Poster Group M - QI in Progress- BPSC2023

Quality Improvement project in surgical education: Focused history-taking communication skills

Dr

Reece Patel

and Dr Khalil Saadeh School Of Clinical Medicine, University of Cambridge

Introduction

There is an abrupt transition from the preclinical to the clinical course at the University of Cambridge. This is similar across many medical curricula in the UK. Thus, students suddenly undertake clinical placements where they are expected to take histories and examine patients with little preparation or formal instruction Most students find this a daunting task.

Incoming clinical students consistently report that they lack confidence in their history-taking ability and feel underprepared for communication skills exams

Aims

Using quality improvement methodology, we aimed to develop a teaching programme that would increase fourth-year medical students’ confidence in clinical history taking and preparation for assessments as measured via a targeted questionnaire over a 6-week clinical rotation.

Methodology

The teaching programme was offered to fourth-year University of Cambridge medical students at Ipswich hospital. Students completed a baseline questionnaire which was used to gauge student preparedness and confidence in history-taking skills.

The programme followed QIP methodology consisting of three Plan-Do-Study-Act (PDSA) cycles:

Comparisons made of student preparedness and confidence against baseline levels allowing identification of which aspects of the teaching programme students found most useful.

A history taking teaching programme was created and offered to medical student’s due to student’s feeling underprepared

Cycle 1 – Peer with supervisor practice

Outcomes were assessed using a post-session questionnaire

Comparisons made of student preparedness and confidence against baseline levels allowing identification of which aspects of the teaching programme students found most useful.

Cycle 2 –

with peer practice

Outcomes were assessed using a post-session questionnaire

Identified that students would struggle to know ‘how’ to ask delicate questions. We decided if the student acted as the patient they could discover how they would respond to different questions

Comparisons made of student preparedness and confidence against baseline levels allowing identification of which aspects of the teaching programme students found most useful.

Students identified that they would want to complete the clinical scenario with a relevant examination

Cycle 3 –History and examination practice

a supervisor

Results

Baseline:

• Baseline questionnaires showed students had a low level of confidence in history-taking (Mean=3.1/5) and preparedness for final year exams (Mean=2.4/5). It also showed that 78.6% of students would like more practice in history-taking.

Cycle 1 – Peer with supervisor practice:

• After Cycle 1 both confidence in history-taking (Mean=3.9/5) and preparedness for final year exams (Mean=3.8/5) increased

• 100% students found receiving feedback with a clear mark-scheme useful

Cycle 2 – Peer with peer practice:

• Cycle 2 showed 77.8% found practicing with peers more useful than with a supervisor.

Cycle 3 – History and examination practice:

• Cycle 3 had the highest confidence in history-taking (Mean=4.1/5) and preparedness for final year exams (Mean=4.0/5).

Cycle 2 implemented a focused history-taking session involving peer-topeer history taking practice

Outcomes were assessed using a post-session questionnaire

Key findings

Cycle 3 involved peer-topeer history taking practice followed by an examination of the relevant system.

Combined key findings from all three cycles to be recommended for implementation in future teaching programmes aimed at improving history taking skills are:

• Use of structured mark schemes for feedback

• The opportunity to practise structured viva

• The opportunity to practise history taking and viva under exam timing

• Students acting as the patient for the history taking session

• Combining an examination of the relevant system following history-taking practice

The golden hour: A quality improvement project

G Suresh1, J Ince1, C Hirst1 E Barratt1, O Parker1, A Bean2

BACKGROUND

• The ʻgolden hourʼ was adopted from adult trauma, specifically traumatic head injury, where prompt medical interventions were shown to reduce mortality1 .

• Reynolds et al. first implemented this concept in neonatal care in 20092 .

• Prompt management in the 1st hour improves both immediate and long term outcomes – intraventricular haemorrhage, hypothermia /glycaemia, bronchopulmonary dysplasia and retinopathy of prematurity1 .

AIMS

LTHT definition of the ʻgolden hourʼ:

RESULTS 46 mins

There was a reduction in average times across all interventions, except PN. Surfactant, central line insertion and PN were achieved within the ʻgolden hourʼ. Surfactant is usually administered in delivery suite. There was a large delay in caffeine prescriptions for eligible babies. PN administration increased post intervention due to PN unavailabilities.

Within 1hr of admission for most interventions.

Within 6hrs of admission for central line insertion and parental nutrition (PN).

<34 weeks gestation

METHODS

• Using electronic patient records, badgernet and K2, data was collected from Jan-Feb 2022 for all babies born at LTHT <34weeks.

• Departmental teaching, poster dissemination around the unit and social media posts about the golden hour, all delivered between MarchApril 2022.

• Re-audited babies born <34weeks at LTHT between May-July 2022.

Post intervention General improvements in achieving the golden hour after teaching and training, except for PN prescriptions.

DISCUSSIONS

• With teaching and training, there was an improvement in compliance in most areas.

• Delays in registering a newborn onto the electronic system meant delays in prescription, thus education for midwifery team to aid faster registration of the baby on the electronic records.

• A longer time period of data collection with regular teaching and training, especially during doctors changeover time, to remind everyone of best practice.

• The aim is for this work in premature and low birthweight babies is to have a knock on effect on term babies.

REFERENCES

1Sharma, D., 2017. Golden hour of neonatal life: Need of the hour. Maternal health, neonatology and perinatology, 3(1), pp.1-21.

1Leeds Teaching Hospitals NHS Trust

2Sheffield Childrens NHS Foundation Trust

2Reynolds, R., Pilcher, J., Ring, A., Johnson, R. and McKinley, P., 2009. The Golden Hour: care of the LBW infant during the first hour of life one unitʼs experience. Neonatal Network, 28(4), pp.211-219.

Improving the quality of medical seclusion reviews on Endcliffe Ward - an Adult Psychiatric Intensive Care Unit

Background

Endcliffe Ward is a purpose built psychiatric intensive care unit (PICU) that provides care for people in a mental health crisis who require a safe environment with high intensity nursing care

As with all PICU settings, incidents of “seclusion” and subsequent medical reviews are a common occurrence on Endcliffe Seclusion is a tool used primarily to manage aggressive and disturbed behaviour that is presumed to be due to the patient's mental disorder 1

There are clear Trust and national guidelines that must be adhered to when healthcare professionals use seclusion, that are designed to maximise a patient's freedom and protect their liberty 1,2 The standards used at Sheffield Health and Social Care (SHSC) are summarised in Figure 1

This work aligns with SHSC’s Trust-wide priorities around ensuring that staff are supported to provide best practice in relation to the use and prevention of force where possible.

1: Review of service user’s physical health

2: Review of service user’s psychiatric health

3: Assessment of currently prescribed medications

4: Assessment of adverse effects of medications

Initial Assessment

5: Review of observations required

6: Assessment of risk to others posed by the service user

7: Assessment of risk to self posed by the service user

8: Assessment of the need to continue seclusion or apply less restrictive measures

The overall aim of this work was to understand and improve current medical seclusion practice by all doctors of any grade on Endcliffe Ward A service evaluation was undertaken in AugustDecember 2022 This demonstrated sub-optimal adherence to medical seclusion standards, with a mean adherence of 66 72% (Figure 3) This evaluation highlighted poor documentation, in particular, entries lacked documentation of prescribed medications, adverse effects of medications and risk to self

Stakeholder Engagement

In order to drive sustained change, we met with the Endcliffe Leadership Team, comprised of representatives from medical, nursing and support staff, psychology, ward management and the administrative department. This gave an opportunity to share established learning Each member of the team contributed to our change ideas, particularly the proforma before its pilot

A medical staff survey of 31 clinicians in 2022 provided insights into current understanding of seclusion reviews, confidence in performing, and suggestions about practical solutions (Figure 2)

36.6% felt “confident” in performing reviews when starting their job.

33.3% of doctors correctly recalled all the medical seclusion standards

SMART Aim

A “SMART” aim has been developed based on service evaluation results and colleague discussions SMART aims are Specific, Measurable, Achievable, Realistic and Timely

We aim to achieve a 90% adherence rate to seclusion guidelines within a 12-month period Greater adherence to all standards of medical seclusion reviews will enhance the quality of care provided to service users who undergo seclusion

Planned Interventions

The Driver Diagram (Figure 3) summarises the areas that are being focussed on The following change ideas are in development:

1. Creation of a proforma document for medical seclusion reviews

2. Teaching delivered at April 2023 Junior Doctor induction

3. Continuous Professional Development (CPD) slot in SHSC Psychiatry Grand Round to share good practice, and teach all clinicians about appropriate medical seclusion reviews

How will we know we are improving?

To visualise improvement a random sample of seclusion entries will be analysed monthly for 12 months, with the mean adherence to plotted onto Statistical Process Control charts Our benchmark is an increase in the overall mean adherence from 66 72%, to 90%

92.6% of medics identified that a proforma would be a “helpful” tool

74% of clinicians identified that faceto-face teaching on reviews would be “helpful”

Our process measures include overall adherence, the time taken to document medical reviews and staff experience A survey to all doctors performed on a 4-monthly basis will enable us to monitor improvement in understanding and documentation time.

Initially, this project aimed to improve seclusions trust-wide We learnt that using small scale interventions in the highest acuity area was more achievable This will enable transferrable improvement trust-wide once interventions had been consistently adopted on Endcliffe

Dr Rosie Oatham, FY2 Doctor, Sheffield Teaching Hospitals NHS Trust

Figure 1: Table outlining the current standards of medical seclusion reviews 2

Figure 4: Driver Diagram

Figure 3: Graphic representation of adherence to medical seclusion guidelines in August 2022

Thank you to Dr Bhavana Karna (Supervisor), Rosina Muir (Clinical Effectiveness), Dr Parya Rostami & the SHSC Continuous Improvement Team

Figure 2: Quotes taken from a staff survey performed August-December 2022

BREAKING RULES, SAVES TIME!

Improved Patient Safety and Experience

In Mental Health settings everyday items, such as phone chargers, can be used as a risk item for self harm or harm of others and can result in blanket restrictions. More rules impact on staff time, with less therapeutic activities which leads to reduced patient engagement and safety. Blanket restrictions and rules imposed upon patients can lead to frustrations and agitation and can escalate to incidents of restrictive practice such as increased medication, physical restraint and/or the use of seclusion.

The mission was to focus on allowing patients to have their phone chargers once risk assessed as safe to do so. Our project aimed to reduce blanket rules by 10% which would lead to a less restrictive, safe and kind environment for the benefit of all and the recovery of the patients.

By allowing patients to have their phone chargers in their rooms, once risk assessed, we have saved on average 404 hours (over 9 months) which equates to 808 x 30 minute interventions with patients. The ward has seen a reduction in complaints directed at night time restrictions due to the implementation of ‘mutual expectations’ overnight and an evening reflection group. The Patient Safety Climate Survey was repeated and has shown improvements in quality of interactions and sense of safety for the patients. There has been a 20% increase in patient’s confidence in staff to deal with difficult situations on the ward and a 25% increase in patients feeling involved in the planning of their care.

45 minutes per shift charging devices

PATIENT SAFETY CLIMATE SURVEY results comparison and quotes

Patient Safety Climate Survey from Royal College of Psychiatry* completed by peer worker with 10 patients, and results shared with the team which led to rich, open conversation about restrictive practice on the ward.

Quality Improvement observation of staff activity was used to define the time taken on tasks related to blanket rules. Review of these tasks undertaken, and the benefit reviewed and solutions found. New practices implemented and restrictions reviewed. This has then been repeated after 6 months and results reviewed again. Changes discussed in both team meetings and ward workshops with lived experience workers involvement. Also in daily morning meetings and weekly community meetings with current patients on the ward.

Individualised risk assessments to allow patients to have their chargers

Over 9 months 404 hours saved which is

808 therapeutic interventions

Underpinning this project, we have worked strenuously to forge relationships and a sense of shared community between our ward staff and our service users, applying a model known as ‘Safewards’.

“My stay overall was excellent… The staff were awesome. I was never bored at any point and I believe my stay on the ward was hugely beneficial. Thanks to all the staff for their professionalism and caring nature”.

* rrp-safety-climate-survey.pdf (rcpsych.ac.uk)

We have been working as part of a national programme to look at reducing restrictive practice in mental health settings and the results of our work are being shared nationally.

By Aiknaath Jain, Heather Lund, Constantinos Parisinos, Hanna Milan

ARE PATIENTS BEING CONSENTED PROPERLY FOR ESWL? HOW CAN WE IMPROVE THE ESWL CONSENTING PROCESS?

This Audit was triggered after over 70% of patients undergoing a new highly beneficial, but risky, procedure felt t hey were not fully informed of the procedure prior to it occurring.

In one instance, someone was admitted to hospital, sedated, placed on the procedure table and withdrew.

Informed consent as a fundamental component of the medical treatment process and forms an essential aspect of one of the core pillars of medical ethics : Autonomy Indeed, the GMC writes : ‘Consent is a fundamental legal and ethical principle … Serious harm can result if patients are not listened to, or if they are not given the information they need - and time and support to understand it

To understand, evaluate and improve the consent process patients undertake before undergoing Extracorporeal shock wave lithotripsy for pancreatic duct stones.

ESWL for pancreatic stones

ESWL is a novel form of medical therapy where high energy shockwaves are delivered to the patient's abdomen to break-up pancreatic stones The procedure carries risks of pancreatitis, significant pain, pancreatic hematoma and internal organ injury

Method

We interviewed all the individuals who underwent ESWL at a major London hospital prior to their procedure in a 3-month period (n=7). We then fed this back to the medical team, adapted the consenting process in clinics and created a patient information leaflet that is being ratified and disseminated. We then garnered further survey feedback from previous patients and new patients undertaking the procedure (n=12).

Pre-intervention

100% of the patients felt as if the consenting process could be improved. The majority felt as if they did not have enough information, time or space to make an informed decision about undertaking ESWL prior to the procedure. 40% felt as if they would have not undertaken the procedure had they known the potential risks. 3 Interventions were generated

Pre-procedure telephone call explaining the procedure to the patient.

Pre-procedure clinic space to discuss the procedure if available

I did not think this procedure was so painful… had I known it.. I definitely would have waited to have it. ..I wish I’d known that I was going to be admitted for more than a day so I could have sorted home care.

Due to my condition I could not lie on my front… nobody told me this so I couldn’t have the procedure.. I spent nearly 2 full days in hospital for NO reason

.A patient information leaflet in which the patient can read about the procedure.

The patient information leaflet was really informative and the junior doctors who explained the procedure made me feel at ease prior to undertaking it. I had plenty of time to think about my options.

Discussion

Cycle 2

Post Intervention

100% of patients undergoing ESWL after the introduction of a pre-procedure phone call, clinic space and a patient information leaflet, felt as if they were adequately consented for the procedure No preventable cancellations occurred following this.

The patient information leaflet was reviewed by patients and adapted to be more patient friendly The leaflet is in the final stages of ratification before trust wide distribution

The next series of junior doctors on the rotation were given an induction on the process so they felt confident explaining the procedure

Consent is a fundamental component of medical ethics and without proper consent patients are at risk of being seriously harmed We found that patients undergoing this procedure did not fully understand the procedure before undertaking it, did not have enough time to evaluate the risks of the procedure and as a result a patient felt harmed unnecessarily and one abandoned the procedure minutes before it occurring Through simple measures such as allocating a specific clinic space for the consenting process and introducing a patient information leaflet, we have ensured that all patients undergoing this procedure in the future, have the time and space to feel adequately consented

Take Home Messages

All procedures- even ones considered low risk need a proper consent process that needs to be timely, relevant and adjusted to a patients needs.

Simple measures like clear times for consenting- preadmission clinic, clerking, and WR are effective at creating a certain and efficient space.

Patient information leaflets can be a fantastic source of information patients can refer to in their times of need and should be utilized!

The Sa butamol Project:

Do you know when your inhaler has run out of medicine?

Authors: Jodi McCreery, Aya Amir, Reem Nasser, Olamide Ibraheem, Hitasha Rupani

THE PROBLEM WITH pMDIs

1. Absence of dose counter

THE VIRTUES OF DPIs

This means that patients don’t know when their inhaler is empty.

Can lead to using it when empty, putting patients at risk for

May also result in premature disposal if thought to be empty and

2. pMDIs have a higher carbon footprint

10 puffs 10 puffs

6.25 miles 17.5 miles

Hydrofluorocarbon gas (HFCs) is an extremely potent gas used in propellant and is associated with high carbon footprint

Inhalers are responsible for 3% of NHS carbon footprint

METHODOLOGY

In this prospective cross-sectional study, we have collected data from 45 patients, with a target sample size of 100.

Inclusion criteria:

1. Patients with COPD/Asthma/other respiratory disease

2. Patients at University Hospital Southampton (UHS)

3. Patients with a prescription of PRN salbutamol inhaler

Data is collected using 7 minute questionnaire (Microsoft Forms) covering several key areas

First 50 patients will focus on data gathering (phase one), followed by introduction of intervention for next 50 patients (phase 2)

During phase 1, we will assess patient ability to accurately determine whether their salbutamol inhaler is full, half full or empty.

Demo inhalers of Salamol/Ventolin (depending on what patient usually uses) in these volumes are blindly provided and their answer is recorded. This is done twice. If the patient has brought in their own inhaler, they will be asked if they think it is full, half full or empty. Their inhaler will be weighted digitally to confirm if their answer was correct and recorded.

We will also determine patient interest levels in switching to DPIs which will be implemented as an intervention in phase 2.

Those who are not in favour of changing devices or unsuitable (i.e. uses spacer for optimum inhalation) will be involved in a pilot study using smart devices. Followed up 3 months using GP records to ensure intervention has maintained.

CONCLUSION

As this is a QI in progress, we are still within our first PDSA cycle prior to introduction of the intervention

Although more than half of the patients claimed to be able to accurately determine that their inhaler was empty, only 20% (9/46) were correct with both demo inhalers.

The majority of patients would consider switching to DPI.

This has set a strong foundation for introduction of our interventions and further progression into PDSA 2 and 3 cycles.

By improving patient education and either changing patients to a DPI or providing patients with a smart device that operates as a dose counter, patients will know when their inhaler has run out, thereby reducing waste, improving safety and self-management

Furthermore, use of DPIs will decrease carbon footprint and environmental impact.

1-Provide patients with NICE decision aid PRIOR to switching devices Contains information on different inhalers and associated carbon footprint

2-Switching to a dry powder inhaler. These produce significantly less carbon and have dose counters attached.

Accurate dosing, patients can tell when inhaler needs to be changed

2. More eco-friendly 20g or less CO2 equivalent per dose in DPIs in comparison to 141g in pMDIs

An attachable, reusable technology that integrates connectivity between inhaler and mobile app

Monitors remaining doses, allowing patient to be aware of when replacement inhaler required

AIMS 3

1. Determine patient capability of recognising if inhaler is empty

2. To explore the possibility of switching patients to DPI

3. To gauge patient education on use and disposal of pMDI

4. Introduction of smart devices for patients unwilling to change to DPI remaining

KEY RESULTS….SO FAR

Over 25% of patients cannot tell when their inhaler has run out at home

appropriate?

Almost 75% of patients would be happy to change to a DPI if clinically appropriate

3- OR The use of a reusable smart device This can be attached to the pMDI when first opened to monitor doses used, allowing the patient to tell when they need a replacement inhaler.

Most patients (80%) are unable to accurately assess how empty or full an inhaler is (full, half full, empty).

Other useful results

52% of patients were asthmatic and 42% had COPD. The remaining 6% had ‘other’ including bronchiectasis.

44% of patients were over 65 years of age 21 patients (46%) were male, 24 (53%) were female 35% have ran into difficulty as a result of running out of inhaler 25% do not check expiry date of inhaler 69% of patients dispose of their inhaler canister in the general waste as opposed to returning to pharmacy for incineration.

4- Follow up GP medical record in 3 months

This is to assess whether the intervention was successful and if patients continued to opt for the DPI as opposed to pMDI post discharge.

5- Qualitative interview with patient at 3 months Discuss experience with change in device/ smart device

Fig 3. Would you consider a DPI if clinically

Fig 2. Ability to determine if demo is full, half-full, or empty

Fig 1. Can you tell when your own inhaler has run out?