BPSC2022 Poster Group D - Full QI Project - Improving patient safety

18th May 2022 Poster Competition Group D Full QI Project Improving patient safety

Improving Central Venous Catheter (CVC) line documentation in Northwick Park Hospital Intensive Care Unit Methods

Introduction

Data was initially collected on the 4th October 2021 using EPRO. We used NICE guidance3 and the London North West Trust paper CVC checklist to establish a gold standard framework for CVC line documentation. Data was then collected from all ICU inpatients with CVC lines on that date.

Three interventions were implemented to improve documentation A further cycle took place on the 1st November 2021 to evaluate the impact of these interventions (n=15) To establish whether improvements were sustained, a third cycle took place on the 22nd November. (n=22)

Insertion of central venous catheters (CVC) is one of the most common procedures to be performed in Intensive Care Units. Mechanical complications arise early after the insertion of a CVC and long-term complications, such as catheter-related infections, thrombosis and chronic venous stenosis, later in the course.1,2 CVC-related complications are associated with increased morbidity and mortality as well as increased costs.

High quality documentation and follow up of CVC insertions form the basis of reducing these healthcare related complications.

Aims and objectives

Interventions

1.Establish how often CVC line and Vascath documentation were documented in accordance with NICE guidance at Northwick Park ICU.

1.

Teaching session on CVC/Vascath documentation

2. Implement interventions to improve documentation in accordance with NICE guidance3 after interventions

2.

Development of template to aid documentation of CVC lines on EPRO

3.Improve patient safety by reducing infection and complication rates related to CVC/Vascath insertions.

3.

Poster displayed around ICU as reminder

Results Pre-insertion data

Insertion data

Post-insertion data

Discussion Post interventions, our 2nd cycle shows an improvement in 13 out of the 26 domains Our 3rd cycle shows sustained improvement in 11 of these domains, and an improvement in 8 further other domains.

Areas where there was poorer compliance post-audit was related to there being no documentation on EPRO at all. This was generally seen when patients were referred to ITU initially and a CVC line was inserted prior transfer.

When the template was being used for documentation, there was nearly 100% compliance with documentation in all domains.

Template most often used when CVCs needed changing on ITU or when a junior was involved.

Template not use with locum doctors.

Confirmation of CXR was poor this is likely due to a lag between obtaining the CXR and remembering to document this on the system.

Further interventions: 1. Emphasise importance of a clear separate documentation of CVC insertions to ICU SpRs who accept ICU referrals 2. Address barriers to documentation e.g. time pressure or lack of computer availability in emergency situations 3. Highlight importance of documenting when CXR reported and if CVC safe to use References 1. Polderman KH, Girbes AJ. Central venous catheter use. Part 1: mechanical complications. Intensive Care Med 2002;28:1 17.

2. Polderman KH, Girbes ARJ. Central venous catheter use. Part 2: infectious complications. Intensive Care Med 2002;28:18 28.

3.Nursing Consultant, Intravenous Therapy Royal Marsden Hospital.

Policy for the Insertion and Care of Central Venous Access Devices (CVAD) in Hospital. Royal Marsden NHS Foundation Trust Policy. 2016.

1748.

A multidisciplinary, patient empowerment approach to improve fluid balance records in patients admitted to a cardiology ward: a quality improvement program William J. Waldock (Foundation Year 1 Doctor)1, Kieran Walsh (Clinical Director at BMJ)2, Cindy Supan (Syon 1 Ward Manager)1 and Callum Chapman (Heart Failure Consultant)1.

1. West Middlesex University Hospital, Chelsea and Westminster NHS Trust. 2. The British Medical Journal. William Waldock can be contacted on william.waldock1@nhs.net

Project Introduction and Aims Heart failure (HF) is one of the most common reasons for admission to hospital; it is associated with long in-patient admissions, and has a high inhospital and post-discharge morbidity and mortality.

Accurate fluid balance measurements are a vital part of management with intravenous diuretics for patients with decompensated heart failure and fluid overload.

On our review of the data collection on Syon 1 Ward (West Middlesex Hospital), there was great variability and poor recording of fluid balance.

The SMART (Specific, Measurable, Applicable, Realistic, and Timely) aim of this Quality Improvement Project was to improve fluid balance recording accuracy from 65 to 75% on Syon 1 (cardiology ward at WMUH) in two months.

Cohort 2 (23/09/2021)

Cohort 3 (12/10/2021)

Cohort 4 (02/11/2021)

Recorded Fluid Balance (ml)

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Box and Whisker Plot showing Interquartile Range, Mean (X), Median, Minimum and Maximum Values of Fluid Balance Recording Accuracy.

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Project Methodology / PDSA Cycles Plan-Do-Study-Act (PDSA) cycles: 1.Assess the quality of fluid balance monitoring on Syon 1 ward compared to NICE guidelines standards on one morning ward round (06/09). Aim: Three weeks of promoting BMJ Best Practice Resources (free to NHS staff) on Heart Failure to Syon 1 staff (posters, electronic resources etc.).

2.Reassess the quality of fluid balance monitoring on Syon 1 ward compared to NICE guidelines standards on one morning ward round (23/09). Aim: Three weeks of offering BMJ Best Practice patient information leaflets to Heart Failure patients on Syon 1 to highlight the importance of fluid balance in their recovery3.

3.Reassess the quality of fluid balance monitoring on Syon 1 ward compared to NICE guidelines standards on one morning ward round (12/10). Aim: Three weeks of offering patient empowerment training to be more active in their own fluid balance recording, including asking them to keep a written record of their fluid input and output levels daily.

4.Reassess the quality of fluid balance monitoring on Syon 1 ward compared to NICE guidelines standards on one morning ward round (02/11).

Cohort 1 (06/09/2021)

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Project Results and Lessons Learnt After implementation of three separate interventions of staff education, patient education, and patient empowerment, median fluid balance accuracy improved from 65% to 80% over two months on Syon 1 WMUH. Patient education with patient information leaflets and subsequent patient empowerment seemed to have the greatest effect on improving the accuracy of fluid balance monitoring. We also noted that it is considerably easier to measure fluid balance in those who are catheterised and only receiving IV fluids, compared to those self-mobilising to the lavatory and drinking independently. We plan to use patient information leaflets more frequently to enable improved independence and empowerment.

Dr Guy Fletcher, Dr Alice Ditchfield, Dr George Ashton • Chelsea and Westminster Hospital Trust Acknowledgement: Dr Mark Lethby, Care of the Elderly consultant supervisor

Reducing Time Taken for Treatment Escalation Plan Completion MEASURES

THE PROBLEM There are significant delays between a consultant decision regarding treatment escalation plan and formal completion of the DNAR/TEP form. Patients on the Care of the Elderly ward may remain without a formal TEP form for a significant period. In the event of deterioration, this can lead to difficult decisions to be made quickly out of hours, and suboptimal care.

AIM

To reduce time from admission to the Care of the Elderly ward to formal completion of the DNAR/TEP form, in order to improve patient care and the legality of medical decisions, particularly those made out of hours.

PROCESS MAP

RESULTS Average time from admission to ward à TEP form completion: • Pre-changes: 3.56 days • After PDSA 1: 2.03 days (43% reduction) • After PDSA 2: 1.94 days (47% reduction vs. pre-changes) Average time from consultant decision à TEP form completion: • Pre-changes: 1.96 days • After PDSA 1: 0.58 days (70% reduction) • After PDSA 2: 1.38 days (30% reduction vs. pre-changes)

RESEARCH

AVG. TIME TO COMPLETE TEP FORM

Focus group held with ward medical team, nursing team and auxiliary staff, ensuring staff at all levels of training from F1 to consultant were represented. A nursing handover was also attended.

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PDSA CYCLES

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PDSA 1

Pre-changes Post-PDSA1 Post-PDSA2

Plan: Change idea: Adding TEP status to clinical ……….handover list used by all doctors on ward Do: November 2021 à allow 1 month to elapse to ………assess the impact and allow sufficient ward …..….turnover Study: December 2021 à Data collection & analysis Act: Next step: allocated member of staff highlights ……….incomplete TEP forms at handover

c

PDSA 2

Data was collected monthly as a snapshot and included time of first consultant decision regarding TEP, time of admission to ward, and time of TEP form completion.

This data was used to generate the following measures: • Time from first consultant decision regarding TEP to TEP form completion • Average time from admission to COE ward to TEP form completion This was used to generate averages at the following data collection points: • Pre-collection data: November 2021 • Data collection following PDSA 1: December 2021 • Data collection following PDSA 2: February 2022

TAKE HOME MESSAGES

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Plan: Change idea: Allocated member of staff ……….highlights incomplete TEP forms at handover Do: January 2022 à allow 1 month to elapse to assess ………the impact and allow sufficient ward turnover Study: February 2022 à Data collection & analysis Act: Plan to extend QIP methodology to other medical ……….wards and continue to reaudit

47% reduction in average time from admission to Care of the Elderly ward to completion of TEP form.

70% reduction in average time from consultant decision to completion of TEP form after PDSA 1.

Simple and time-efficient changes can improve level of patient care and legality of DNR documentation without significant increase in staff workload.

The project highlights the valuable role of junior staff when empowered to speak up.

NEXT STEPS

Presentation of work at local faculty group meeting to further spread awareness of the project.

Continue to re-audit to ensure new standard maintained.

Expansion of QIP to additional Care of the Elderly wards, then to all medical wards.

To size your poster correctly Go to Design in Bar above Go to Slide Size • Page set up • Custom • Pick portrait orientation • Key dimensions into Width and Height 59.4cm x 84.1cm

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Improving call bell reachability in an acute older persons' ward A gentle reminder in daily nursing handover (Safety huddle) increased call bell reachability to almost double Background: Call bell within reach is an important part of quality of care and a standard in the RCP inpatient fall Audit.

Changes : First change: Stickers in medical notes as a reminder Second change : Teaching session to nurses Third change: A short video posted in closed social group Fourth change: A gentle reminder (as a component of safety huddle) in daily nursing handover

Initial data collection showed 56% patients had call bell in reach indicating potential for improvement.

Aim: Improve call bell reachability from 56% to 95% or more

Measurement 10 bed spaces reviewed 3 times a week for 2 weeks (in the afternoon) before and after introduction of each change Balancing measure of weekly falls data for the ward (all beds)

Learning: Stickers can be easily ignored Doctors' contribution in ensuring call bell reachability is important but nurses & HCSW have the most frequent role Teaching is effective but it may not be able to involve all the staff especially when staffing is not consistent. Despite attending the teaching, implementation of gained knowledge from the teaching session may not sustain Social media can be used to improve patient care provided maintained but it was not an effective change for this project.

Reminding the staff of the importance of project was our patient care immediately being delivered afterwards

Outcome: First 3 changes

any sustainable improvement The 4th change which was a quick reminder to nurses/ HCSW during every morning & evening handover by senior nurses was successful in achieving significant & sustained improvement with >95% call bell in sight and reach Falls on the show any specific corelation with call bell reachability changes

AUTHORS: Md F. Islam, M. Noor, C. Spice Portsmouth University Hospitals NHS Trust

I need a weight!

Improving weight recording in the Paediatric Accident & Emergency Department , a Quality Improvement Project Dr Katherine Styles, Dr Richa Ajitsaria and Nicola Davey What’s the problem?

• Children are not routinely weighed in our A&E, a lost moment for health promotion.

• It also causes frustrating delays to prescribing.

• Even worse, some children are admitted to the ward without accurate weights leading to drug errors and disruption in their care What’s currently happening?

• 23% of total patients, 27% of infants under 6 months are weighed • In 3 consecutive shifts average 7 children per shift had delay to prescribing as no weight available

Understanding the problem: Fishbone diagram

Aim: 1. Weigh 80% of all attenders 2. Weigh 100% of infants < 6 months PDSA 1:Engagement - Need to continue to engage senior nurse - Engage junior doctors especially weighing infants

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- Engaging Matron/ Consultants first workedsupportive, most senior- ordered new scales!

“weight is NOT PART of the Manchester Triage system” “the words triage and weight SHOULD NOT BE MIXED”

Engagement 1.1 Matron 1.2 Consultants 1.3 Practice Development Nurse

PDSA 2: Swap triage chair for weighing chair - Does the change persist?

- Need a different intervention for infants ?

- Faster prescribing for weight-based prescribing - However, sitting on scales ≠weight

- 3 children weight available for prescribing - 1 did not - 2 extra children weighed

PDSA 3: Infant focus - Repeat reminders on shift - Empower nurses to get doctors to weigh or request scales

- Engage junior doctors to weigh infants themselves at the end of their examination

- 2 doctors needed to be shown scales and how to use them - Doctors weighed 5 infants on shift

- Information sharing in work WhatsApp group - Day-to-day encouragement on ‘shop floor’

Results: 1. Overall weighing: Increased 19% to 75% 2. Infant weighing: Increased 19% to 78% I presented my QI project at our departmental governance meeting, increasing awareness and support.

Conclusions: It has been possible to increase the number of children being weighed in our A&E department using quite simple change ideas which mostly focused on engagement. Most professionals were willing to try change ideas.

My learning: Being taught QI methodology completely changed my experience of QI projects. I realise how important it is to fully understand the problem first using diagnostic methods then moving onto PDSA cycles.

IMPROVING THE SERVICE AT THE BREAST ONE-STOP CLINIC Dr James Sheldon, Mr Mustafa Khanbhai and Ms Laura Johnson

Background At the breast one-stop clinic (OSC), patients were asked a series of questions related to breast disease and breast cancer risk, by the clinician from a pro-forma. This included specific questions such as age of menarche, age of menopause, date of LMP, and patients would often need a long time to think about their answers to these questions. This was time consuming for the clinician and would often put patients under pressure to provide answers quickly, leading to some of the information being inaccurate.

Aims To save time during the clinic appointment.

To improve patient experience at the breast one stop clinic.

To ensure patients provide the most accurate answers to questions asked.

PDSA Cycle

ACT

DO PLAN Analyse effectiveness of current system.

Gather feedback on current system.

Re-design proforma.

Implement new system on trial basis.

Gather feedback on new system.

Methods Over a one week trial period, all patients attending the one-stop breast clinic filled out a questionnaire in the waiting room, using questions adapted from the original pro-forma. Completed questionnaires were given to the clinician at the start of the consultation.

Clinicians then completed feedback forms after the clinic, to assess the effectiveness of the new system.

Conclusions

STUDY

Make further changes to proforma.

Implement new proforma on permanent basis.

Analyse feedback from trial period with new system.

Results § 83% of clinicians found the new system saved time. § 75% felt that patients were able to give more accurate answers to the commonly asked questions. § 85% of clinicians felt it led to improved patient engagement during the consultations.

We see potential for this being implemented and used in all breast one stop clinics, with a patient questionnaire which is validated and recognised nationally to create standardisation across all breast centres. This trial saved time, improved patient interaction, provided more accurate answers to questions asked and should ultimately lead to better patient care and clinical outcomes.

Limitations

Next Steps…

Not all patients understood the questions on the Modify pro-forma further and repeat the trial. proforma. Language barrier for patients who could not Education on new system before trial to increase speak English. Some clinicians didn’t adopt new system. compliance amongst clinicians.

Cancer patient summaries for safer on-call decision making Nader Raafat1, Rosie Hattersley1

Oncology Department, Torbay General Hospital, Torbay and South Devon NHS Foundation Trust, UK

1

BACKGROUND

AIMS

Caring for cancer patients poses unique challenges to both the on-call team and ward juniors. They are often on unfamiliar and complex treatments, and have nuanced treatment escalation plans (e.g. resuscitation status, further oncoliogical intervention) that may not be intuitive. As a mainly outpatient specialty, there is no daily consultant ward round at Torbay, making it more difficult for ward juniors to escalate confidently and for on-call teams to understand a patient’s background, inpatient plan, and longer term trajectory.

To address this, we set out to design an oncology admission proforma that would achieve the following:

METHODOLOGY: Inpatient notes were audited at weekends for documentation of the following:

» Cancer diagnosis/treatment history » Treatment Esclation Plan (TEP) » Named oncology consultant » Reason for admission » Clear inpatient plan (incl. weekend) » Current problems

Improve documentation

Facilitate communication

An aide-memoire to ensure all patients have sufficient documentation of core information discussed by a specialist in-hours, avoiding ambiguity for on-call teams.

A single source of information for ward juniors to escalate, make referrals, etc... Facilitates handovers after e.g. nights/ leave and enables on-call teams to quickly obtain relevant background for acute reviews.

Documentation needed to be in a clearly visible proforma or in the latest two entries to qualify. A total of 5 PDSA cycles were carried out. Cycles 3 and 5 were carried out to ensure improvements were sustained as juniors rotated.

Interventions: Intervention #1

Intervention #2

Intervention #3

Staff of all grades surveyed for most pertinent information to include in proforma.

Initial proforma drafted.

Juniors and registrars surveyed for suggested improvements given initially low proforma uptake and absence of improvement.

Results of improvement disseminated to staff.

Further modifications made based on registrar suggestions.

Junior doctor changeover.

Intervention #4

Intervention #5

Ward clerks and nursing coordinators ensuring proforma printed in notes on admission.

Junior doctor changeover.

Proforma printed on pink sheets to make it easier to find.

Lessons Learned: Engaging stakeholders

As junior doctors we are often the most transient members of the ward team, so it is essential that more premanent staff (e.g. senior nurses, ward clerks) are consulted to ensure change outlasts doctor rotations.

Results: Initially, no domain was accurately recorded for all inpatients, and

<=50% of patients had a clear weekend plan or valid TEP form. By the second iteration, proforma uptake was 90% and documentation rates were 90-100% across 7 out of 8 domains.

Following junior doctor changeover, proforma uptake fell to 30%, and TEP form completion fell to 50%. This was reversed following nursing/ward clerk collaboration, and maintained on subsequent audit (see table above).

The most significant improvement was in TEP form completion (Fig. 1), crucial given the importance of end-of-life care for this patient group.

100

Integrating into workflows

Change is much more likely to be sustained independently of the individuals behind it when it is integrated into existing processes.

By integrating the proforma into admission flows, friction was reduced and medical staff reminded to keep using it.

% of inpatients

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60

TEP completion 40

Proforma completion 20

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Importance of iteration

The first and last versions of the proforma had the same skeleton but markedly different emphasis and layout, evolving as doctors started using it and finding issues.

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Acknowledgements: Many thanks to the oncology consultants at Torbay General Hospital and the Devon and Exeter Cancer Fund for their ongoing support. Vector art from vecteezy.com

Improving communication through List Documentation Dr. Annabelle Hook (FY2) and Ms. Jemma Rooker (Consultant)

Introduction

Clear list documentation helps aid informed handover of patient care between teams. Lists that contain concise and relevant information can support informed decision-making processes. The trauma and orthopaedics (T&O) on-call list at GWH is used at the daily trauma meeting (TM) where the multidisciplinary team (MDT) are present and supports the identification of issues. Good lists aid safe handover of care between night and day teams highlighting outstanding jobs, reducing work duplication and time spent revisiting plans.

Aims To create a new standardised list system containing relevant and useful information whilst being stored appropriately and consistently on the computer system. It was retrospectively measured by reviewing 13 days of consecutive lists post each change to analyse how many of the predetermined parameters were documented on each list. The aim was achievable and realistic as the new list was created to meet the needs of a specific department where the previous list system needed to be replaced. Project time frame was 6 months.

Problems The previous custom built list system was no longer functional. This resulted in lists being saved in different places and/or under different filenames, lacking standardisation. Even when the old list system was in place, key information such as AMTS, bloods and time of arrival was infrequently documented on the list and as such, not readily available when asked for within the TM (without loading multiple programs). The information then had to be found afterwards.

Finally, the old lists lacked frequently used contact details/bleeps, resulting in much time spent going through the switchboard to obtain these numbers.

Secondary aim was to see improvement in list documentation of AMTS, blood results and time of arrival list documentation.

Parameters identified to be useful for the list: For all patients, list documentation of: • Date • On-call consultant initials per patient • Location of patients • Patient details (3 identifiers) • Admitting problem • Key history and examination • Blood results • Scan results • Plan

Methodology & Plan Do Study Act (PDSA) Cycles The quality improvement project was registered at the hospital. TM were observed, and discussions took place with a consultant to establish which parameters were needed, or not captured, with the current prompts on the old list. Baseline data was collected considering the presence of these parameters on the old list. 13 consecutive days of lists were analysed. Parameters observed in TM as frequently not documented on the list: AMTS, blood results and time of arrival. Post each PDSA cycle change, 13 consecutive days of lists were similarly analysed.

Structure measures: Access to the list system, ability to safely store the list system on a computer system.

Process measures: Number of times each parameter documented on list. Specific parameters where improvements were desired: AMTS, bloods results and time of arrival documentation.

Outcome measures: Percentage of each parameter documented on the list. Number of pages needed to contain all parameters.

Balancing measures: New list being incorrectly completed resulting in parameters being unavailable during TM. More pages needed to contain all the parameters.

Those for operation, list documentation of: • Marked and consented (M&C) • Eating Status • COVID Status • Number of Group and Saves Those with Neck of Femur Fracture (NOF#) for operation, list documentation of: • M&C • Eating Status • COVID Status • Number of Group and Saves • AMTS • CXR completed • Time of arrival Other elements included readability and number of pages.

Flow Chart: To depict PDSA cycle actions.

Results 64 lists analysed. Total of 661 patients across those lists. 111 non-NOF# operations, and 83 NOF# operations.

(65th list (25th November) unavailable due to site-wide computer system upgrade, and alternative method used).

Cycle 1: New list

Cycle 2: Teaching session

Cycle 3: Feedback & list change

Cycle 4: Guidance document

Radar Chart 1: Improvement in list documentation

Radar Chart 2: Deterioration in list documentation

The average number of pages of the list decreased from 4.1 to 2. Finally, the readability of the list improved.

Median AMTS %

Median Time of arrival %

Median Blood results %

Run Chart: To depict % change of AMTS, time of arrival and blood results over time.

Example from PDSA Cycle 1: Introduction of new list system.

Key learning points and next steps: A standardised list system is now in place and is consistently being used. Everyone has read and write access to this list (who requires it). It is stored in a safe and appropriate place on the computer system. The list contains prompts for useful and relevant information. A guidance document on how to use the list is available to ensure consistency of use during changeover periods.

Improvements seen: improvements were seen in a number of key parameters (Radar Chart 1). These include the documentation of: Blood results, AMTS and time of arrival (Run Chart). Improvements have been seen in the readability of the list and the number of pages used for each list.

Issues noted: changing to the new MS Word-based list system means that individuals can edit the list format depending who is on call. Whilst prompts are on the list for people to follow there are no mandatory fields that prevent partial completion of the document. If the computer system goes down, alternatives must be used.

Next steps: complete data collection following Cycle 5 (the addition of the guidance document to the T&O introduction booklet). Monitor usage of the new list system. Aim to improve deteriorated areas (Radar Chart 2). Locally present new findings, and survey whether any further changes should be made to the new list system.

Reflections: change does not equate to improvement. Multiple PDSA cycles are required to make incremental changes to work towards an aim. By involving the MDT early, support can be gained from the team and working together a list system can be created that benefits the department and meets its needs, whilst improving list documentation.

Limitations: It is important to highlight that not documenting a parameter on the list, does not mean that it has not been completed or is not available. The absence of documentation on the list means people must rely on human memory, or go back to check the original documentation, or open a different computer application. It is important to remember list documentation will always vary depending on the user and how busy each shift is. This is also affected by staffing levels and seasons. The list has been designed to include prompts for each of the useful parameters, but this does not mean they must be completed. It is important to remember that these results represent a baseline 13day consecutive period compared to each post-change 13-day consecutive period, this may not reflect all lists outside of these recorded time periods.

Easing the pressure: taking time out for reflection to engage staff and improve care Kristina Thomson, David Fletcher, Rachel Major, Jackie Holley, Christine Herdman, Michele Dowling, Milton Keynes Community Nursing Service

Introduction

Aims

Milton Keynes District Nursing (DN) Service provides care at home for frail and vulnerable patients across 7 Primary Care Networks in Milton Keynes. Over the past year the service has worked to create a learning system where staff can reflect on practice, develop skills, and ensure that they provide consistent, high level care across all nine DN teams (approx.

130 staff). Due to the multiplicity of factors involved in the prevention of pressure ulcers, the team has been tracking the development of Category 3 pressure ulcers in service as a proxy measure for high quality care.

While the stated improvement aim is to reduce category 3 pressure ulcers by 10% over the year to June 2022, the team wanted to achieve more than this:

• Create a safe, supportive environment where staff could reflect and learn new skills and knowledge to improve practice; • Reduce unwanted variation in practice across the 9 teams working in Milton Keynes; • Encourage staff of all grades to use data to inform and improve their practice.

V. Kopanitsa1, S. Flavell2, J. Ashby2, I. Ghosh2, S. Candfield2, U. Srirangalingm2, L. Waters2

Since June of last year this work has been part of a QI Practicum across Central and North West London NHS Trust, which has provided the(UCL) team with structure and a 2. platform 1. University College London Medical School; Central and North West London NHS Foundation Trust to develop and share their work. The aim of this work is: The team has used Quality Improvement methodology to structure the work and track progress1. This has focused on a small number of PDSA cycles to track change and To reduce Category 3 pressure ulcers developed in service by 10% by the end of improvement: June 2022.

• monthly workshops for staff - half day sessions each month where 2 teams come together to follow a programme for reflection, learning and improvement within a space The work took a whole service approach, and the service manager (sponsor) took an that provides psychological safety for all staff; active role in the work throughout. It was overseen by a team led by one of the Practice • development of Quality Improvement Performance Portfolios (QIPPs) - team level Development nurses, supported by the Data Quality Officer, a Tissue Viability Nurse, B5 performance reports produced each month to ensure teams can see how they are District Nurse, Health Care Assistant and Improvement Advisor. performing, and learn more about their patient profiles; • mentoring - where staff with specific skill sets (e.g. tissue viability nurses) can support colleagues to develop skills, leading to earlier intervention and better patient care.

Methods

Results Workshops have been at the heart of what we have done over the past year, providing both a safe space for reflection and learning, and a way for staff in different teams to get to know each other and discuss different ways of working.

Better working across teams has allowed the service to work more flexibly, providing cover for caseloads at times of staff pressure, and allowing them to keep protected time for learning even at times of high operational pressure. Using team level Quality Improvement Performance Portfolios (QIPPs) has encouraged teams to take ownership of their own data and understand data relating to their own caseloads.

Earlier identification and intervention, higher levels of staff confidence and better working across teams has resulted in a drop of up to 40% in Category 3 PUs since we started our work last summer. Since we started our work in April 2021, the reduction in Cat 3 PUs has meant an average reduction in costs to the whole system from £54,000 in 2020 to less than £20,000 in the last three month period.2

We didn’t set out to make savings – but our work has released resource back into nursing practice ensuring a de facto return on investment. Earlier identification and better nursing care has meant less clinical time spent on investigating and reporting on incidents. This in turn means better caseload management and more time for clinicians to spend looking after patients.

Better use of resources, allows us to release time back into clinical care.

Two of our teams at a monthly workshop, where they have had time to explore their own data using the Quality Improvement Performance Portfolio.

We’ve noticed some healthy competition between teams as they work to improve their team performance!

QIPPs provided a whole system overview of how teams were doing – great context for our work on pressure ulcers and emphasising the importance of a holistic approach to care.

Lessons Learnt

• In complex systems, it may be difficult to measure the direct impact of our actions on

performance measures. Take time to understand your system and develop meaningful measures over time.

• Improvement is a marathon not a sprint – you need to know why it is worth staying the

distance. Dialogue with all team members gives them ownership of their improvement and development.

• Improvement work happens in context, not in isolation. Our teams used QI to provide

structure to a range of initiatives we wanted to introduce. This structure helped us to see the big picture, think of our service as a system, and helped us to prioritise our activities.

It’s also helped us to move from simply ‘doing’ to following through on the impact of our actions on our practice, professional development and patient experiences.

• Get data out of traditional performance reports and into formats that make sense to

operational teams. Use it in ways that helps them to tell their own story, in ways that matter to them.

What patients said about our service

• Make time for reflection – it is a valuable investment, especially when under operational pressure.

• Better working practice releases resources and allows clinical staff to spend more time on direct patient care. We’ve made a start in tracking this, and we will be doing more as we continue to improve our practice.

• We need to do more to get service users and carers involved. As we move into

continuous improvement, patient involvement is a key area for development. Roll on our next adventure in QI!

1. Langley et al, The Improvement Guide, Josey-Bass Books, San Francisco, 2009 2. Bennett, Dealey and Posnett, “The cost of pressure ulcers in the UK”, Age and Ageing, 2004, 33: pp230-235 . Costs based on 2004 values, uplifted for inflation.

e-nformed consent Can Digitalisation improve the safety and quality of surgical consent?

Dr Laura Burney Ellis, Dr Amy Cleese, Ms Jennifer Barcroft, Mr Dafydd Loughran, Mr Edward St John, Mr David Phelps Introduction • Our unit conducts around 800 Gynaecology surgeries each year • GMC guidance Decision making and consent states: ‘Give patients the information they want or need in a way they can understand.’

• Royal College of Surgeons Good Surgical Practice states: ‘Recognise that seeking consent for surgical intervention is not merely the signing of a form…It requires time, patience and clarity of explanation.’

Aim: • To evaluate whether patients understood the risks and complications of the planned procedure and whether they had adequate time to ask questions.

• Whether the use of a digital consent form improved the consent experience.

Lessons learnt Initially, questionnaires themselves were available on paper and online via a QR code, however patients were much more inclined to take part when we took them through the questions in either format. This highlights the human interaction as key in the doctor-patient relationship, and emphasises technology as a facilitator in this process.

Identical questionnaires were used to assess both paper and electronic consent.

Questionnaires were completed between one and seven days post-operatively.

A questionnaire was designed, using a 5-point Likert Scale (strongly agree being most positive, and strongly disagree most negative).

Fifty anonymised questionnaires were collected from patients who had been consented using paper forms.

Questions included: "I understood the potential complications of the procedure" and "I had adequate time and opportunity to ask questions”

Data were collected from a tertiary London GynaecologicalOncology centre between October 2020 and July 2021.

Plan

Conclusion

Overall, consent-taking appeared comprehensive regardless of the method. However, e-consent appears more likely to provide a framework for patients to feel they fully understood the risks and complications and to have the opportunity to ask questions.

Digitalisation of healthcare can potentially improve not only efficiency but also the quality of our consent-taking discussion, empowering the patient to make a safe and informed choice.

Fifty anonymised questionnaires were subsequently collected from patients consented electronically.

Do

'I understood the potential complications' 50 40

Act

Study

30 20 10 0

E-consent system Concentric was implemented, and one month's grace period allowed

Paper-consented

Lessons learnt Some staff members were more resistant to change than others; we organised a virtual teaching session on use of the e-consent system

Strongly agree

E-consented Agree

Disagree

'I had opportunity to ask questions' 50 40 30 20 10 0 Paper-consented Strongly agree

E-consented Agree

Disagree

References: 1. GMC Online. Decision making and consent. Available from: https://www.gmc-uk.org/ethical-guidance/ethical-guidance-for-doctors/decision-making-and-consent 2. Royal College of Surgeons. Standards and research: Good Surgical Practice 3.5.1 Consent. Available from: https://www.rcseng.ac.uk/standards-and-research/gsp/domain-3/3-5-1-consent/

INSULIN INFUSION REQUIRED? YES or NO

A Vital Question for ALL Critical Care Transfers

Dr Richard Healy & Dr Nour El-Shafei – Clinical Fellows, Wessex Neurosciences ICU

“Incidents involving insulin are frequent and cause considerable distress to people with diabetes and anxieties to their families and carers”1 What Prompted this Project?

The Scope of The Problem NATIONALLY

A personal experience of the authors having worked at the same hospital as the death mentioned above • Level 3 transfer from ICU to CT scanner - multiple infusions running • Stack prepared by Critical Care Technician – all infusion pumps transferred on to stack • Checklist completed • NG feed stopped and aspirated, as per checklist • Went to CT • Sudden realisation that Actrapid was still running without NG feed • Re-checked BM • No harm caused but was a “near-miss”

• Insulin, hospitals and harm: a review of patient safety incidents reported to the National Patient Safety Agency (NPSA), 20112 • 16,600 incidents involving insulin were identified • 24% reported harm to the patient • 1,042 incidents of moderate harm • 18 incidents with fatal and severe outcomes • National Diabetes Inpatient Audit England and Wales, 2016 • One quarter of inpatients with Type 1 diabetes had a severe hypoglycaemic episode during their hospital stay (27 per cent).

Actions and Interventions

LOCALLY

• Incident Form completed – “near-miss” • Discussion with Clinical Director of NICU • Idea of amending the ICU transfer checklist to ask…

“Insulin Infusion Required? YES/NO” • Discussions with MetaVision Team to do this for all ICUs in the Trust • Approval needed from GICU/CICU & PICU Clinical Directors/Matrons etc.

• Slow process before approval for change was granted

• Difficult to say exactly

• Probably a lot of unreported incidents

• Anecdotal evidence from colleagues re similar problems • CEPOD patients

• Reviewed Incident Forms relating to “Insulin” for a 6 month period: • 9 reported in total (inc. ours) • Most relevant:

The NEW Checklist

• Bedside nurse turned off an IVI containing glucose as it had finished but did not replace it and left insulin running for 2 hours without glucose

Learning Points

The Future Presented at Thames Valley and Wessex Critical Care Network quarterly meeting • Regional transfer checklist will be changed to include the question…

Insulin Infusion Required?

YES or NO

• Insulin is dangerous • A simple mistake & near-miss can go a long way to improve patient safety • Checklists are very useful, but have their limitations • They can still miss things • We ALL need to be willing to raise concerns/suggestions as they are realised • It is easy to rely too heavily on the Critical Care Technicians • Think about all infusions running – are they all required for a transfer?

• Have a low threshold for completing Incident Forms • A valuable learning resource – for all members of MDT • Change takes time and can involve many hurdles References 1.

2.

3.

4.

BBC News. Basingstoke hospital “neglect” over diabetes patient death. 2020 Oct 6 [cited 2022 Jan 19]; Available from: https://www.bbc.co.uk/news/uk-england-hampshire-54439184 Observer B. Hospital apology after patient dies from negligence [Internet]. Basingstokeobserver.co.uk. [cited 2022 Jan 19]. Available from: https://www.basingstokeobserver.co.uk/hospital-apology-after-patient-dies-from-negligence Cousins, D; Rosario, C; Scarpello, J. Insulin, hospitals and harm: a review of patient safety incidents reported to the National Patient Safety Agency. [Online]. Available from: https://pubmed.ncbi.nlm.nih.gov/21404780/ [Accessed 28 February 2022].

NHS Digital. National Diabetes Inpatient Audit. [Online]. Available from: https://digital.nhs.uk/data-andinformation/clinical-audits-and-registries/national-diabetes-inpatient-audit [Accessed 28 February 2022].