BPSC2022 Poster Competition Group A - Audit Education and Training

18th May 2022 Poster Competition Group A Audit Education and Training

Peri-operative capillary blood glucose monitoring in diabetic patients undergoing general anaesthesia Authors: Trino Cruz Cervera, Maeve Curran, Jeffrey Chit Wong

Background

Methods

ØDiabetes is becoming an overwhelmingly common comorbidity in the peri-operative setting with 1015% of patients presenting for surgery having diabetes, equalling to over 323,000 patients per year, nationally [1]. Diabetes patients are at risk of having a longer term infective and non-infective complications [2]. Poor glycaemic control is therefore essential and will also help to reduce the overall disease management cost. Consequently, it was important to assess our compliance with local and national guidelines [1].

ØData was collected retrospectively, 250 patients were reviewed, 38 of which were eligible, diabetic patients undergoing general anaesthesia for a surgical procedure. The standards applied were set by the Joint British Diabetes Societies for Inpatient Care, and included capillary blood glucose percentage of time that diabetic patients have their peri-operative CBG between 6mmol/l and 12mmol/l (target 100%) [1]. Management of patients with CBG outside the desired range was also recorded.

Results PACU

Theatre

32% 42% 58%

Measured Hourly

Measured

Not Measured Hourly

Not Measured

68%

Figure 1. Hourly measurement of CBG in theatre and in PACU

Discussion

Maintaining CBG between 6-12mmol/l

21%

50% 29%

ØCBG was measured appropriately in 32% of patients in theatre and in 58% of patients in PACU. CBG was maintained within the appropriate range in 50% of patients; however in 21% of cases CBG was not documented. From those patients with CBG outside of the appropriate range (612mmol/l), three required starting of a variable rate insulin infusion (VRII) and one required hypoglycaemic treatment. Four patients were discharged from PACU with CBG outside of this range.

Within range Outside range Not documented

Figure 2. Percentage of patients where CBG was maintained within range.

References 1. Centre for perioperative care; Guideline for Perioperative Care for People with Diabetes Mellitus Undergoing Elective and Emergency Surery, March 2021 2. Klein, A.A, Meek, T., Allcock, E., Cook, T.M., Mincher, N., Morris, C., Nimmo, A.F., Pandit, J.J., Pawa, A., Rodney, G. and Sheraton, T., 2021. Recommendations for standards of monitoring during anaesthesia and recovery 2021: Guideline from the Association of Anaesthetists. Anaesthesia.

Ø There was an overall poor adherence to CBG monitoring, particularly in theatre, although this may also be due to poor documentation. Two of the patients from PACU with a CBG >18mmol/l were not managed prior to discharge, these will be reviewed. After discussion, we have recommended several changes including; review of guidelines at clinical governance meetings, adding ‘is the patient diabetic? and has CBG been monitored?’ to the sign in or sign out checklist in theatre, implementing and consolidating discharge criteria from PACU and making these known via email, teaching and local posters. Increasing the availability of CBG and ketone monitoring devices should also be explored. We expect that these changes will improve perioperative CBG monitoring and we will be re-auditing in the following months.

Compliance of BAD advice on the safe prescribing of Isotretinoin Nada Khalil (FY2), Leah Mapara (Dermatology SpR), Randa Alhajar (Dermatology Consultant)

Background • •

Oral Isotretinoin (Roaccutane) is a very effective treatment used for moderate and severe acne vulgaris. It is also being used for other conditions e.g. hidradenitis suppurativa, seborrhoea and rosacea.

Careful assessment and close monitoring is imperative when prescribing this medication given its side effects and teratogenic nature. The British Association of Dermatology (BAD) have created clinical guidelines on the safe introduction and continued use of isotretinoin. There are 5 clinical audit points based on these guidelines that every specialist prescribing isotretinoin must adhere to.

Aims and objectives 1. Assess the safety of isotretinoin introduction in Northwick Park (NPH) and Ealing Hospital (EH) Dermatology clinics 2. Assess the safety of monitoring isotretinoin therapy in NPH/EH Dermatology clinics 3. Identify areas of improvement within clinical practice when prescribing and monitoring isotretinoin 4. Promote safe practices among clinicians when prescribing isotretinoin

Previous audit (Jan-April 2018): • Based on 38 patients – 9 males, 29 Females from Northwick Park Hospital only • Variable compliance with BAD guidance.

• 100% compliance with lipid levels monitoring • Poorer outcomes with pregnancy testing 5 weeks after course completed and documentation of mood at baseline an during treatment.

BAD Audit points 1. Female patients of childbearing potential receiving isotretinoin will have signed the ‘acknowledgement of PPP information’ form indicating that they have received appropriate information.

2. All patients will have had serum lipids checked prior to starting treatment and at least once during treatment.

3. All females of childbearing potential will have pregnancy tests before treatment and at monthly intervals and at 5 weeks after treatment.

4. The number of pregnancies occurring in patients taking isotretinoin with a target of 0% pregnancies as the standard to be achieved (note these must be reported on the yellow card system).

5. There will be documentation of mental health and mood state for all patients commencing isotretinoin, both at the assessment for treatment and at each follow-up appointment.

Results of re-audit

Interventions implemented since last audit 1. SHO led acne clinic for new patients 2. Pharmacist led Roaccutane clinic using checklist 3. Transition from paper to electronic documentation

Methods Audit population identified: • Dermatology patients who had been prescribed isotretinoin between 01/09/2020-01/05/2021 • Exclusion criteria: missing clinical records, incomplete records • Seen in Dermatology clinics at NPH/Ealing Clinical records analysed and relevant information recorded: • GCIS and EPRO for clinic letters.

• ICE for blood results • Clinic pregnancy test book and EPRO for pregnancy tests (Also B-HCG due to Covid and tele appointments)

• Overall improvement since last audit in all audit domains.

• 100% compliance with audit points 2-4 • Need to ensure better documentation of mood disorder prior to starting treatment To improve compliance further: • Continue Roaccutane pharmacy led clinic with checklist • SHO acne clinic for new patients– newly created guideline using 2021 NICE guidelines has been created to use in clinic.

• Hand out Roaccutane alert cards to patients • Every patient should receive BAD leaflet – may help reduce drop out rate/reduce DNAs • Upload pharmacy Isotretinoin check list on EPRO – all documentation in one place

Improving Driving Advice Provided to Cardiology Patients at West Suffolk Hospital Dr Ayesha Ahmed, Dr Adel Khalifa

Introduction Many cardiac conditions can restrict the ability of patients to drive. It is the responsibility of the doctors involved in the care of the patients to educate and inform them of any driving restrictions and is particularly important after certain diagnoses and procedures. The DVLA publishes detailed guidance for patients and healthcare professionals on medical restrictions to driving in order to safeguard patients, passengers, pedestrians and other drivers.

Aims: To increase the adherence and provision of appropriate driving advice provided to patients on discharge from the cardiology ward at West Suffolk Hospital.

Initial Results

Methods • Baseline data were collected by first auditing a selection of patients discharged from the cardiology ward over a 1-month period in December 2021.

• Exclusion criteria: q Patients transferred to other hospitals q Deceased patients • Discharge letters and clerking proformas were assessed to see if there was documentation of driving status on admission and appropriate DVLA advice on discharge.

• Using a questionnaire, we then evaluated our doctors’ knowledge of current DVLA guidelines.

• A total of 44 patients were included in the study.

• Out of these 44 patients, only 2 had driving advice included in their discharge summaries and documented on their admission clerking notes.

• From the questionnaire circulated among the junior doctors of the ward, we found that only 2 out of 10 doctors were confident in giving verbal and written driving advice to patients.

Are you familiar with DVLA guidance after a cardiovascular incident?

Intervention

No, 10%

Yes, 30%

• Posters of the DVLA guidance for the common cardiac conditions were placed on the softboard of the ward to encourage and remind doctors to provide written driving advice to patients.

• We also created a template with standardised driving advice that was available on all ward computers.

Do you add driving guidance in patient discharge notes regularly?

Yes, 10%

No, 90%

A little 60%

Plan

Improvement Post intervention, discharge summaries of 31 patients were assessed and it was seen that out of 31 patients, 25 had driving advice documented on their discharge letters whereas 27 had driving status documented on their clerking proformas.

Patients with Patients with driving advice driving status documented on documented on discharge letters admission Pre intervention

4.5% (N=2)

4.5% (N=2)

Post intervention

81% (N=25)

87% (N=27)

Change

+76.5%

+82.5%

Plan We planned to study whether patients discharged from the cardiology ward received appropriate driving advice based on their diagnoses.

Act Posters of the DVLA guidelines specific to cardiac conditions were placed on the ward.

A discharge template was made and saved on all computers of the ward.

Do Survey distribution to all doctors of the ward.

Data collection of patients discharged in December 2021 to assess whether appropriate driving advice was provided.

Do

Following the intervention, we planned to assess whether posters and templates helped improve provision of driving advice to the patients

Re-audit of patients discharged over a 20day period post intervention to assess change

Act

Study

Following the significant improvement of driving advice provision, a teaching session for newly inducted doctors to the ward was recommended

Clerking proformas and discharge letters of the re-audited patients showed an increase in driving advice provision on discharge and driving status documentation on admission

Study We saw that majority of the discharged patients did not have driving advice documented in their discharge letters, the root cause being inadequate knowledge of the DVLA guidelines.

Conclusion We saw significant improvement in the adherence and provision of driving advice to cardiology patients and increase understanding of DVLA among the junior doctors. After introducing our template and hardcopies in the ward, the proportion of documented driving advice on discharge summaries increased from 4.5% (2/44) at baseline to 81% (25/31). We demonstrated that simple educational interventions and a standardised template improved the quality and quantity of provided driving advice.

Audit of Patients with Severe Ulcerative Colitis Megan Rotherham, Peter Basford | St. Richards Hospital, Chichester

BACKGROUND Between 15-25% of patients with Ulcerative Colitis (UC) will require admission for an Acute Severe Ulcerative Colitis (ASUC) flare at some stage during their disease. It is potentially life-threatening and requires baseline bloods, stool culture with Clostridium difficile assay, radiological imaging and flexible sigmoidoscopy, with close monitoring after admission. A significant proportion of admitted patients are likely to fail to respond adequately to intravenous (IV) corticosteroids and are likely to require medical rescue therapy or surgery.

BSG guidelines indicate 67% of patients with ASUC showed a response to steroids, 29% required a colectomy and there is a mortality rate of 1%. ASUC patients’ risk of VTE is 2-3 times higher than inpatients without IBD. C. difficile infection has been associated with a worse outcome in hospitalised IBD patients and needs prompt treatment with Vancomycin in additions to steroids. Investigations, prescribing and management plans were assessed according to those deemed necessary by BSG.

AIMS

STANDARDS

The aim of this audit is to review the care of patients admitted at St Richard’s Hospital or Worthing Hospital for ASUC in accordance with the British Society of Gastroenterology consensus guidelines on the management of IBD. In addition, the proportion of patients who were visited by specialist teams will be reviewed and the effectiveness of the Oxford Criteria at predicting the requirement for surgery or salvage medical therapy.[1]

The guidelines for management of ASUC have been set out by British Society of Gastroenterology (BSG).[1] The audit also used Truelove and Witt’s criteria and Oxford Criteria for assessing patient severity.[2]

METHODOLOGY Participants were included if they met Truelove and Witt’s criteria or if they were identified as having Severe UC requiring intravenous steroid treatment by a Gastroenterologist between July 2019 and July 2020.

Patients were also assessed according to the Oxford Criteria for the response to steroids at 72 hours.

Patients medical notes, drug charts, investigations, imaging and any endoscopy or surgery notes were reviewed to source the information.

RESULTS 43 patients were identified with severe UC admitted between July 2019 and July 2020. Of these, 18 (41.9%) were female and 58.1% of patients (25) met Truelove and Witts criteria. In total 19 patients required Infliximab and 14 patients required surgery.

30

38

25

NUMBER OF PATIENTS

35

35

30 25

20

28

10

24

22

15

20 15

G R A P H TO S H O W T H E T I M E TA K E N TO S TA R T IV STEROIDS AND VTE PROPHYLAXIS IN PAT I E N T S A D M I T T E D W I T H S E V E R E U C

NUMBER OF PAITIENTS

40

G R A P H TO S H O W W H E T H E R T H E I N V E S T I G AT I O N S W E R E P E R F O R M E D W I T H I N 2 4 H O U R S O F A D M I S S I O N F O R PAT I E N T S WITH SEVERE UC

14

10

15

5

5 Faecal sample

Abdo X-Ray/CT

1

0 Flexible Sigmoidoscopy

On admission

INVESTIGATIONS Within 24 hours

For the 25 patients who met Truelove and Witt’s Criteria, 12 (48%) patients required Infliximab and 12 (48%) patients required surgery

5

8

0

15

After 72 hours of receiving IV steroids 5 patients (11.6%) met the Oxford Criteria.

Over 24 hours

Within a 24 hour period • 65% of patients had a Faecal sample sent • 88% had an abdo x-ray or CT scan • 19% had a Flexible Sigmoidoscopy

2

Within 24 hours

4

3

Within 24-48 Over 48 hours hours TIME TAKEN IV Steroids VTE Prophylaxis

0

1

Not given

On admission • 56% of patients received IV steroids • 51% received VTE prophylaxis Within 24 hours • 88% had received IV steroids • 86% had received VTE prophylaxis

18 patients did not meet Truelove and Witt’s Criteria, 7 (38.9%) patients required Infliximab and 2 (11.1%) patients required surgery

DISCUSSION BSG guidelines suggest that 67% of ASUC patients show a response to steroids, with 29% having a colectomy and a mortality of 1%.

This audit found 62.8% did not sufficiently respond to steroids, with 32.6% requiring a colectomy and a mortality rate of 0%.

Truelove and Witt’s Criteria identified 63.2% of the patients who required Infliximab and 83.3% of the patients who required surgery.

80% of those who met the Oxford Criteria went on to require Infliximab or surgery.

• This accounts for 21% of patients who required Infliximab and 7.1% of the patients who required surgery

OUTCOMES AND FUTURE PROJECTS • Creation of a "Care Bundle" sticker for medical team to enter into the notes prompting necessary investigations and management on admission and for monitoring.

• Future investigation around Oxford Criteria at 72, 96 and 120 hours to explore impact of weekends on CRP and stool frequency documentation and impact on outcomes

RECOMMENDATIONS Additional training with regards to sending stool samples with C. diff testing, prompt IV steroids and VTE prophylaxis all within 24 hours Improvement must be made in the number of patients who have a flexi-sig within 24 hours Improvement required in the documentation of stool frequency and CRP testing at 72 hours to monitor steroid response

REFERENCES 1.

2.

Lamb CA, Kennedy NA, Raine T, et al. British Society of Gastroenterology consensus guidelines on the management of inflammatory bowel disease in adults. Gut 2019;68:s1-s106.

Moore AC, Bressler B. Acute Severe Ulcerative Colitis: The Oxford Criteria No Longer Predict InHospital Colectomy Rates. Dig Dis Sci. 2020 Feb;65(2):576-580. doi: 10.1007/s10620-019-056686. Epub 2019 May 15. PMID: 31093812.

An audit and re-audit of adult venous thromboembolism risk assessment compliance with NICE guidelines in the Medical for Older People department in University Hospital Southampton.

Srishti Sarkar and Jessica Grayston, Hu Chan, Megha Bhandari, Tomilola Adepoju, Ibrahim Bodagh University Hospital Southampton

INTRODU CTION Venous thromboembolism (VTE) is the third most common cardiovascular disease in the UK. 60% of VTEs are hospital-associated and cost the NHS £570,000 daily. The COVID-19 pandemic has highlighted the increased risks of VTE and reinforced the need for VTE risk assessment. As per the Department of Health, risk factors for VTE include age over 60, reduced mobility, dehydration and malignancy. All Medicine for Older People (MOP) patients have at least one of the aforementioned risk factors. A correct assessment prevents harm from VTE and also reduces the risk of bleeding from unnecessary pharmacological prophylaxis.

The aim of this audit and reaudit was to assess the MOP departments compliance with completing the VTE risk assessment as per NICE guidelines [NG89].

Results 44% of patients did not have a risk assessment completed within 24 hours of admission.

This decreased to 5% in the re-audit.

Figure 1: Completion of VTE Risk Assessment within 24 hours of admission 120

100

80

60

40

20

0 Audit

Re-audit Completed

Not Completed

Figure 2: Completion of appropriate prophylaxis prescribing according to renal function and weight 120

100

80

60

40

20

METHODS The University Hospital Southampton (UHS) Adult VTE assessment is based on the Department of Health VTE assessment and additionally requires input of weight and renal function in order to guide prescribing. 100 consecutive MOP patients across 5 different wards formed the sample population in May 2021 for the audit and then again in December 2021 for the re-audit. Data was collected from the UHS electronic record, CHARTs. Three standards were selected; VTE risk assessed on day of admission, VTE prophylaxis appropriately prescribed for weight and renal function and re-assessment within 24 hours completed. These findings prompted the intervention of teaching sessions on the importance of VTE prophylaxis prescription, delivered to the MOP junior doctor team at a local meeting.

0 Audit Renal Function

Reaudit Renal Function Inaccurate Prescribing

Audit Weight

Reaudit Weight

Accurate Prescribing

Figure 3: Completion of reassessment within 24 hours of admission

Reaudit

Audit

0%

10%

20%

30%

40%

50%

Completed within 24 hours

60%

70%

80%

90%

100%

4% of patients did not have appropriate prophylaxis prescribed according to renal function and 7% for weight in the audit. In the reaudit, this was 4% and 9% respectively.

94.5% of patients had no re-assessment done within 24 hours in the audit and 99% of patients in the re-audit.

Not Completed within 24 hours

Conclusion Prescribing according to weight and renal function and reassessment remain an issue. With this re-audit, we wish to create a 24 hour re-assessment reminder popup on CHARTs and make a VTE assessment sticker which can be placed in patient notes to improve this. No patient developed a pulmonary embolism as a result of inappropriate VTE prophylaxis prescribing.

Dr Ameena Ahmed Khan*, Dr Anas Khan* Charing Cross Hospital, Imperial College Healthcare Trust

Investigating how often daily weights are recorded in acute heart failure patients

How often were daily weights recorded -

How often were daily weights recorded? (n=32)

100%

Introduction

1. Investigate how often daily weights are documented in AHF inpatients 2. Explore whether prescribing daily weights is associated with higher documentation rates

Target criteria & Standard NICE Clinical guideline [CG187] Acute heart failure: diagnosis and management: 1.3.5 Closely monitor the person's renal function, weight and urine output during diuretic therapy.

ICHT Acute heart failure guideline: 5.6.1 Management of the haemodynamically stable patient with AHF - 1. All patients should be weighed daily

A retrospective analysis of 55 inpatients referred to the AHF specialist team between 1st November and 31st December 2021 was performed.

Patients were required to fit stringent inclusion and exclusion criteria. For each patient, we recorded the total length of stay in days and the number of daily weights documented. As part of the secondary analysis, we hypothesised drug chart would have higher documentation rates (ICHT uses Cerner EPR a type of electronic patient record). Therefore, we also recorded if were compared, between patients prescribed daily weights on the drug chart and those who were not, with an unpaired T-test.

Results There were 32 patients who met our criteria (M:F 56:43%, age 77.7±2.5).

(83% vs 46%, p<0.05), however only 25% of patients had this prescribed.

63%

46%

25%

Baseline (NovDec)

Cycle 1 (Feb)

Cycle 2 (Mar)

Daily weights prescribed Daily weights measured * these authors contributed equally to this work A-

Not measured, 54%

Measured, 46%

Weights prescribed

25% 0%

Discussion

to healthcare staff to measure and monitor this parameter, with the added benefit of allowing easy comparison of diuretic dose and effect.

Studies have shown that inpatient weight loss in those with decompensated heart failure is associated with lower mortality, reduced length of stay and lower hospital readmissionB. This suggest that regular body weight measurements, which is a measure of success for diuresis, can improve clinical outcomes. Daily measurement also allows for setting a target of weight loss e.g. 0.5kg/day and can identify when diuretic dose resistance starts following prolonged treatmentC.

Recommendations for change This audit highlights there is scope for improving weight recording and has identified a novel method for addressing this. The act of writing

Method

67%

Weights not prescribed

50%

Daily weights may not always be prioritised in busy departments and can be missed in handovers, particularly when patients are moved

Aims

67%

*

75%

Acute heart failure (AHF) is a leading cause of hospital admissions, accounting for nearly 70,000 admissions in the UK in 2019-20. AHF can present as new-onset or decompensated chronic heart failureA. Symptoms arise from a build-up of fluid in the lungs or body causing dyspnoea and peripheral oedema respectively. The mainstay treatment of fluid retention is diuretics. Both NICE and local trust (ICHT) guidelines recommend close monitoring of weight whilst on treatment. Daily weights are an objective measure of fluid balance and guide titration of diuretic dose. We noted that within an acute unit in a busy tertiary hospital these weight measurements were not recorded consistently.

70%

not prescribed?

in increasing the measurements rates. This simple and cost-effective change is easy to implement in all trusts that use both electronic and paper drug charts. We suggest advising doctors on the medical take, in the acute medical units and acute pharmacists of this simple addition when prescribing diuretics.

Limitations A potential confounding factor in our data was some patients refused to have weights measured, leading to an underestimation of readings.

We focussed on one aspect of diuretic monitoring and ideally would have also audited how well renal function and urine output are recorded, as per NICE guidelines. Lastly, the generalisability of our data is limited due to the relatively small sample size, single hospital location and restricted selection of patients referred to the AHF specialist team. Future audits should aim to expand the cohort of patients and collect data points such as morbidity, mortality and readmissions rates to demonstrate whether increased monitoring of daily weights improves clinical outcomes.

Implementation and Re-audit These findings form the basis of our quality improvement project, which is currently in progress. In the first PDSA cycle taking place over the month of February, the findings were shared with the cardiology team who, with the AHF nurses, started prescribing referred patients. In the second PDSA cycle we presented our findings to doctors in the acute unit, put a message in the medicine newsletter and placed posters around the hospital. In the next cycle we plan to survey the nurses on medical wards to identify any barriers. Initial results are promising with daily weights rising from 46% to 70% and 67% of admission days in Feb (n=15) and Mar (n=8) respectively. Finding methods to maintain this long-term will be key.

https://www.nicor.org.uk/heart-failure-heart-failure-audit/.

B - Gill, Gauravpal S., Phillip H. Lam, Vijaywant Brar, Samir Patel, Cherinne Arundel, Prakash Deedwania, Charles Faselis, et al Cardiac Failure, 23 December 2021, S1071-9164(21)00485-1. https://doi.org/10.1016/j.cardfail.2021.11.017.

Cco European Heart Journal 35, no. 19 (14 May 2014): 1284 93. https://doi.org/10.1093/eurheartj/ehu065.

Journal of

Improving Awareness of Indications and Yield of Diagnostic Paracentesis Safiya Hashemi, Yueqi Ge, Devnandan Chatterjee

Chelsea and Westminster Hospital NHS Foundation Trust

Background Diagnostic paracentesis (ascitic tap) is indicated in all patients presenting with decompensated liver disease with ascites.

This is to identify underlying aetiology of ascites as well as complications, including spontaneous bacterial peritonitis (SBP), which in particular carries a high mortality (1).

In decompensated liver disease, the first 24 hours is important for early intervention to reduce mortality and length of hospital stay, which is reflected in the British Society of Gastroenterology (BSG) admission bundle (2).

BSG guidance recommends that the following parameters should be measured in ascitic tap samples: fluid cultures, white cell count, albumin, protein, cytology. However all of these parameters are not always measured when samples are taken.

This could therefore result in delayed identification and management of serious aetiology or complications of ascites, which in turn can increase hospital stay and mortality.

Methods 1. Retrospective analysis of all ascitic taps performed between May and November 2021 at Chelsea and Westminster Hospital Audit data: patient demographics, indication of ascitic tap, requested parameters, time from patient presentation to ascitic tap being done, and outcomes 2. Baseline survey of junior doctors Experience and confidence with ascitic taps, including technique, indications and contraindications, and knowing which parameters need to be measured

Aims 1) To evaluate whether diagnostic paracentesis is being performed in a timely fashion 2) To evaluate whether all recommended parameters as per BSG guidelines are being measured in ascitic tap samples 3)

Results 1. Data collection: All diagnostic paracentesis samples taken in May to November 2021 at Chelsea and Westminster Hospital were included (n=90).

Data was collected on patient demographics, indication of ascitic tap, requested parameters, time from patient presentation to ascitic tap, and outcomes Most common indication was decompensated liver disease (83%)

2. Survey of junior doctors: 35 responses from a range of grades (FY1 SpR) and specialties Outcomes in patients diagnosed with SBP (n=11): 37.1% were not confident in requesting all of the recommended parameters for ascitic Full treatment was given in 25%, mortality in 27% tap samples Only 51.4% correctly identified that diagnostic paracentesis should be done within 1h In patients with suspected malignancy (n=11), of a patient presenting with suspected SBP cytology was not sent in 18%.

94% would find it useful having a standardised order set on the hospital computer system for ordering all recommended parameters for ascitic tap samples

Lessons Learned & Next Steps A large majority of diagnostic paracentesis samples were not sent with all recommended parameters as per BSG guidelines. This could result in a delay in recognition and management of both underlying diseases and life-threatening complications of ascites.

Planned interventions based on results: 1. Teaching sessions for junior doctors, in liaison with the postgraduate education team 2. Creating a standardised order set for the hospital computer system to order all recommended parameters for ascitic tap Following the interventions, we will reaudit to assess for improvement in the following aspects: Greater proportion of ascitic taps have all recommended parameters requested and measured Shorter mean time from patient presentation to ascitic tap Higher levels of confidence of junior doctors with performing ascitic taps

Act Depending on results of re-audit

Study Postintervention audit

These interventions aim to raise awareness of the indications for ascitic taps and the parameters that need to be measured, as well as make this easier with the use of a standardised order set. The aim of this is to enable early recognition and management of underlying diseases and complications of ascites, which is important in reducing length of hospital stay and mortality in patients with decompensated liver disease (2).

References: 1 B. Niu, B. Kim, B. Limketkai, J. Sun, Z. Li, T. Woreta, P. Chen, 2018. Mortality from Spontaneous Bacterial Peritonitis Among Hospitalized Patients in the USA. Digestive Diseases and Sciences, 63(5), pp.1327-1333.

2 British Society of Gastroenterology & British Association for the study of the Liver. S. McPherson, J. Dyson, A. Austin, M. Hudson. 2014. Decompensated Cirrhosis Care Bundle - First 24 Hours.

Plan Retrospective analysis Junior doctor survey

Do Teaching sessions Order set

Documentation of Ascitic Paracentesis Dr Mostafa Afifi, Dr Goon May Hong, Dr Nong Zhang, Dr Allen Roby

Introduction Abdominal paracentesis is a common procedure that is undertaken in patients with decompensated liver cirrhosis. Although the complication rates are low, approximately 1.6% with complications ranging from local mild complications, up to significant bleeding and rarely death.

The British Society of Gastroenterology (BSG) has published a large volume paracentesis safety toolkit. This quality improvement project aims to improve documentation of ascites drains to improve patients’ safety.

From our baseline study, we have identified that 46.4% of the documentation satisfies the key elements recommended by the BSG’s safety toolkit. Following this, we have worked with the IT department in implementing an ascitic drain insertion and removal proforma on our electronic documentation system (Quadramed). Parameters used were recommended by the BSG safety toolkit.

Proforma Template Name of person doing the procedure Designation Confirm correct patient Presence of drainable ascites (clinically or USS) Written consent IV access Albumin requested and on the ward Therapeutic anticoagulation Pre-drain weight Surgical ANTT Time of insertion Site of insertion Number of attempts Colour of initial ascites For Has Time of removal (max 6 hours) Stop diuretics for 24-48 hours post drain Optimize nursing care (show in documentation): Apply dressing. Leave in free drainage. Avoid clamping. Keep drain below patient.

Monitor (Show in documentation): Colour of fluid. Drain output. Half hourly patient observations during drain.

Notes/Comments

Fishbone Diagram

Aims 1. To improve efficiency of documentation in ascitic paracentesis and ascitic drain removal 2. Decrease time needed for documentation 3. Improve safety and communication between medics and nursing team.

PDSA Cycle Plan

Do

• •

Identify problems Retrospective data collection for baseline data between 1st January 2020 and 30th April 2020.

•

Implementation of the proforma on QuadraMed. Retrospective data collection of post-proforma implementation between 1st July 2021 and 30th October 2021.

•

Data analysis of baseline data and post-implementation data. Conducted survey forward staff which showed improvement in satisfaction with plans and time of documentation and data accessibility on ward rounds.

Planning of 2nd cycle to increase awareness of proforma implemented.

Study •

Act

•

To increase awareness of abdominal paracentesis’ management and importance of clear documentation of plans with further cycles to be carried out.

Driver Diagram

Results

Lessons Learnt • Since the proforma was introduced, 38.1% of the patients notes used the proforma for ascitic drain documentation. Overall, compliance with the proforma was inadequate as the fill rate of the entire proforma was 53.9 % on average.

• Management errors can occur in the absence of clear documentation of drainage plans. This is because not all healthcare workers are experienced in paracentesis and there is no unified streamlined protocol to follow.

• Furthermore, implementing the proforma on its own into the IT system is not enough, as fill rate remains inadequate, this needs to be supplemented with increased awareness.

The mean documentation compliance pre proforma was 46% and after the introduction of proforma was 53%.

Next Steps Moving forward, our next steps consist of: • Increasing awareness of the proforma.

• Measuring the length of hospital stay and complication rates.

The management of deranged blood glucose levels in neurosurgical patients taking dexamethasone George Buckland¹, Susrata Manivannan¹, Antony Kaldas¹, Kathryn Hill¹, Paula Johnston², Mayank Patel² 1. Department of Neurosurgery, Wessex Neurological Centre, University Hospital Southampton 2. Inpatient Diabetes Outreach Team, University Hospital Southampton

Introduction Corticosteroids cause hyperglycaemia in patients with and without pre-existing diabetes, and evidence suggests most patients receiving high dose corticosteroids will experience hyperglycaemia. The majority of patients with brain tumours receive dexamethasone perioperatively to reduce oedema and the associated neurological deficits.

Alongside the obvious potential complications of hyperglycaemia, in neurosurgical patients it can also trigger a cascade of systemic and local cerebral effects that are associated with: poorer surgical outcomes, increased complications, prolonged admissions and increased mortality. In the Wessex Neurological Centre, we anecdotally observed that a proportion of neurosurgical patients’ taking dexamethasone that had delayed discharges due to deranged blood glucose levels (BGL), and there was an overreliance on the input of the hospital’s Inpatient Diabetes Outreach Team (IDOT) in the management of these patients.

Aims • •

To identify the number of delayed discharges due to deranged BGL in neurosurgical patients taking dexamethasone, and the proportion of which were known to have preexisting diabetes To improve the neurosurgical team’s ward-based management of post-operative patients with deranged BGL by developing a tailored protocol with with the aim of reducing the number of IDOT referrals and delayed discharges

Primary outcome measures • •

To define the proportion of patients with deranged BGL that are referred to IDOT, and/or have delayed discharge solely due to high BGL. The development of a safe and effective protocol approved by IDOT and neurosurgical teams using an evidence based approach

Methodology We conducted multi-faceted PDSA cycles to delineate the impact of high BGL and how and where we could optimise BGL management in neurosurgical patients taking dexamethasone.

• PDSA 1 - A questionnaire to explore the perceived confidence of the neurosurgical senior house officers/advanced nurse practitioners in managing hyperglycaemia in neurosurgical patients taking dexamethasone. This enabled us to tailor our intervention of developing concise clinical guidance, and subjectively gauge the future impact or improvement with the planned intervention.

• PDSA 2 - Patient Pre-op/BGL/Discharge data: We undertook retrospective data collection of patients undergoing resection of brain tumour (excluding biopsies, and meningiomas) between January–February 2021 in a single UK based neurosurgical centre. Data collected included pre-operative HbA1c (Yes/No), Known diabetes (Yes/No), Deranged BGL (>2 readings of >12mmol/L in 24 hours) (Yes/No), IDOT referral (Yes/No), Delayed discharge (Yes/No).

• PDSA 3- Flow charts for the management of hyperglycaemia, were co-developed by the UHS Neurosurgical and Adult Diabetes teams based on Joint British Diabetes Societies –‘Management of Hyperglycaemia and Steroid Therapy, May 2021’.

Right)

7/38 (18.42%) patients receiving postoperative dexamethasone had high BGL. 3/7 were new diagnoses of diabetes according to pre-operative HbA1c levels. 3/7 were previously known to have diabetes and 1/7 did not have diabetes. 3/38 (7.89%) patients had delayed discharges as result of high BGL.

Results of 3 (of 12) questions from the questionnaire for neurosciences SHO/ANP team regarding management of hyperglycaemia in neurosurgical patients. 1 –Not at all confident; 5 – Very confident

25 20

21/38 had HbA1c checked a pre-assessment or a recent HbA1c. 2/4 patients with known diabetes had there HbA1c checked. 4/21 patients who did have their HbA1c checked, were new diagnoses of diabetes but were not acted upon prior to admission.

Local standards: HbA1c should be requested for all patients with diabetes. However routine testing for patients not known to have diabetes is variable, and there is no current standard.

15

Number of patients

An unexpected finding - Pre-operative HbA1c measurement results

10

PDSA 2 - Patient BGL, diabetes status and the effect on discharge (Bar chart

12 healthcare professionals in neurosurgery responded to the questionnaire. Results indicated a scope for further education and guidance in order to increase confidence in managing hyperglycaemia and reduce reliance on IDOT.

012345

We retrospectively identified 57 patients under the neuro-oncology team in a 2-month period. Exclusions were 4 meningioma resections, and 11 biopsies. Of the 42 patients undergoing resection of a brain tumour, 38 received post-operative dexamethasone and were included in analyses.

PDSA 1 - Questionnaire Results

30

Patient identification

Perioperative Glucose Control in Neurosurgical Patients, Godoy et al 2012

Normal BGL

High BGL

No diabetes

Normal BGL

High BGL

Known diabetes

No delayed discharge

Normal BGL

High BGL

New diagnosis of diabetes

Delayed discharge

Verbal discussion with pre-assessment team elicited that in patients not known to have diabetes there is no formal escalation plan for high HbA1c

PDSA 3- Managing hyperglycaemia in neurosurgical patients: ward-based management flow chart Acknowledging our findings from PDSA 1 and 2, we initially developed written guidance to facilitate the neurosurgical team managing hyperglycaemia. However after discussion, the utility of a flow chart was preferred. Managing diabetes can be daunting for healthcare professionals. However, the desired impact of this guidance will allow the neurosurgical team to independently and safely manage hyperglycaemia in patients taking dexamethasone.

This will reduce the clinical burden on the IDOT team, and empower the neurosurgical team. The aim is that this will directly result in reduced delays in treatment time for patients, by mitigating having to wait for IDOT review. The outcomes from our changes and the implementation of this guidance will be measured by evaluating future IDOT referrals and delayed discharges for this patient group.

Conclusions

Our preliminary findings elucidated a rationale for the development of further guidance in managing high BGL in neurosurgical patients taking dexamethasone. It is a common and predictable sequelae of the treatment, with potential to increase admission time.

Lessons learnt and reflections We took a multifaceted approach which enabled us to identify multiple areas in which improvements could be made. It has helped me recognise the importance of a functioning MDT in the continuity of care of patients through from pre-assessment to discharge. The involvement of all stakeholders facilitated the sharing of ideas and the construction of an intervention that would benefit all. Pertaining to our unexpected finding that significant HbA1c results were going unactioned, I think that accountability as an individual and as a clinical team needs to be emphasised to maintain patient safety.

Guidance flow charts developed for the neurosurgical team in managing patients with hyperglycaemia taking dexamethasone. (Left) Patients known to have diabetes. (Right) Patients not known to have diabetes.

What next?

• •

Implementation and raised clinical awareness of the guidance and flow charts., after which repeat cycles of PDSA 1 – to gauge improvement in perceived knowledge and confidence of staff. PDSA 2 - To objectively measure the impact of the new guidance on IDOT referrals and delayed discharges. PDSA 3– Any further changes to the guidance or troubleshooting will be undertaken if required.

The next aim will be to address the issue of ensuring elevated pre-operative HbA1c are escalated appropriately, in order to medically optimise patients before surgery and mitigate inpatient high BGL, and thus complications and prolonged admissions.

By Ibukun Osuntoki, Aiknaath Jain, Gbemi Ajao and Issa Beegun

Are patients receiving their medications within an appropriate timeframe following their admission under ENT? INTRODUCTION AND AUDIT RATIONALE

AIM

A 50-year-old gentleman presented to hospital with chronic rhinosinusitis and was prescribed topical decongestants.

Due to a lack of availability of medication, his condition worsened, his hospital stay lengthened, and he required sinus drainage procedures This was one of many cases in which ENT specific medications were not delivered promptly and a patient resultantly suffered. After liaising with the pharmacy service, we were informed that many ENT medications were not stocked/ordered as a priority on the wards.

This was related to the fact that the the National Patient Safety Agency (NPSA) and Specialist Pharmacy Service, who assess the risks of delay or omission for drugs or drug class, note ENT is a low-risk speciality in terms of drug delay or omission.

The aim of this project was to examine the extent of the delay in delivery of medications at Northwick Park Hospital and improve the ward availability of critical ENT drugs.

DEFINITIONS Dose Delay: Dose not given within 2 hours of time prescribed Dose Omission: Dose not administered by the time of the next scheduled dose (A dose delay or omission is noted by a 7 on the drug chart at Northwick Park Hospital)

Standard: Drugs should be safely administered as close to the time noted on the prescription with little delay and no omission.

METHOD

The drug charts of all patients admitted under ENT at Northwick Park Hospital between September and October 2021 were reviewed (n=122 patients). If there was a delay of delivery or omission of a drug it was documented, along with the type of medication, prescribed dose and the length of time taken to the administration of the first dose.

RESULTS 23% of ENT patients (n=28) admitted to Northwick Park had drugs either omitted or delayed during their inpatient stay The most significant delay existed in antimicrobial agents. It took 13% of the cohort 30 hours to receive their first dose of antimicrobial agent. One patient with a skull base osteomyelitis waited three days for the first dose of their topical antibiotic.

Furthermore, there existed delays in the delivery of medications in multiple other groups including steroids and nasal decongestants There was an average of a 25-hour delay for over-the-counter medications.

DISCUSSION: THE RISK OF DELAY

RECOMMENDATIONS AND OUTCOMES

ENT patients suffer from a multitude of serious conditions that when left untreated, can not only be sight threatening but also lead to complications such as meningitis, neurological deficit and death. Certain ENT medications, such as topical antimicrobial ear drops are paramount in the treatment of these conditions in the early phases and alternatives, e.g. oral switches , are not as effective or evidence based. Furthermore, certain medications, such as nasal douches, are essential in the early (24-48hr) post-operative period to prevent post-operative complications, and their effectiveness declines as time increases from the procedure.

TAKE HOME MESSAGES Local: Emergency Hospital ENT stock

Local: ENT specific Pharmacist

Regional: Audit of delay/omission of ENT medications

National: Reassessment of the low-risk stratification

Although considered low risk, certain ENT conditions such as Otitis Externa and Chronic Rhinosinusitis have potential for significant deterioration if early therapeutic intervention is not achieved.

The low-risk stratification of ENT as specialty has contributed to poorer patient outcomes and extended hospital stays for our cohort of patients

Medical and pharmacy staff should review the risk of medications in the context of their patient groups and stratify more appropriatelyparticularly if the hospital has increasing volumes of patients under the specialty

Improving the Management of Rib Fractures and Compliance with the Rib Fracture Pathway Dr Farzana Rahman, Dr N. Maxwell, Dr S. Shidane, Dr M. Bhagalia, Mr A. Abu

Introduction & Background:

Methodology & PDSA Cycles:

Since 2019, there has been an increase in the number of patients with Rib fractures admitted to Whipps Cross, for local management at a district general hospital, than being transferred directly to the Regional Centre for trauma, Royal London hospital (RLH).

o Conducted a retrospective data collection from January 2021 to September 2021 o Obtained PACS database of radiologically proven Rib fractures, o Correlated databases with patient case notes online to collect data to compare management with recommended published pathway guidelines. o Inclusion criteria: Patients presenting to Whipps Cross hospital, Age > 16 years old

Rib fractures are among the most common causes of thoracic trauma, associated with a high risk of morbidity and complications, primarily if not managed early and well1.

Complications include atelectasis to severe pneumonia and mortality, which can be prevented to a degree by early and effective pain management as per evidence-based medicine 2.

Act: Reflect on results, Plan next cycle after improved awareness of Rib fracture Pathway.

Plan: Identify current compliance with published Rib fracture pathway

Study: Analyse Data: Better adherence improves patient outcomes with Rib Fractures

Do: Increase awareness of pathway via posters in ED, Doctor offices, emails and teaching.

Act: Reflect on results, provide pain scores in published new guidelines .

Study: Analyse data – lack of prescribing due to lack of assessment & understanding of pain ladders.

Plan: Identify reasons for ineffective pain control within 48 hours of admission

Act: Amend current pathway – include guidance in referrals, & trauma referrals/ Pain team and anaesthetics.

Study: Analyse data – current pathway focuses more on management than on acceptance of referrals.

Do: Include standardised pain scoring for assessment of Pain – e.g., PIC Scores.

Plan: Identify cause of non-compliance, Work with clinical effectiveness leads to improve published guidelines Do: Questionnaires to SHOs – that are responsible for accepting referrals

Aims of Audit: § §

Investigate the compliance with the published Rib fracture pathway.

Identify ways to improve the current pathway.

Results:

Paracetamol NSAIDS Codeine/ Tramadol Tier 1 48.6% 8% 18.9%

Rib Fractures by Age & Sex Female

Male

94.60%

Rib Fracture Details

86.50% % of Patients

Referrals Made: 1) Referrals to Pain Team: § 40% were referred to the Pain team § 70% - patients were referred when only prescribed paracetamol with no adjuvant medications e.g. PRN Oramorph prescribed § Only 15.5% of all patients were prescribed the PCA Morphine 2) Referrals to ITU/ Anaesthetics: § 75% were appropriate however 25% too premature.

3) Referrals to Trauma Consultant at MTC – RLH: § 4 patients were transferred to RLH due to Poly trauma: i. Of which 75% were referred to by GS SHOs rather than ED – delaying treatment times for patients.

59.50% 40.50% 13.50%

16-30 31-40 41-50 51-60 61-70 71-80 81-90 91-100 Figure 1: Rib Fractures by patient demographics.

Rib Fracture Site Unilateral # Bilateral #

5.40% No. Fractures Flail segment Single # Flail Segment Multiple # No Flail Segment Figure 5: Rib Fracture details

PRN Oramorph Haemothorax 5%

18.9%

Referral to Pain Team PCA Morphine Gabapentin Tier 2 40% 15.5% 12.5%

Additional Rib Injuries

Haemothorax Pneumothorax

Nil Additional injuries 76%

Regional Block Tier 3 10.8% Figure 2: % of Patients prescribed medications within 24 hrs

Pneumothorax 19%

Figure 3: % of Patients undergoing XRs and CTs

Discussion & Lessons Learnt: 1) Referrals: o Currently in Whipps Cross – admitting more patients with Rib Fractures o When patients have poly trauma – should be discussed with Trauma consultant/ referrals should be made (Ideally by ED): § Ensures patients that require transfer to RLH → transferred early, § If trauma consultant agrees for local management → To be managed at Whipps. o Identified a need to include this within the Rib Fracture pathway 2) Radiology: o CT Chest allows better understanding of the Rib Fracture injuries: o Pneumothorax, haemothorax, flail segments etc. o Identified a need to include guidance for when to request CT Chest within guidance 3) Pain management: § Initiating early treatment → Results in improved outcomes, shorter hospital stays, reduced risks of complications forming § Prescribing effective analgesia: § Follow current Tiers of management § Referrals to Pain Team – available 9-5: o Ensure we are prescribing analgesia before referrals – many patients are easily managed with Tier 1 medications and only 15% were initiated on PCA

Nil Additional injuries

Figure 4: % of Patients with additional injuries

Proposed Interventions at this stage: • •

Increased awareness with current Rib Fracture pathway Including a standardised Pain score to assess pain to aid in prescribing

Next Steps: • •

Re-audit to assess whether improvement with prescribing after sharing Rib Fracture pathway in ED, Gen surgery Doctor offices.

Eventually working with Clinical effectiveness lead → Update the current Rib Fracture guidelines

References: Kim, M. and Moore, J.E. (2020). Chest Trauma: Current Recommendations for Rib Fractures, Pneumothorax, and Other Injuries. Current Anesthesiology Reports, 10(1), pp.61–68.

Yazkan, R., Ergene, G., Tulay, C.M., Gunes, S. and Han, S. (2012). Comparison of Chest Computed Tomography and Chest X-Ray in the Diagnosis of Rib Fractures in Patients with Blunt Chest Trauma. Journal of Academic Emergency Medicine.

Acknowledgements: Thanks to the department of General Surgery and Anaesthetics at Whipps Cross Hospital For Further information: Contact Dr F Rahman: Farzana.Rahman12@nhs.net