18th May 2022 Poster Competition Group I Audit Improving care pathways
IMPACT OF FIRST WAVE OF COVID-19 ON REFERRALS TO MTARFA MENTAL HEALTH CLINIC Dr Roberto Galea, Dr Martha Anne Apap Bologna, Dr Catherine Dimech, Dr Anton Grech
Introduction The COVID-19 pandemic necessitated social measures to curb the spread of disease. This disrupted daily activities & social interaction with attendant impact on mental well being, as well as mental health service provision. The study aims to investigate first contact community psychiatry referrals to the Mtarfa mental health clinic before & after the onset of COVID -19 & the adequacy of the service response.
Methodology Following necessary approvals an index of new case appointments was constructed from the register at Mtarfa MHC from 11 March 2019 to 31 December 2020 & cross referenced with eMR. The imposition of social distancing on 12 March 2020 was used to separate the date into before & after the onset of COVID-19. Figure 1
Results 236 new case appointments were identified: 92 before and 144 after the onset of COVID-19 with an increase in mean number of new referrals from 7.4 to 21.2 per month after the first wave (Figure 1). Mean waiting time decreased from 21.6 to a steady 7.4 weeks after. The proportion of new case referrals was stable across all age groups except for men and women aged 60-80 (Figure 2). The majority of referrals are Maltese nationals, both before and after the onset of COVID-19. Primarily referrals are made by community General Practitioners. Referrals from Mater Dei Hospital & the Accident & Emergency department are also encountered. Trends in reason for referral showed a change prior and during COVID-19 pandemic: anxiety dropped from 38% to 32%, depression increased from 33% to 40% while psychosis doubled (2% to 4%) & alcohol misuse was halved (2% to 1%) after the onset of COVID-19 (Figure 3).
Figure 2
Discussion This study comprises three phases – one year before the onset, during the first wave & the six months after the COVID-19 pandemic onset. The increased referral of retirement age patients may reflect health anxiety & adverse impact of isolation in this age group. Referrals in other age groups remained stable. A 286% increase in new appointments was met by a fivefold increase in clinic frequency, successfully decreasing waiting time from 21.6 to 7.4 weeks. Constituting in a 66% drop in waiting time despite a threefold increase in workload. The combined effects of the Psychiatric Outpatients Department closing down and probable increased demand for psychiatric community services has resulted in a median fivefold increase in demand. This was met by an increase in clinic frequency and staff allocation - increasing the monthly number of new case appointments from 7 to 20. Analysis of presenting complaint revealed a relative increase in depression and a drop in anxiety. The latter deficit may be obscured by imposed proportional analysis and/or the changing case mix after the onset of COVID-19.
Figure 3
Conclusions Following closure of the Psychiatric Outpatients Department at Mater Dei Hospital, patients were redistributed to community mental health clinics simultaneously achieving better social distancing, limiting potential COVID-19 transmission & allowing for better community service provision. COVID-19 posed significant challenges. Major service restructuring through decentralisation increased the demand on community mental health clinics. These challenges were met through staff redeployment & increasing clinic frequency - successfully meeting a threefold increase in new case appointments & decreasing waiting time by two thirds. This study focuses on the early stages of the COVID-19 pandemic & it is likely that mental health burden will continue to increase with time. Further studies would be well-placed to assess longer-term effects.
References 1. Kim DM, Bang YR, Kim JH, Park JH. The prevalence of depession, anxiety and associated factors among the general public during COVID-19 pandemic: a cross-sectional study in Korea. Jorean Med Sci. 2021; 36(29): p. e214. 2. Micallef S, Piscopo TV, Casha R, Borg D, Vella C, Zammit MA, et al. Correction: The first wave of COVID-19 in Malta; a national cross-sectional study. PLoS One. 2021; 16(8): p. e0255881. 3. Bonello F, Zammit D, Grech A, Camilleri V, Cremona R. Effect of COVID-19 pandemic on mental health hospital admissions: comparative population-based study. BJPsyh Open. 2021; 7(5). 4. Mazziotti R, Rutigliano G. Tele-mental health for reaching out to patients in a time of pandemic: provider survey and meta-analysis of patient satisfaction. JMIR Ment Health. 2021; 8(7): p. e26187.
Oral Propranolol in the Treatment of Proliferating Infantile Haemangiomas Dr Eliza Hutchison, Dr Malobi Ogboli and Dr Samantha Ibbs Birmingham Women’s and Children’s NHS Foundation Trust
INTRODUCTION • Infantile haemangiomas (IH) are the most common vascular tumour of infancy1 • Propranolol is the first-line treatment for complex IH (Figure 1). • The Dermatology department at Birmingham Children’s Hospital (BCH) recommend and follow the 2018 British Society for Paediatric Dermatology (BSPD) consensus guidelines on the treatment of IH with oral propranolol2
Figure 1: IH before and after oral propranolol treatment (images from dermnetnz.org1)
THE PROBLEM:
THE AIM:
Oral propranolol for IH is initiated by multiple specialties at BCH and practice amongst these specialties varies
To establish the current practice for managing IH across the different specialties at BCH and to assess adherence to the BSPD guidelines
METHODS
RESULTS
• An online survey was distributed to 19 consultants and registrars from multiple specialties at BCH • The survey consisted of 14 questions based on the BSPD guidelines • Data were collected anonymously • The survey had an 89% response rate (Figure 2) Paediatrics 6%
Ophthalmology 13%
Dermatology 37% Plastics 13% ENT 31%
• Results showed inconsistent practice amongst specialties when initiating oral propranolol for IH • A variety of different guidelines are being followed (Figure 3) and dosing regimens vary (Figure 4) • Only 60% of responders perform a full cardiovascular examination prior to commencing propranolol (Figure 5) and only 23% of clinicians report feeling confident doing this (Figure 6) • Results were discussed at each department’s audit meeting • On discussion with clinicians from each specialty we discovered that several departments are still inappropriately admitting patients for propranolol initiation despite them being low risk • This impacts on both patients and hospital services and delays commencement of therapy
Figure 2: responders by specialty
No response No guideline followed Consultant/colleague advice Melbourne Children's Hospital guideline BCH Plastic Surgery guideline BAD guideline BSPD guideline
4
Ensure non-segmental IH
1 2 1 1 2 6
Figure 3: guidelines followed at BCH when prescribing propranolol for IH
BSPDrecommended starting dose (1mg/kg daily in 3 divided doses ) 47%
10 (67%)
0.5mg/kg daily in 2 divided doses 12%
Heart rate
14 (93%)
Blood pressure
14 (93%)
Cardiovascular system examination
Figure 5: features checked for on examination before starting oral propranolol
0.5 mg/kg daily in 3 divided doses 17%
Other 53% 1mg/kg daily in 2 divided doses 12%
9 (60%)
Yes 23%
No 53%
'As per BCH guideline' 12%
Figure 4: starting dose of oral propranolol for IH
Somewhat 24%
Figure 6: proportion of responders who feel confident examining an infant’s cardiovascular system prior to starting oral propranolol for IH
CONCLUSION AND LESSONS LEARNT • • • •
Results of this audit confirm that there is a lack of consistency when initiating patients on oral propranolol for IH Not all departments use the BSPD guidelines when initiating patients on oral propranolol for IH Differing guidelines, dosing regimens and treatment pathways are currently being followed This audit supports the need for a single BCH guideline to be used across departments. We are currently liaising with the teams to develop this.
References 1. 2.
Wong, D [2012]. Propranolol for infantile haemangioma [online]. Available from: https://dermnetnz.org/topics/propranolol-for-infantile-hemangioma [accessed 5 April 2022] Solman, L., Glover, M., Beattie, P.E., Buckley, H., Clark, S., Gach, J.E., Giardini, A., Helbling, I., Hewitt, R.J., Laguda, B. and Langan, S.M., 2018. Oral propranolol in the treatment of proliferating infantile haemangiomas: British Society for Paediatric Dermatology consensus guidelines. British Journal of Dermatology, 179(3), pp.582-589.
An audit identifying ‘double bookings’ within primary care and exploring whether they could be reduced during the COVID-19 pandemic M. Kyriacou Introduction
- During the COVID-19 pandemic general practices (GPs) have revolutionised the way in which they operate consultations, moving from the majority being face-to-face (FTF) to mainly remote consulting. - Triage systems have been created in order to prioritise patient complaints and to allocate them to either a remote or limited FTF appointment. However, for some patients a remote consultation led to a secondary FTF appointment due to the nature of their problem. These occurrences, referred to as ‘double bookings’, lead to reduced efficiency and resource availability within GPs.
Aims
1. Identify the demographics of ‘double bookings’ that occurred within a one-week period. 2. Identify the types of complaints that led to these ‘double bookings’. 3. Provide recommendations to assist in the allocation of FTF appointment.
WHY?
To significantly reduce the number of ‘double bookings’ that occur in GPs, leading to a more efficient and cost-effective service.
Results
Figure 1 shows a large proportion (18%) of patients were under 10 years of age and an even larger majority (28%) over 71 years, suggesting that perhaps at each extreme of age there is more of a clinical requirement for a FTF consultation. This could be due to the fact that children have a lower threshold for physical examination, and many of the elderly population are living with chronic conditions.
Figure 3 shows that out of the 7 patients (10%) requiring an intimate examination, the majority (4) were for per rectal (PR) examinations. 3 out of the 4 PR examinations were conducted on patients who had presented with ‘rectal bleeding’. Rectal bleeding is a common presentation within primary care and has a positive predictive value (PPV) of 8% for colorectal malignancy in those over 50.
Recommendations
Figure 2 shows that the large majority (64%) of FTF appointments were for physical examinations. This demonstrates that it is impractical for a GP to only offer remote consulting as there is still a definite clinical need for physical examinations to take place.
Figure 4 breaks down investigations with the majority (5) needing to provide a urine sample. All of these patients presented with clinical symptoms indicative of a urinary tract infection (UTI). This suggests that these patients could have been identified prior to telephone allocation as needing a FTF or even as needing to provide a urine sample in advance of a telephone consultation thus reducing the number of ‘double bookings’.
- From the results, a lower threshold for the allocation of FTF appointments is being recommended for the following complaints: - Any patient under the age of 16 or over 71 - Any patient, over the age of 50, presenting with ‘rectal bleeding’ as this may warrant a PR examination - Any patient presenting with clinical signs suggestive of a UTI as they may require urine sampling - Therefore, GPs should triage their patients and prioritise F2F appointments based on the presenting complaint and/or via the adoption of a selection criteria e.g. for any patient who may require a physical examination, intimate examination, investigation or child assessment as demonstrated in this investigation. Further studies are needed in order to provide a more evidence-based selection criteria.
ENT Department Compliance with GIRFT Guidelines – a DGH Experience Authors: J N 1
1 Parekh ;
S
1 Vijayakumar ;
ENT Department; Sandwell and West Birmingham NHS Trust
M
1 Mian
Introduction:
Ear, Nose and Throat (ENT) Surgery is a speciality where a significant proportion of operations are performed as daycase operations. Patients therefore can attend and leave hospital on the same day. Getting it Right First Time (GIRFT) is a national standard and guidance to promote collaboration and a set standard to enable departments to achieve the best outcomes for patients. Nationally, the GIRFT review has identified significant degree of unwarranted variation which can cost up to a combined approximate cost of over £30 million.
Aim:
1) Review and inform local ENT department compliance with GIRFT standards following COVID-19 pandemic 2) Identify ways to improve standards to reduce Length of Stay (LOS) and streamline the day case pathway 3) Identify key operations that may not meet GIRFT standards and address them
Methods:
• Retrospective data collection from electronic patient notes and discharge summaries over a two month period identifying all patients who underwent an operation in the ENT department. • Data was stratified by LOS, reasons for prolonged LOS, operation type and if it was adult or paediatric patient. • This data was matched to GIRFT standards to identify if patients were having prolonged stays. • A patient was classed as having a prolonged admission if their inpatient stay was >23 hours (unless previously indicated as planned and reasoning justified). Data was then tabulated in a table. • Operations of interest included (adeno)tonsillectomy, polypectomy, manipulation of nasal bone fracture under anaesthesia, septoplasty amongst others. • Key GIRFT standards included: • Day case paediatric tonsillectomies is 80% (UK average is 55%) • OSA operations should be done early to facilitate same-daydischarge • Septoplasty day case rates should be 78% • Day case adult tonsillectomies is 81% (UK average is 70%) • No clear guidance on thyroid surgery
Conclusions:
Results
184 operations performed in first audit cycle. 178 included for analysis. 65 were paediatric and 113 were adult patients. Initial audit demonstrated excellence in meeting standards in adult day case operations. Results are demonstrated below. 80% day case rates were achieved with 93% of adult tonsillectomies having a same day discharge. Paediatric tonsils showed the lowest with 69% with a target of 80%.
The key area to improve was within paediatric day case surgery as most cases for prolonged admissions were secondary to monitoring for obstructive sleep apnoea (OSA). Consultants were advised of current guidance and pre-operative planning of lists. Discussions took place with bookings team for theatre as well. GIRFT has direct recommendations for improving day case rates for OSA patients. These were implemented. Reaudit Results Following discussions and implementation of changes, a reaudit was performed 4 months following this. A shorter period was reviewed, with 62 patients included. 20 were paediatric, 113 were adult patients. The key target was to identify if day case rates improved in paediatrics. Adult day case rates remained stable. Paediatric day case rates and adeno-tonsillectomy day case rates improved significantly up to 93%
Identification of problem areas and addressing them can improve day case rates in ENT surgery. We clearly identified an area which could be improved, implemented changes and successfully improved day case paediatric surgery rates.
Ensuring Early Involvement of the Diabetic Foot MDT in Management of Diabetic Foot Infection Dr R Anderson, Dr D Kalathil
Introduction
• •
The prevalence of diabetes mellitus in the UK continues to rise, making diabetic foot infection an increasingly significant public health issue.1 Diabetic foot infection has substantial effects on patient livelihood, mobility, and social participation.2,3 Early involvement of a multidisciplinary diabetic foot service has been shown to improve patient safety, through reducing admission length, lowering mortality rates, and reducing severity of amputation.4
The Standard • NICE guidance recommends that patients admitted with diabetic foot infection are referred to the diabetic foot service within 24 hours of assessment.5
• • • •
Referral to the Diabetic Foot MDT: In 10% of spells (n=6) analysed, referral was not completed when clinically indicated. Factors contributing to this included being on a medical outlier ward, and diagnosis later in admission. Time from Referral to Review: 51% of patients were reviewed by a member of the diabetic foot service within the first 24 hours of admission. In the 2 spells where the patient was not seen by an MDT member until >72 hours into admission, this was related to late referral.
30
Time to First Review by Member of Diabetic Foot MDT 26
25
Number of Patients
•
Results
20 16
15
Objectives
10
• To evaluate whether referral to the diabetic foot service was completed for patients presenting with diabetic foot infection within 24 hours of assessment in A&E. • To measure the time from referral to review by a member of the diabetic foot MDT.
7
5
2
0 <24hrs
24-48hrs
48-72hrs
>72hrs
Time (hours)
Interventions Methodology • A business information request identified 165 spells with a primary diagnosis of diabetic foot infection, attending the hospital within a specified 3 month period. • Spells were excluded if the admission was elective, if ulcers were chronic and non-infected, or if the patient took their own discharge prior to full assessment. • After patient selection (see diagram below), there were 60 spells, for which information about referral to the diabetic foot MDT was extracted. • Information was collected from hospital notes and the ICE computer system, and inputted into a password-protected spreadsheet.
Patient Selection
Spells identified by information request, n = 165
Spells meeting inclusion criteria, n = 60
Alternative primary diagnosis, or chronic leg ulcers, n = 90
Spells excluded, n = 105
Elective admission, n = 14
Patient took own discharge prior to full assessment, n = 1
The following interventions are being implemented: 1. Educational posters in A&E and AMU in areas where clinicians complete clerking documentation, to encourage referral at the time of initial assessment. 2. Addition of quick reference guide for managing diabetic foot infection to hospital handbook phone application and intranet, targeting patients who may be diagnosed later in admission.
Conclusions & Lessons Learnt • Patients were reviewed in a timely manner once referred, however referral to the diabetic foot service could be improved. • This has implications for patient safety as evidence demonstrates early involvement of the diabetic foot MDT results in better patient outcomes. • A multi-departmental approach is required to ensure buy in at each stage of the patient journey. • Next steps include re-auditing of the outcome measures to evaluate the impact of interventions. References:
(1) Diabetes UK (2019). Diabetes Statistics. Retrieved from Diabetes UK: www.diabetes.org.uk/professionals/position-statements-reports/statistics (2) Edmonds, M., Manu, C., & Vas, P. (2021). The current burden of diabetic foot disease. Journal of Clinical Orthopaedics & Trauma, 88-93. (3) Crocker, R., Palmer, K., Marerro, D., & Tan, T.-W. (2021). Patient perspectives on the physical, psycho-social, and financial impacts of diabetic foot ulceration and amputation. Journal of Diabetics and its Complications, [Online]. (4) Buggy, A., & Moore, Z. (2017). The impact of the multidisciplinary team in the management of individuals with diabetic foot ulcers: a systematic review. Journal of Wound Care, 324-339. (5) National Institute of Health & Care Excellence. (2015, August 26). Diabetic foot problems: prevention and management. Retrieved from NICE Guidance: www.nice.org.uk/guidance/ng19/chapter/Recommendations#diabetic-foot-infection
Improving elective paediatric sedation for magnetic resonance imaging Aims Dr A. Ma
Sedation for MRI scans in the paediatric population is common to reduce fear and anxiety and to minimise movement for the procedure1.
• Evaluate current pracLce in the paediatric department by reaudiLng against local guidelines • Assess whether the implemented changes from a 2016 audit have resulted in an improvement in pracLce • IdenLfy further areas for improvement and implement changes to improve care
Sedation itself is unpredictable and carries risks including airway obstruction, apnoea, hypoxia and cardiopulmonary arrest2.
Results
FY2, Royal Bolton Hospital
Background
✓9/15
Over 50 children were sedated to facilitate MR imaging in 2020 at our hospital, a district general in the North West.
standards reached 90% adherence
Methods This was a retrospecLve audit of 27 paLents sedated for MRI between Jan 2020 and Feb 2021. Paper and electronic notes, including the sedaLon proforma, were reviewed. The process of sedaLon was audited against the local guideline for sedaLon for painless procedures in children in 15 separate standards. Results and recommendaLons were presented at the local clinical audit meeLng and changes implemented.
There was evidence of some improvement from the 2016 audit however, updates to the guideline and changes to the pro-forma meant that direct comparison could not be drawn.
15 standards from guideline Assessment for fitness for sedation History of convulsions d/w specialist ASA 3+ d/w specialist Sedation pro-forma completed Valid consent form Baseline observations recorded Weight recorded Time of last oral intake recorded Accompanied by APLS-trained staff 15-min observations Documentation of sedation process Feeding challenge Discharge criteria fulfilled Post-sedation written instructions given Oral chloral hydrate for sedation
% adherent to standard 2016 2021 △ 90 ↑ 100 88 100 100 97 = 96 85 74 100 ↓ 15 100 33 ↑ 52 100 96 77 ↑ 81 93 ↑ 96 96 ↑ 100
Recommendations 1. Development of a ‘doctors 2. AddiLon of a box for 3. quick guide’ to improve assessment for sedaLon and facilitate escalaLon to specialists where appropriate. This guide is being reviewed for piloLng in the department.
exact weight and exact >me since last oral intake to be added to the sedaLon pro-forma.
Sub-standard observaLon frequency remains an important issue and further work in parallel with nursing colleagues is needed to explore ways to improve this.
Lessons Learnt ‣ This service is provided by a multidisciplinary team and, as such, all parties should be included in the audit process and generating ideas that can lead to meaningful change ‣ Simple processes can help reduce error and affect change without much increase in workload e.g. two extra elements to the pro-forma checklist ‣ There are both benefits to and limitations of retrospective studies and using ‘proxy data’ such as documentation to audit practice References 1 NaLonal InsLtute for Health and Care Excellence. SedaLon in under 19s: using sedaLon for diagnosLc and therapeuLc procedures. [CG112] Published in 2010, updated 2014 Oct. Available from: hXps://www.nice.org.uk/guidance/cg112 2 Arlachov Y et al. SedaLon/anaesthesia in paediatric radiology (2012). The BriLsh Journal of Radiology, 85 (2012), e1018-e1031.
With many thanks to Dr Miriam Leach and Dr Lisa McGullion for their guidance and supervision
IV Fluid Prescription in Trauma and Orthopaedics
Poster 150
Aditya Trighatia, Nadia Youssef, Thomas Kerr, Mamdouh Elbannan, Adithya Varma Aneurin Bevan University Health Board
Introduction
Results
•
Fluid management constitutes a significant part of medical prescribing, especially on surgical wards where patients are often nil by mouth.
•
In the first cycle patients received an average of 2.8L of IV fluids during their hospital stay. This reduced to 2.3L in the second cycle.
•
As it is prescribed routinely and often thoughtlessly, the adverse effects of IV fluids are frequently overlooked.
•
Most commonly prescribed fluid type was Hartmann’s solution, and the main indication was maintenance, followed by replacement.
•
NICE has identified that errors in IV fluids prescriptions commonly occur in surgical wards due to lack of relevant critical care experience and knowledge.
•
13.6% of patients had their weight recorded in the first cycle, compared with 0% in the second cycle.
Objectives Evaluate the adherence to the IV fluids NICE guidelines in the Trauma and Orthopaedics' department at the Grange University Hospital.
Methods • • •
Two audits were performed four weeks apart on all T&O inpatients who were prescribed IV fluids
Correctly prescribed
Cycle 1
Cycle 2
Resus Fluid
62%
53%
Volume*
36.4%
50%
Type
0%
0%
81%
94%
Maintenance Fluid
Replacement Fluid
*Volume of maintenance fluid prescribed
Prior to the second cycle, medical staff received teaching on the current IV fluid guidelines.
CYCLE 1 Under 27%
Collected data: Patient’s weight; type, amount and duration of IV fluids prescribed; indication; and any adverse effects.
Over 7%
Over 37%
Under 43% Correct 50%
Correct 36%
Discussion • When IV fluids are prescribed incorrectly, it results in adverse effects such as AKI and electrolyte imbalance.
CYCLE 2
• Most common adverse effect of incorrect IV fluid prescription was electrolyte disturbance.
• Teaching alone did not produce fruitful outcomes. Cycle 1
• We propose a collaboration with pharmacists to introduce a drug chart which encloses a protocol for IV fluid prescription.
References Nice.org.uk. 2017. Overview | Intravenous fluid therapy in adults in hospital | Guidance | NICE. [online] Available at: <https://www.nice.org.uk/guidance/cg174> [Accessed 11 April 2022].
Cycle 2
0%
10%
20%
30%
40%
50%
• There was one recorded major adverse effect of IV fluid over prescription in the first cycle.
ADVERSE OUTCOMES ASSOCIATED WITH BILIARY STENTS ‘LOST TO FOLLOW UP’ DR HANNAH NOONE, DR GEORGINA SANDERSON, DR AJEYA SHETTY & MR AWAD SHAMALI
1|INTRODUCTION
2|AIM
Endoscopic retrograde cholangiopancreatogram (ERCP) with endoscopic sphincterotomy and stone extraction is considered the treatment of choice for bile duct stones.1,2 In patients with irretrievable biliary stones, endoscopic insertion of a plastic stent into the common bile duct (CBD) can facilitate biliary drainage whilst awaiting an elective laparoscopic cholecystectomy.1,2
Implement local policies to standardise the follow up of endoscopic stent placement, and thereby reduce the potential for adverse events associated with stents ‘lost to follow up’.
Current European Society of Gastrointestinal Endoscopy (ESGE) guidelines emphasise that stenting in these circumstances should be temporary (3-6 months), as long-term biliary stent placement is associated with higher morbidity and mortality.1 Complications of long-term biliary stenting include cholangitis and stent dysfunction (migration or occlusion).1,2 Patients usually require a second ERCP to remove or replace the stent as appropriate. Other indications for temporary biliary stent insertion include benign bile duct strictures and bile leaks.1 Endoscopic biliary stent insertion may be considered definitive management for bile duct stones in patients with high surgical risk2 or palliation in malignant biliary obstruction.1 Endoscopic placement of pancreatic duct (PD) stents forms part of the management for inflammatory pancreatic diseases and prevention of postERCP pancreatitis.3,4 In contrast to CBD stents, PD stents usually pass spontaneously. At this trust, an abdominal X-Ray is performed 10-14 days after insertion to confirm spontaneous passage of the stent. Occasionally, PD stents are retained and subsequently require removal by ERCP. Recently within the trust, two patients suffered adverse outcomes as a result of temporary biliary stents that were ‘lost to follow up’ and subsequently not removed (CASE 1 and CASE 2). Local guidance for the duration and follow up of temporary plastic biliary and pancreatic stents does not exist.
CASE 1 Oct 2016 Jun 2020
Bile leak post-laparoscopic cholecystectomy. ERCP and CBD stent insertion. No further follow up; stent not removed. Patient admitted with sepsis secondary to cholangitis and multiple liver abscesses.
• For the purpose of this audit, 6 months was considered the standard of best practice for maximum duration of temporary biliary and pancreatic stent placement in accordance with ESGE guidelines1. • Patients who had a plastic CBD or PD stent inserted during a 3-year period were identified. Each patient’s endoscopy report, corresponding discharge summary, relevant clinic letters and radiology results were reviewed to establish the indication for stent insertion, duration of stent placement and subsequent follow up arrangements. • Patients for which stent insertion was considered definitive management, patients referred to tertiary hospitals for further care and patients who moved out of area were subsequently excluded. • Patients with stent duration >6 months were considered ‘lost to follow up’ if the documented follow up arrangements did not occur. • All patients with stent duration > 6 months, stents not removed, stents lost to follow up or adverse outcomes associated with stent duration > 6 months were reviewed in a virtual clinic.
4|RESULTS During the 3-year period, nearly 800 patients underwent ERCP, of these, 64 patients had plastic CBD or PD stents inserted (FIGURE 1). Stent placement was considered definitive management in 28 cases. 10 cases were excluded due to patient relocation or referral to tertiary hospitals. Of the remaining 26 cases, 14 stents were removed or had passed spontaneously within 6 months, corresponding to 54% compliance with the audit criteria. On further review, 3 patients had been lost to follow up and 4 patients had associated adverse outcomes including cholangitis, pancreatitis and irretrievable stents. FIGURE 1
64
•
28 cases: stents considered definitive management
•
10 cases: referred to tertiary hospitals or moved out of area
12
•
14 cases: stent removed or passed spontaneously within 6 months
4
•
8 cases: stent duration > 6 months and no recorded adverse outcomes
36
CASE 2 Jun 2013
Presented with obstructive jaundice secondary to bile duct stone. ERCP and CBD stent insertion.
Feb 2014
Elective laparoscopic cholecystectomy. No further follow up; stent not removed.
Jun 2020
Patient presented with abdominal pain and deranged liver function tests. Ultrasound abdomen demonstrated CBD stent and 4cm stone.
Aug 2020
3|METHODS
Longitudinal choledochotomy performed to remove CBD stent and stone.
26
5|FUTURE DIRECTIONS & REFLECTIONS FIGURE 2 CBD and PD stents 1. Patient and stent details recorded on the database at the time of stent insertion by the endoscopist. Pathway for CBD stents 2. Endoscopist to notify General Surgeon of stent insertion and details / timescale for follow up. 3. General Surgeon to complete referral to Gastroenterologist requesting endoscopic stent removal when appropriate (for example, once Laparoscopic Cholecystectomy performed). 4. Endoscopist to update database when stent removed.
Pathway for PD stents 2. Endoscopist to book a follow up abdominal X-Ray, documenting the timescale to be performed. 3. Endoscopist responsible for reviewing the X-Ray and endoscopic stent removal if required. 4. Endoscopist to update database when stent removed.
CBD and PD stents 5. Database to provide an alert when stent duration approaches 6 months with repeat alerts thereafter if required. Database monitored regularly by a responsible clinician to identify patients with temporary stents that require review for possible stent removal or replacement.
Our results emphasise the importance of timely follow up for patient safety. Subsequently, Gastroenterology and General Surgery teams have implemented a cross-speciality pathway and stent registry to standardise local follow up arrangements and thereby reduce the potential for adverse events associated with stents ‘lost to follow up’ (outlined in FIGURE 2). We plan to re-audit 1 year following implementation. Key learning points: • A number of follow up arrangements were in progress during initial data collection, consequently a second round of data collection was required to update the results. In the future, we recommend delaying data collection to avoid this. • Our results also highlight implications of the COVID-19 pandemic on routine patient follow up and subsequently patient outcomes.
REFERENCES 1.Dumonceau, J. M. et al. Biliary stenting: Indications, choice of stents and results: European Society of Gastrointestinal Endoscopy (ESGE) clinical guideline. Endoscopy 44, 277–298 (2012). // 2.Sohn, S. H., Park, J. H., Kim, K. H. & Kim, T. N. Complications and management of forgotten long-term biliary stents. World J. Gastroenterol. 23, 622–628 (2017). // 3.Testoni, P. A. Endoscopic pancreatic duct stent placement for inflammatory pancreatic diseases. World J. Gastroenterol. 13, 5971–5978 (2007). // 4.Dumonceau, J. M. et al. ERCP-related adverse events: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy 52, 127–149 (2020).
Peri-operative anaphylaxis: incidence & follow up. B. Prince, C. Harris Introduction:
Aims:
In 2018, the Royal College of Anaesthetists published its national audit project (NAP6), which identified that peri-operative anaphylaxis has an incidence of 1 in 10,000(1). Although rare, its consequences are often a lifethreatening emergency. For this reason, follow-up after peri-operative anaphylaxis was recommended within 100 days; to allow safe practice for future anaesthetics.
This audit project aims to evaluate the incidence of peri-operative anaphylaxis in Aneurin Bevan University Health Board (ABUHB) and the subsequent timing to follow up clinic. This was in comparison to national standards; set out by the NAP6 project. A secondary aim was to establish the availability of written documentation following allergy clinic appointments.
Methodology: The “in-house” anaesthetic alert database was used to identify all patients who had experienced perioperative anaphylaxis. The Anaesthetic alert database is continually updated when new events occur. Electronic records of each patient were scrutinised to identify if patients were referred to allergy clinic and if so, how long it took for follow up to occur. Records were also reviewed to look for evidence of relevant clinic letters. Results: • Between 2006 & 2021 there were 46 peri-operative anaphylaxis events that occurred at ABUHB. • Data for the five-year period of 2017-2021 demonstrated an incidence of 0.85 in 10,000 operations. • Of the 46 patients, 62% were subsequently followed up in allergy clinic; with a mean time to follow up of 8.4 months. • Allergy clinic letters/documentation was available in 47% of patients. Analysis & recommendations for change: • Local incidence of peri-operative anaphylaxis, at ABUHB, is in line with what was observed nationally. • Time to allergy clinic follow up is significantly delayed compared to the national recommendation, potentially compromising on patient safety. • A change to the anaesthetic allergy clinic referral process has been recommended; facilitated now by a regional service rather than an individual clinician. • We recommend re-audit in 12 months to evaluate the new service. References 1) National Audit Project 6 report; Anaesthesia, Surgery & life-threatening allergic reactions. May 2018. Royal College of Anaesthetists
Hyperkalaemia: Improving Safety and Quality of Treatment Dr Miles Geldart, Dr Lucy Andralojc, Dr Leia Alston, Dr Giorgio Gentile, Miss Pollyanna Bastian
Current issues with patient care Hyperkalaemia is a commonly encountered electrolyte abnormality with potentially life-threatening complications. NHS Improvement released a Patient Safety Alert in 2018 [NHS/PSA/RE/2018/006] following a report into 35 cardiac arrests, local guidance was found to be not evidenced based and management was variable. We have conducted an audit investigating the safety and quality of acute hyperkalaemia management at the Royal Cornwall Hospital, Truro.
The Aims
To investigate the current management of hyperkalaemia by comparing our practice to standards of care derived from the latest UK Renal Association guidance 2020. This guidance included two recent updates of particular interest: - The use of Sodium Zirconium Cyclosilicate (Lokelma) in severe hyperkalaemia - Prophylaxis of iatrogenic hypoglycaemia
Methodology We identified all adult inpatients with life threatening hyperkalaemia (K+ ≥ 6.5mmol/L) over a six-month period. Following the application of exclusion criteria - a cohort of 29 patients was formed. Case notes and the electronic patient records were scrutinised to assess adherence to our standards of care derived from the UK Renal Association. Pertinent patient outcomes were also recorded – mortality, duration of admission, iatrogenic hypoglycaemia and AKI
The standards of care for severe Hyperkalaemia (Target 100%) Treatment 1. 2.
Initiation of treatment should occur within 1 hour All patients should be treated with IV calcium salts a) The preferred prescription is 30ml of 10% Calcium Gluconate All patients should receive oral Sodium Zirconium (Lokelma) All contributing medications should be suspended Patients with a pre-treatment blood glucose less than 7.0mmol/L should receive a 25g glucose infusion after the insulin infusion
3. 4. 5.
Monitoring 6.
Patients should have a 12-lead ECG within 15 minutes 7. Patients should have urine output monitoring 8. Patients should have continuous ECG monitoring 9. Blood glucose testing should occur within 1 hour of completing the insulin/glucose infusion 10. A repeat ECG should be obtained 5-10 minutes following IV calcium salts 11. A repeat serum potassium measurement should occur within 6 hours of initial result Only 55% of patients received Lokelma. Mostly this followed senior review – there was a delay in prescription.
Fig 1. Compliance with Standards [%] 100 80
22% of patients had an episode of hypoglycaemia following insulin treatment. Half of these had a low pre-treatment blood glucose. None received a prophylactic glucose infusion.
60 40 20 0 1
2 2a 3
4
5
6
7
8
9 10 11
Interventions to improve practice ü Improved local guideline – our new guideline clarifies the indication for Lokelma, steps to prevent iatrogenic hypoglycaemia and monitoring requirements. ü Getting the word out – we used grand round to raise awareness and uptake of the new guideline. ü The next cycle – we plan to re-audit to ascertain whether we have made an impact to local management of hyperkalaemia.
Lessons learnt and future work • • • •
Clear local guidance improves patient care, where this was already available there was better compliance Lokelma is currently under-prescribed by junior doctors Poor awareness of risk of hypoglycaemia More focussed data collection on our behalf could help drive further change
Choroidal naevus monitoring in a tertiary centre: Implementing new guidelines N. Rees, S. Schimansky, G. Bizley, B. Balasubramaniam, L. Kobayter
Introduction Choroidal naevi are common with an estimated prevalence of 5-8%.1 They can transform into melanomas, the commonest intraocular malignancy.1,2 Nearly 50% of patients with choroidal melanomas die from metastatic disease, despite tumour eradication.3 Robust monitoring guidelines for these patients are extremely important for early diagnosis, treatment and improved patient outcomes. The MOLES score is a new evidence-based choroidal naevus risk stratification tool.4 Fig. 1 Choroidal melanoma2
Aim
Evaluate impact of transitioning from previous (2015) to new (2021) choroidal naevus monitoring guidelines.
Methods
Initial Results (Cycle 1) Criterion number 1 2
2 audit cycles undertaken with implementation of new guidelines based on MOLES scoring system between cycles Cycle 1
Cycle 2
Based on 2015 guidelines
Based on new 2021 MOLES guidelines
January-February 2020 n(naevi)= 288
April-August 2021 n(naevi)= 97
Criterion number 1 2 3
Criterion for both cycles
3
69% 98% 47%
Fig. 2
45%
61%
33% 21%
26% 13%
1%
Target
Appropriate baseline imaging 100% undertaken Risk factor score in guidelines 100% used and documented Patient follow-up in 100% accordance with guidelines
Adherence to criterion 3 especially, was low. More than 50% of patients were being followed up in hospital for unnecessarily long periods of time.
Adherence
0 risk factors
0% 1 risk factor
2 risk factors
3 risk factors
Existing 2015 guidelines scored many patients as high risk which means they are followed up in hospital for longer.
0 risk factors
1 risk factor
2 risk factors
3 risk factors
Most of the same patients were low risk with the proposed new MOLES score. This would reduce unnecessary hospital follow up.
Intervention MOLES risk factor grading score for developing melanoma
MOLES score
Follow-up
Mushroom shape 0 (absent), 1 (incipient), 2 (definite)
0 (common naevus)
Discharge to community optometrist
Orange pigment
0 (absent), 1 (dusting), 2 (clumps)
1 (low-risk naevus)
Follow-up for 3 years overall
Large size
0 (<3DD + <1mm), 1 (3-4DD +/ 1-2mm), 2 (>4DD, +/ >2mm)
2 (high-risk naevus)
Follow-up for 3 years overall
Enlargement
0 (none), 1 (possible), 2 (definite)
3 (probable melanoma) Same day referral to ocular oncology
Subretinal fluid
0 (absent), 1 (trace), 2 (significant)
A novel risk stratification tool called the MOLES score4 was introduced and imaging and follow-up guidelines changed.
Improvement (Cycle 2)
Conclusion
Improvement in criteria adherence before and after implementation of new guidelines 100%
+26%
-9%
+45%
75% 50% 25% 0% Criterion 1
Fig. 3
Criterion 2 Cycle 1
Cycle 2
Criterion 3
Adherence to criterion 3 significantly increased after adoption of the new MOLES score 2021 guidelines. Slight decrease in adherence to criterion 2 likely due to period of adjustment to new guidelines.
Initial results showed that poor adherence to follow-up guidelines resulted in >50% of patients being followed up for unnecessarily long periods of time in a tertiary centre. The new MOLES score and improved imaging pathways were introduced and incorporated into guidelines. Post-intervention, adherence to follow-up guidelines improved by 45% and to imaging guidelines by 26%. This allowed us to safely focus our resources on a smaller patient cohort with high-risk naevi. We plan to re-audit in December 2022.