BPSC2022 Group J - Audit - Improving healthcare outcomes

18th May 2022 Poster Competition Group J Audit Improving healthcare outcomes

A complete audit cycle assessing how accurately VTE prophylaxis assessments were completed for elective surgical patients at King’s Mill Hospital.

Dr Leah Fagan, Dr Chioma James Supervisor: Dr Migara Seneviratne

INTRODUCTION

CURRENT STANDARDS

The nature of having a surgical procedure increases the risk of a patient developing a venous thromboembolism (VTE)1. Both NICE and local Trust guidelines state that patients undergoing a surgical procedure must be assessed for their thrombosis and bleeding risk and then receive the appropriate VTE prophylaxis.

• 100% of VTE risk assessments must be accurately completed for patients admitted for elective surgery.

• 100% of patients assessed as being at risk of developing a VTE should have the appropriate thromboprophylaxis prescribed .

AIMS To determine if patients undergoing elective surgery at King’s Mill Hospital received an accurate VTE assessment and subsequent appropriate VTE prophylaxis prescribed.

METHOD

FINDINGS

82 VTE risk assessment forms were reviewed in conjunction with the patient’s medical history. The forms were assessed against our VTE data collection proforma and received points for accurate completion. The maximum number of points that could be attained for each section was 1.

The results revealed several deviations and discrepancies from the national compliance criteria, which included missed patient and admission related factors.

SCAN QR CODE TO SEE VTE ASSESSMENT PROFORMA

Data collection

Initial Audit Results

Re-audit Results

31% VTE assessment forms were accurately completed.

73% of patients received the appropriate VTE.

33% VTE assessment forms were accurately completed.

77% of patients received the appropriate VTE.

Interventions

VTE AUDIT COMPLIANCE 100% accurate VTE assessments

Re-audit

Accurate VTE prophylaxis prescribed

77%

73%

INTERVENTIONS • Teaching session for surgeons, anaesthetists and trainees.

33%

31%

• Production and distribution of a poster and audit report highlighting the considerations missed during assessment.

2020

LESSONS LEARNT

FUTURE CONSIDERATIONS

• High BMI is associated with venous thromboembolisms2 and it was a factor that was often under appreciated.

• Disaggregate sections on the VTE assessment forms so that more significant sections weigh more than others e.g. bleeding and thrombotic risk weigh more than date and time.

• Procedural length including the duration of surgery and total anaesthetic time was poorly assessed. It is the responsibility of both the Surgeon and Anaesthetist to consider and discuss this, in order to complete the assessment appropriately.

• Poor documentation of date, time, name and designation was identified, lead to the suboptimal VTE assessments.

1.

2.

3.

2021

• To encourage clinicians to further complete VTE assessments accurately, review Datix system for entries that answer the question: ‘Has there been patient harm or potential patient harm as a result of incorrect VTE assessment completion or prescribing?’

• To further investigate patient safety, correlate the VTE thromboprophylaxis prescribed to the VTE thromboprophylaxis administered to the patient.

REFERENCES Agnelli G. Prevention of Venous Thromboembolism in Surgical Patients. Circulation. 2004;110:IV-4–IV-12 Klovaite J, Benn M, Nordestgaard BG. Obesity as a causal risk factor for deep venous thrombosis: a Mendelian randomization study. J Intern Med. 2015 May;277(5):573-84.

Recommendations | Venous thromboembolism in over 16s: reducing the risk of hospital-acquired deep vein thrombosis or pulmonary embolism | Guidance | NICE, 2020.

ACKNOWLEDGEMENTS Special thanks to Dr Migara Seneviratne for the support and feedback throughout this audit and thank you to the Anaesthetic and Surgical Division at King’s Mill Hospital for presentation opportunities.

Dr Daisy Williams Nottingham University Hospitals NHS Trust

Gastroprotection for patients aged over 70 on antiplatelet therapy Antiplatelets are one of the most prescribed medications in the UK. Reduce vascular mortality by 15% and nonfatal vascular events by 30%.

Aspirin increases gastrointestinal bleeding risk by 60%, and of these bleeds 10% are fatal.

Gastrointestinal bleeding is the greatest cause of hospital admission or death due to adverse drug reactions.

PPIs decrease the risk of GI bleeding by 80%.

NICE guidance is summarised below:

Background

Aims

Methods

Benefits, risks and side effects were standardised.

53 patients had a discussion regarding gastroprotection with PPI.

Results

Co-prescription of a PPI with antiplatelet should be considered in 100% of high-risk patients.

How many patients aged over 70 and on antiplatelets were not on gastroprotection?

How many patients had this been discussed with?

Contact patients to discuss the benefits and risks of starting PPI. 64.2% decided to start gastroprotection.

Older patients were more likely to choose gastroprotection.

The most common reason for patients to decline was that they were currently asymptomatic, followed by concerns of side effects, and taking too many medications.

Reasons for declining gastroprotection 8 7 6 5 4 3 2 1 0

The majority of patients chose to start gastroprotection, particularly older patients.

Demonstrated the importance of involving patients in decision making.

Emphasis given on silent GI bleeding.

Initiation of antiplatelet may be the best time to discuss gastroprotection.

Opportunistic discussion at medication reviews with annual re-discussion.

Findings were presented locally to increase clinician awareness.

Option for SystmOne warning prompt.

No current symptoms

Side effects

Taking too many medications

No reason given

Not taking antiplatelet

Conclusions Phoning the patients was time consuming, as many wanted to discuss other complaints also.

Next time, phone patients ahead to book appointments into dedicated slots.

Reflections

Next step is to reassess in 12 months – are patients still being co-prescribed gastroprotection? Are more patients being offered gastroprotection at initiation or medication review?

Accurate Prescribing of Post-operative Extended Thromboprophylaxis in Colorectal Cancer Patients Dr C Sandberg, Mr M Archer, Mr O Aly Royal Hampshire County Hospital, Hampshire Hospitals Foundation Trust

Introduction Cancer patients are at higher risk of venous thromboembolic events (VTE), and this risk increases again post-operatively1. Data suggests the risk of VTE without prophylaxis after abdominal surgery can be between 15-40% 2. This can result in adverse events such as pulmonary embolism and deep vein thrombosis with associated morbidity and mortality. Trihn et. al. found there to be a five fold increase in mortality (OR 5.3, p<0.001) for major cancer surgery patients who had been found to have a VTE in comparison to those who had not3.

As a result, NICE best practice guidelines recommend an extended 28 day course of VTE prophylaxis to reduce the risk of VTE both during the inpatient stay and also whilst recovering at home.

Previous audit within Royal Hampshire County Hospital (RHCH) showed poor adherence with these recommendations, with one patient experiencing postoperative VTE as a result.

Results July-December 2020 Proportion of patients discharged with extended VTE prophylaxis Patients prescribed extended VTE prophylaxis on discharge

5%

95%

Patients not prescribed extended VTE prophylaxis on discharge

42 patients underwent operative intervention for an abdominal cancer.

Two patients (4.76%) were not prescribed appropriate VTE prophylaxis on discharge.

There were no serious complications found.

Both patients were discharged out of hours.

Proportion of patients prescribed 28 days of VTE prophylaxis Patients prescribed a course of 28 days of VTE prophylaxis

15%

Aims

Assess local trust adherence to the national NICE guidelines Establish if there is a difference in adherence when patients are discharged by less experienced team members out of hours Establish if there is variation in adherence around junior doctor changeover

Percentage of patiets discharged with extended VTE prophylaxis 100% 80% 60%

40%

NICE guidelines NG89

Consider extending pharmacological VTE prophylaxis to 28 days postoperatively for people who have had major cancer surgery in the abdomen2.

Results

85%

Patients prescribed a course of VTE prophylaxis that was not 28 days in length

20% 0%

2017

2018

2020

2021

Year

Conclusion

There is good adherence with the national VTE prophylaxis guidelines, with evidence showing increased adherence with every audit cycle.

Simple measures such as increased education and putting up posters as physical aide memoirs can help increase compliance.

Shortfalls repeatedly happen when patients are discharged out of hours.

This is possibly because the out of hours team do not normally work within the colorectal team and may be less familiar with the guidelines.

Recommendations Looking at a flow chart of the patient's journey within the hospital allows us to see where interventions can be put in place to ensure information about the VTE guidelines is correctly communicated and put into practice, as seen in the diagram below.

Fifteen percent of patients did not receive the correct number of doses of enoxaparin.

Sixty seven percent of these patients were discharged out of hours.

Secondary Aims:

Assess whether any patients who were not prescribed appropriate VTE prophylaxis on discharge suffered any serious complications as a result.

Methods The local colorectal database was used to identify eligible patients.

Inclusion criteria: All patients admitted under the colorectal team between 1/7/2020-31/12/2020 with the diagnosis of cancer who underwent surgery. This was inclusive of both elective and emergency admissions.

Reaudit patients: All patients admitted in the 28 day period before and after foundation doctor changeover; 10/3/21-7/4/21 and 8/4/21-10/5/21.

Exclusion criteria: Patients with diagnosis of cancer that did not undergo any form of surgery. Patients who underwent endoscopic procedure only. Patients still in hospital at the time of audit.

Definitions: Serious complications were defined as any complication requiring readmission to hospital within 30 days of discharge.

With thanks to Dr Walters and Dr Collins for allowing us to use the previous audit data from 2017 and 2018 for comparison.

Intervention

Surgical F1 verbal introduction when starting their surgical rotation.

Posters put up in surgical wards reminding juniors of the guidelines.

Results March-May 2021 Proportion of patients prescribed the correct number of days of VTE prophylaxis postintervention 10%

90%

Patients prescribed a course of VTE prophylaxis that was not 28 days in length Patients prescribed a course of 28 days of VTE prophylaxis

100% of patients were discharged with appropriate VTE 90% of patients were discharged with the correct course of VTE prophylaxis.

The discharge in question was out of hours.

The error occurred after junior changeover.

1. Clear instructions in operation note post-operative plans. This aims to act as a prompt for juniors who are the most likely to order discharge medication.

2. Highlight the need for extended VTE prophylaxis in ward round plans.

3. Educate juniors on the guidelines.

4. Educate pharmacy staff on guidelines as they are the team that check all medications prior to discharge.

5. Aim for the patient's regular day team to complete discharge paperwork to reduce out of hours errors.

References

1. Felder S, Rasmussen MS, King R, Sklow B, Kwaan M, Madoff R, Jensen C. Prolonged thromboprophylaxis with low molecular weight heparin for abdominal or pelvic surgery. Cochrane Database Syst Rev. 2019 Mar 27;3(3):CD004318. Update in: Cochrane Database Syst Rev. 2019 Aug 26;8:CD004318. PMID: 30916777; PMCID: PMC6450215.

2. Geerts WH, Heit JA, Clagett GP, Pineo GF, Colwell CW, Anderson FA et al. Prevention of venous thromboembolism.

Chest 2001; 119(Suppl): 132S 175S. 3. Trinh VQ, Karakiewicz PI, Sammon J, et al. Venous Thromboembolism After Major Cancer Surgery: Temporal Trends and Patterns of Care. JAMA Surg. 2014;149(1):43 49. doi:10.1001/jamasurg.2013.3172 4. National Institute for Health and Care Excellence. Venous thromboembolism in over 16s: reducing the risk of hospitalacquired deep vein thrombosis or pulmonary embolism [Internet]: NICE; 2018 [updated 2019 Aug; cited 2021 Mar 24 ]. (Clinical guideline [CG89]). Available from: www.nice.org.uk/guidance/ng89

CAUTI IN ELDERLY AUDIT- CAN WE DO BETTER? Sharwini Paramasevon, Freda Chen, Iuliana de Jong

Introduction Catheter-associated urinary tract infections (CAUTIs) represent a large proportion of nosocomial infections. of patients are catheterised during their hospital stay.

of hospital-acquired UTIs are associated with urinary catheter use.

CAUTI risk increases by 3-7% for each day an indwelling urinary catheter is in place. 1

Length of time a urinary catheter is kept in situ.

Risk of developing a catheter-associated UTI

To compare the current practice of catheter care against NICE guidelines Identify measures to reduce CAUTI incidence among elderly care patients

Aims

Standards

their risk of infection minimized by the completion of specified procedures necessary for the safe insertion and maintenance of the catheter and its removal as soon as it is no longer needed NICE Quality Standard 61 for Infection prevention and control-Apr 2014

Methods

Prospective audit over 8 weeks involving 50 patients from the care of the elderly ward (mean age of 83) who were catheterised during November-December 2021.

Findings Measure of quality

Discussion Standard

Results

Documentation of rationale of catheterisation

100%

96%

Documentation on insertion

100%

72%

Documentation of regular reviews of catheter need

100%

18%

Documentation of catheter removal

100%

100%

0%

40%

Incidence of CAUTI

unnecessary urinary catheterisation

Two main concerns identified

prolonged catheterisation due to lack of regular reviews

Average duration of unnecessary catheterisation

120%

100%

80%

Learning points

60%

40%

Insert only when indicated.

20%

Removal plans ASAP!

Robust system for daily reminder

0%

rationale of insertion

regular review

Departmental teaching sessions for nurses on catheter maintenance Clinicals skills sessions on aseptic insertion

removal documentation

incidence of CAUTI

Conclusion Timely removal contributes to improved patient experience and reduces overall NHS burden.

Re-audit in 6 months

Insert catheters only for appropriate indications and leave in place only if needed Regular reviews to assess the need of catheterization.

Action Plan Limitations Simplified form for urinary catheter insertion pathway

LocSSIP for urinary catheter insertion

1. Complex admissions taking longer time for discharge.

2. Advanced age itself is a predisposition to urinary tract infection.

Reference: 1. Centers for Disease Control and Prevention (2015). Catheter-associated urinary tract infections (CAUTI). [online] Available at: https://www.cdc.gov/hai/ca_uti/uti.html.

AN AUDIT INTO APPROPRIATE ANTIMICROBIAL PRESCRIBING FOR SPINAL REHABILITATION PATIENTS, IN THE CONTEXT OF AN MDRO OUTBREAK Dr S. Linley-Adams, W.Y. Lee, Dr S. Shanbhag BACKGROUND A multi-drug resistant organism (MDRO) outbreak of Klebsiella species on the spinal rehabilitation wards has prohibited new admissions, slowed rehabilitation processes and put additional strain on healthcare staff. MDRO organisms are driven by inappropriate antimicrobial use.

AIM To evaluate the appropriateness and accuracy of antimicrobial prescribing in spinal rehabilitation patients METHODOLOGY An audit toolkit was created, based on the ‘Start Smart Then Focus’ (SSTF) antimicrobial stewardship initiative for secondary care.

All antibiotics prescriptions for the 34 spinal rehabilitation inpatients between January and September 2021 were included.

THE BASIC NUMBERS 16 patients were prescribed antibiotics, totalling 53 prescriptions of antibiotics. The indication is detailed in the table below; the majority were for UTIs, largely catheterassociated (CAUTI).

Indication Unknown/’?chest?urine’/sepsis Urinary Tract Infection (UTI) MDRO +ve infection Cellulitis Other

Percentage 32% 42% 13% 8% 6%

35 of the prescriptions (66%) were made by on-call teams, while 18 (34%) were made by the day team.

GUIDANCE USED IN ANTIBIOTIC CHOICE The choice of antibiotic was ‘appropriate’ in 89% of cases (based on Microguide, Microbiology advice or culture & sensitivities). Day team and on-call team prescribed appropriately 97% and 72% of the time, respectively.

Both the day and on-call team relied heavily on microbiology advice in choosing antibiotics.

None of the prescriptions made by on call team were based on Microguide.

Day team

On-call 77%

50% 26%

38%

46%

0% Microguide

Microbiology

C&S

DOCUMENTATION OF INDICATION AND DURATION Documentation of indication was generally good, but duration less so, particularly by on-call teams, presumably leaving it to the day team to rationalise and decide on duration.

Day team 83%

40% of antibiotics did not have a documented senior review within 72 hours

On-call

89% 71%

69% 67%

28%

26% 11% Indication in medical notes

Indication on drug chart

Duration in medical notes

Duration on drug chart

ANALYSIS AND DISCUSSION Both day teams and on-call teams rely heavily on discussion with Microbiology for help in prescribing for spinal rehabilitation patients, which can be impractical and timeconsuming.

Microguide is rarely used to guide choice. Reasons for this could be: • Non-specific symptoms in rehab patients; spasms, increased tone and temperatures, poorly localised pain • Complexity of medical history • Unclear pathways for e.g. CAUTI – requires you to follow upper UTI guidelines and give IV gent which is not always appropriate nor practical

Intended duration is poorly documented, and senior reviews are not reliably carried out.

FUTURE PLANS 1. Implement long-stay Antibiotic Review Kit (ARK) charts on the spinal rehabilitation wards. This necessitates a 3-day review and prompts continual assessment.

• Being trialled in a nearby local health board • This should encourage regular review of antibiotics 2. Spinal injury-specific sections on Microguide (e.g. suprapubic catheter, long-term catheter infections and bladder colonisation) to educate and guide doctors • Discussed at the Antimicrobial Management Group for Cardiff & Vale University Health Board 3. Re-audit by new juniors on spinal rehab ward REFERENCES AND CONTACT DETAILS Antimicrobial Stewardship: Start Smart – then focus. (2011).

Public Health England. Available at: https://www.gov.uk/government/publications/antimicrobialstewardship-start-smart-then-focus

For any further information, please email: serena.linley-adams@wales.nhs.uk

An Audit Cycle of Antibiotic Prophylaxis for Laparoscopic Cholecystectomy Sohail Singh, David McMaster, Muhammad Shaikh, Hussein Elghazaly, Payman Dahaghin, Hemant Sheth London North West University Healthcare NHS Trust

Background Approximately 67,000 cholecystectomies are performed every year in the UK, with 92% of these performed laparoscopically. Level 1 evidence shows that perioperative antibiotics do not significantly reduce the risk of surgical site infections or overall nosocomial infections in patients undergoing elective cholecystectomies.1 Due to the lack of clinical benefit, and the risks of unnecessary antimicrobial use, current national guidelines do not recommend prophylactic antibiotic use in low-risk elective laparoscopic cholecystectomies, reserving their use for high-risk patients only.2,3

Aims The aim of this audit was to assess compliance with local and national guidelines on antibiotic usage for laparoscopic cholecystectomies, to identify areas of improvement, implement change and re-audit to assess the effectiveness of this change.

Methods Data was collected retrospectively between 01/05/2021 and 01/08/2021 for patients undergoing elective laparoscopic cholecystectomies.

Following the initial data collection, we presented the results at a local clinical governance meeting and implemented change by attaching pre-printed stickers of local antibiotic prophylaxis guidance to pre-operative notes. We prospectively re-audited between 01/11/21 and 01/12/21 to assess the effectiveness of this change.

1st cycle

Elective cases n = 41

Low risk 3/21 (14%)

Implementation of change

2nd cycle

Correct antibiotic prophylaxis meeting Trust standards

High risk 7/20 (35%)

Results presented at local meeting

Pre-printed stickers of local antibiotic prophylaxis guidance attached to pre-operative notes and anaesthetic charts

Correct antibiotic prophylaxis meeting Trust standards

Elective cases n = 20

Results In the initial three-month period, 24.4% (10/41) of elective cases received correct antibiotic prophylaxis, with 58.5% of patients prescribed unnecessary post-operative antibiotics in the post-operative plan. Following the implementation of change, in the re-audit period there was a significant improvement, with 55% (11/20) of elective cases receiving correct antibiotic prophylaxis, and only 25% prescribed unnecessary post-operative antibiotics.

Low risk 6/14 (43%)

High risk 5/6 (83%)

Laparoscopic cholecystectomy Antibiotic prophylaxis is NOT recommended but should only be considered for high risk patients* *High risk patients: jaundice pregnancy immunosuppression insertion of prosthetic devices

intraoperative cholangiogram bile spillage conversion to laparotomy acute cholecystitis/pancreatitis

If antibiotic prophylaxis is required:

Conclusion We show that pre-printed stickers are a simple intervention that can improve adherence to local guidance and reduce injudicious use of antibiotics. Improving antibiotic prescribing for laparoscopic cholecystectomies,

First line

Co-amoxiclav

1.2g

IV

Single dose at induction ONLY

Alternative regimens: Penicillin allergy

Low risk

Cefuroxime 1.5g IV AND Metronidazole 500mg IV at induction ONLY

High risk

Ciprofloxacin 400mg IV AND Metronidazole 500mg IV at induction ONLY

ALL patients: If MRSA positive ADD Teicoplanin 400mg IV at induction.

procedures, highlights the potential for significant cost savings and improved antimicrobial stewardship.

Figure 1: Sticker of London North West University Healthcare NHS Trust guidance for antibiotic prophylaxis for laparoscopic cholecystectomy.

References 1. Pasquali S, Boal M, Griffiths EA, Alderson D, Vohra RS; CholeS Study Group; West Midlands Research Collaborative. Meta-analysis of perioperative antibiotics in patients undergoing laparoscopic cholecystectomy. Br J Surg 2016;103(1):27-34.

2. Society of American Gastrointestinal and Endoscopic Surgeons. Guidelines for the Clinical Application of Laparoscopic Biliary Tract Surgery. 2010. Available at: https://www.sages.org/publications/guidelines/guidelines-for-the-clinicalapplication-of-laparoscopic-biliary-tract-surgery/ 3. Scottish Intercollegiate Guidelines Network. Antibiotic prophylaxis in surgery: a national clinical guideline (SIGN Guideline 104). 2014. Available at: https://www.sign.ac.uk/our-guidelines/antibiotic-prophylaxis-in-surgery/

Comparison of routine maintenance Intravenous fluid prescription in Adult surgical patients in a District General hospital to NICE guideline standard.

Mr. Mohamed Elfeky, Dr. Bihu Malhotra, Mr. Islam Mabrouk, Mr. Usman Rafique

Aim & Objectives

Introduction Intravenous Fluid(IVF) is one of the most common treatment received by Adult surgical patient.

As per the National Confidential Enquiry into Patient Outcome and Death, Estimated harm from inappropriate fluid & electrolyte management is 1 in 5 patients.

It was observed that almost all Acutely admitted surgical patients receive either Normal Saline or Hartman’s solution only.

to ensure that maintenance IVF prescribed for all adult surgical patients is up to the standard of the NICE guideline, and if not, to improve the prescription through several interventions to reach the standard.

Through - Review patients’ IVF charts and compare prescription to NICE Guideline for Intravenous fluid therapy in adults in hospital.

- Identify the defect in the Volume and Content of prescribed IVF. - Investigate the causes of the defect and how to improve it.

Methodology All adult surgical patients who were acutely admitted through surgical triage unit between 25/11/2021 and 25/02/2022 who were kept nothing per mouth (NBM) for 24 hours and have been prescribed maintenance intravenous fluids.

We included all the patients that we were able to obtain their IVF charts after excluding those who do not meet the inclusion criteria(On sliding scale or receiving DKA treatment).

Our aim was to collect 50 patients.

The type and content of IVF prescribed for 24hr has been compared to the NICE guideline.

An anonymous questionnaire aimed at level 1& 2 doctors was performed in November 2021 to set the par of knowledge about NICE guideline for IVF. A review of available IVF bags in the surgical wards was also done.

Results NICE IVF Guideline Whole IVF prescription Volume Na & Cl content K content Glucose

Met the standard 1 26 2 2 10

Did not 49 24 48 48 40

NICE IVF KNOWLEDGE No

Unsure

Yes

23%

12%

65%

Upon review of available IVF types in surgical wards, all types used per NICE guideline are available

Recommendations and Actions Mandatory teaching session to level 1,2&3 doctors about NICE guideline for IVF prescription and to be repeated on induction for new surgical members.

IVF Algorithm poster to be present in doctors’ room in surgical wards.

Modification of current IVF chart to include a table of the 5R of IVF and a column for reason of IVF( see below).

Pocket card for IVF prescription to be given to Level 1& 2 doctors.

Re-audit to be conducted after implementation to assess improvement.

Remember the 5 Rs: Resuscitation, Routine maintenance, Replacement, Redistribution and Reassessment.

Resuscitation [R] use Hartman’s Solution or 0.9%Nacl (NS), with a bolus of 500 ml over less than 15 minutes.

Routine maintenance [M] Water 20–30 ml/kg/day and potassium, sodium and chloride 1 mmol/kg/day and glucose 50–100 g/day

Replacement Redistribution [P] Seek expert help if patients have Adjust the IV prescription (add to a complex fluid and/or electrolyte or subtract from maintenance redistribution issue or imbalance, needs) to account for existing or significant comorbidity fluid and/or electrolyte deficits or excesses, ongoing losses

Write R, M, P next to each bag of IVF to indicate the Reason for prescription

Reassessment for resuscitation, Use ABCDE approach All others need daily reassessments of clinical fluid status, laboratory values fluid balance charts, weight twice weekly

Using digital documenta0on to improve hip fracture outcomes in the technological age Introduction • • •

Methods

Neck of femur fracture (NOF#) is a major contributor to morbidity and mortality.

National Hip Fracture Database ‘Best Practice Tariff’ (BPT) criteria outline the gold standard of NOF# care.

Appropriate assessment and management of NOF# reduces delays in surgery, and pre and post operative complications.

Aim •

•

•

To maximise adherence to BPT standards to improve care quality and patient outcomes.

•

RetrospecKve data collecKon of adherence to NOF# BPT criteria for pre-operaKve: • Assessment: blood tests, AMT10, fracture classificaKon, ECG, chest X-ray.

• Management: prescripKon of analgesia, laxaKves, VTE prophylaxis, regular medicaKons, intravenous fluids, fasci iliaca blocks.

Replaced paper NOF# clerking document with digital ‘NOF# clerking proforma’.

Measured compliance to BPT criteria at 2 and 4 weeks a[er introducKon of pro forma.

1. Pre-op assessment of NOF# 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0%

99%

96% 81%

76%

24% 0%

2. Pre-op management of NOF# 96%

100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0%

74% 56%

Analgesia

• • • •

Significant Improvement of NOF# classification, preoperative blood tests and AMT10 completion (graph 1).

Widespread improvement in prescribing of analgesia, laxatives, regular medications and VTE prophylaxis (graph 2).

Correct IV fluid prescription fell whilst postoperative AKI increased (table 1).

Reduced pre-op ECG (88% to 80%), CXR requests (84% to 81%) and fascia iliaca block (64% to 57%).

Table 1. IV fluid prescription and AKI Patient group

IVI Post-op AKI

Retrospective Week 0-2 Weeks 2-4 Total at 4 weeks

92% 94% 71% 84%

12% 12% 29% 19%

Laxatives

Retrospective (n=25)

Total at 4 weeks (n=93)

Results

98% 92%

64%

28%

NOF# Bloods Pre OP AMT 10 Classification (including G&S) Retrospective (n=25)

95%

Regular Meds

VTE prophylaxis

Total at 4 weeks (n=93)

Conclusions • • • •

PosiKve feedback for ‘NOF# clerking proforma’ - “Half the work”.

Data demonstrates the fantasKc work by the T&O team in pre-operaKve assessment and prescribing.

Rising levels of AKI demonstrate the importance of appropriate IV fluids. Future audit cycles will look to improve this.

Our team are looking at ways to ease the workload of A&E staff by:

1. Training T&O staff to do fascia iliaca blocks 2. Developing an early alert system of possible NOF# paKents

Completion of Treatment Escalation Plan (TEP) and Do Not Attempt Cardio-Pulmonary Resuscitation (DNACPR) form in Acute Medical Unit/ Same Day Emergency Care for Medicine for Older People Department HYC Chan- Foundation Doctor, J Grayston- Foundation Doctor, T Adepoju Foundation Doctor, C Robins Foundation Doctor, I Bodagh - Consultant, Medicine for Older People Department

Introduction Treatment escalation plans (TEP) and Do Not Attempt Cardio-Pulmonary Resuscitation (DNACPR) forms aid clinicians in making appropriate decisions whilst managing patients who are deteriorating1. Ideally, these decisions on the ceiling of care and resuscitation should have been discussed with the patient when they have capacity2 when necessary. This project aims to identify the completion of TEP form when patients under the Medicine for Older People (MOP) team are admitted through the Acute Medical Unit (AMU) or Same Day Emergency Care (SDEC) unit, and assess if the discussion of DNACPR was performed and subsequent completion of form.

100%

Results

Methods Patients who were under the MOP Team were audited in July 2021 (n=125). This was re-audited in November 2021 (n=124) after distributing results to department. Patients on the MOP work-list were selected, regardless of ward location in the hospital.

The clerking booklets were reviewed. Standards involved valid TEP completion, valid DNACPR form completion and reasons of incompletion for both.

TEP form Completion July 2021

November 2021 25

27

20%

22%

80%

78%

UHS Guidelines Treatment Escalation Plan (TEP)

98

99 TEP not completed

TEP completed

TEP level indicated Signed by senior doctor or advanced clinical practitioner

DNACPR completion November 2021

July 2021 Do Not Attempt CardioPulmonary Resuscitation (DNACPR)

Signed DNACPR form by consultant or equivalent present in folder If no DNACPR, was it discussed

40

44

32%

35% 35% 65%

65%

81

DNACPR completed

68% 84 DNACPR not completed

Conclusions and Implications Similar rates of completion after 3 months of distributing information, with slight improvement in TEP and DNACPR completion A teaching session was delivered on 17 March 2022 to Medicine for Older People Department junior team, presenting results, introducing guidelines in hospital and importance of completion A re-audit will be performed in 2 months to see if there is an improvement in completion rate.

REFERENCES 1.

2.

Paes P, O'Neill C Treatment escalation plans a tool to aid end of life decision making? BMJ Supportive & Palliative Care 2012;2:A60 Obolensky L, Clark T, Matthew G, et al A patient and relative centred evaluation of treatment escalation plans: a replacement for the do-not-resuscitate process Journal of Medical Ethics 2010;36:518-520.

A Emergency Medicine audit in Southampton General Hospital

By Dr Mehak Malhotra Title

Cognitive assessment in older people: an Emergency Medicine audit

Introduction

Undiagnosed delirium contributes greatly to mortality and morbidity in Emergency Departments. The assessment is often missed in the ED.

Standards

Fundamental- doing a cognitive assessment in eligible patients Developmental- inclusion in ED discharge letter Aspirational- assessment using a delirium bundle

Cycle 1

st 1

th 30

JuneNovember 2021

Cognitive assessment in

9%

Changes introduced: • Recommendation in Top Tips • Teaching sessions for doctors and ENPs • Reminder emails to doctors • Introduction of AMT4 • Induction for new starters

Cycle 2

th 15

th 14

AprilOctober 2021

Cognitive assessment in 24%

Lessons learnt: We need to spread awareness among Emergency medical staff on the importance of cognitive assessment in older people in order to reduce morbidity and mortality from Dementia and Delirium.