Poster Group P - Patient Safety Audit- BPSC2023

QIP: MINIMISING RADIATION DOSE IN COMPUTED TOMOGRAPHY OF KIDNEYS, URETERS AND BLADDER (CT-KUB)-

THIRD CYCLE

Garvit Nama, Ahmed Emira, Ahmed Eissa

Introduction of posters/flyers/discussion with radiographers to

•

BACKGROUND

• The standard is to commence the scan sufficiently cranially to include both kidneys in their entirety but be well collimated thereafter in order to minimize patient dose

• As the majority of the patient demographics is younger or middle aged population, it becomes crucial to limit their unnecessary exposure to ionizing radiation

Over-scanned region Us ng Sag tta Scout view to easi y count/identify the vertebrae

• Posters/Flyers/Discussion with the radiographers was done 2-3 months prior to the data collection

• Retrospective data is collected for 100 consecutive CT-KUBs performed in September 2022, at Luton and Dunstable hospital

• The data included patient’s hospital number, age, gender, date of the scan, vertebrae level at which scan commenced and at which kidneys are included, CTDIvol and DLP values

• Vertebrae levels are identified based on Sagittal films and sometimes, axial views

• The data is collected and tabulated on Excel and analyzed on the basis of the set standards

• Average vertebral height and Scan length are to analyze the difference in the radiation dose between 1 vertebral level

RESULTS

PART 1

• At least 20% of the scans are commenced from T8 and T9 vertebral levels

• Only 80% of the scans are within the acceptable level of the standard

• 100% of the scans included kidneys from at least T10 vertebral level

RESULTS

PART 2a* (Inconsistencies)

• Various inconsistencies are noted between the level at which scans commenced and kidneys visible, For e g , 60 scans included kidneys well below T12 level, but only 29 begin from T12

• On average, there was a difference of 1 3 vertebral levels between commencing the scan and kidneys being included

• 3 scans starting from T11, T12 and L1, did not include the upper pole of the kidneys

PART 2b* (Radiation exposure)

• For the given sample sizeAverage CTDIvol: 4 88 mGy Average DLP: 209 3867 mGy*cm

• The CTDIvol values range from 1 41 to 12 06 mGy and the DLP values from 57 86 to 471 05 mGy*cm

• Average scan length: 42 14 cm

• Amount of radiation exposed per vertebral level is 14 64 mGy (average vertical vertebral height 3cm)

of the scans should meet the

Average vertical distance between 2 vertebral bodies 3cm

• The ideal CT-KUB should start with T10 or below and up to the pubic symphysis

• 80% of the current scans comply with the standard, compared to only 69% in the last cycle

• The inconsistencies (such as starting the scan from T8 even if the kidneys begin from L1) in CT-KUBs are well noted and needs improvement

• In terms of radiation dose, it has resulted in a 12% radiation dose reduction per patient (equivalent to 39 mSv for 100 patients in 1 month)

THE IDEAL CT-KUB: Kidney are ust ncluded and up to the pubic symphysis

ACTION PLAN/IMPROVING PATIENT SAFETY

• Enabling training of the radiographers to efficiently identify and enumerate the vertebral bodies and encourage limitation of the upper extent of scan coverage to T10

• Re-audit in every 6 months to track the improvement

• The audit aims to reduce the amount of radiation exposure to the population, and compared to the last cycle, it has resulted in a 12% reduction in the radiation exposure dose per patient

• Furthermore, recommendations are to meet the compliance of 100% that will further reduce the radiation dose per patient by 9 2%

REFERENCES • Refer- Mak ng best use of a Department of Cl nica Rad ology, Guide ines for Doctors, 8th Edition 2017, The Royal Col ege of Radiologists, London • Hasaam Uldin Eunan McG ynn and Morgan Cleasby Us ng the T11 vertebra to minim se the CT-KUB scan fie d DOI https //doi org/10 1259/bjr 20190771 • Alexios Tsiotras R Daron Smith an Pearce Kieran O F ynn and Ol ver W seman British Association of Urologica Surgeons standards for management of acute ureteric col c Journal of C inical Uro ogy 2018 Vo 11(1) 58 –61 Sagepub co uk/ ournals DOI 10 1177/2051415817740492 journals sagepub com/home/uro

Improving Communication of Driving Advice to Patients Undergoing Day-case General Surgery

Identifying the problem…

- Elective vs. Emergency: We recognised that elective patients were often seen in pre-op clinics or sent information booklets prior to surgery with driving advice included. Emergency admissions on the other hand, often had short stays in a busy environment with limited contact from healthcare professionals.

- The dangers: There are well recognised risks from driving under the influence of strong painkillers, sedation or medications used in general anaesthesia, as well as post-operative pain. Insurance companies may not cover driving after certain procedures.

Advice we can draw on: Royal College of Anaesthetists, Royal College of Surgeons of England, Patient information booklets

Initial Audit

Aim: Assess the level of documentation of driving advice given to patients after emergency day case surgery and whether advice given is appropriate. Conducted over a four week period.

Inclusion Criteria:

• Non-elective General Surgery at Bristol Royal Infirmary

• Discharged as day-case or within 48 hours

• Had a procedure under GA or sedation

Result:

132 patients, 24 met inclusion criteria

1 (4.2%) had driving advice documented on d/c summary Was not in line with recommended guidance.

Intervention

• Posters placed in theatre corridor and surgical offices.

• Weekly discussions with on-call teams to highlight advice and discuss barriers.

Re-audit results

Carried out 2 months after interventions made, over same 4 week period:

63 patients, 15 met inclusion criteria

4 (26.6%) had driving advice documented All were consistent with guidance

Barriers to change…

Although we saw small improvements with this increased awareness, there still lacked a consistency of documentation. Barriers included:

- Changing staff every 4 months.

- Busy on-calls with short stays

- Advice for specific operations requires direct search

- No standardised location to document advice

Action Plan

Following a meeting with the surgical department leads, it was agreed to introduce a mandatory tick box on all electronic discharge summaries:

“Following your surgery/procedure, you must not drive until you can comfortably wear a seatbelt and can safely perform an emergency stop without pain. You must be free from any side effects of strong painkillers or anaesthetic medications. You must inform your insurance company before driving again.”

“No driving advice needed”

In essence, raising the compliance of driving advice documentation to 100% for all future patients.

Day-case Surgery?

Have you documented driving advice?

Dr A. Crawford, Dr A. Nelson

Shortening in -hospital stays for patients presenting with paracetamol overdose

Introduction Aims

• Patients presenting with paracetamol overdose that require pharmacological management are given the antidote N-Acetylcysteine (NAC).

• Traditional treatment regimen comprises of 3 infusions of NAC over 21 hours.

• SNAP regimen comprises of 2 infusions of NAC over 12 hours

• In November 2021, RCEM (Royal College of Emergency Medicine) released a statement supporting the use of SNAP regimen to reduce length of in-hospital stay, and anaphylactoid reactions to NAC.

• Paracetamol overdose is estimated to result in over 50,000 acute hospital admissions each year.

• The Office for National Statistics reported 227 deaths in the UK from paracetamol overdose in 2021.

Methodology

Assess impact of using SNAP regimen in management of paracetamol overdose, specifically:

1. Impact on length of hospital stay

2. Impact on prevalence of anaphylactoid reactions to NAC

3. Impact on prevalence of liver damage

Intervention

• Trust guidelines changed to recommend SNAP regimen for the treatment of paracetamol overdose in patients aged 16 and over.

Measurements

• Retrospective data collection from before and after SNAP regimen was implemented, using electronic patient records.

o Pre-intervention data: Sept 2020 – Sept 2021

o Post-intervention data: Dec 2021 – May 2022

o Each data set included 100 patients, randomly selected.

• Types of data collected:

o Length of in-hospital stay

o Evidence of liver damage (deranged LFTs)

o Documented anaphylactoid reactions to NAC treatment

Results

1. Mean length of in-hospital stay reduced from 56 to 20 hours (1.5 day equivalent).

Conclusions

1. A 64% reduction in mean length of in-hospital stay following switch to SNAP regimen supports the statement released by RCEM.

2. Interestingly, the mean reduction of 36 hours is much greater than the 9 hour difference in SNAP vs traditional treatment regimen, suggesting other factors have contributed to the reduction in hospital stay length.

3. The reduction in documented anaphylactoid reactions, and stable proportion of patients suffering liver damage whilst using the SNAP regimen, is further evidence to support its use.

1. Continue to use SNAP regimen in managing paracetamol overdose at the Trust.

2. Educate staff (including pharmacy) around timely paracetamol overdose management and benefit of SNAP regimen.

3. Further PDSA cycles focussing on other drivers of increased length of patient stay besides treatment regimen length.

2. Reduction in documented anaphylactoid reactions to NAC from 8% to 0%.

3. No evidence of increased liver damage following SNAP regimen use. Levels remained at 2%.

Rebecca Richardson, Shruti Mehra, Dayana El Nsouli, Petra Popovic, Tin Htun Aung

Improving timely senior input in maternal postnatal readmissions (PNRA)

Dr Chloe Webster (ST1), Dr Alex van der Meer (Consultant) Great Western Hospitals NHS Trust

WHAT’S NEW IN POSTNATAL READMISSION CARE?

• Consultant review within 14 hours

• Followed by daily review

• Trusts must develop a system to ensure review process

46 true maternal PNRA (inpatient >24 hours) over 6-month audit period

RESULTS

PNRA seen by Consultant within 24 hours. Target =100%

Most senior doctor seen during PNRA SHO Registrar Consultant

DISCUSSION

No clear and systematic handover process for PNRA CHANGES IMPLEMENTED

• Twice daily PNRA handover process

• Additional MDT huddles

• Changes to handover documentation

Emergency care of open fractures with respect to antibiotic treatment and neurovascular assessment

Dr Anoir Lagzouli , Mr Muattaz Kazzam, Mr Ahmed Ahmed, Miss Joanne Round, Mr Nicholas Hancock, Mr Amir Qureshi

Major Trauma centre: Southampton General Hospital

Introduction

• Open fractures are a common presentation to A&E, and require urgent assessment and management by the orthopaedic team.

• A fracture is ‘open’ when there is a direct communication between the fracture site and the external environment.

• The British Orthopaedic Association Standards for Trauma (BOAST) guidelines offer clear guidance on the management of open fractures. 1 This includes guidance on antibiotic choice, timing to antibiotics, and documentation of neurovascular assessment.

Standard

Aims

• To establish adherence of antibiotic prophylaxis with local guidelines. 2,3

• To assess documentation of sequential neurovascular assessment.

Clinical questions

1. Are patients having antibiotics within 3 hours of injury?

2. Are patients having the 1st line antibiotic as per local guidelines?

3. Are patients having sequential neurovascular assessments?

Methodology

• Of the 27 (62.8%) patients given the incorrect antibiotic, all were given co -amoxiclav.

• 13 (30.2%) patients were given the wrong antibiotic in ED, 3/13 initiated by the Ortho team.

Conclusions

• Most patients are incorrectly being prescribed co -amoxiclav

• All patients audited had sequential neurovascular assessments.

• Of the patients that received the wrong antibiotic, many were seen by an orthopedic team member at time of administration.

• A significant number of patients received delayed antibiotics, often due to logistical complications.

Action plan

Night Terrors: Supporting Junior Doctors Working At Night

Charlotte Lim, Madhumati Shah, Jessica Davies, Aminath Fakir, Anees Fatima, Sarah Ingham, Henry Penn, Laurence

Introduction

Northwick Park Hospital is a busy district general hospital with over 450 medical patients. Two medical senior house officers (SHOs) primarily provide overnight ward cover on the night shift. Surveys of SHOs consistently reveal concerns about the overwhelming workload and patient safety. This in turn negatively affects SHOs' experiences of the night shift. A multicycle, year-long QIP was undertaken to correct this.

Concerns raised

'impossible'

Project Aims

1. Improve SHO night shift experience and workload by – reducing unnecessary handovers, reducing bleep volume and improving staffing

2. Improve quality of care and SHO-reported perceived patient safety by improving SHO workload

Figure

Descriptions of experience of ward cover night shifts from SHO surveys

PDSA Cycle 1

• Reduce inappropriate and unnecessary handovers – estimated to be 30%

Plan

Do

Study

Act

• Lunchtime talks and circulars for junior doctors re: appropriate handovers

• Compulsory registrar presence at handovers to screen handovers and ensure clear plans

• Minimal improvement in survey outcomes as maximal efficiency reached – majority of overnight workload stems from bleeps and emergencies

• Reduce workload generated during shift i.e. bleep volume

PDSA Cycle 3

• Increase junior doctor staffing as maximal efficiency has been reached

Plan

Do

Study

Act

3. Monitor outcomes with 2 monthly SHO surveys

PDSA Cycle 2

Plan Reduce bleep volume – estimated 5-10 an hour.

Do

Study

Act

• Current trust policy states bleeps to doctors must be screened by ward Nurse-In-Charge

• Sample nurses to assess awareness of bleep screening procedures, providing education in process

• 2 week campaign by Chief Nursing Officer to reinforce bleep screening

• Only 20% of nurses aware of trust-wide bleep screening policies

• Minimal improvement in bleep volume as high volume of agency nurses that are difficult to reach

• Maximal efficiency reached based on current staffing levels

Balancing measures – FY1 initiation to night shift

• Presented data to senior doctors and administrators in hospital

• Junior doctor staffing increased from 2 SHOs to 2 SHOs + 1 FY1 + 1 locum SHO

• Most significant improvement in junior doctor experience and perceived patient safety

• Carry out balancing measures as FY1s are newly added to night shift rota

Results

At baseline, 50% of SHOs perceived that care overnight was 'unsafe'. This was unchanged throughout the first two cycles. Increased staffing was introduced in April 2022 and there was an improvement in SHO-reported perceived patient safety, with 30% feeling that care overnight was unsafe by June 2022. The introduction of increased staffing overnight made the greatest difference to SHO-reported perceived patient safety and quality of care, with 90% and 100% of respondents reporting an improvement, respectively. Surveys of FY1s post-initiation into night shifts were highly positive – educational value had a mean rating of 8/10 and enjoyability had a mean rating of 8/10.

Conclusions and Discussion

PDSA cycles 1 and 2 produced minimal change in subjective SHO reporting of night shift safety. Although these cycles coincided with winter pressure months, it is more likely that no difference was seen because efficiency had been maximized in the areas targeted in these cycles. This added strength to the argument that increasing staffing was the key intervention. Increasing staffing in PDSA cycle 3 ultimately made the greatest difference in SHO-reported experience, quality of care and patient safety. Although it was feared that including FY1s on the night shift would cause considerable anxiety and take them away from specialty days, FY1s found the experience educational and enjoyable.

This was an ambitious QIP that addressed an important safety issue within the hospital. The project would not have been possible without multi-level and multi-disciplinary engagement. Moving forward, we hope to improve rest facilities for junior doctors overnight.

'extreme' 'relentless' 'horrific'

1:

Who is the consultant?

Dr E Jamnadass, Dr D Majidian, Miss K Cole, Dr M Macdonald, Dr A Mann

Background Aims

Many patients aren’t discharged under the correct consultant leading to:

• Confusion within the team caring for them

• Discontinuity of care

• Possible medicolegal ramifications

• Establish how many patients were discharged under the incorrect consultant

• Determine the cause of this

• Implement intervention

• Evaluate change following intervention

• Establish further areas for improvement

Methods

• Retrospective analysis of colorectal patients from January 7th to 21st 2022

• Colorectal database was used to obtain all emergency and elective patients within this time period

• EPR records analysed to look for discharge summaries, take information, ward round and operation notes

• Notes of all patients discharged under the incorrect consultant were analysed to determine cause

Source: RCS Good Surgical practice

Poster distributed in surgical juniors’ office

Conclusions

• Patients (elective and emergency) continue to be discharged under incorrect consultants

• Some emergency patients are discharged under the incorrect team

• Intervention was aimed at surgical juniors – may need to expand this

• Intervention improved results by 42% - not complete resolution

• 1 patient without discharge summary

Limitations

• Different patient numbers within same time periods

• Only looked at colorectal patients , not all surgical patients

• Limitations of database – data from one source only

Introduction

Quality of Information provided

on wound care, prevention and early recognition of Surgical Site Infections among patients operated under General Surgery

Surgical site infection is the most common postoperative complication globally (GlobalSurg Collaborative, 2018). Many surgical operations involve patients with significant underlying health conditions which leads to increased risk of postoperative complications (Gillespie et al., 2020). NICE guidelines on prevention and treatment of surgical site infections recommend that patients should be given clear advice on wound care, prevention, and early recognition of surgical site infections. Besides, information on how to seek help if they recognize signs of surgical site infections should be provided to patients (National Institute for Health and Care Excellence (NICE), 2019). This audit is aiming to assess the adherence to the NICE guidance on wound care advice in the general surgery department of a District General Hospital.

Aims/objectives

The main aim of the audit was to assess the compliance of the department in giving wound care related advice as per national recommendations by NICE.

Methodology

The following NICE guidance was used as the main standard of the present audit: "Surgical site infections: prevention and treatment"(NICE, 2019). This guidance recommends that information on wound care, signs of infection and when-how to seek help should be provided to patients and their carer's. This audit was a prospective project and involved consenting 50 patients on the day of their operation to be able to contact them later to find out if they were given appropriate advice on wound care before being discharged. Patients were contacted one to eight weeks following their operation to ask about the advice on wound care. The audit was limited to general surgery department. Patients were contacted by phone using their telephone number available on their medical records. Adult patients were only included. Data collection happened 19th October 2022 to 21st December 2022.

Results

Results and lessons learnt

Out of 50 patients who consented to participate in this audit, only 26 patients answered the survey eventually. 25 patients (96%) had an elective surgery. 17 patients (65%) were provided information on wound care, prevention and recognition of surgical site infections before being discharged from hospital. 12 patients (46%) were provided with written advice. In conclusions, poor adherence to NICE guideline was noted which makes it necessary to educate the clinicians in the department on the importance of providing appropriate wound care guidance. A leaflet should be designed and provided to all patients with detailed information on wound care. Re-audit will happen following these interventions to measure the improvement.

Many thanks to surgeons, staff and patients who kindly helped with this audit.

Dr Alireza Sherafat (1), Mr Monirul Islam (2), Dr Segun Lamidi (1), Dr Arwa Ali (1), Mr Biraj Karmakar (3)

1- Foundation Trainee, Kettering General Hospital, Kettering, England

2- General Surgery Registrar, Kettering General Hospital, Kettering, England

3-General Surgery Consultant, Kettering General Hospital, Kettering, England

Proportion of patients who were provided with verbal vs written advice on wound care