BPSC2022 Poster Competition Group B - Audit - Patient Safety

18th May 2022 Poster Competition Group B Audit Patient Safety

An Audit of COVID-19 Vaccination in Elective Surgical Patients Dr Grace Hillsmith and Dr Emma Gravett. Supervised by Dr Bhaskar Dutta

Introduction

Baseline Results

• Growing numbers of elective surgical patients have received • 47% of patients had received their first COVID-19 the COVID-19 vaccination vaccination • The Royal College of Surgeons have released guidance on • Only 7.6% of patients had their vaccination status vaccination in regards to elective surgery documented in preassessment notes • Consistent documentation of vaccination status is imperative • 21% of patients were given advice on vaccination and to ensure patient safety surgery, however the advice given was very varied Aims • Advice ranged from waiting between 4 days and 6 weeks between vaccination and surgery Prevent ambiguity for patients and staff • 2 patients had their COVID-19 vaccination within 7 days of their surgery.

Prevent on-the-day cancellations

Reassessment Results

Improve documentation To complete the audit loop: • Reassessment of baseline data • Comparison of baseline and reassessment data

RCS Guidance and Literature Review • RCS guidance: • Non-urgent elective surgery can take place soon after vaccination • Essential urgent surgery can take place regardless of vaccination status • Surgery should be separated from vaccination by a few days (at most 1 week) to reduce confounding symptoms • Literature evidence suggests between 48 hours and 7 days delay between vaccination and the date of elective surgery

• 90% of patients had received at least one vaccine, with 38% being fully vaccinated • Documentation has much improved, with 86% having vaccination status recorded in their preassessment notes • 59% of patients were given advice, the majority of which was a delay of 7 days between vaccination and surgery.

• No patients had their vaccination within 7 days of surgery.

Documentation of COVID-19 Vaccination in Preassessment 8% Documented Not documented

92%

Assessment of notes including preassessment documentation, surgical and anaesthetic notes

• •

• •

86%

Cycle 1

Not documented

Cycle 2

21% Yes

Proforma of questions to patients undergoing elective surgery

Documented

Advice regarding COVID-19 Vaccination and surgery

Methods Retrospective audit

14%

41%

Yes

No 59%

79%

Cycle 1

No

Cycle 2

Conclusions and Recommendations

• Increasing numbers of elective patients are fully vaccinated as the vaccine rollout continues across the UK • Implementation of the policy of a 7-day gap between Audit cycle vaccination and surgery has been successful, with the Baseline (cycle 1) data was gathered for 34 patients over a 2 majority of patients receiving the correct advice week period starting from 1st March 2021 • Documentation of vaccination status has improved but is This data was presented at the Anaesthetic Safecare meeting, not yet 100%. where it was decided to adopt a policy of a 7-day gap pre• We recommend introducing a specific question on the and post-surgery for vaccination, and to also document preassessment document regarding COVID-19 vaccination vaccination status at preassessment to improve documentation to 100% Information on these new policies was disseminated to the References anaesthetic department and preassessment clinic staff.

• https://www.rcseng.ac.uk/coronavirus/vaccinated-patientsReassessment (cycle 2) data was gathered for 29 patients guidance/#:~:text=Non%2Durgent%20elective%20surgery%20can,vaccination% 20or%20the%20operation%20itself. over a 2 week period starting from the 19th April 2021 • https://assets.publishing.service.gov.uk/government/uploads/system/uploads/a ttachment_data/file/147832/Green-Book-updated-140313.pdf

Re-audit: NG89 Venous thromboembolism reducing the risk for patients in hospital Dr. Vasiliki Bisbinas (FY2), Dr. Imogen Pulley (FY2), Hanna Tunbridge (Clinical Audit Lead) Background: Venous Thromboembolism (VTE) is the primary cause of preventable deaths in hospital, (25,000 deaths/year in the UK with 55-60% occurring during or following hospitalization). Psychiatric inpatients may be at higher risk due to reduced mobility, poor fluid intake, restraint, catatonia, sedation and antipsychotic use. Evidence suggests anti-psychotic use may be an independent risk factor for developing VTE. Comprehensive VTE risk assessment completed on admission and reviewed regularly is necessary. The NICE audit standard is a 100% rate of VTE assessments on admission.

Aim: Ensuring staff adhere to the NICE guidelines when caring for patient’s who are at risk of VTE Past compliance: 68% (Dec 2019), 76% (Sept 2019) Materials/Methods: The sample was collected via Rio ePMA and included all patients who were discharged from the Trust’s mental health inpatient units during 1-30th September 2021 (n=58) and evaluated against an online audit tool devised using criteria taken from the NICE guidance NG89 created by the Trust’s clinical audit team.

Results:

Compliance for the 14 audit criteria: Ø 6 >90% (green) Ø 2 80-89% (amber) Ø 6 <80% (red)

Discussion: • Overall compliance improved since 2019 audit: 82% • Consideration of VTE risk within 24 hours of admission in clerking documentation was accepted as assessment of VTE risk - on many occasions the editable letter for VTE assessment as per protocol was not completed and uploaded to the patient’s electronic file • Only 3/48 patients were assessed as at risk of developing VTE so some questions were only relevant to a very small number of patients Conclusion: • Highlighting the importance of VTE assessment in psychiatry at Junior Doctor inductions • Remind Junior Doctors of the need for the completion of VTE assessment on admission for all patients and throughout the admission as clinically indicated • VTE has now been integrated into Rio - no editable letter/easier input • Re-audit is recommended – (started April 2022)

Re-audit to optimise computed tomography kidneys, ureters, bladder (CT KUB) imaging in investigation of renal colic Dr Adesh Ajmani, Foundation Doctor Background Renal stones or calculi are made of crystalloid and organic matrix. The passage of these stones through the urinary tract can result in acute renal colic pain. This is a common condition and typically affects people between the ages 20-40; more often affecting men than women. Symptoms include abdominal pain in the flank region which may radiate to the groin and is intermittently like spasms. They may have fever, sweats, nausea, vomiting and haematuria. The gold standard to investigate renal colic is with non-contrast computed tomography kidneys, ureters, bladder (CT KUB) in UK practice. This imaging modality works by using x-ray beams that rotate in a circle around the body which allows different views (axial, coronal and sagittal) to be generated. There are risks involved with CT scanning due to the radiation exposure. Only essential anatomical areas should be scanned to ensure the patient is not exposed to excess radiation. In the instance of CT KUB, only the upper pole of the highest kidney needs to be scanned. Scanning higher than this point is not needed.

Aim An initial audit was carried out in 2017 to assess if patients being investigated for renal colic with non-contrast CT KUB at St Helens and Knowsley teaching hospital (STHK) were being overscanned and received unnecessary radiation. They had found that 26% of patients were being scanned as per the audit standard.

Further, the aim of the re-audit conducted in 2019 was to assess if there has been an improvement in results of patients being scanned as per the audit standard. To assess how current practice is compared to best practice.

Results

Standard/Method Local standard at STHK outlines that 100% of CT KUB scans carried out should not exceed 10% excess scan length. Radiographers scan two scout views - lateral and coronal - from

excess scan length. 59 patients were over scanned. Of those 59, 32 had the upper pole of

above the upper pole of the kidney to below the pubic symphysis. If the kidneys are not visible on the scout, then the radiographer should scan from the middle of the stomach.

Summary of audit standard Title of guideline Setting Standard

Non-contrast KUB (CURIT) guideline Local (STHK) Excess scan length above upper pole of highest kidney should not exceed more than 10% of total scan length

Criteria

Coronal scout is used to plan the scan and visualise the upper pole of the kidney

Exception

If kidney is not visualised on the coronal scout, then the patient should be scanned from the middle of the stomach

Target

100% of CT KUB performed for investigation of renal colic

Suggested number of scans to provide adequate data

50 - 100

Patients who had CT Urinary tract without contrast between 6/5/2019 to 17/6/2019 were searched using PACS. This totalled 201 patients.

the upper pole of the kidney. 3 patients scans were unable to be measured because in these cases the upper pole of the highest kidney had not been scanned and cut off. One of these 3 patients had had a second series done to include the upper pole. The finding from this audit compared to the results from the audit in 2017 can be seen in the table below.

Summary of results compared to the previous audit results This audit findings 100 Total number of patients scans measured Total number of patients who had been scanned as 38 per standard 59 Total number of patients over scanned 32 Number of over scans for which upper pole of kidney was visualised on coronal scout 27 Number of over scans for which upper pole of kidney could not be visualised on coronal scout 3 (1 had a second Number of scans that had been under scanned series) Male: 50 Gender Female: 50

Systematic sampling was used to collect data from a

2017 audit findings 100 26 74 50 24 0 Male: 49 Female: 51

sample size of 100 patients. Their CT KUB scan was

Discussion

measured in coronal section. The distance between the upper pole of the highest kidney and the top of the

There has been a reduction in the number of patients being over scanned in practice

scan was measured in mm. Then the total length of

compared to the results in the last audit. However, the audit standard target has not been

scan was measured in mm. This is shown in figure 1

met. Also, 1/3 patients that had been under scanned required a second series which meant the patient was exposed to higher levels of radiation. The recommendation is that

The percentage of over scan was calculated as follows:

Figure 1 Example of measuring the CT KUB scan in coronal view.

Over scan = Length of the region above the upper pole of the kidney (mm)

X 100

Total length of the scan in the coronal plane (mm)

the findings are presented at the audit meeting. This means positive feedback can be given but provides opportunity to encourage further vigilance and recap the trust guidelines. Should it be necessary, staff could receive further training.

Strengths and limitations of this audit:

As per the audit standard, reasonable sample size of 100 patients to ensure that there were a sufficient data

no more than 10% was allowed. In cases where

X only included patients within a 6 week time frame

there was over-scan the

X only 1 person was assessing the coronal scouts which allows for observer bias

coronal scout image was visualised to assess

Conclusion

whether the upper pole of the kidneys could be seen. This is shown in figure 2 and 3.

This audit shows evidence in the reduction of patients being over scanned when Figure 2 Example of coronal scout where upper pole of kidneys can be visualised.

Figure 3 Example of coronal scout where upper pole of kidneys cannot be visualised.

investigated for renal colic with CT KUB; more patients are being scanned as per the standard compared to the results in 2017.

Author: Dr Adesh Ajmani, Foundation Doctor, aajmani@doctors.org.uk, supervised by Dr Joseph Evans, Consultant Radiologist

Delays in CT scanning for stroke patients Dr T. Ambulkar, Dr. P. Meenamkuzhy-Hariharan Nottingham University Hospitals NHS Trust Results

Introduction RCP Guideline for Stroke recommends urgent CT scan for patients within 1 hour of hospital admission for suspected acute stroke1.

Door to scan time is an important measure used to compare performance across stroke units nationally.

An urgent CT head scan is vital to deliver appropriate treatment promptly, particularly in the context of thrombolysis (which has a narrow time window of 4.5 hours from time of symptom onset).

Learning points

First audit cycle (February – March 2021)

Reasons for delayed CT scanning

• Importance of raising awareness in frontline healthcare professionals about the importance of an urgent CT head (including indications for urgent scanning) • Low threshold for clinical suspicion of stroke – if in doubt, escalate to a senior/stroke specialist

16% 2% 46%

Future plans

15%

• Continue to audit door to scan times and compare local performance with national data • Raise awareness about the indications for urgent CT scanning in stroke patients • Endeavour to improve data collection on qualitative reasons for scan delay (for e.g. recording reason for delayed scan in admission booklets)

0% 21%

CT scan associated factors

Difficult cannulation

Complex clinical assessment

Delays in admitting patient on system

Others

No delay identified

First audit cycle: • 56.0% of all patients with suspected stroke scanned within 1 hour • Most important qualitative reasons for scan delay: • Others: delayed medical clerking/triage • CT scan associated factors • Complex clinical assessment

Second audit cycle (September – October 2021) PDSA Methodology

Door to scan time (minutes)

<60 (within 1 hour)

>60 (out of 1 hour)

Number

35

40

Percentage

46.7%

53.3%

Image 2: Informational poster distributed amongst junior doctors after first audit cycle

Methodology • Random selection of 75 patients admitted to to the Stroke Department, Queens Medical Centre (Nottingham) • 2 completed audit cycles: First cycle data collection: February-March 2021 Second cycle data collection: September – October 2021 • Electronic information sources used: DHR/Medway/NOTIS/Nervecentre • Data collection proforma used • Percentage of scans occurring within 60 minutes were compared to percentage of scans being performed after 1 hour • Potential qualitative factors that could contribute to scan delay were identified: Ø CT scan associated factors; difficult cannulation; complex clinical assessment

Second audit cycle: • 46.7% of all patients with suspected stroke scanned within 1 hour • Most important qualitative reasons for scan delay were identified as: • Complex clinical assessment: atypical presentation of strokes (generally unwell, dizziness) • CT scan associated factors: limited scanning facilities, scan requested promptly but performed late

Conclusions There was a reduction in number of scans being performed within 60 minutes when the results from the second cycle are compared to the first cycle. However, not all patients included fit the criteria for an urgent CT scan.

Complex clinical assessment and delayed medical triage and clerking (in the Emergency Department) are the most important factors contributing to scan delay. Emphasis on improving these factors through educational seminars on stroke presentation and increasing collaboration between the Stroke department and the Emergency Department may help improve door to scan times.

Image 1: Data collection proforma

References 1. RCP London. 2022. RCP guideline calls for suspected stroke patients to be scanned within 1 hour of hospital admission. [online] Available at: <https://www.rcplondon.ac.uk/news/rcpguideline-calls-suspected-stroke-patients-be-scanned-within-1hour-hospital-admission> [Accessed 18 April 2022].

2. Nice.org.uk. 2022. Recommendations | Stroke and transient ischaemic attack in over 16s: diagnosis and initial management | Guidance | NICE. [online] Available at: <https://www.nice.org.uk/guidance/ng128/chapter/Recommen dations> [Accessed 18 April 2022].

3. NUH Hospital logo: www.facebook.com. 2022. Facebook. [online] Available at: <https://m.facebook.com/nottinghamhospitals/photos/a.702100 206476604/3493007134052550/> [Accessed 22 April 2022].

Special acknowledgements o Professor Adrian Wills (Consultant, Nottingham University Hospitals NHS Trust) o Dr Sunil Munshi (Stroke Consultant, Nottingham University Hospitals NHS Trust)

Improving temperature management post-cardiac arrest in a District General Hospital Intensive Care Unit Regina Askary, Ben Whittaker, Adam Revill

• • • •

NHS ambulances attend 30,000 out-of-hospital cardiac arrests (OOHCA) in the UK each year with a 9% survival rate.

Return of spontaneous circulation (ROSC) is achieved in approximately 30% with the majority being unconscious and needing ICU admission, and with only 30-50% being discharged alive.

Therapeutic hypothermia showed promising results in significant clinical trials and was the management of choice for many years but the recent Targeted Temperature Management 2 (TTM2) trial concluded that there was no benefit to cooling patients to 36°C following OOHCA if the arrest was due to cardiac/unknown cause.

Our local guidance until know suggested that patients post-ROSC should be maintained at 36°C or below for the first 36 hours followed by prevention of pyrexia (defined as >37° in the local guidance) for the following 36 hours. Regular temperature monitoring is essential to achieve this.

Aim

Outcomes measured

The aim of this audit was to compare current targeted temperature management at Torbay ICU with the hospital and national guidance, reviewing adherence to maintaining 36°C through invasive cooling and fever prevention to improve how we care for patients post-cardiac arrest.

Data collection The included data runs from February 2020 to March 2022, collected via the Torbay ICU online database.

Exclusion criteria: • In-hospital cardiac arrest • Cardiac arrest secondary to non-cardiac causes • Conscious patients following verbal commands post ROSC • Temperature <30°C on presentation • Systolic BP <80mmHg despite adequate support (fluid loading, inotropes/balloon pump) • Intracranial bleeding • Severe COPD with LTOT • Pregnant or presumed pregnant

1. Whether regular temperature management was recorded 2. Adherence to 36°C for 36h 3. If pyrexia was avoided for the following 36 hours (through use of invasive cooling and regular antipyretics)

Results A total of 39 patients were identified over the 2 year period: 39 participants with appropriate data for the first 36hours 18 patients who made it past 36h (up to 72h) requiring temperature management

89.7% had t>36°C 61.5% had t>36°C for at least 2 continuous hours 30.8% received invasive cooling 38.5% received regular paracetamol

• 16.7% had all hourly temperatures recorded but most (77.8%) had them recorded the majority of the time (majority defined as >90%) • 20.5% were 36°C or below appropriately most of the time.

• We were able to prevent t>37 °C in just 22.2% of patients who made it past the initial 36h.

How can we improve our care?

Recent guidance from ERC-ESICM has confirmed that avoidance of pyrexia (defined as 37.8° and above) is the new aim post cardiac arrest.

1. We propose to improve temperature monitoring in these patients, and reduce pyrexia through regular paracetamol and earlier initiation of invasive cooling.

2. We are updating our hospital guidance in line with these recommendations to make this information freely available to staff.

3. Education for nursing staff and doctors will be undertaken through clinical effectiveness meetings, journal clubs, MDTs and reminders through admission paperwork and handovers for temperature targets when these patients are present on the unit.

Simple, point-of-care reminders improve VTE risk assessment and prophylaxis prescription in medical patients Rohin K. Reddy1,2, Michele Mantega1, Zahra Arzoky1, Asjid Qureshi1 1 Department 2 National

of Endocrinology and Metabolic Medicine,Northwick Park Hospital, London, UK

Heart and Lung Institute, Imperial College London, London, UK

Aims

Methodology

NICE guidelines recommend assessment of all patients >16 to identify VTE and bleeding risk, with thromboprophylaxis should be start ed within 14 h of admission.

2-cycle audit, evaluating the effect of addition of a reminder column to daily inpatient lists

We sought to improve VTE assessment and prescription rates by introducing a point-ofcare reminder by modifying inpatient lists via the electronic health record.

Retrospective chart review was performed to calculate rates of VTE assessment and prophylaxis pre- and post-intervention..

Results and Lessons During the baseline pre-intervention period, 68/81 (84%) of patients were appropriately assessed , and 73/81 (94%) were prescribed appropriate VTE prophylaxis.

In the post-intervention period, 23/26 (88%) of patients were assessed appropriately, and 25/26 (96%) were prescribed appropriate VTE prophylaxis.Appropriate VTE risk assessment increased by 4% and thromboprophylaxis prescription increased by 2% post-intervention.

Through seamless integration in existing clinical workflows, we demonstrate VTE assessment and prophylaxis can be improved via simple point-of-care reminders.

We aim to replicate this work in future cycles involving a greater number of patients across the Integrated Medicine Division at our institution.

Improving the Management of Anaemia in Solid Tumour Patients receiving Chemotherapy at a Tertiary Oncology Centre Sina Yadollahi, Kim Teasdale, Shenthiuiyan Theivendrampillai, Luke Nolan, Jack Broadfoot Cancer Care, University Hospital Southampton (UHS) NHS Foundation Trust, Southampton, United Kingdom

Background The primary aim of the audit was to determine the current management of anemia in cancer patients receiving chemotherapy at University Hospital Southampton and how it measured against current national guidelines.

The audit was designed to identify what we are doing well and where things can be improved on if any.

Introduction Anaemia affects up to 67% of cancer patients.

Anaemia is associated with fatigue, reduced quality of life and worse overall survival.

Liberal red blood cell transfusion (RBCT) leads to adverse outcomes including transfusion-associated circulatory overload (TACO).

NICE guidelines recommend restrictive RBCT and use of transfusion-sparing agents.

NICE/ESMO/ASCO guidelines Recommend treating anaemia with erythropoiesis-stimulating agents (ESA) and intravenous Iron Recommend baseline and regular assessment of iron studies during chemotherapy Haemoglobin (Hb) transfusion threshold: 70-80g/L or severe symptoms requiring immediate correction Single unit transfusion recommended in non-bleeding adults Pre-assessment of TACO risk factors recommended (BSH, ISBT, SHOT) Aims & Methods To assess and optimise anaemia management and RBCT safety in line with NICE (TA323 and NG24), ESMO and BSH guidelines.

Pre and post-intervention audits of all patients starting chemotherapy in Sept/Oct 2020 and Mar/April 2021 (6 month follow-up periods).

Interventions Educational: multi-disciplinary teaching sessions, posters and computer screensavers.

IT: new pre-chemotherapy blood test bundle, mandatory pre-RBCT risk assessment, and prompts in chemo referral forms.

Governance: new Southampton General Hospital trust guidelines and cancer-specific Red Blood Cell Transfusion codes (via liaison with hospital transfusion committee).

35%

Pre-Intervention Post-Intervention

30%

Pre-intervention

Post-intervention

108

106

Patients with Hb<110g/L

56

72

Total RBC units given

44

27

Patients given >1 RBCT (%)

27

21

RBC units per transfusion

1.8

1.4

180hrs

TACO Risk Assessment (%)

0

100

Projected annual chemo unit chair time saved

Total patients

25% 20% 15% 10% 5% 0% Baseline haematinics checked

Erythropoeitin stimulating agents

Projected annual chemo unit costs saved £20,928

Conclusions Multi-disciplinary staff education and new standard operating procedures improved adherence to national guidelines, reduced RBCT and improved patient safety.

ESMO European Society for Medical Oncology BSH - British Society for Haematology, ISBT - The International Society of Blood Transfusion, SHOT Serious Hazards Of Transfusion

Who is your consultant?

Recommendation 236: Allocation of responsibility Dr Jumaina Firdaws Ali, Mr Faisal Jawad Yahyaa Hassan, Widad Ramadan, Zohra Haiderkhan

1. Introduction Recommendation 236 from the Francis Inquiry Report 2013 states that hospitals should reintroduce the practice of identifying the clinician that is responsible for a patient’s overall care. A named nurse should also be nominated at each nursing shift for each patient.1. This principle requires clinicians to be accountable and ensure effective communication with patients and their supporters.

2. Aims and objectives •

• • • •

Post-implementation data was further analysed.

There appears to be a strong correlation between correct headboard information and patients’ awareness of their consultant.

Implementation of change

The primary aim is to ensure that a patient’s stay in hospital is ‘coordinated, caring, effective and efficient’ with the responsible clinician taking responsibility for the patient’s overall care2.

Every patient should know who their named consultant is.

Every patient should know the name of the nurse responsible for their care.

Relevant information should be clearly displayed eg: above the patient’s bed (2).

All of the above is to ensure effective and accurate communication between the patient and their clinical team.

3. Drivers

PDSA (Plan, Do Study, Act) cycles were formed.

PDSA 1: Education of junior doctors to ensure that headboard information is correct Education of Junior doctors on the ward took place.

This was to ensure that patients are told who their named consultant is. This also included ensuring the patients understood who is responsible for their overall care. Junior doctors were provided with marker pens. They were given the responsibility of ensuring headboard information was correct.

Could not name their consultant

Could name their consultant

Figure 3: Proportion of patients able to name their consultant, stratified by headboard information

6. Discussion

The wards were re-audited using the same questionnaire, with the addition of the following question: “how satisfied are you with your care from 0 to 10. (0 is the worst and 10 is the best).”

Baseline data indicated that the hospital was significantly underperforming in line with the recommendations made in the Francis Inquiry Report. There were significant improvements in performance after the implementation of PDSA1.

5. Results • Baseline data indicated that less than half of the patients knew who their named consultant was.

• After implementation of PSDA 1, more than half of the patients knew who their named consultant was.

• The results are graphically summarised below.

• Results have been further stratified to highlight the differences found between elective patients and emergency patients.

However, the standard set by the guidance is that every patient should know who their responsible clinician and named nurse is. PDSA 1 did not lead to improvements that were fulfilling this standard – there were a significant proportion of patients unable to name their consultant.

Without identification of a team leader ‘confusion can creep in’ for patients, ultimately impacting their inpatient experience. Therefore, steps must be taken to improve the hospital’s performance.

Limitations and challenges • Small sample size – a larger sample size would increase the power of the audit and be more representative of the actual patient cohort.

• Did not include medical/obstetric/paediatric patients.

• PDSA 1 utilised a bottom-up approach – the medical student carrying out the audit was responsible for educating and motivating the junior doctors on the ward. Motivation and engagement with making changes was low amongst junior doctors.

• High patient turnover and the fast-paced environment in the surgical assessment unit made implementation of PDSA 1 challenging – is there a different approach that is more suitable to this environment?

• “There are a lot of nurses” – many patients reported recognising nursing staff’s faces but not their names, often due to shift changes.

• Often the headboard is blank – encouraging nurses to implement changes in the current bureaucracy is challenging.

Figure 1: Driver diagram

4. Methods Baseline data collection Baseline data was collected through the use of a questionnaire: • Who is your consultant?

• How would you find out?

• Who performed your operation?

• Who is your nurse?

• Are you aware of your long term plan?

Other data was collected from the patient notes: • Headboard information – correct or incorrect?

• Length of hospital stay • Patient surgical status

7. Future

• PDSA cycle 2: We will utilise a top-down approach – the consultant surgeons will be informed about the current findings of the audit during a departmental meeting. They will be given responsibility to ensure junior doctors are motivated to drive the change.

• PDSA cycle 3: Patients will receive an admission card, stating their responsible clinician and named nurse. This is in accordance with the guidance, that states ‘relevant information should be appropriately displayed.’

• A re-audit will subsequently take place.

• Future audits will include a range of specialties

Patients with dementia or cognitive impairment were excluded. In total 43 patients were surveyed.

Baseline data was used to propose and implement change – every patient should know who their Responsible clinician and named nurse are.

Figure 2: Francis report questionnaire

Figure 2: Summary of results, un-stratified and stratified by emergency and elective admissions. The green line indicates the standard of care that the guidance stipulates.

(1) (2)

Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry, Executive summary, February 2013. https://hee.nhs.uk/sites/default/files/documents/WES_Executive_summary.pdf Guidance for taking responsibility: Accountable clinicians and informed patients, Academy of Medical Royal colleges, June 2014, http://www.aomrc.org.uk/images/dmdocuments/aomrc_papers_takingresponsibility_final.pdf

VTE Prophylaxis In Urology Patients - Preventing The Need To Anticoagulate The Patient With Haematuria Dr Alexander Morgan Kingston Hospital NHS Foundation Trust Corresponding address: a.morgan10@nhs.net

Introduction Most hospitals in the United Kingdom have systems in place that ensure a patient's venous thromboembolism (VTE) risk is assessed on admission. Thirty percent of patients that are admitted under Urology via the emergency department present with haematuria.

Often anticoagulation is held. Failure to restart when bleeding has subsided can put patients at risk of the complicated and potentially catastrophic situation in which anticoagulation is needed to treat VTE in a patient with ongoing or at high risk of bleeding.

At our centre, a VTE prophylaxis assessment tool is used that must be completed for all patients on admission. Often Urological regular anticoagulation is intentionally held or they are not started on prophylactic anticoagulation. Since this is only formally assessed at the beginning of their admission, we noticed that occasionally there were delays in their pharmacological VTE prophylaxis or regular anticoagulation being started.

Results

Aims

Percentage of patients that had mechanical VTE prophylaxis prescribed before and after list change 100

Percentage

Using the NICE guidelines on VTE prophylaxis: All patients to be assessed repeatedly and the correct anticoagulation decision to be made.

To assess whether prophylaxis, using a specifically designed section of the teams list, improved the quality of this prescribing.

75 50

Methodology 25 0 Before

record and the normal teams patient lists.

The patients were assessed as to whether they had their VTE prophylaxis prescribed (both mechanical and pharmacological).

We identified that a potential way to improve our prescribing was by adding an additional column to the teams patient list that encouraged the team to continuously assess the VTE prophylaxis used with each patient. Rather than just on admission.

Percentage of patients whose pharmacological VTE prophylaxis was delayed, reviewed and not needed, and correctly prescribed without delay before and after list change 100

6

10

22 Percentage

Data was collected retrospectively

After

38 50

72 52

PLAN

Pharmacological VTE prophylaxis reviewed and not needed

DO

STUDY ACT The re-audit used the same methodology to see if there was an improvement in the quality of VTE prophylaxis prescribing.

Pharmacological VTE prophylaxis delayed

Lessons learnt for continued improved VTE prophylaxis prescribing.

Suggestions made and discussed with team at local governance meeting.

0 Before 07/02/20 14/02/20

After

Pharmacological VTE prophylaxis Prescribed

15/02/20 21/02/20

The percentage of patients prescribed pharmacological VTE prophylaxis appropriately remained similar 90% compared to 94%

What We Learnt The addition of the new column has increased prescribing of mechanical VTE prophylaxis.

This addition of the new column has not improved our pharmacological prescribing of VTE prophylaxis.

From discussing with the team, they felt that in general they were more aware of VTE prophylaxis prescribing for each patient.

Acknowledgements We would like to thank the Urology team of Kingston General Hospital for their guidance through this audit.

References (Overview | Venous thromboembolism in over 16s: reducing the risk of hospital-acquired deep vein thrombosis or pulmonary embolism | Guidance | NICE, 2018)

There was always some debate as to the best time to restart pharmacological VTE prophylaxis after episodes of haematuria. We suggested the following interventions to reduce delays in prescribing.

Encourage the patient to mobilise as soon as possible Ensure mechanical VTE prophylaxis is prescribed if indicated Ensure patient remains well hydrated Senior to assess each day and make the risk/benefit decision to whether or not to start pharmacological VTE prophylaxis