BPSC2022 Poster Group F - QI in Progress - Flow and efficiency by munglani

18th May 2022 Poster Competition Group F QI in Progress Flow and efficiency

#GHCQI

COMMUNITY THERAPISTS IDENTIFYING AND ESCALATING THE DETERIORATING PATIENT APPROPRIATELY K. GREAVES, L. LANGFORD, J.SMITH

BACKGROUND • ↑ Acuity of patients seen within Integrated Community Teams (ICTs), particularly on Home First (HF) pathway – further exacerbated by Covid-19 pandemic. ICTs have NO direct line of medical support. • Staff reporting lack of confidence and competence in identifying deteriorating patients. • ICT therapists have varying levels of competency or provision of kit to undertake Clinical Observations (CO). • No local escalation policy for community therapists to follow to highlight a deteriorating patient, resulting in varying response / wait times for medical advice/assistance.

AIM Specific: For Band 4+ Forest ICT therapy staff (HF & Referral Centre) to be competent in recognising a deteriorating patient and escalate appropriately for a prompt response from supporting services. Measurable: HF and referral centre visits to have a full set of CO taken and recorded. Realistic/relevance: Need identified by staff due to reduced confidence and competence. Time: End Dec 2021 (countywide June 2022).

MEASUREMENT 1. Clinician competency - % of clinical visits with NEWS2 completed

2. Appropriate escalation pathway - % of visits followed agreed escalation pathway

PDSA CYCLES

PLAN

• Bespoke • therapist CO 1 training • • Competency sign off • Regular • communication 2 with teams / key stakeholders • Data collection • 3

ACT

STUDY

CO mandated for all visits Follow set escalation pathway

• +ve staff feedback • 67% CO compliance • 89% followed escalation pathway – clinically reasoned if not followed Modification to escalation • Drop in CO compliance – 40% pathway • 90% followed escalation – proactive community Rx & no adverse outcomes CO mandated for initial • CO Compliance ↑ 84% visits only • 98% followed escalation

LESSONS LEARNT • Providing CO training and clear escalation pathway provides benefits to staff and patients. • Internal escalation pathway has enhanced MDT working within ICTs and Rapid Response. • Evidence of earlier identification of deteriorating patients, leading to proactive community treatment and potential admission avoidance. • Reduced response times for clinical support by using the right person at the right time.

Amend Low / Medium risk classification on escalation pathway

Amend when to mandate taking CO to support clinical autonomy Test in another locality

NEXT STEPS • • • •

Upscale to all ICTS within Gloucestershire. Embed within therapist training matrix. Capture future data within Trust’s NEWS2 audit. Build on collaborative working with Urgent Care Directorate. • Review need and benefit of advancing practice roles for therapists. ACKNOWLEDGEMENTS CORE project group - J.Jenkins; K.Roberts; C.Andrews; A.Wadley; S.Manssuer; M.Tippins; A.Willan, T.King, Forest of Dean Therapy Team, Training & Development Team – S.Haile, C.Hodges, Rapid Response Team.

Arabic Language Prompts to Facilitate Triage Dr. Lasith Ranasinghe, Dr. Zaid Alsafi, Dr. Aruni Mathyalakan Background Language barriers in healthcare result in miscommunication between medicalprofessionals and patients. This can affect patient satisfaction and quality of care. This is particularly important in the emergency department triage setting, where the initial assessment determines the urgency with which the patient will be managed.

How many times do you need a translator for an Arabic-speaking patient during a triage shift?

Triaging exclusively Arabic-speaking patients takes longer than English-speaking patients.

13%

12%

25% 63%

87%

0-1 times

2-4 times

5-7 times

Disagree

Agree

Strongly Agree

Objectives To assess the impact of an Arabic triage sheet on the perceived efficiency of the triage process.

Methods Questionnaires were sent to triage staff and Arabic-speaking members of staff to gauge the effectiveness of current methods used to triage Arabic-speaking patients, and the disruptions to clinical practice and training caused by the pressure placed on Arabic-speaking members of staff to interpret on an ad hoc basis. An Arabic triage sheet containing pictorial depictions of common clinical presentations with the terms written in English and Arabic was then designed and made available in all A&E triage rooms at St. Mary’s Hospital. After a study period of 2 weeks, surveys were issued to triage staff to qualitatively assess the impact of the intervention on the triage process.

Results 87.5% of triage staff said they encounter an exclusively Arabicspeaking patient 2-4 times per shift, with 12.5% reporting 5-7 times per shift. 87.5% agreed that triaging Arabic-speakers is significantly slower than triaging English-speakers. Methods employed to communicate include language line, Arabicspeaking staff, family and online translation tools. The majority of Arabic-speaking staff reported that their clinical work is disrupted by having to act as an ad hoc interpreter. Following the introduction of the triage sheet, 100% of triage staff agreed that it made the triage process more efficient.

How useful did you find the Arabic Triage Sheet in facilitating your assessment of an Arabic-speaking patient in triage?

17%

83%

Somewhat Useful

Very Useful

Discussion Despite not being a replacement for a thorough clinical history, an Arabic language triage sheet helped streamline the triage process and ease the pressure on Arabic-speaking members of staff. This model can be applied in other settings where an A&E department caters to a significant minority of non-English speakers.

Dishonourably Discharged? Improving timely sending of discharge summaries at the Royal Devon & Exeter (RD&E) Hospital Royal Devon & Exeter Hospital: Dr Luke Glover, Dr Simon Brackley, Dr Lucy Andrews, Dr Georgia Wright, Dr Lauren Eddy, Dr Miles Edwards, Dr Riordan Deehan Jackson, Dr Smruthy Chakka

Understanding the Problem & Setting our Aim Discharge summaries are vital for ongoing patient care and often contain important tasks for GPs (Abrashkin et al 2012) Delayed sending creates additional workload for GPs, hospital doctors and administrative staff and risks patient safety (Kripilani et al 2007) At our hospital, we have had numerous complaints regarding the impact of delayed discharge summaries on patient care We aimed to increase the percentage of discharge summaries sent to GPs within 2 working days to 90% across all departments by 14th July 2022

Setting up Measurements 0) to present 22.6% of discharge summaries (12965/57367) were not sent within 2 working days We stratified these unsent summaries by location, specialty, discharge method, day of week and hour of day in order to target our tests of change

Figure 1: summaries (DCS) sent within 2 working days from 76% to 87%, although unmeasured at the time.

Figure 2: One example of the powerful nature of our data collection in this case the ability to see how many discharge summaries are not sent within 2 days by each hospital specialty.

Discharges as Deceased

Patient Lists

Cycle 1: Creating a "culture of completion" Intervention We engaged the medical

Cycle 1: Colorectal Intervention - Changing use of "lists" by colorectal doctors to include discharged patients with unsent paperwork within 30 days

problem, issued them a poster and asked that they encourage junior doctors to send RIP summaries at the time of writing death certificates

Result - 6 week increase in completion within 2 working days of deceased discharge from 50-80% (run chart below - intervention at red line)

Automated Sending 75% of delayed summaries are signed but waiting for the final administrative step of clicking send It represents the largest potential area of improvement

Result - We realised our initial data collection didn't allow sole measurement of colorectal discharges. We also had poor take-up. We were grateful for starting on a small scale and learnt from this for our next cycle Cycle 2: Respiratory Intervention Learning from cycle 1, we targeted a respiratory ward (where our data allowed measurement) and engaged all doctors on the ward Result - Though we now had 100% uptake, the intervention has as of now had no effect (run chart below change at red line)

Engaging with Trust Plan - Implement trust-wide changes to our EPR so summaries automatically send to the GP when signed

Result - We thought this was in process, but meeting the trust's digital fellow, found that little progress had been made What we learnt - Implementing change is difficult, with multiple factors at play. Early MDT support is critical What we learnt - with the right approach there is the capacity to meet our target. "Soft interventions" like posters have temporary effects as their initial impact diminishes Plan for Cycle 2: Our next intervention must be more robust. We plan to practically automate creation of deceased discharge summaries and have begun discussions with the ME's team

Engaging Stakeholders Intervention - We attended two trust taskforce meetings where we presented our data & reasoning for the change

What we learnt - We asked the respiratory doctors who were ambivalent about using the changed list. We must make sure our next intervention is not perceived to increase work. Our cycle also coincided with changeover of doctors to different teams

Result - We have the support of significant members of the medical staff and consultant body Future plan: Pushing change requires careful thought about who is affected (patients and staff). After further consultation we hope to make this software change and measure its effect on a day-by-day basis

Discussion and Next Steps Our major advantage in this project is the extremely detailed continuous measurement we have managed to create and analyse By engaging with stakeholders, we can combine the subjective feedback with the above data to target our tests of change It is a big problem to tackle. Our parallel approaches to target different aspects, combined with small tests of change and learning from previous cycles gives us confidence in achieving our aim There are multiple considerations for future cycles that we have learnt: the rotation of healthcare staff during testing (and later implementation), the balancing measures that need to be considered (e.g. workload in midst of a pandemic) and the importance of early MDT involvement and communication Our Pareto chart suggests our most powerful change may be through targeting the signed unsent summaries, with the potential to exceed our target. We are currently in discussion with groups across the trust to make this happen

CWTCH in the community - Improving education to reduce adverse outcomes for patients who fall in Nursing Homes (NH). A.J. Burgess1; D. Clee1; E.A. Davies1; D.J. Burberry1; L. Keen2 1. Older Person’s Assessment Service (OPAS), Morriston Hospital, Swansea Bay University Health Board (SBUHB) 2. Welsh Ambulance Service NHS Trust (WAST).

Introduction Falls have significant morbidity and mortality and these are more common and more likely to cause significant harm in NH residents. We have proposed that by improving education to NH staff, we can reduce the amount of 999 calls and reduce adverse patient outcomes. NH residents are more at risk of further falls as interventions and risk factor modification is more difficult. Intervention Phase 1 We looked at the NH in SBUHB (Swansea and Neath) and all 999 calls between 1st Jan 2020 to 28th Feb 2022 where an Emergency Ambulance vehicle attended the scene. We looked at calls coded as Falls and could be Falls+ (Sick person, trauma injuries, convulsions/ fitting, Haemorrhage/lacerations,fainting). A survey was sent out to NH to see how the staff treated falls. Phase 2 ENP/SpR delivered an education package to NH staff members encouraging staff to consider CWTCH • Can we move them • Will it harm them? (neck pain, back pain), • Treat them – pain relief, dressing wounds • Can – eat & drink • Help – when to call 999). A survey was then performed showing whether staff felt more confident post intervention and whether this would change their practice. Results Phase 1 4907 calls were made, 866 were coded as falls (17.65%), 1032 were potential falls (21.07%). Over the COVID-19 pandemic the calls for falls were higher than for COVID-19 (Graph 1). Of all calls, 60.45% were conveyed to hospital, 13.50% treated at scene, 26.05% referred to GP/ alternative services. The questionnaire showed 47% of NH do not have falls guidelines, all patients are kept Nil by Mouth & 88.24% of fallers are not moved. Emergency services are contacted 88.24% of the time. Phase 2 Education was delivered to all NH in Swansea (122 staff). Feedback showed 100% feel more confident in giving food and drink, moving patients and all found the session helpful with 90.98% less likely to contact 999. There is a clear educational need as 75.40% had not received prior training. RE analgesia, 96.72 % feel more confident but comments from staff felt that this could be improved upon. Conclusion Falls remain a significant burden on WAST and ED, with opportunity to reduce morbidity and mortality. NH do not have adequate procedures and a rapid falls intervention could have an impact as 39.55% patients remained at scene. Future directions include delivering the education package to all NH in SBUHB. OPAS at Morriston Hospital offer same day assessment for NH residents via GPs and is collaborating with WAST to provide a rapid response for falls and minor injuries in the community. We are working with local GP’s about providing PRN analgesia e.g. PENTHROX for fallers.

Streamlining electronic venous thromboembolism (VTE) risk assessments and enhancing safe prescribing in acute admission units. Hui Mei Wong, Foundation Year 1 Doctor, Whittington Hospital

Introduction: Venous thromboembolism (VTE) accounts for about 5-10% of deaths in hospitalized patients and causes significant morbidity in non-fatal cases. In response to this, a key NHS quality requirement is to assess for venous thromboembolism (VTE) risk in 95% of all inpatients aged 16 and above.1 In the 2020/2021 year, the Whittington Hospital did not achieve this requirement and it was a priority for the Trust to increase VTE risk assessment compliance to a national standard of 95%. The Whittington Hospital uses an almost fully electronic system comprising multiple different online platforms; this includes the VTE risk assessment form, which is audited annually to assess whether the trust meets national quality requirements. All medical documentation including clerking and post take ward round proformas are recorded on CAREFLOW*, electronic prescribing is done on JAC* and the VTE risk assessment form is done on ICE*. Hence, for the clerking doctor to admit the patient and complete VTE risk assessment and prescribing, they would have to open three separate systems. This is inefficient and ill-suited to a busy admissions shift and allows for multiple gaps where human errors can occur, compromising patient safety (eg: forgetting to prescribe VTE prophylaxis or prescribing inappropriate VTE prophylaxis.) (*These acronyms are various brand names of electronic software)

Insights and feedback from the preintervention questionnaire •

• •

An anonymous, online questionnaire was distributed to doctors of all grades within the Trust via a generic mailing list. This questionnaire was also flagged up during a Foundation School teaching session. 19 doctors responded to this questionnaire. 73.7% of respondents reported that they did not find the separate VTE risk assessment form useful 89.4% of respondents reported that they do not regularly complete the separate VTE risk assessment form

Aim: The primary aim is to increase uptake of mandatory VTE risk assessments to the national target of 95% within one acute medical admissions unit and one acute surgical admission unit. The secondary aim is to increase the number of appropriate VTE prophylaxis prescribing. Method: Pre-intervention data was also collected for a week prior to the first intervention for baseline data. Feedback was also collected via a questionnaire regarding the existing VTE risk assessment system on ICE to identify key issues and to gather suggestions on how to further improve the current system.

Image 2: Integrated risk assessment form on proforma

QIP data was collected from each Wednesday and Friday over 18 weeks (11/8/2021-17/12/2021) to quantify the number of VTE risk assessment forms completed and the number of VTE prophylaxis prescriptions completed. VTE prophylaxis prescriptions were also assessed to check if the prescription was appropriate for renal function, weight or if the patient was already on other anticoagulation therapy. PREINTERVENTION DATA Assessments completed

20%

% complete prescriptions

76%

% appropriate prescriptions

88%

ACT: Intervention did not improve assessments; did not circumvent issue of multiple systems/forgetting to complete form STUDY: n=186 11/8/2021-27/9/2021 Assessments completed

18.3%

% complete prescriptions

72.0%

% appropriate prescriptions

88.2%

Image 1: 2 mandatory ‘tick box’ prompts on CAREFLOW proforma

ACT: Slight improvement but still below target of 95% assessments; did not circumvent issue of having multiple systems

PLAN: Raise awareness through mandatory Foundation teaching session

1 DO: 11/8/2021

Anticoagulation teaching session and how to access the risk assessment form was carried out

STUDY: n=196 28/9/2021-14/11/2021 Assessments completed

32.7%

% complete prescriptions

74.0%

% appropriate prescriptions

89.3%

PLAN: Include 2 mandatory ‘tick box’ prompts on clerking/Post Take proforma (Image 1) 28/9/2021 2DO: Modified version of the

ACT: Significant improvement in completed assessments but still below target as only implemented in Medical proformas

PLAN: Integrate VTE risk assessment form into the MEDICAL clerking/post take proforma (Image 2)

3 DO: 15/11/2021

STUDY: n=95 CAREFLOW clerking/post 15/11/2021-7/12/2021 Assessments 77.9% take proforma was released to include these completed % complete 71.6% prompts: Q1: Has VTE prescriptions assessment been % appropriate 82.1% completed? (Yes/No); prescriptions Q2: Has VTE prophylaxis been prescribed? (Yes/No)

RESULTS:

Medical CAREFLOW proformas was modified to include VTE risk assessment form. ICE risk assessment form no longer in use.

ACT: Significant improvement in completed assessment; but still below national target of 95%.

PLAN: Integrate VTE risk assessment form into both MEDICAL & SURGICAL clerking/post take proforma

STUDY: n=69 DO: 8/12/2021 8/12/2021-17/12/2021 Surgical CAREFLOW Assessments 85.5% proformas was modified completed to include VTE risk % complete 84.1% assessment form. prescriptions

% appropriate prescriptions

95.7%

Medical Admissions Unit

COMBINED DATA FROM ACUTE MEDICAL AND SURGICAL UNITS 100%

100%

90% 80%

90%

70% 60%

80%

50% 40% 30%

70%

20% 10% 60%

09 /0 8/ 20 21 16 /0 8/ 20 21 23 /0 8/ 20 21 30 /0 8/ 20 21 06 /0 9/ 20 21 13 /0 9/ 20 21 20 /0 9/ 20 21 27 /0 9/ 20 21 04 /1 0/ 20 21 11 /1 0/ 20 21 18 /1 0/ 20 21 25 /1 0/ 20 21 01 /1 1/ 20 21 08 /1 1/ 20 21 15 /1 1/ 20 21 22 /1 1/ 20 21 29 /1 1/ 20 21 06 /1 2/ 20 21 13 /1 2/ 20 21

50%

% complet ed risk assessment form 40%

% VTE prophy laxis prescribed

% appropriate presciption

Surgical admissions unit 100% 90%

30%

80% 70% 20%

60% 50% 40%

10%

30%

13 /1 2/ 20 21

06 /1 2/ 20 21

29 /1 1/ 20 21

22 /1 1/ 20 21

15 /1 1/ 20 21

08 /1 1/ 20 21

01 /1 1/ 20 21

25 /1 0/ 20 21

% VTE prophy laxis prescribed

% appropriate presciption

% complet ed risk assessment form

18 /1 0/ 20 21

11 /1 0/ 20 21

04 /1 0/ 20 21

27 /0 9/ 20 21

20 /0 9/ 20 21

13 /0 9/ 20 21

06 /0 9/ 20 21

30 /0 8/ 20 21

23 /0 8/ 20 21

10% 16 /0 8/ 20 21

0% 09 /0 8/ 20 21

20%

% complet ed risk assessment form

1ST INTERVENTION: TEACHING

2ND INTERVENTION: TICKBOX PROMPT

CONCLUSION AND KEY LEARNING POINTS Streamlining systems and integrating the VTE risk assessment tool into the clerking and post take proforma improves overall patient care by enhancing appropriate VTE prophylaxis prescription. Following the 4 PDSA cycles, the overall VTE assessment improved from 20.0% to 85.5%. The overall appropriate prescription of VTE prophylaxis increased from 88.0% to 95.7%.

3RD

INTERVENTION: INTEGRATION OF FORM (MEDICAL ONLY)

% VTE prophy laxis prescribed

% appropriate presciption

4TH

INTERVENTION: INTEGRATION OF FORM (MEDICAL & SURGICAL)

1ST INTERVENTION: TEACHING

2ND INTERVENTION: TICKBOX PROMPT

3RD INTERVENTION: INTEGRATION OF FORM (MEDICAL ONLY)

4TH INTERVENTION: INTEGRATION OF FORM (MEDICAL & SURGICAL)

FOOD FOR THOUGHT: A WORK IN PROGRESS - This QIP focuses on the medical and surgical acute admission units where patients are referred from ED and clerked by the Take team.

Patients who are admitted onto these wards via other routes such as elective surgery, day cases or through maternity use separate proformas and the risk assessment tool has not been integrated in this. Modifying these proformas may help to further improve risk assessments to the target of 95%. The integrated risk assessment tool could also include other elements such as patient’s weight & eGFR to enhance safe VTE prophylaxis prescribing. However, the benefits of this must be balanced against creating an inefficient, ‘over bloated’ proforma. The final intervention should be re-audited to see if the improvements in VTE risk assessment and prescription are sustained after a longer period of time.

Reference: 1. NHS Standard Contract Team (2019) NHS Standard Contract 2019/20 Technical Guidance [PDF] https://www.england.nhs.uk/wp-content/uploads/2019/03/8-NHS-Standard-Contract-Technical-Guidance-1920-v1.pdf

“Anyone know how to refer to... ?!”: Improving ease of referral pathways at Homerton University Hospital Dr Nadia Eden1, Dr Mishka Venables1

INTRODUCTION: A large part of medical practice is making sure patients are referred to the appropriate speciality in a timely manner. Difficulties in accessing those specialties can lead to delayed diagnoses, prolonged hospital stays and generally a poorer outcome for patients. When we first started as F1s at Homerton University Hospital (HUH), a busy central London teaching hospital, we soon realised that there was no single point of access to find out how to refer to a specialty and that there were several different methods of referral and the only way to find out was through word of mouth. AIM: to improve the process and ease of referring to specialties by 25% by August 2021

Cycle 1

RESULTS of SURVEY: • The survey found that all doctors referred at least once a week and 50% of those were referring once a day. • On a scale of 1 to 10, 44.8% of doctors rated the difficulty in referring as a ≤5, (with 10 being extremely challenging).

METHODOLOGY: Plan: to identify patterns and barriers to referral, preferred referral pathways and suggestions for improvement

Act: an online referral directory (see Fig 1) was created and distributed via the intranet, email, Whatsapp, F1 Induction talk and included in the updated Acute Care handbook

Feedback and suggestions of the current referral systems:

Do: We designed a qualitative and quantitative survey as a Google Form and distributed it to all the doctors in the hospital via email

• There was a fairly even distribution of preferences for the 8 different ways of referring: • Neurology, ENT and Vascular were reported to be the most difficult specialties to refer to • The process of referring to these specialties at HUH is via paper ‘Yellow Boards’ or a phone call, neither of which are in the top three preferred methods of referring.

Study: 50% indicated that they would prefer a single unifying method of referring to specialties The other 50% all suggested electronic methods of referring

Figure 1

DRIVER DIAGRAM: to help formulate Act section of PDSA Cycle 1

”a document on how to refer to each specialty” Please feel free to scan to access our referral directory!

“It would be easier if there was one referral system for all specialties”

“Significant stress and ping pong process. Very stressful as unable to provide cleat timeline or clarification to patients.”

Cycle 2 METHODOLOGY:

Plan: To evaluate the effect of the referral directory and their experience of using it

Act: To convert the directory into a mobile phone app available to all doctors for free to improve ease of access to the directory (currently in progress)

Do: We sent a follow-up survey asking for people’s opinions on the directory i.e. how much it has helped them/suggestions for improvement

Study: 82.3% rated the directory 4 or above out of 5 for ease of use. Most common improvement suggestion was regarding ease of access to the directory.

RESULTS/REFLECTIONS: • The improvement in ease of referral went up by 8.2% (from 44.8% to 53% scoring ≤5, with 10 being extremely challenging) with the implementation of the referral directory • 82.3% rated the directory ≥4 out of 5 for ease of use • 88.2% used the directory when they were unsure how to refer • We did not reach our 25% improvement target, likely due to multiple factors as follows: o Access to the directory Ø 82.4% were aware of the directory however, feedback on the survey showed there is still room for improvement: o Phrasing/scaling of survey questions Ø Our key question for measuring the outcome: “On a scale of 1-10, 10 being extremely challenging, how easy do you find referring to a different specialty? o Poorer response rate for 2nd survey Ø 40 people responded to the 1st survey and only 17 to the 2nd one Ease of Referring 54.00% 52.00% 50.00%

"It’s amazing!! So so helpful, thank you for making it"

"Excellent resource! Hugely helpful!"

Feedback from Cycle 2 Survey "More easily available i.e. intranet or S drive. Could be a good app"

48.00% 46.00% 44.00% 42.00% 40.00%

"Added to more place and posters around the hospital"

Cycle 1

Cycle 2

% of doctors that rated the difficulty of referring </ to 5 (with 10 being extremely challenging)

CONCLUSION/NEXT STEPS: • We did not meet our target of improving the process and ease of referring by 25% • According to our survey, the next steps to try and achieve this would be improving access to the directory • We are looking into creating an app to be ready to use in time for the new starters in August 2022

Responsible Clinician Documentation in General Surgery: can we do better? H Shaikh, E Zarook, A De Zanna, S McCluney Introduction At Whipps Cross Hospital, every patient should have the correct named consultant for the appropriate encounter on CRS. This reduces inappropriate workload, helps to ensure investigation results are actioned by the correct person, it means other health professionals are aware of the correct team to contact, and is essential for appropriate clinic follow up on discharge. All of these relate to patient care and are important for patient safety.

Aims and methodology The Surgical Access list is updated at least daily and reflects the most accurate method of determining which general surgical (GS) patients are admitted under which consultant. This is often not reflected on CRS and can affect patient care as described above. We compared the surgical access list to CRS for any given week. Data collected between 9th to 16th June showed that only 76% of GS in-patients had the correct responsible consultant named on CRS. Our aim was to improve this to 100%.

Continue to collect data, continue to educate juniors rotating onto general surgery about ensuring named consultant surgeon is correct

Identify barriers to the correct responsible surgeon being named on clinical documentation – noted that mainly errors were occurring from patients admitted through ED

Collected data at two to four monthly intervals to see if improvements in percentage of correct responsible surgical clinicians made and sustained

Liaised with Switchboard, ED matron, rota-coordinator and junior doctors, emphasis on ensuring the day consultant was the admitting consultant throughout the on-call week

Results Week beginning 9th June: 76% correct Post intervention, week beginning 28th June: 100% correct Intervention repeated after junior doctors rotated to ensure they were aware of how to change named consultant if incorrect on CRS Week beginning 2nd December: 89% correct

Percentage of correct named general surgical consultants 100

0 Jun-21

Jul-21

Pre-intervention, 76% correct

Aug-21

Sep-21

Oct-21

Immediately post intervention, 100% correct

Nov-21

Dec-21

Five months post first intervention, 89% correct

Reflections and further work Communication between the surgical department and other departments including ED and medical staffing is key to ensure good handover and accurate responsible clinician documentation. As junior doctors rotate through the specialty, it is important for them to be informed about ensuring each ward patient has the correct surgical consultant on CRS, and how to change this if incorrect. Further QI projects to check percentage of correct named consultants, to review if named consultant on discharge is correct and if not, impact on clinic follow up/ follow-up investigations.

Developing GP led Same Day Emergency Care (SDEC) in a District General Hospital Dr Louisa Morris, General Practitioner and Clinical Lead for Quality Improvement, Prince Philip Hospital, Llanelli. Louisa.morris@wales.nhs.uk

Aims and Drivers

Introduction • • • • •

Prince Philip Hospital (PPH) Llanelli is a 223 bed DGH within Hywel Dda University Health Board. PPH ‘Front of House’ consists of Acute Medical Assessment Unit (AMAU) and GP led Minor Injuries Unit (MIU). Pressures on existing services were analysed using retrospective data collection from Feb 19Feb20 (pre COVID-19)1 New challenges Mar 20 onwards resulting from COVID-19 and social distancing requirements. Medical Same Day Emergency Care (SDEC) proposed in order to address current pressures and improve patient care.

Methodology • • • • • • • • • • • • • •

Business case (Oct20) for pilot funding from Welsh Government (WAG) until 31 Mar 21. HB continued funding thereafter. Engagement with key stakeholders. Initial location & staffing model agreed. GP led model agreed. Patient selection based on clinical conversation, AMB3 score / NEWS4 score and set pathways. PDSA 1: Phase 1 pilot: 16-19 Nov 20 (8 hrs/day Mon-Fri). PDSA 2: Phase 2 pilot: 7 Dec 20 – ongoing (10hrs/day Mon-Fri). PDSA 3: Initial pathway based model moved to a process based model with defined exclusions. Patient feedback via central service accessed by QR code. Planned next PDSA cycles: PDSA 4: Introduction of Advanced Nurse Practitioner (ANP) from Apr 22. PDSA 5: Publicity campaign aimed at key stakeholders e.g. Primary Care / Ambulance / 111 PDSA 6: initial triage of all medical referrals to hospital by SDEC clinician.

Primary Aim: Reduce Medical

Admissions by 30%

Primary Drivers:

Secondary Aims:-

Reduce Overcrowding in Hospital.

Discharge from SDEC within 4 hrs. Admit less than 10% of total seen in SDEC.

• 1. Phase 1 pilot (Nov 20) • 2. Phase 2 (Dec 20) • 3. Process based model (May 21) • 4. Introduction of ANP (planned April 22) • 5. Publicity camp

Community management where possible Improve patient experience

• 1. Open 8hrs/day • 2. Open 10 hrs/ day • 3. Exclusions rather than inclusions

Plan

Act

Study

• 1. Change opening hours. • 2. Maintain new hours. • Planned PDSA 4/5/6

• 1. Data analysis • 2. Data analysis • 3. Data analysis

Conclusions • • • • • • • Median

• 80%

• 60%

PDSA 2

Rapid access to investigations

Welsh National Metrics for Ambulatory Emergency Care were used to set aims2

From 5 April 21- 4 April 22 (Q1-Q4): • Total patients seen in SDEC = 1098 • Average proportion of acute medical take seen in SDEC over 24 hr period 21.2% (see Fig 1) - Q1: 17.1 % - Q2: 16.2% - Q3: 18.3% - Q4: 31.1% • Average acute medical take seen in SDEC during hours of operation 36.51% -Q1: 30.6% -Q2: 28.0% -Q3 30.7% -Q4 53.7% • On average 96% of patients were discharged on the same day. • Average length of stay was 160 min. • Most discharged with no follow-up. Other exit strategies are GP follow-up/ Hot Clinic / OPD / Acute Response. • Patient feedback has been 100% positive to date with staff feedback overwhelmingly positive.

PDSA 1

Early senior doctor review

Stream patients away from front door

Results

100%

Secondary Drivers:-

PDSA3

SDEC is currently operating in line with national metrics. Progress hindered and data skewed by recruitment issues and COVID related sickness leading to frequent short notice closures and interruption to service. Possible missed opportunities identified including: default referral to medical team patients arriving outside SDEC hours those with length of stay < 24/48/72 hrs. Numbers steadily increasing as service beds in. Not possible to draw conclusions relating to influence of SDEC on overall inpatient length of stay due to variability in admissions data over last 18 months. Ongoing PDSA cycles include the introduction of an ANP from April 22 followed by a poster based publicity campaign and complete triage of all medical referrals. Need to focus on PROMS as the central feedback service ( accessed via QR code) has yielded low numbers. Nationally SDEC is now an integral part of Urgent and Emergency Care plan.5 Next steps include a business case for ongoing funding for a proposed 12 hr / 7 day service however staffing is a significant challenge in current 5 day service.

40%

20%

10/5/2020 10/12/2020 10/19/2020 10/26/2020 11/2/2020 11/9/2020 11/16/2020 11/23/2020 11/30/2020 12/7/2020 12/14/2020 12/21/2020 12/28/2020 1/4/2021 1/11/2021 1/18/2021 1/25/2021 2/1/2021 2/8/2021 2/15/2021 2/22/2021 3/1/2021 3/8/2021 3/15/2021 3/22/2021 3/29/2021 4/5/2021 4/12/2021 4/19/2021 4/26/2021 5/3/2021 5/10/2021 5/17/2021 5/24/2021 5/31/2021 6/7/2021 6/14/2021 6/21/2021 6/28/2021 7/5/2021 7/12/2021 7/19/2021 7/26/2021 8/2/2021 8/9/2021 8/16/2021 8/23/2021 8/30/2021 9/6/2021 9/13/2021 9/20/2021 9/27/2021 10/4/2021 10/11/2021 10/18/2021 10/25/2021 11/1/2021 11/8/2021 11/15/2021 11/22/2021 11/29/2021 12/6/2021 12/13/2021 12/20/2021 12/27/2021 1/3/2022 1/10/2022 1/17/2022 1/24/2022 1/31/2022 2/7/2022 2/14/2022 2/21/2022 2/28/2022 3/7/2022 3/14/2022 3/21/2022 3/28/2022 4/4/2022

Fig 1: % of acute medical take who are managed on Ambulatory Emergency Care Pathway (over 24 hr period)

References: 1. Data collection (FoH) Feb 19-Feb 20 2. Developing Ambulatory Emergence Care in Wales – Advice to Health Boards 2018 (pdf) 3. https://www.rcplondon.ac.uk/guidelines-policy/acute-care-toolkit10-ambulatory-emergency-care 4. https://www.mdcalc.com/national-early-warning-score-news 5. https://gov.wales/6-goals-urgent-and-emergency-care-policyhandbook-2021-2026

Plan

Dedicated time and place for monitoring Available staff and equipment

Identify patients with outstanding screening

Act

Physical health monitor being conducted on an adhoc basis only

Centralised spreadsheet Accessible by all

Study Documentation increase from 30% to 67%

Act

Follow-up for patients who decline Duplicated workload

Physical health clinic Advertised; posters and in daily meeting

Study

Documentation increase from 67% to 86%

The Reduction of Junior Doctor Bleep Load by the Use of Microsoft Teams for Communication Amongst the Multidisciplinary Team Ryoon Wha Kang1, Joanna Mort1, Abigail Obeng1, Nive Theivendran1, Saima Sheikh1, Gavin Fong1, Edward Hewertson2 1. University Hospital Southampton NHS Foundation Trust 2. University Hospital Southampton NHS Foundation Trust, Medicine for Older People consultant and QI lead

Introduction & Aim: The mainstay of communications between doctors and the multidisciplinary team (MDT) is the bleep system. All bleeps should be answered in timely manner, as the urgency of the bleep cannot be determined. However, the increase in bleep load can compromise patient care, because doctors are interrupted during ward rounds, procedures or breaking bad news. The aim was to define urgent and non-urgent tasks for doctors and encourage the use of the Microsoft (MS) Teams amongst the MDT for communicating non-urgent tasks, leaving the bleeps for urgent tasks only.

Methodology/PDSA Cycles: • • • •

Introduced the MS Teams to doctors and the MDT Monitored the active users on the MS Teams and the bleep traffic data Satisfaction survey was done to doctors and the MDT regarding the MS Teams usage The MDT was not clear on which junior doctor to contact on the MS Teams or which bleep to use • The morning meeting for junior doctors was started to ensure each consultant had an assigned junior doctor, available on the MS Teams and bleep • The bleep load was still heavy and engagement on the MS Teams varied due to individual junior doctor preferences or the importance of the MS Teams not clearly stated from the induction • • • •

Monitored reasons and frequency of bleeps throughout the day Urgent and non-urgent tasks were defined The bleep list for the MDT was updated The bleep traffic and the MS Teams engagement data were recollected

Results:

• The average number of urgent bleeps during a day was 29.4 and non-urgent bleeps was 61.5, across 10 teams, although there was a significant variation number of bleeps between each team • The busiest teams with the highest bleep burden struggled to record data due to the high workload and bleep load • 100% expressed preference of using the MS Teams over bleeps and 60% of them felt that at least 30 minutes of their time was saved per day. Figure 2. The Average Number of Bleeps Received Throughout the Day 16

Number of Bleeps

08:30 - 10:00

10:00 - 12:00

12:00 - 14:00

14:00 - 16:00

16:00 - 17:30

Time

Conclusions:

• Robust inductions for doctors and the MDT is the key to promote the use of the MS Teams for non-urgent tasks, hence to reduce the bleep load for urgent tasks • Enough lap tops or devices are required amongst doctors and the MDT to access the MS Teams conveniently • The culture has to be changed in order to move onto the new communication platform