timely access to potentially life-saving treatment, working within the constraints of A&E pressures and complex mental health inpatient dynamics.

Project Aim: by October 2023 increase the number of eligible cases of patients with paracetamol overdose in working age inpatient psychiatry offered activated charcoal treatment as per NICE guidelines by 50%.

causative

Results

Common themes surrounding this issue were drawn from observation of clinical practice in hospital. Discussion with key stakeholders and members of the healthcare team with an expertise in overdose management revealed various causative factors, which were explored with the use of a fishbone diagram (Figure 1).

A case note review of overdoses in the last 3 months was completed to assess alignment with optimal management, using the TOXBASE guidelines (2) for paracetamol overdose as per NICE recommendation. (1) Each case was assessed for whether activated charcoal was appropriate using the following criteria:

ü Paracetamol ingestion over 150mg/kg

ü Staff informed within an hour of overdose

Criteria such as documented delay in A&E attendance and reasons for this were also noted to inform recommendations. Findings were presented to the Physical Health Group for Gloucestershire Health and Care, and recommendations were made to improve care. Each action will be monitored using a PDSA cycle model to check for improvement in the following areas:

ü Was activated charcoal discussed with the patient if appropriate?

ü Was outcome/refusal documented?

ü How many times has activated charcoal been used in hospital since stocking?

Systematic factors

- Short staffing – delays in A&E attendance

- Long wait times to be seen by doctor in A&E

- Unclear how many overdoses occur in hospital

- Patient dislike of the A&E environment

- Refusal of treatment

- Misunderstanding and lack of Awareness of risks of overdose

Pharmacy and stock

- Activated charcoal not stocked in hospital

- Location of medicine for availability across wards

- No TOXBASE login for trust

- Understanding of use of activated charcoal

- Urgency of overdose management

- Importance of documentation

- Awareness of OD guidelines

Patient centred factors

Case note review was completed and yielded 8 cases of overdose over 4 months. In all cases there was a documented delay in A&E attendance. In 50% of cases, staff were informed within an hour of an overdose which would have warranted considering activated charcoal.

On examination of these case notes, it became clear that delay in A&E attendance was due to two main factors:

Firstly, patient refusal to attend A&E contributed to most delays. This could be further subdivided into two groups; patients who disliked the A&E environment and did not wish to attend due to the busy nature of the department or the long wait times, and patients who were refusing treatment altogether regardless of the setting. In the former situation it was not possible to start recommended treatment in the psychiatric ward environment because activated charcoal was not stocked in the hospital.

Secondly, delays were also caused either by short staffing in the psychiatric hospital, or long wait times in A&E. Short-staffing results in lack of staff availability to accompany patients to A&E, causing delays where patient was consenting to attend A&E but staff could not compromise safe staffing levels on the inpatient unit. Furthermore, there was one case where the time period for activated charcoal lapsed due to wait times in A&E.

Staff Awareness/Education

Recommendations

These findings were collated and presented to the inpatient Physical Health Group, where the multidisciplinary team generated recommendations as follows:

- Activated Charcoal to be stocked in hospital for a 6 month trial.

- Partnership with the local A&E to develop a Standard Operating Procedure which will assist clinical decision making.

- Ward staff education sessions to raise awareness of overdose management and ensure prompt action and documentation where appropriate

These action points will be assessed for effectiveness using a PDSA cycle process. The assessment will centre around the criteria described in the methods section, and further recommendations developed from repetitive cycles of improvement.

Learning Points

This process provided an opportunity to better understand the process of changing hospital policy as a member of the healthcare team. It was a new and exciting experience to become involved in the process of improving care and it also revealed the challenges associated with interventions that require approval from multiple departments and healthcare teams. In fact this obstacle highlighted the need for a multidisciplinary approach to intervention, in order to maintain a safe and cohesive healthcare environment.

Figure 1: Fishbone diagram showing an analysis of the

factors contributing to suboptimal overdose management for psychiatric inpatients

Have we been making our patients dopesick? Removing MR Opioids from our Enhanced Recovery Protocols.

INTRODUCTION

In light of growing evidence, we have been challenged to review our perception of Modified Release (MR) Oxycodone and it’s use in orthopaedic Enhanced Recovery Protocols (ERPs).

This led us to consider whether MR Opioids are as essential to postoperative pain as we had been led to believe? Have we been making our patients dopesick?

OBJECTIVES

Our aim was to reduce the risk of opioid related harm by removing MR opioids from our orthopaedic ERPs without significantly increasing pain scores or decreasing satisfaction.

METHODS

Changing the protocol required approval from Orthopaedic & Anaesthetic Divisional Governance, and Safer Medicine Practice Group meetings.

Retrospective data was collected from 38 lower limb arthroplasty patients notes prior to prescription change. 3 PDSA cycles were conducted subsequently in which during the first PDSA cycle, MR Opioids were replaced by NSAIDs and a short acting weak opioid. Subsequently for 2nd PDSA cycle, PRN buccal Prochlorperazine was added as a rescue anti-emetic. Eventually, regular Senna was added to the prescription to counter constipation and monitoring data is being continuously collected to ensure effective improvement of care.

-Main Improvement measures: Average Oxycodone dose per patient and pain scores.

-Other measures: Analgesia satisfaction scores and time to discharge.

-Balance measures: Side effects like Constipation, Nausea, Vomiting, Dizziness, Hallucinations.

3rd PDSA CYCLE

Summary of Prescription Change

RESULTS

1st PDSA CYCLE CONCLUSION

2nd PDSA CYCLE

Our results showed that average oxycodone dose reduced, pain scores decreased, time to discharge decreased and patients’ analgesia satisfaction improved. Hence we achieved our aim of removing MR Opioids as per national guidelines. Constipation and nausea were initially troublesome, which have been now addressed by adding another rescue anti-emetic and a stimulant laxative.

Mohammad Alnajjar, Rashid Khan, Anneka Field, Roshan Shanbhogue, Ibrahim Tuati, Ani Kunnath, Angela Deeley

How well do we perform in monitoring the physical health of patients on antipsychotics?

Dr Ameer Khan, Dr Harry Large

Background

Monitoring cardiovascular parameters is important for people who are on antipsychotics. This is because antipsychotics can have an impact on the cardiovascular system, leading to an increased risk of cardiovascular events such as heart attack and stroke.

The National Institute for Health and Care Excellence (NICE) provides guidance on the monitoring of cardiovascular parameters for people who are on antipsychotics in CG178. According to NICE, healthcare providers should monitor blood pressure and heart rate at the initiation of treatment and then periodically throughout treatment. They should also consider additional monitoring for people who are at increased risk of cardiovascular events, such as those who have a history of cardiovascular disease or who are taking other medications that can affect the cardiovascular system. Additionally, NICE also recommends that healthcare providers consider the use of metabolic monitoring for people who are on antipsychotics, as the use of these medications can lead to weight gain and metabolic changes. This includes monitoring of body weight, glucose, and lipids at the initiation of treatment and then periodically throughout treatment. The guidance also recommend that healthcare providers should consider switching to an antipsychotic with a lower risk of metabolic side effects for people who are at high risk of metabolic problems or who are experiencing significant weight gain or metabolic changes.

Annual monitoring of cardiovascular parameters are recommended as per the guidance

This includes annual recording of :

•weight (plotted on a chart)

waist circumference

pulse and blood pressure annually

Aims

To see our compliance rate to the NICE guidance of the annual monitoring for patients on antipsychotics and their cardiovascular parameters

To revise our practice to ensure we comply with national guidance so that we continue in our provision of high-quality care and to integrate new technology to allow efficient monitoring.

Methods

The audit cycle was conducted for the period beginning 31st of December 2021 until 31st of December 2022. All data was collected retrospectively and was collected across one general practice in the Tameside area

All patients who were on antipsychotics including were included in this data search, these included all antipsychotics licensed as per the British National Formulary. Data collected included whether weight, waist, pulse rate, blood pressure, fasting glucose, HbA1c, lipid profile, prolactin, any movement disorders, diet assessment, and ECG.

NICE Clinical guidance CG 178 was used as a reference for this audit

A snapshot of second cycle was then conducted in February 2023 which showed a significant increase in compliance to the guidance with an over 90% request rate for all relevant tests to measure the annual cardiovascular parameters

An electronic automatic template was generated using the GP EMIS system that would generate an alert for healthcare professionals to be aware that patients

Results

• A total of 28 patients were identified that met our criteria for the audit

These patients were found to be on antipsychotics namely: aripiprazole, chlorpromazine, quetiapine, flupentixol, risperidone, sulpiride & olanzapine

• Mean age was 54.89

• 15 females & 13 males

• 3 patients had dedicated antipsychotic medication monitoring appointments

• 50% had weight/BMI recorded

• Pulse and blood pressure were 61% and 68% respectively

• No prolactin and no ECG for any patients

Discussion

Studies have shown that patients taking antipsychotics are at a higher risk of developing cardiovascular disease compared to individuals not taking these medications. This is because antipsychotics can have an impact on several biological factors that are associated with cardiovascular disease, such as lipid levels, insulin resistance, and inflammation.

• This increased incidence of cardiovascular disease in patients taking antipsychotics is not only a concern for the health and well-being of the patients but also for the financial burden it places on the National Health Service (NHS) in the United Kingdom. Cardiovascular disease is one of the leading causes of death and disability globally, and the cost of treating these conditions can be substantial. The NHS spends billions of pounds each year on treating cardiovascular disease, which puts a significant strain on the healthcare system.

• Resources are stretched within primary care however prevention is a critical aspect of public health, as it can lead to improved health outcomes, reduced health disparities, cost-effectiveness, and sustainability

Learning points/ Take home message

• In an era where public health has become ever more important, it is vital that all preventative measures are adopted to ensure that we reduce the incidence of iatrogenic illnesses. The ever increasing awareness of a mental health will mean that more patients will be prescribed treatments that may involve antipsychotic use.

• It is vital that we monitor these patients parameters closely so that the physical health is maintained and we continue to provide holistic patient centred care and integrate new technology to enable efficient use of time and resources.

References

https://www.nice.org.uk/guidance/cg178/chapter/Recommendations

Figure 3 EMIS Antipsychotic Monitoring template

Figure 2 Snapshot Reaudit

Figure 1 Original Audit

If in doubt, put bloods out?

Reducing Unnecessary Blood Tests in Postoperative Elective Urology Patients

Introduction and Audit Rationale

Urology juniors at the Royal Devon and Exeter Hospital (RDE) have highlighted uncertainty about which bloods are required post op, with the handbook for juniors stating “if in doubt, put them [bloods] out”. Informal discussions with the juniors suggested that a lack of local or national standardised protocol for post op bloods was a contributing factor. To explore the impact of this, we audited the number of unnecessary bloods taken in post op urology patients at the RDE.

Local rationale: Reducing the number of unnecessary blood tests taken would reduce the burden on the junior team, prevent discharge delays and reduce risk of patient harm1,2. Additionally, all departments should aim to have a local protocol as per NHS England. 2 Wider rationale: Reducing the number of unnecessary blood tests taken and processed would save money, reduce environmental impact, prevent discharge delays and reduce risk of patient harm.1,2

Aims

This ongoing quality improvement project aims to reduce the number of unnecessary blood tests by 10 % by July 2023. Unnecessary bloods are defined as bloods that are not recommended by the devised local protocol or requested by the lead surgeon.

Methods

Using Epic to gather 4 weeks of retrospective data, information on all blood tests done day one post op in elective urology patients was collected and interpreted.

Audit standards were defined by a local protocol drawn up in collaboration with a urology consultant.

Blood tests were deemed unnecessary if they did not meet the local protocol and had not been specifically requested by the surgeon.

Audit Results

82 patients underwent an elective urological surgery within a four week time period, of these, 43 met the audit inclusion criteria

Key findings: In this 4 week time period, 100% of CRPs; 13.6% of FBCs; 9.1% of RFTs; 100% of LFTs done were unnecessary.

Over the four week period, there were 11 unnecessary blood tests that cost the laboratory £31.46.

Where an op note specified which bloods were required, there was a reduction in unnecessary blood tests.

Day One Local Protocol

PDSA Cycle 1

Local protocol of post-op bloods needed for each type of urological surgery was made into a poster and put up in the Urology juniors office to guide juniors.

Future Steps

Following the first implemented change, we will collect data to assess the impact of the poster on numbers of unnecessary blood tests. A second PDSA cycle will focus on trialling standardised instructions for post op bloods in the operation notes.

L Romer, M Blaylock, L Assad, H Mulligan, P Vernon Simpson, L Andrews, H Diment, N Campaign

Peri-operative Comprehensive Geriatric Assessment Of Older And Frail Patients Undergoing Emergency Laparotomy

Background

Frailty doubles the risk of mortality of patients aged over 65 undergoing emergency laparotomy from 5.9% to 13%1. At Derriford Hospital, Plymouth, as with many across the country, there is no formal process for highlighting these patients for a Comprehensive Geriatric Assessment (CGA) by a geriatrician. Of the standards against which the National Emergency Laparotomy Audit (NELA) assesses, geriatrician input remains the most poorly achieved2. This is despite evidence showing a significant reduction in mortality when CGA occurs, 13% vs 22.3% amongst frail patients1

Aim

Provide a CGA for all patients ≥80yrs or ≥65yrs with a clinical frailty score (CFS) ≥5 within 7 days of emergency surgery

Primary Drivers

Recognition of frail patients ≥65yrs and all those ≥80yrs undergoing emergency abdominal surgery

Referral of appropriate patients for Comprehensive Geriatric Assessment

Secondary Drivers

Creation of poster explaining NELA CGA referral process

Update surgical proforma with CFS

Education of wider surgical team on NELA CGA referral pathway

Methods – Cycle 1

• NELA nurse assesses CFS of all surgical patients ≥65 years old and electronic referral completed

• Two half days are allocated between two Geriatric Medicine Registrars to review those patients

Conclusion

Methods – Cycle 2

• Surgical admission proforma updated with CFS and QR code linking to CFS App

• Education sessions with junior surgical team at induction and surgical team teaching sessions

• Initial results show that during the 5 months the project has been running, there has been an improvement in numbers of patients reviewed by a Geriatrician from 0% to 67%. This is compared with the same 5-month period the previous year.

• There was a reduction in median length of stay from 15 days to 12 over the same time period.

• A number of patients who met the criteria for review were not referred during a 3 -week period as the NELA nurse was on leave. Cycles 2 and 3 are hoping to address this as a “single point of failure.”

• At this point we do not have enough data to assess for an effect the CGA is having on mortality but in the future, we would hope to see a similar result to the national findings.

Going Forward

Methods – Cycle 3

• Specific NELA CGA electronic referral adapted from local Healthcare of the Elderly electronic referral form

• Electronic referral form added to local systems

Ongoing education to rotating surgical doctors regarding the importance of identification and referral of appropriate patients.

The updated Best Practice Tariff for emergency laparotomy 2023 focuses on perioperative frailty team input for older and frail patients, and preoperative risk assessment3. We are already exceeding the target of 40%.

Appointment of a new Consultant Geriatrician with special interest in NELA CGA. Ongoing service development and regular involvement of Geriatric Medicine Registrars to develop perioperative experience.

Dr Katie Stevens, Dr Katy Binmore and Nicolae Preda (NELA nurse)