18th May 2022 Poster Competition Group E QI in Progress Education and Training
Junior doctor confidence, and competence, in wound care management in the emergency department Dr E Beck Introduction Wound management is an essential part of emergency medicine practice. Clinicians care for wounds ranging from minor and simple lacerations or abrasions, to complex wounds (1). Approximately 4 million patients with a wound, are managed by the NHS per year. The annual cost of wound management in the NHS equates to £8.3 billion (2). During my emergency medicine job, I noticed that, despite the high prevalence in presentation and cost to the NHS; junior doctors were not confident in wound care. This was particularly apparent out of hours when staffing levels are lower, and seniors are often busy and unable to help.
Aims 1. 2.
To establish whether junior doctors felt confident in their ability to manage wounds in the Emergency Department
To establish if junior doctors were competent in wound care does their knowledge of wound care meet hospital guidelines? 3.
4.
To establish if junior doctors had access to quality resources they could use for help with wound management
To identify common knowledge gaps that can be targeted when creating future educational resources and training programs
Methodology Cohort study of junior doctors (F2 to middle grade, n = 22) working in different emergency departments in the UK (predominantly Worthing hospital). Confidence in wound care management was assessed using a self assessment questionnaire where participants would grade how confident they felt in different wound care scenarios. Competence was evaluated using a series of single best answer questions (based on hospital and best practice guidelines) common scenarios that can present in wound care in the emergency department: dressing types and suitability, basic suturing techniques, risk factors for delayed healing and criteria for referral to a specialist plastic surgery centre etc. Answers from all participants were then combined to identify common knowledge gaps that can be targeted.
Competence in wound care as per SBA score
Participant's self-assessed confidence in different aspects of wound care Interrupted sutures
Results Only 20% of participants felt confident in wound care overall in the emergency department.
Non suture techniques Tetanus prophylaxis
Participants felt least confident in knowing when a patient needed referral to plastic surgery (15%), and most confident in applying interrupted sutures to a wound (90%).
Antibiotic prophylaxis Dressings Mattress sutures
Only 5% felt medical school had adequately prepared them for wound care management.
Local anaesthetic dosing Bleeding wounds
Score greater than 50%
Score of 50% or less
Facial wounds Plastics referral criteria 0%
10%
20%
30%
Confident
40%
50%
60%
70%
80%
90%
The lowest score in the SBA was 0%, the highest was 75%. The average score was 42%.
100%
Unconfident
"Medical school adequately prepared me for wound care management"
"A concise intranet resource for wound care management, that we could refer to out of hours, WOULD be useful"
Agree 5%
Strongly agree 0%
Disagree 4%
Neutral 5%
Strongly disagree 9%
Disagree 33%
Strongly agree 64%
Agree 9%
Know where to find help with wound care when seniors are busy Very unconfident 14%
Have a reliable online resource they can refer to for help with wound care management
Very confident 14% Confident 18%
Unconfident 36%
Neutral 18%
Only 40% were able to correctly list 3 wound criteria that would mean a referral to plastic surgery should be made. Only 5% were able to correctly identify iodine wash should be used with cation. 63% were able to correctly identify ONE dressing that should be used on a wound type (bleeding wounds). Only 18% were able to correctly match all dressings to wound type.
Neutral 14%
Strongly disagree 57%
Only 33% scored higher than 50% in the competence SBA assessment.
>60% of participants said it took between 1-2 hours to receive a plan from the local plastic surgery centre once the referral had been made. Only 32% felt they knew where to find help with wound care if seniors were busy or it was out of hours. Only 4.5% felt they had a reliable online resource they could refer to for help with wound care. 73% felt a concise intranet resource to help with wound care would be useful.
Yes
No References
Conclusions and lessons learnt 1. Junior doctors are neither confident nor competent in wound care 2. Medical schools currently do not adequately train medical students in wound care 3. There are not sufficient online resources to provide accurate wound care guidance 4. Junior doctors are not sufficiently supported out of hours in wound care management 5. Junior doctors can correctly identify areas in wound care where their knowledge is lacking 6. Better education in wound care is needed 7. Waiting for specialist advice from plastic surgery is excessively time consuming
Next steps I am working with Worthing hospital A+E consultants and advanced nurse practioners (ANPs) to create a concise, evidence based, online guide; that junior doctors can refer to for help with wound care. This aims to be a comprehensive guide, but with special focus on the knowledge areas that were identified in this study to be lacking e.g plastic surgery referral criteria. In the future we hope to design a complete wound care course that junior doctors will complete during their A+E rotations. This will include a series of teaching sessions from senior doctors and ANPs. On successful completion of the course junior doctors will be provided with a certificate.
1.
Wound closure techniques. C Azmat and M Council. Treasure Island (FL): StatPearls Publishing. Jan 2022.
2.
Cohort study evaluating the burden of wounds to al. BMJ Open. Dec 2020
3.
Worthing hospital wound care guidelines
4.
Wounds. Spiro DM, Zonfrillo MR, Meckler GD. Pediatr Rev. 2010 Aug;31(8):326-34; quiz 334. doi: 10.1542/pir.31-8-326. PMID: 20679098 No abstract available.
5.
Methods of laceration closure in the ED: A national perspective. Otterness K, Thode HC Jr, Singer AJ.Am J Emerg Med. 2020 Jun;38(6):1058-1061. doi: 10.1016/j.ajem.2019.158365. Epub 2019 Jul 25.PMID: 31466912
6.
Advanced laceration management Brown DJ, Jaffe JE, Henson JK. Emerg Med Clin North Am. 2007 Feb;25(1):83-99. doi: 10.1016/j.emc.2006.11.001. PMID: 17400074 Review.
Improving Patient Education About Pre-Diabetes in the Community – A QIP Authors – Carey C1, Natarajan S2 1 = Manchester University NHS Foundation Trust, 2 = Limelight Health and Wellbeing Hub Methods • Drivers of improved knowledge about pre-DM and dietary interventions were identified (Fig 1)
Introduction • Pre-DM is heavily linked to high carbohydrate intake • Many are unaware of what dietary improvements can be made • 1-to-1 consultations focused on reducing carbohydrate intake can improve pre-DM (1) Aims
• Patients were identified and selected using EMIS reports (Fig 2) • A questionnaire was constructed based on the UKDDQ and used to interview patients
• Improve patients' understanding of pre-DM over 1 – 2 weeks
• Carbohydrate reduction advice was given verbally and a diet sheet produced by Unwin et al was provided
• Reduce carbohydrate intake using 1-to-1 dietary consultations
• A second call after 7 – 14 assessed the impact of the advice
Figure 1 – Driver Diagram
GP consultations about patients’ diet
Good patient education and individualised dietary assessments
Improved knowledge about pre-diabetes and dietary interventions
Clear communication and advice Written information with diet/lifestyle advice
Retainable information
Regular lifestyle consultations
Figure 2 – Patient Selection Process
Concern About Pre-DM 100.00
65 excluded – HbA1c <42 or >48 24 excluded – only 1 HbA1c recorded 49 pre-DM patients identified 18 excluded – uncontactable 31 pre-DM patients included for 1st interview 9 excluded – uncontactable
Percentage of Respondants
138 patients identified on EMIS reports
90.00 80.00 70.00 60.00 50.00 40.00 30.00 20.00 10.00 0.00
22 pre-DM patients included for follow up interview
Concerned
Not Concerned
Dietary Changes
100.00
100.00
90.00
90.00
80.00
80.00
Percentage of Respondents
Percentage of Respondents
Carbohydrate and Pre-DM
70.00 60.00 50.00 40.00 30.00 20.00
70.00 60.00 50.00 40.00 30.00 20.00
10.00
10.00
0.00
0.00
Mentioned Carbohydrate
Did Not Mention Carbohydrate
Unclear
Made Dietary Changes
100.00
100.00
90.00
90.00
80.00 70.00 60.00 50.00 40.00 30.00
Unclear
80.00 70.00 60.00 50.00 40.00 30.00
20.00
20.00
10.00
10.00
0.00
0.00
Not Helped by Diet Advice
No Dietary Changes
Knowledge Post Dietary Advice Percentage of Respondents
Percentage of Respondents
Impact of Dietary Advice
Helped by Diet Advice
Unsure
Unclear
Knew More Post Consultation
Did Not Know More Post Consultation
Unclear
Conclusions • Awareness of the contribution of carbohydrates to pre-diabetes improved following the consultations • Pre-diabetic patients should be given verbal and written information about lowering carbohydrate intake References 1) Unwin D, Khalid AA, Unwin J, et alInsights from a general practice service evaluation supporting a lower carbohydrate diet in patients with type 2 diabetes mellitus and prediabetes: a secondary analysis of routine clinic data including HbA1c, weight and prescribing over 6 yearsBMJ Nutrition, Prevention & Health 2020;bmjnph-2020-000072. doi: 10.1136/bmjnph-2020-000072
‘Blood, sweat and tears’ Reducing delays in transfusion with a new major hemorrhage protocol, algorithm and virtual reality simulation. Dr Rachel Nigriello, Dr Chris Waters, Dr William Mears, Ms Helen Maria-Osborn, Royal United Hospital Bath
Introduction
Aims
On average, there are three major haemorrhage (MH) calls a week at the Royal United Primary Aim: To reduce the time between MH protocol activation and the start of transfusion Hospital (RUH), Bath, UK. As junior doctors working in different departments, we observed by 25% by December 2022. Secondary aims include improving confidence of staff in varied practice and confusion about how to utilise the MH call. After several serious incidents managing an MH call and improving staff knowledge of the MH protocol. Our study excluded at the RUH which involved significant delays in transfusion following a major haemorrhage obstetric MH calls as they had already developed a separate process. call, we formed a multidisciplinary team (MDT) to address this issue.
Measuring Current Practice Several steps were undertaken to understand the current system and measure current practice: 2) Baseline measures of time from MH call activation to transfusion showed a mean of 1) An MDT process map identified several areas of potential delay to transfusion (Fig 1). 38 minutes from March 2021-Oct 2021 (Fig 2).
Fig.3
Fig.1
Fig.2
3) A staff survey showed 85% had no training in MH calls and none could correctly identify the exact personnel on the MH team. 4) ‘Point of care' (POC) simulation of MH was performed to evaluate human factors and latent safety threats and test the whole system. We identified that correct personnel did not attend call and no-one is routinely sent to collect blood products (Fig 3). 5) Key stakeholders (transfusion committee, patient safety committee and risk register) supported the initial interventions of development of a new MH algorithm and immediate amendment of personnel alerted by an MH call.
Interventions Measured current practice and developed new algorithm Monitor transfusion audit data
Difficult to maintain 1:1 teaching. Approached groups to deliver larger group teaching on algorithm on departmental study days
Monitor transfusion audit data
Developed e-prescribing ‘care plan’ and mandatory elearning video
VR SIM and algorithm
Wider departmental teaching
1:1 virtual reality simulation combined with ‘tea trolley training’ in 3 ‘high MH frequency’ areas; MAU, SAU and ICU Quantitative and qualitative data collected from participants.
Large group teaching combined with trauma debriefing in partnership with our Trauma Risk Management team to recognise the emotional aspect of learning from MH. Quantitative and qualitative data collected from participants.
Collected quantitative and qualitative feedback from staff
Trained 49 staff across 3 areas with VR sim
Collected quantitative and qualitative feedback from staff
Monitor transfusion audit data
Trust wide teaching with e-learning and e-prescribing package Sustainability of our project required us to develop a trust wide mandatory elearning and e-prescribing package. This cycle is still in development.
Large groups taught in multiple Audit compliance departments such with e-prescribing as urology, and e- learning endoscopy and medicine
Target whole hospital with e- learning and eprescribing
Results and Discussion Initial VR simulation did not produce any significant change in our outcome measure (time taken to initiate transfusion). We were limited to how many people we could train due to our own work pressures. It was clear that to establish real change we needed to target larger groups of staff without disrupting normal working. However our secondary measures (below) improved substantially and qualitative feedback was positive. Staff survey quantitative data from VR training Confidence in managing MH 55%
Knowledge of 'shock pack A’ 63%
Identification of personnel available to collect blood 55%
ICU SHO added to MH call
Knowledge of personnel attending MH call 55%
VR sim
Large group teaching
Staff survey quantitative data from large group training Confidence in managing MH 41%
Knowledge of 'shock pack A’ 79%
Identification of personnel available to collect blood 57%
Knowledge of personnel attending MH call 48%
Fig.4
Whilst this intervention is still ongoing, we will continue to monitor transfusion audit data using SPC chart analysis. Current SPC chart analysis shows a decrease in variation around the mean although no definite shift in practice (fig 4).
Future Plans Future plans include implementing a trust wide mandatory e-learning package to allow this training to be delivered to every staff member. We are also creating an e-prescribing package to reduce time taken to prescribe blood and reduce variation in practice. These strategies will ensure sustainability of the project. Audit data analysis will be taken on by the transfusion team and will be reported to the transfusion committee and patient safety committee.
Acknowledgements We would like to thank Dr Leslie Jordan, Professor Jerry Nolan and Dr Sian Venables
Reducing Neonatal Inequality Does Training Impact Midwives Understanding of Implicit Bias and the Care of Black, Asian and Minority Ethnic Babies? Bea Chubb @Mrs_Chubbs_ Becky Cockings @Becky81RM Emma Symonds @emmasymonds24 Vanessa Heaslip @HeaslipVanessa Janine Valentine
Background In 2021, the MBRRACE-UK report into maternal deaths revealed that there has been no statistically significant change in the disparity of outcomes for black and Asian women since 2014; black women are four times as likely to die, during pregnancy or shortly afterwards, than white women, while Asian women are almost twice as likely to die. Sadly, these disparities continue and affect the babies of black and Asian women. Within the first four weeks of life Asian babies have a 60% higher risk of dying, while black parents are 45% more likely to experience this devastating loss than white parents. Interventions to reduce stillbirth and neonatal death have had more effect on reducing the rates for white families and there are recognised inequalities throughout care in neonatal units with black babies suffering most (Sigurdson, 2019). Knight et al (2021) discussed microaggression and bias as factors contributing to poor outcomes in the UK, similarly in the USA, Suliman (2021) suggested that disparities occur as a result of racism within the care that is provided, not because of the race of mothers and their babies. A 2021 report into maternity training provision indicated that less than a third of UK trusts provide cultural specific training (Ledger et al, 2021) which made the authors reflect on their own training in which exclusively white mannequins were used.
1000 words for £1000 The authors entered a Quality Improvement (QI) competition, ‘1000 words for £1000’- write 1000 words about something that could improve care and win £1000 to put this into practice. We considered all white resuscitation dolls and text books (Mukwende, 2021), alongside non-inclusive language and lack of specific training as barriers to having open conversations and the ability to fully care for all babies – ‘Can’t see, can’t treat’. After winning, we requested the purchase of black resuscitation dolls to adapt training. However, with support from Bournemouth University we were encouraged to take this further and lead a bigger QI project, developing a training package for midwives and evaluating current knowledge, attitudes, and measuring the impact of the training.
“Thank you for this, so valuable - it will make a difference if we all attend!” Midwife 2
Methods
7 Steps of QI
In partnership with the Equality, Diversity and Inclusion lead, a training package was created for midwives. Topics covered include implicit bias, stereotyping and microaggression and the how these can impact care. Alongside this, clinical scenarios were explored, including jaundice, assessment of perfusion at birth and beyond, and reviewing ‘red flag’ advice for parents. By ensuring co-production, including discussions with Somerset Diverse Communities, we were able to present lived experiences of black mothers in maternity care and also ensure this training was culturally sensitive. Anonymous pre and post-training surveys were developed using simple yes or no questions and free text answers to capture basic demographics, baseline understanding pre-training and evaluation of the training and midwives understanding post-training. Descriptive analysis was used for the statistics and thematic analysis was used for the free text answers.
The 7 steps of QI, grounded in theory from the world-renowned Institute for Healthcare Improvement, is the approach utilised within our NHS Foundation Trust and was used in this project. As part of the Plan Do Study Act (PDSA) cycle of the 7 steps we ran a pilot training session to give time to make changes and improvements to both the training package itself and the data collection if required.
“Most valuable training I’ve had in a long time”
Will this training change your practice as a midwife?
Midwife 1
Results
Do you feel that maternity guidelines are supportive and inclusive for all women and babies?
“I feel braver to challenge bad care and racist comments” (post-training)
76.1% of midwives within the trust were trained and positively 98% of midwives will change their practice following training with areas mentioned including documentation, advice to parents and assessment at birth. 42% of midwives said they would now feel confident to challenge stereotypes in practice and would take more time with their care. Similarly, 98% of midwives expressed they had gained new knowledge and understanding from the training. 96% of midwives felt that the APGAR scoring system was not suitable. 100% of midwives indicated that trusts should be doing more to ensure their guidelines are fully inclusive and felt that healthcare settings were impacted by bias. Midwives were asked if they felt there were any differences when assessing babies from different ethnicities, pre-training 46% felt there were no differences compared with 93% recognising these differences post-training. Surprisingly, only 62% of the midwives had heard of implicit bias before the training session. The thematic analysis found three themes, a quote highlighting each has been included Shocked about inequality and impact of bias - “I didn’t realise there was so much inequality” Midwife 4 Positive about change - ”found it really useful and will change my practice in a positive way” Midwife 5 Not ready to accept - “as a mainly white British group it is inevitable” Midwife 6
Midwife 3
Future Practice A key recommendation for practice from this project is that training equipment needs to be representative of the population and while training mannequins alone are not the answer, they do allow a starting point for conversations and understanding. Training, alongside these mannequins for maternity staff must include recognition of the rates of inequality, both for women and babies and impact of bias. Trainers need the knowledge to be able to give evidenced based answers to questions that are raised regarding assessment of babies from black and Asian backgrounds, as recommended by Healthcare Safety Investigation Branch (HSIB) in 2021 following the death of a three-month-old baby. We must consider language used and use of the APGAR scoring system as it stands today and ensure that care provided promotes equity. Continued poor awareness of implicit bias and its subsequent effect on patient safety must be understood to provide families with safe and personalised care (Parker, Corden and Heaton 2011; NHS England, 2016) and work to reduce unacceptable disparities. Maternity units need to look with fresh eyes at their guidelines to ensure they are inclusive, and training and equipment needs to be representative of the population. Following the presentation of this project NHS England and NHS Improvement - South-West have purchased mannequins for all maternity trusts in the SouthWest region which is an exciting first step.
Introduction of an Electronic Handbook and Video Resource for Foundation Doctors in General Surgery Areen Hassan Haleem, Yasmin Jessa, Kristen Medalla, Zhan Ng (Foundation Doctors) Introduction
Results
The transition from medical student to Foundation Year One (FY1) doctor can be challenging, especially in a fast-paced specialty as General Surgery. New FY1s often face a steep learning curve in acquiring ward-based knowledge while providing patient care. The aim of this project was to ease the transition period for new foundation doctors in General Surgery by creating an electronic handbook and video resource for both learning and reference purposes.
We had a 66.7% response rate from the FY1s for both the pre and post intervention surveys (n=6/9). The pre-implementation survey showed half the FY1s (50% n=3/6) did not feel prepared to work on General Surgery. One third of the FY1s (33.3% n=2/6) reported insufficient resources to answer common ward-based questions. Figure 5: Overall level of confidence post-guide The pre-implementation survey was used to identify areas the FY1s highlighted as important. The topics with the highest votes were working a night shift (n=3), preparing a handover sheet (n=3) and the daily SAU schedule .(n=3). All of these topics and more were included in the handbook and video.
Figure 1: Pages from the Electronic Handbook
Methodology
The QIP is designed to continue over one year. Data will be collected every four months to reflect FY1 changeover. The poster highlights data collection from the first set of FY1s. AIM:
Following the pilot introduction of the handbook a post-reference guide feedback form was sent. This showed 100% of the FY1s had (n=4/6 agreed, n=2/6 strongly agreed) improved confidence at work in all ward-based tasks assessed. An improvement in median confidence levels on a 5-point Likert scale was observed in all areas including: working night shifts, clerking patients, preparing handover lists, prescribing medication and fluids, and writing discharge summaries.
To improve efficiency in completing ward-based tasks to subsequently facilitate patient management.
INTERVENTION: Created an electronic handbook and pre-recorded video to provide easy access to important ward-based information.
MEASURED OUTCOMES: Overall FY1 confidence: using pre and post intervention feedback forms Confidence in carrying out specific ward-based tasks and ability to answer ward-based questions Free Text feedback for suggested improvements
Figure 2: Showing Aims, Intervention & Measured Outcomes
We ran three PDSA cycles in-order to create the resources and measure the above-mentioned outcomes. The PDSA cycles are outlined in figure 3 below. PDSA Cycle 1: Identifying the improvement focus.
Figure 6: Confidence improvements in individual tasks
Conclusion
PDSA Cycle 2: Formal Feedback
This QI project highlighted the gap in ward-based information given out to new rotating FY1s and the benefit of having a formal resource to address the issue. We learnt the importance of the multidisciplinary team when developing an information resource. It elucidated the different perspectives of how ward based tasks could be addressed.
PDSA Cycle 3: Evaluating project impact.
Using a free text feedback box expanded the breadth of the qualitative data in developing the project. Additionally, we found WhatsApp to be a more accessible platform to distribute resources and retrieve feedback. Figure 3: Depicts the three PDSA cycles
- Night Shift Guide - Handover List - Daily Schedule - Clerking Processes
- Booking a patient to theatre - Medications - Requesting scans
- Chasing scans - Making Referrals - Discharge summaries - Common bleeps/contacts
Figure 4: Ward-based tasks assessed in pre- and post- intervention questionnaires
Moving forwards there is scope to develop similar resources for other specialities including community-based placements and mandatory FY1 requirements such as the Horus e-Portfolio. This project developed our networking abilities liaising with different members of the surgical team to source out information and time management skills.
Trust Specific Lanyard Flashcards Improving ease of access to trust guidelines amongst junior doctors
Dr Megan Foster, Dr Ryan Beazley
Junior doctors rotate regularly through different hospitals and trusts. We know that guidelines between hospitals differ, which makes keeping up with changes difficult. We recognise that at Musgrove Park Hospital (MPH), juniors are finding the trust approved guidelines difficult to access and understand, resulting in increased use of non-trust guidelines (i.e. google!).
Alterations made to the cards to improve usage: size, content, QR codes. Cards distributed to larger group.
We measured difficulty in both finding and understanding guidelines, rated 1 (easy) to 5 (difficult), alongside the usage of trust/non-trust guidelines per week.
ACT
STUDY
PLAN
DO
Our preliminary survey of 24 F1s found that whilst 100% aimed to use trust guidelines at work, 70% found them difficult to access and 50% found them difficult to understand. This led to the average use of nontrust guidelines 3-4 times per week. Introduction of trust specific lanyard flashcards to 2 F1s, containing 12 topics voted by their peers.
Use of trust vs non-trust guidelines before and after intervention 1. Non-trust guidelines
2. 3.
Trust guidelines
0
2
4
Difficulty rated 1( easy) to 5 (difficult)
1.
4 3
1. For all F1s at MPH to have easily accessible and comprehensive guidelines by August 2022, as voted by pre and post intervention questionnaires. 2. To reduce use of nontrust guidelines to 0-2 times per week by August 2022.
OUTCOMES
Reduction of difficulty in both accessing and understanding guidelines. Increased confidence amongst juniors, as voted by questionnaire. Reduced use of non-trust guidelines from on average 3-4 times/week to 0-2 times/week.
6
Number of times guidelines accessed per week Difficulty in accessing and understanding trust guidelines at MPH
AIMS
2.
WHAT WE LEARNT
Feedback suggested F1s were less likely to use the cards as they were ‘too bulky’ and some included useless information. Questions raised as to the reliability of cards once trust guidelines are updated.
2
NEXT STEPS…
1 0 Difficulty in finding Before cards
Difficulty in understanding After cards
1. Reduce the size of cards and limit information. 2. Include QR codes on each card linking to the most recent guidelines (updated regularly by MPH). 3. Distribute the updated cards to all medical F1s at MPH for PDSA cycle 2.
: The impact of the COVID pandemic on pledge themes made as part of Human Factors training Dr Jennifer Macallan, Mrs Jenny Sutcliffe and Dr Suzi Lomax. SCReaM Team, Royal Surrey County Hospital Introduction & Problems
Plan
Do
In order to provide safe and high-quality care, it is imperative that staff ensure that they look after themselves physiologically and psychologically first.
Continue HF training during the pandemic
Delivery via a virtual platform to enable ongoing training during the pandemic
New structure to enhance interactive discussion about life on the frontline and to improve relevance of self-care to working lives
Alter structure and content of programme for increased short comfort breaks. Relevant self-care content to tailor to need during pandemic. Introduce course expectations to enhance safe
Increased interactive discussion and engagement. Delegates wanting to put learning into practice regarding selfcare, but felt disempowered to. Perception of whether a was acceptable
Identify ways of improving acceptability use pledges to provide staff with an opportunity to e.g. peer examples of selfcare pledges during training and change of approach to self-care as a professional duty
Give delegates
Delegates given peer examples of self-care related pledges. Used a professional duty approach
Some delegates found it more acceptable to undertake self-care based pledges in feedback. Missed opportunities in mentor groups noted by faculty
Use mentor groups to capture opportunities and further enhance acceptability
Smaller breakout groups for pledges with mentors
Increased self-care pledges made on course. Smaller groups enabled delegates to sound out self-care ideas and receive support in planning and actioning
Expand awareness of acceptability of self-care and challenging perception that self-care is a professional duty rather
This has been particularly important during the COVID pandemic. The huge burden of patient care and demands on staff, combined with new ways of working and unpredictability, has perversely meant this self-care has been often overlooked by staff. This leads to burnout & sickness and therefore impacts patient care.
Aims & intervention The SCReaM Human Factors (HF) and Team Resource Management Programme at the Royal Surrey NHS Foundation Trust, as part of its remit, delivers multi-disciplinary Human Factors (HF) training. Part of our SCReaM HF training is ensuring that staff are placed at the centre of patient safety, requiring them to implement self-care as a priority. To empower our delegates to translate their learning into practice, they undertake a pledge after their course - something that they have taken away from our HF training that they wish to try out to improve their working lives. In March 2020, at the start of the pandemic, we aimed to empower staff to recognise and implement ways to improve their physiological and psychological wellbeing. We did this using the for and the previous QI work we had undertaken to
to make the focus of their pledge selfcare Changes to pledge mentor session
translation of learning into practice after classroom training prior to the pandemic.
Change ideas & measures To accomplish this staff empowerment, we developed a number of change ideas and undertook PDSA cycles to adapt and improve delivery of our HF training during the pandemic. We transitioned from a classroom to a virtual format, refreshed both our course content and pledge sessions to increase the translation of self-care related learning into practice.
Study at home with no work interruptions. Several IT issues noted. Difficult to facilitate interactive conversation in virtual environment.
Act Improve frequency of comfort breaks. Improve IT planning & support. Improve interactive discussion relating learning to daily working lives.
Results Number of completed pledges before March 2020: 81 Number of completed pledges after March 2020: 99 We saw more than a five-old increase (5% to 28%) in pledges related to selfcare after March 2020, following implementation of our change ideas.
The measure that we used was the number of completed self-care themed pledges made after each course. We looked at the impact of our change ideas following March 2020.
Lessons learnt Change idea testing has allowed us to set up robust facilitative style HF training virtually, enabling continuation of HF training opportunities during the pandemic. Tailored mentor sessions increase the number and quality of selfcontrol. Giving staff the permission, that they believe to be required, is a priority to change their perception of self-care from Providing past examples of self-care themed pledges gave staff the acceptability that they need to on their own oxygen mask
Next steps Embedding the virtual model of training in the future alongside our classroom training to make HF training more accessible to a wider audience. We aim to empower staff to implement changes related to self-care. By celebrating the positive impact of the changes that people have noticed through their self-care pledges, this -care within the Trust. We have reflected on pledge process and are developing further change ideas to look at barriers to completing pledges, particularly those related to self-care. References available on request
Who can drive home from the hospital? Assessing healthcare professionals’ knowledge and understanding of DVLA guidelines in relation to substance misuse within Greater Manchester secondary care. Aim
To ensure pa5ents with substance misuse and dependency issues are correctly informed of driving safety informa5on as per DVLA guidelines.
Objec5ves
1. To assess and improve healthcare professionals’ knowledge and understanding of DVLA guidelines in rela5on to substance misuse. 2. To improve the recording of driving safety advice for pa5ents with substance misuse and dependency issues on discharge leGers.
Introduc5on and Ra5onale •
In 2019/20, alcohol-specific conditions were accountable for 347,761 hospital admissions in England, (equivalent to 2%).1 Twenty-seven percent of adults living in the North West consume more than the weekly recommended amount, making this the second highest region in England for excessive alcohol consumption.1 Drug use is also increasing in Greater Manchester; over the last decade, there has been a 74% rise in drug related deaths within the region.2 Hospital admission rates for alcohol-related conditions are around 53% higher in Greater Manchester than elsewhere in England.2
•
The DVLA requires individuals with certain medical conditions to self-report, as their ability to drive safely may be affected.3 The General Medical Council (GMC) states that it is a medical practitioner’s responsibility to ensure patients are aware of this requirement.3 The DVLA have published guidance outlining which medical conditions require DVLA notification which includes substance misuse/dependency issues.4 Previous research has demonstrated that there is poor awareness of these guidelines amongst healthcare professionals and patients. 5
•
Although 12 to 15% of all NHS A&E admissions are alcohol related, and drug use amongst adults increasing, previous research conducted has demonstrated a lack of awareness amongst both patients and healthcare professionals regarding the impact of substance misuse on driving safety.5 Although results from papers consistently show that UK doctors’ awareness of DVLA guidelines (in particular in relation to substance misuse/dependency) is limited, very few studies have been published, with many conducted over 5+ years ago. No recent studies, audits or QIPs on this topic have been completed in the North West, although this represents the second highest region for alcohol excess.1
DVLA substance misuse reportable condi5ons • • • • • •
Alcohol misuse Alcohol dependence Alcohol related disorders such as: hepa*c cirrhosis with chronic encephalopathy, alcohol associated psychosis, cogni*ve impairment Alcohol related seizure Drug misuse or dependence Seizure associated with drug use
Do Baseline data and survey results analysed. Initial survey results
Planned future PDSAs
•
Over 90% of healthcare workers have daily/frequent contact with patients with substance issues
•
However almost three-quarters ‘rarely’ • Only 2/60 (~3%) of discharge letters or ‘never’ enquire about driving-status contained driving safety information
•
Case-based questions concerning driving and substance misuse/dependency averaged a 44% incorrect response-rate
Educa5on of pharmacists who check TTOs with aim to flag missing safety informa5on to clinicians
Plan Baseline data collected to determine current practice within AMU with additional survey to establish healthcare workers’ knowledge and understanding of issues.
Baseline data • Over a two month period, 60 patients admitted to AMU had DVLA reportable substance issues
• The information for both letters was in relation to alcohol withdrawal-seizures
First intervention: Departmental teaching
Posters to raise awareness of DVLA guidelines placed near computers in AMU
Second interven5on: WhatsApp messages
Driving safety information question added to electronic discharge proforma
Reminder WhatsApp messages sent on AMU WhatsApp group containing all AMU junior doctors
Proposed interventions for target-group formulated and timeframe over which to deliver (6 months).
Act Reflect upon results and determine effectiveness of intervention and strategize and adjust future interventions.
P D A S
• Departmental teaching not that effective – numerous team members unable to attend. Will likely need repeated refreshers delivered at end of other teaching sessions especially due to rotation of staff. • Group WhatsApp messages able to reach all team members. • Appears more effective in reminding staff to check and document.
Study •
Data collected following each interven5on.
•
Daily acute-take list examined to detect pa5ents admiGed with substance misuse and/or dependency issues.
•
Discharge leGers further inspected to assess for inclusion of driving safety informa5on for those mee5ng DVLA criteria.
First intervention: Departmental teaching • •
Marginal improvement Around 7% of discharge letters contained driving safety information for patients admitted and discharged from AMU over 14 day period
Second intervention: WhatsApp messages
Take home messages
• • • •
Research has demonstrated poor awareness of DVLA guidelines amongst healthcare professionals in relaAon to substance misuse The survey results reflect this and this has translated into poor documentaAon of driving safety informaAon in discharge leEers Although change can be slow and takes Ame and perseverance, text reminders have shown a posiAve improvement Future PDSA cycles are necessary to gain a beEer picture of data overAme to determine which intervenAons are most successful in creaAng change
• •
Data collected over 14 day period. 30% of discharge leGers for pa5ents contained driving safety informa5on for pa5ents discharged from AMU
References 1. Zambon N. 2021. Alcohol statistics: England. House of Commons. 2. Knight, M., 2021. Greater Manchester Drug and Alcohol Strategy. 20192021. 3. Confidentiality, G.M.C., reporting concerns about patients to the DVLA or the DVA: General Medical Council, 2009. Online: www. gmc-uk. org. 4. UK, G., 2018. Assessing fitness to drive: a guide for medical professionals. 5. Collier, A., Watts, M., Ghosh, S., Rice, P. and Dewhurst, N., 2015. Alcohol dependence and driving: knowledge of DVLA regulations. BJPsych bulletin, 39(1), pp.35-38.
ACCESS TO ACCESS
Improving access to ultrasound equipment and ultrasound-guided cannulation training for use in patients with difficult intravenous access DR OLIVER GEORGE, DR GEORGINA SANDERSON, IZZY ELKINGTON, DR THEA MORGAN & DR RICHARD CRAIG
BACKGROUND Peripheral intravenous cannulation is essential for the treatment of many patients in hospital. Establishing intravenous access can be challenging1. Repeated cannulation attempts and subsequent delays in obtaining intravenous access have significant implications for patient safety and experience2,3. Patients with difficult intravenous access are frequently escalated to the anaesthetics team within the trust, forming an appreciable contribution to on call duties. In patients with difficult intravenous access, ultrasound-guided cannulation is associated with increased overall success rates and fewer complications compared to standard techniques3-5.
SCALE OF THE PROBLEM • Difficult intravenous access referrals to the anaesthetics team were surveyed using a two-part form, the first section completed by the referrer and the second by the individual receiving the referral. Initial data collection demonstrated 4.8 cannulation attempts on average prior to referral. • Difficulty obtaining intravenous access was associated with delays to medication administration in 79% of cases (FIGURE 1), this included blood transfusions, intravenous antibiotics and fluid resuscitation. • Further data collection demonstrated that FIGURE 2: ULTRASOUND-GUIDANCE FIGURE 1: ASSOCIATED DELAYS TO FIGURE 3: REASONS FOR NOT ATTEMPTING ATTEMPTED PRIOR TO REFERRAL MEDICATION ADMINISTRATION ULTRASOUND PRIOR TO REFERRAL anaesthetists used ultrasound-guidance techniques in 55% of patient referrals. 80% (16) 31% (5) 31% (5) No 21% (4) • Only 20% of referrers had attempted ultrasound25% (4) guided cannulation prior to referral (FIGURE 2). • Of those that had not attempted ultrasound13% (2) guidance techniques, 31% had not received training, 20% (4) 31% reported that ultrasound equipment was not Yes 79% (15) available and a further 25% reported both lack of Y N training and availability of equipment (FIGURE 3). Not received training
Equipment not available
No training & no equipment
N/A
AIM Reduce delays to intravenous medication administration in patients with difficult intravenous access, and thereby improve patient safety. Our initial results highlight two key areas for improvement: (1) ultrasound equipment availability on the wards and (2) access to ultrasound-guided cannulation training within the trust.
METHOD A driver diagram, as outlined in FIGURE 4, provides a framework to explore factors that influence intravenous medication administration in patients with difficult intravenous access. Access to ultrasound-guidance cannulation training and ultrasound equipment form two of the primary drivers, reflecting the two key areas for improvement identified in our initial data collection. A Plan-Do-Study-Act cycle for establishing ultrasoundguidance cannulation training within the trust is illustrated in FIGURE 5.
AIM
PRIMARY DRIVERS
SECONDARY DRIVERS
CHANGE IDEAS
Assessment
Routine use of intravenous access assessment tool on admission
Documentation & handover
Record alert on patient record
Equipment availability
Increase awareness of equipment availability, locations and sign out processes
Postgraduate training
Purchase new equipment / regular equipment checks and services
Undergraduate training
Ultrasound-guidance training for postgraduates
Multidisciplinary team training
Ultrasound-guidance training for undergraduates
Familiarity with equipment available
Ultrasound-guidance training for Multidisciplinary team
Escalation to senior team members
Opportunities to practice
Referral to anaesthetics team
Referrals process
Identification of patients with difficult intravenous access
Access to ultrasound equipment
Reduce delays to intravenous medication administration in patients with difficult intravenous access Ultrasound-guidance training
Escalation when unable to obtain intravenous access
FIGURE 4: DRIVER DIAGRAM
FIGURE 5: PDSA cycle
ACT Following analysis, we plan to: (1) review the interventions and make adjustments as appropriate, and (2) share the results at relevant clinical governance meetings and with key stakeholders (described previously, see PLAN). STUDY Following completion of further training sessions, we plan to re-analyse difficult intravenous access referrals to the anaesthetic team using the same two-part form as previously and compare these results to baseline. Our main outcome measure is the number of patients with delays to intravenous medication administration due to difficulty establishing intravenous access.
ACT STUDY
PLAN DO
PLAN Using the driver diagram outlined in FIGURE 4, we considered factors that influence ultrasound-guidance training (postgraduate, undergraduate and multidisciplinary team training, and familiarity with equipment available) and identified relevant change ideas. Discussions with key stakeholders included: anaesthetics consultants and trainees, acute medicine consultants, chief nurse, midwives, vascular access practitioners, postgraduate and undergraduate medical education departments. DO Established weekly ultrasound-guidance training drop-in sessions in Swindon academy: • Available to postgraduate trainees, undergraduate medical students, nurses, midwives and Allied Health Professionals across all specialties within the trust. • Portable wireless SONON® 300L ultrasound and standard cannulation model used. • No previous ultrasound experience required; opportunity to practice and develop skills. • Purchasing additional equipment for ultrasound training (cannulation and otherwise); same equipment as available on the wards to ensure transferability of experience.
REFLECTIONS & FUTURE DIRECTIONS • Low response rates to the surveys limited our data collection. Following discussions with the anaesthetics team and colleagues from each division within the trust, we have adapted our forms to improve future engagement. We are also working with the pharmacy team to collect further data from the electronic prescribing systems regarding intravenous medication delays due to lack of intravenous access to guide further PDSA cycles. • Future PDSA cycles aim to focus on improving access to ultrasound equipment for clinical use. As outlined in the driver diagram (FIGURE 4), change ideas include: (1) increasing staff awareness of the current equipment available for ultrasound-guided cannulation within the trust, (2) ensuring consistent availability of equipment and ‘sign out’ processes during the day and out of hours, and (3) purchasing additional equipment as required. • Key learning points from this Quality Improvement Project include liaising with key stakeholders from each division within the trust and forming a business case for the purchase of additional equipment for training purposes. REFERENCES 1. Rodriguez-Calero, M. A. et al. Risk factors for difficult peripheral venous cannulation in hospitalised patients. Protocol for a multicentre case-control study in 48 units of eight public hospitals in Spain. BMJ Open 8, (2018). // 2. Fields, J. M., Piela, N. E. & Ku, B. S. Association between multiple IV attempts and perceived pain levels in the emergency department. J. Vasc. Access 15, 514–518 (2014). // 3. Liu, Y. T., Alsaawi, A. & Bjornsson, H. M. Ultrasound-guided peripheral venous access: a systematic review of randomized-controlled trials. Eur. J. Emerg. Med. 21, 18–23 (2014). // 4. Davis, E. M. et al. Difficult intravenous access in the emergency department: Performance and impact of ultrasound-guided IV insertion performed by nurses. Am. J. Emerg. Med. 46, 539–544 (2021). // 5. Egan, G. et al. Ultrasound guidance for difficult peripheral venous access: systematic review and meta-analysis. Emerg. Med. J. 30, 521–526 (2013).
Virtual On-Call (VOC): Using simulation based teaching to prepare final year medical students for their first on-call shift C. Halevy1, R. Evans1, X. Lee1 King’s College Hospital, London, United Kingdom
1
AIMS
BACKGROUND
The COVID-19 pandemic has had an unprecedented effect on medical education in the past 2 ▻ To adapt an in-hospital simulated teaching program years, affecting 2 cohorts of final-year medical students. In particular, a study completed by Choi to a COVID-safe classroom setting and continue to provide 1, et al found that, on average, 59.3% of the student cohort felt less prepared to start FY1. In equally high-quality teaching. particular, they felt that the postponement or cancellation of student assistantships had the ▻ To improve final year medical students’ confidence largest impact on this. in managing the acutely unwell patient, prioritizing tasks, giving Tolsgaard2 described a framework of “continue, postpone, adapt, drop, and add”, to an effective handover, and knowing how to escalate. consider how aspects of medical education could be changed. Taking this into account, a ‘Virtual On-Call’ simulation session was set-up at King’s College Hospital to develop a COVID-safe environment for in-person teaching. The sessions, facilitated ▻ The level of confidence along with other data was collected by current foundation doctors, allowed final year medical students to experience an using a pre- and post-session feedback form between ‘on-call’ with case-based scenarios. Students were asked to review patient, by means August 2021 and April 2022. of a case file, thus allowing them to consider the management of an acutely unwell ▻ The QI project used the model for improvement methodology, patient. They also had opportunities to learn how to prioritize jobs, along with giving there were 3 PDSA cycles completed within this period. and taking handovers.
METHOD
P D S A
P D
Establishing ‘VIRTUAL ON-CALL’ • Set-up weekly simulation-based teaching sessions facilitated by juniors doctors. • Design feedback form to measure pre- and post- session confidence levels of students • • • •
Introductory talk given at Induction Liaise with PGDME* about attendance Created WhatsApp group for facilitators Created QR codes for easy access *PGMDE: Post-graduate to feedback form department of medical education
LOGISTICAL: • Low uptake of feedback forms • Inconsistent attendance • Difficult punctual 5pm start time TEACHING CONTENT: • Identified out-of-date scenarios/materials OUTCOME MEASURE: • Global improvement in confidence levels
CYCLE 3: Feb 2022 – Apr 2022
CYCLE 2: Nov 2021 – Jan 2022
CYCLE 1: Aug 2021 – Oct 2021
• Continue weekly VOC and feedback collection • Implement changes identified in Cycle 1 • Refresher introductory talk given at induction • Changes implemented from Cycle 1
S
LOGISTICAL: • Improved feedback uptake and attendance • Difficulties with facilitator engagement TEACHING CONTENT: • Students wanted formal handover teaching OUTCOME MEASURE: • Nil adverse impact on confidence levels from changes implemented
A
LOGISTICAL: • Email sent to foundation/IMT doctors for recruitment, with certificate incentive TEACHING CONTENT: • SBAR handover teaching at start of sessions implemented
LOGISTICAL: • QR code re-displayed with weekly WhatsApp reminders • PGDME staff to send weekly reminders • Start time moved to 5.15pm TEACHING CONTENT: • Updated scenarios with up-to-date clinical guidelines
“
RESULTS AND DISCUSSION
P D
• Refresher introductory talk given at induction • Changes implemented from Cycle 2
S
LOGISTICAL: • Difficulty with real-time communication between facilitators/students TEACHING CONTENT: • Students wanted takeaway written material to support teaching given OUTCOME MEASURE: • Continue overall improvement in confidence as reported by students
A
LOGISTICAL: • Virtual Noticeboard created to facilitate communication for real-time logistics changes TEACHING CONTENT: • A4 summary document drafted about SBAR handovers, job prioritization.
"Some of the notes could be replaced/information has worn off
“
• Continue weekly VOC and feedback collection • Implement changes identified in Cycle 2
We had great facilitators who ran the session well and had great tips for us. I found having done the on-call session a second time I felt better and more confident.
Pre-VOC session
“
[I would like] More practical advice e.g. how to contact colleagues, chain of escalation, writing a jobs list
Post-VOC session
Each question asked the students to rank their confidence in that particular skill on a scale of: ‘very unconfident’, ‘unconfident’, ‘neutral’, ‘confident’ or ‘very confident’. These answers were then allocated a numerical values from -2 to 2 respectively. An average was taken pre- and post- session for each cycle of students to demonstrate the trend and allow comparison from cycle to cycle. Results demonstrated consistent improvement in confidence across all aspects. Due to the small number of students involved, it is difficult to prove statistical significance. Free-text answers also provided qualitative data and specified teaching content feedback.
WHAT WENT WELL:
• We were able to identify and adapt teaching content to student feedback, allowing appreciation of: ▻ Autonomy of managing simulated patient scenarios ▻ Reviewing practical aspects of on-call logistics with facilitators ▻ Effective handover techniques • Effective use of technology to improve ease of organization and access to teaching materials/feedback
AREAS TO IMPROVE:
• Communication between VOC leadership team, facilitators, PGDME, and students to relay realtime logistical challenges and unforeseen delays • Identifying methods to ensure consistent facilitator engagement across the year • Feedback was student-focused, there is a gap for facilitators to feedback on barriers to effective teaching delivery
NEXT STEPS: Introduce a feedback form for facilitators to identify barriers to delivery of teaching Set-up real-time communication platform to triage logistical issues
Post COVID/ COVID-safe reintegration into hospital setting PDSA 4: Formal handout sheet for distribution post-session (SBAR handover, prioritization)
References: 1) Choi, B., Jegatheeswaran, L., Minocha, A., Alhilani, M., Nakhoul, M. and Mutengesa, E., 2020. The impact of the COVID-19 pandemic on final year medical students in the United Kingdom: a national survey. BMC Medical Education, 20(1). 2) Tolsgaard, M., Cleland, J., Wilkinson, T. and Ellaway, R., 2020. How we make choices and sacrifices in medical education during the COVID-19 pandemic. Medical Teacher, 42(7), pp.741-743.