18th May 2022 Poster Competition Group K Full QI Project Improving primary and secondary care
STAURM: Streamlining Troubles in Dr. S Cowan, Dr. O Rushworth, Miss K Knowles
Summary
Royal College of Emergency Medicine standards:
ED in line with the RCEM standards.
How do we know change is an improvement? By comparing our results to RCEM standards, alongside impact of each implemented change.
1 robust speciality follow-up. to improve access for all members of
DRIVER DIAGRAM
An old unused catheter trolley with outof-date and inappropriate equipment was updated and relaunched. This included the design of a bespoke home kit for discharge - complete with all catheter home care needs. A copy of
1 Displaying of posters and visual prompts within the emergency department.
appropriate follow up.
ABDOMINAL PAIN AND CAN’T PASS URINE?
THINK AUR rates were analysed in four domains: 1. Care in ED overall about the next steps in their care about how to
a - analgesia u - urinary catheter r - refer to twoc clinic SEND HOME WITH CATHETER PACK AND ENSURE CATHETER CARE EXPLAINED
catheter Number of received catheter care equipment on discharge
increased across all domains, with
Next Steps 1. Sustainable change adapts system processes to allow new ways of thinking to become normal.
1. Further review of the VTWOCC sustainability.
system. Empowering and developing specialist nurses re-design of discharge process.
ED improving from
management to arrange access to to project progression.
References: 1: Marshall J, Haber J, Josephson E. An evidence-based approach to emergency
approach whilst allowing easy mapping of change.
from the STAURM stakeholders.
An informal management style and a visible presence in a department can give you vital informal feedback.
with AUR out-of-hours as this is not currently available in the ED. Review process map and target new
IMPROVING DISCHARGE SUMMARIES OF SPINAL INJURY PATIENTS DISCHARGED WHILST RECEIVING NEUROPATHIC PAIN AGENTS A QUALITY IMPROVEMENT PROJECT Dr Alexandra Ross, Dr Roshan Gunasekera, Dr Rohit Bhide Sheffield Teaching Hospitals
INTRODUCTION
Ø Patients discharged from Sheffield Teaching Hospital’s Spinal Injuries Unit are commonly prescribed neuropathic pain agents Ø These drugs can have considerable side effects and potential for abuse or addiction (Murnion, 2018) Ø A diagnosis of neuropathic pain should be clearly documented on the discharge summary to ensure appropriate prescription and to improve communication with the General Practitioner Ø Some discharge summaries were noted to omit the diagnosis of neuropathic pain
AIMS
Ø Quantify the omission of neuropathic pain diagnoses on discharge summaries for patients prescribed neuropathic pain agents Ø Reduce the percentage of patients discharged with neuropathic agents without an accurate diagnosis of neuropathic pain on the discharge summary within one year
METHOD
Ø Discharge summaries of patients prescribed neuropathic pain agents between April and September 2020 were analysed (n=41) Ø Those without a documented diagnosis of neuropathic pain were identified and the case notes reviewed Ø The percentage of patients discharged with neuropathic pain agents who had a diagnosis of neuropathic pain in their notes but omitted from their discharge summary were calculated for each two-week time period Ø Reasons for omission were considered and an intervention was implemented between October and November 2020 Ø Data collection was repeated for discharges between December 2020 and May 2021 (n=37) and analysed on a run chart
PLAN
INTERVENTION Ø A discharge summary template was updated to emphasise neuropathic pain documentation (see Figure 2) Ø This was distributed to junior doctors and advanced nurse practitioners by email and displayed on the unit notice board Pain
DO
Analysed discharge summaries (n=41). Considered reasons for omission of diagnosis
Updated discharge summary template and distributed this to junior doctors and advanced nurse practitioners
ACT
STUDY
Continue to distribute the new template for each cohort of new clinicians. Consider future interventions
Repeated the data collection after 6 months (n=37). Conducted a run chart which showed a significant change
• If present and management • If on Neuropathic agent, confirm presence of Neuropathic pain (with patient) and document in Diagnoses.
Figure 1. PDSA cycle.
Figure 2. Extract from the updated discharge summary template.
RESULTS AND LESSONS LEARNT
After the intervention, there was a significant reduction in the percentage of patients discharged with neuropathic agents without an accurate diagnosis of neuropathic pain on the discharge summary
Intervention
80 70
Ø Shift of eleven points below the median on the run chart and a reduction in the median from 50% at baseline to 16.7% after 50 the invention Ø Although the sample size was limited, the project met its aim 40 of improving discharge summaries within one year Ø Perhaps the template prompted clinicians to document the 30 diagnosis or to review and/or stop the prescription of the 20 neuropathic pain agent Ø This intervention had a positive outcome but has not 10 eliminated the problem. Future PDSA cycles might involve a teaching session for clinicians 0 Ø The updated discharge summary template continues to be used and distributed to clinicians via email, notice boards and Time (two-week period) an induction booklet Figure 3. Run chart showing percentage of patients discharged with neuropathic Ø While this project was specific to neuropathic agents for agents without accurate documentation on the discharge summary. discharges from one department, similar templates might be assessed for the use of other drugs, for example antibiotics, to Reference: Murnion, B.P., 2018. Neuropathic pain: current definition and review of drug treatment. Australian Prescriber improve documentation and communication with the General [Online], 41(3), p.60. Available from: https://doi.org/10.18773/AUSTPRESCR.2018.022 [Accessed 20 April 2022]. Practitioner in a wider setting
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Enhancing job satisfaction when the NHS is under pressure: The importance of induction Dr U. Watson. University Hospitals Sussex NHS Foundation Trust
Aim
What?
Why?
Positive induction experiences effect employee job satisfaction, commitment, quality of work and job retention(1–3). NHS Employers state that the induction process is ‘crucial’ for staff retention(4). The British Medical Association recently identified that the NHS is short of over 49,000 full-time-equivalent doctors(5). Inductions are essential now, and for the future sustainability of the NHS.
A QIP to assess and improve Acute Care Common Stem (ACCS) trainee satisfaction with their induction to University Hospitals Sussex (UHSx, East sites) via selfreported satisfaction scores.
For no ACCS trainee to rate their induction as ‘poor’ or worse; thus ‘satisfactory’ or better within 24 months.
How: PDSA timeline Cycle 1 Plan & Do Aug 2019 -> • New intake of ACCS trainees • All ACCS trainees surveyed
Cycle 1 Study & Act
Cycle 2 Plan & Do
Cycle 2 Study & Act
Jan 2020 -> • Findings and suggestions presented to ACCS Local Faculty Group • Changes implemented
Aug 2020 -> • New intake of ACCS trainees • All ACCS trainees surveyed
Jan 2021 -> • Findings and suggestions presented to ACCS Local Faculty Group • Changes implemented
Cycle 3 Plan & Do Aug 2021 -> • New intake of ACCS trainees • All ACCS trainees surveyed
Cycle 3 Study & Act Jan 2022 -> • Findings and suggestions presented to ACCS Local Faculty Group • Changes implemented
How: Interventions and their effects Cycle 1: Baseline trainee satisfaction • 20% induction ‘poor’ or ‘very poor’ • 80% induction ‘satisfactory’ or better • Mean satisfaction score: 2.6/5
Stakeholders ACCS trainees (54 questionnaires distributed; 30 responses obtained), Local Faculty Group members: trainee representatives, consultants, administrators, HR
Target # Plan Do 1 All trainees to be aware of how Develop induction presentation their training is structured and for August induction delivered locally on commencing their training in August Develop trainee handbook and distribute in their induction email prior to commencing in August 2
3
Study 2019: Prior to QIP 55% found this helpful 2022: Post QIP 67% found this helpful 2019: Prior to QIP Handbook not being used 2022: Post QIP 100% found this beneficial All trainees to know which Inform trainees of their starting 2019: Prior to QIP speciality they will start in prior specialty prior to commencing in 64% knew starting speciality to commencing their training in August via their induction email 2022: Post QIP August 89% knew starting speciality All trainees to know their Inform trainees of their clinical 2019: Prior to QIP Educational and Clinical and educational supervisors prior 57% knew ES & CS 2022: Post QIP supervisors (ES & CS) prior to, or to commencing in August via within 2 weeks of starting their their induction email 78% knew ES & CS training in August
• •
•
Act Re-introduce face-to-face induction post-COVID-19 Introduce social welcome event
Induction email to be distributed prior to commencing training in August containing: o Trainee handbook o Starting speciality o ES and CS
Outcomes Lessons learned and future plans • Responding to trainee feedback can improve satisfaction with their induction • Induction email and training handbook complement but do not replace face-toface inductions. The loss of face-to-face inductions as a result of COVID-19 measures negatively impacted on trainee satisfaction with their induction. Plan to re-introduce face-to-face inductions for this coming August intake • Involving all stakeholders is essential for positive change to be sustained • Plan for a mentorship scheme for new trainees as the next target for change References 1. Acevedo JM, Yancey GB. Assessing new employee orientation programs. J Work Learn. 2011;23(5):349–54. 2. Kristof-Brown AL, Zimmerman RD, Johnson EC. Consequences of individuals’ fit at work: a meta-analysis of person-job, person-organisation, person-group, and person-supervisor fit. Pers Psychol [Internet]. 2005 Jun;58(2):281–342. Available from: https://onlinelibrary.wiley.com/doi/10.1111/j.1744-6570.2005.00672.x
Cycle 3: Post-QIP trainee satisfaction • 0% ‘poor’ or ‘very poor’ • 100% ‘satisfactory’ or better • Mean satisfaction score 3.5/5
3. Chartered Institute of Personnel and Development. Induction | Factsheets | CIPD [Internet]. 2021 [cited 2022 Jan 21]. Available from: https://www.cipd.co.uk/knowledge/fundamentals/people/recruitment/induction-factsheet#gref 4. NHS Employers. Attract and recruit - NHS Employers [Internet]. 2021 [cited 2022 Jan 21]. Available from: https://www.nhsemployers.org/your-workforce 5. British Medical Association. Medical staffing in England: a defining moment for doctors and patients. 2021;1–60.
working with patients, as part of a multi-disciplinary team to improve fluid balance monitoring Hamzeh Al-Arqan ,Michael Guirguis, Muhammad Usman Khan Correspondence to Hamzeh.al-arqan@nhs.net /@dr_harqan
PROBLEM: Water is essential for life, and maintaining the correct balance of fluid in the body is crucial to health. 1 Maintaining adequate fluid balance is of paramount importance, especially for at risk patients and incorrect fluid balance levels increase the risk of Acute Kidney Injury (AKI) or fluid overload and delaying our patient's recovery. 2 To help ensure patients have appropriate fluid balances, it is important to accurately monitoring and documenting fluid charts. Although the Trust and the National Institute of Clinical Excellence have guidance to help ensure fluid balance is monitored efficiently, there was poor compliance to the recommendations. Although previous work to improve this had been done, improvements had not been sustained, therefore a multi-disciplinary approach was adopted, that included patient involvement.
FISHBONE DIAGRAM The following diagram was developed by the multi-disciplinary team to tackle the reasons for poor fluid balance monitoring.
Nice Guidelines for Fluid balance monitoring (CG174) All patients continuing to receive IV fluids need regular monitoring, this should include daily assessment of clinical fluid status, laboratory values and fluid balance charts along with weight measurement twice weekly 3 AIM: accurate input, output and balance by February 2022. Continued Improvement and Involvement of other teams/hospitals. Early detection of imbalance and intervening accordingly. Avoiding potential health implications of dehydration and overload. Delivering holistic patient care as per NICE guidelines.
RESULTS Project Run chart showed a median improvement of 90% with 100 % achieving the targets at some points; compared to only 10% compliant to the guidelines at the baseline and 70% QI Results /Impact. The QI model reflects a great teamwork with patients, nurses, house
DRIVER DIAGRAM The following driver diagram was developed by the multi-disciplinary team to help achieve the above goals.
asked to implement our QI project to other areas in the trust. AMU will be our next station to Improve. Project is in line with Nice Guidelines/Trust policy.
AIM
Primary Drivers
A team approach to fluid balance monitoring
100% of fluid balance charts on General medical ward to have accurate input, output and balance totals by 1st of February 2022
A clear process of monitoring, documentation and escalation of fluid balance monitoring
Secondary Drivers
Change Ideas
Effective team communication
Attendance at safety huddles and handover to increase staff awareness
Effective ward round reviews of fluid balance
Ensure fluid balance review every patient, every ward round
Effective case reviews, and data sharing
Case reviews and debriefs with staff following escalation of positive or negative fluid balance
Equipment needed to monitor fluid input and output
Review equipment levels of e.g. jugs, weighing scales and order more if needed
Standardised use of documentation
Position and placing of equipment and documentation required is close to where staff need it to be
Response to escalation
A patient centred approach to fluid balance monitoring on the ward
Information available for patients Patient involvement where possible in fluid balance monitoring
Importance of fluid balance posters available for patients and staff Involve patients in their own fluid balance monitoring where possible by discussion, providing jugs and use of information
METHODS As well as developing a driver diagram, a range of QI tools and methodology was used to ensure to achieve the aims. For example, PDSA cycles were used to test changes on a small scale and then refine and scale them up gradually across the Trust and beyond, based on learning. An example of a PDSA cycle is provided below: PLAN PLAN
DO
STUDY
ACT
References:
Interventions to raise awareness of the QI project and baseline data developing a team approach to improving fluid balance monitoring on the ward Displayed posters to educate and remind staff on the QI project and the importance of fluid balance charts placing it near the nursing station and in each bay Ensured that the fluid balance charts were used and present in the correct set of notes i.e., bedside notes Engaged the ward team, attending safety huddles Ward leaders reviewed compliance with available fluid balance training There was some improvement due to our initial interventions, but we still needed to achieve our target. Tested proformas to involve able patients in fluid balance monitoring. Placed copies of the project poster in bedside patient notes next to the fluid balance charts. Position and placing of equipment and documentation required was moved closer to where staff need it to be
LESSONS LEARNED 1. The value of a multi-disciplinary approach was the key of success to achieve our goals and improve the quality of care. 2. Involving patients was challenging at first but worth it. As a
3. 4. 5.
understood the importance for his health. Highlighting the impact patient education can have on their own care. Regular and effective communication between all staff members in Board/Ward rounds and safety huddles regarding fluid balance monitoring status. Continuous monitoring of achieved improvement and re-auditing. Transfer of improvement to other Trusts and wards.
FURTHER WORK The work is already being scaled up across the Trust and there are plans to scale up further. Further work is ongoing to ensure that there is more consistent data to maintain the improvements. ACKNOWLEDGEMENTS Thank you to the multidisciplinary team and patients who took part in this work.
1. Welch, K., 2010. Fluid balance. Learning Disability Practice, 13(6). 2. Bagshaw, Sean M., et al. "Fluid balance as a biomarker: impact of fluid overload on outcome in critically ill patients with acute kidney injury." Critical care 12.4 (2008): 1-3. 3. Scales, Katie. "NICE CG 174: intravenous fluid therapy in adults in hospital." British journal of nursing (Mark Allen Publishing) 23.8 (2014): S6-S8.
Hurry up with those Blood Gases! Improving the delay in blood gas sampling in the Neonatal Intensive Care Unit (NICU)
Sanpera-Iglesias J1, Davey N2, Runnacles J2 1 Croydon NHS Trust, 2 QIC learn BACKGROUND
DIAGNOSTICS
Blood gases are done and run by doctors, not nurses in our neonatal unit. This unusual situation delays decisions about the care of our babies and causes friction between our two tribes. Currently, only 2 out of 10 blood gases will have been carried out within two hours of the decision being made.
AIM & MEASUREMENT DEFINITION
CHANGE IDEAS •
Aim: By the end of February 2022, blood gases in the neonatal unit should be completed within 2 hours of the decision. The aim is to achieve this in 8 out of 10 blood gases performed.
• • • • • • • •
PDSA CYCLES
Measurement: Length of time (in minutes) between when a decision was made to do a blood gas and when this was actually carried out.
Agree with nursing staff a convenient time when a blood gas can be carried out (before a feed, after cares have been done, before cot linen has been changed) Raise awareness to staff. Provide training to use blood gas machine. Provide log-ins to staff with no access to blood gas machines Teach junior nurses how to run a blood gas Teach junior nurses how to do capillary blood gas Educational sessions around blood gas interpretation Allocate a doctor to do all the blood gases in the unit. Explain to parents what a blood gas is and why it is important. They could remind staff to carry out the blood gases.
REFLECTIONS & LEARNING
RUN CHART
| qiclearn.com | londonpaediatrics.co.uk | @qiclearn | @LondonPaeds
Using the model for improvement I was able to tailor and adapt my interventions to the people that I wished to influence, easily seeing what interventions were helping and which were not. Testing small changes led to more ideas!
Acknowledgements:
My primary aim was to reduce the delay in blood gas sampling by encouraging teamwork – doctors, nursing staff and parents.
My next steps will be to review whether these changes are sustained and suggesting further changes e.g. whiteboards to write plans for babies, organising further POC training and access…
Improving Echocardiography Education for Junior Doctors Dr Molly Nichols, Jane Draper and Dr Jessica Webb
BACKGROUND: • Echocardiography is a non-invasive diagnostic and monitoring tool • Most widely used cardiac imaging modality • Good understanding of echocardiography and accurate report interpretation is essential for patient safety and care
AIM: • To improve understanding of echo amongst junior doctors • To improve confidence with echo report interpretation amongst junior doctors
PDSA CYCLE 1 – ASSESSMENT OF EDUCATION AND CONFIDENCE/UNDERSTANDING Developed a teaching session for junior doctors to improve understanding of echocardiography and confidence with report interpretation
Act Survey responses highlighted a lack of prior echo education and low levels of confidence and understanding amongst junior doctors
Study
After struggling with echo report interpretation in my job role, I wanted to gain an understanding of echocardiography education received in the UGME and PGME settings and assess perceived understanding of echo and confidence with report interpretation amongst juniors
PROBLEM: Only 6% of junior doctors felt confident at echocardiography report interpretation 88% of doctors of doctors interpreted an echo report ≥1x/week 94% thought it was an important skill
Plan
1
OUTCOMES
Do
Designed and distributed a survey for FY1 and IMT doctors regarding echo teaching received, echocardiography understanding and involvement in job role
>2 1-2 ≤4
>2 ≤4 0
<4 0
1-2
<1
<1
PDSA CYCLE 2 – EDUCATIONAL INTERVENTION Significant average increase in mean confidence/ understanding across all areas: • FY1 49% • IMT 46%
Plan to establish echo teaching in the annual FY1 and IMT teaching schedule, to expand for delivery to FY2 doctors, to develop a practical echo course alongside lecture based session
Act
Plan
2
OUTCOMES
Study
100% found the teaching relevant to their job role 91% would recommend the teaching
After reviewing the survey responses, I aimed to improve confidence and understanding of echo and report interpretation skills amongst FY1 and IMT doctors
Survey responses displayed significant increase in confidence and perceived understanding of both groups in echo report interpretation, understanding of echo components, identification of pathology/emergencies and clinical management of echo findings
Do Delivered a teaching session on echocardiography for FY1 and IMT doctors involving an interactive case based quiz. Designed and distributed a survey following the teaching to assess efficacy of the intervention
CONCLUSION The quality improvement project has been shown to make a positive impact on the confidence and understanding of echocardiography and report interpretation amongst junior doctors. Going forward, I hope to assess how this translates to improved patient care through more appropriate referrals, better recognition of pathology and improved patient management.
E Seite, R Sawhney, M Innab
Quantitative Results PRE: • 71% of SHOs felt ‘not very confident’ in managing ENT patients • The majority (57-86%) were unaware of various referral destinations and processes
Method 1) Questionnaire and quiz (preintervention) 2) Flowchart widely circulated 3) Questionnaire and quiz (postintervention)
POST: • 100% of SHOs felt ‘somewhat’ or ‘very’ confident in managing ENT patients • 100% of SHOs knew where and how to refer patients
Additional qualitative data collected from wider ENT team about their experiences
Qualitative Results
Moving Forward
The ENT team reported:
• Local presentation of QIP resulted in wider sharing of the flowchart across IT systems in the Trust • Inclusion of the flowchart in induction presentations for new surgical SHOs – survey of new SHOs found that 100% found the flowchart useful • Opportunity to adapt and distribute the flowchart to the Emergency Department • Further improvement needed in quality of handover from SHOs to Registrars
Reduction in patients seen in ambulatory clinic, unnecessary admissions, overnight telephone referrals No reduction in patients missed during handover
FY1 General Surgery Survival Guide Adetoro Akintunde, Sashini Iddawela
Introduction:
General surgery at Good Hope Hospital is typically a fast-paced, ward cover centred job for a Foundation year 1 (FY1) doctor which requires learning a lot of administrative skills specific to not only the Heartlands, Good Hope & Solihull (HGS) trust but also Good Hope Hospital (GHH) specifically. The administrative skills may not be commonly exercised among seniors - who have different job requirements – and consequent reduced understanding or reduced transference of such skills may delay the process of adapting to the job.
Aims:
§ To aid FY1 transition into the general surgery job. § To improve confidence of FY1s working in general surgery.
Methods:
Dr S. Iddawela authored an informal guide style document for FY1s and distributed it to the GHH GS cohort commencing the FY1 role on 04/08/21 (cohort 1). Qualitative and quantitative feedback for this guide was obtained via online survey. This feedback was used to update, reformat, and add to the information within the guide; the updated guide was then distributed to the next cohort of GHH GS FY1s commencing the job from 01/12/21 (cohort 2).
Results: A graph to show the difference between the quantitative feedback of two different general surgical FY1 cohorts following guide improvement 10 9 8 7
Favourite things about guide: Cohort 1: • ‘Written by someone with boots on the ground experience’ • ‘Had info I may not have been able to receive from seniors’ Cohort 2: • ‘Gastrograffin protocol, easy to understand format, reassuring tone’. • ‘Good brief summary of tasks expected of F1’
6 5 4 3
Areas for guide improvement:
2 1 0
Confidence Relevance of about the information role before within the receieving guide for the guide surgical FY1 role
Information Guide offered Ease of guide Guide within the useful navigation & improved guide was resources reference transition easy to into role of understand surgical FY1 Cohort 1
Cohort 2
Conclusion:
Despite general lack of confidence around starting general surgery, a guide specific to FY1s improved their transition into the job. Further improvements of the guide based may allow for the guide to stay up to date and relevant to the ever changing cohorts. Future work may involve continually collecting feedback for this guide, updating, and improving it for future cohorts to refer back to. References:
1. Iddawela S. General Surgery (New) FY1 Survival Guide – The Admin. 2021 Aug.
Cohort 1: • More information regarding different IT systems like CARMAH • Format and layout, clarity of information resources and topics in the guide. Cohort 2: • Length/structure • tips on what is expected from night on calls • Information about the handover list/ booking TWOC clinics/ M&M.
Improving Paediatric Prescribing in London North West Healthcare Trust Dr Emily Ching, Dr Clemency Britton, Dr Ashiya Ali
Background More than 237 million medication errors are made each year in England, according to a recent BMJ analysis (1). Prescribing errors in the UK cost up to £98 million and more than 1700 lives each year (1). Potentially harmful errors are three times more likely to occur in prescribing for paediatrics than for adults (2) Errors in paediatric prescriptions are common nationally, approximately 13.2% of prescriptions contain an error (3).
Results
Common prescribing errors seen:
Incomplete dose written for medication.
Insulin dose should be written on s/c insulin page not regular page.
Objectives This QIP aims to: Assess the adherence of prescriptions on the paediatric ward to national standards To reinforce the prescribing standards we expect from doctors in common practice To improve the quality of prescribing through weekly educational emails highlighting areas for improvement
Lack of dosing and inaccurate units, should be written in CAPITAL letters. Handwriting difficult to read.
Good example of Allergy Box filled in, signed and dated.
Run chart of results:
Methods Each week a random selection of 5 drug charts were collected from the pediatric ward. These drug charts were scored according to a selection of national prescribing standards that, after discussion with our MDT - including pharmacists, were commonly unmet on the ward. The proportion of charts meeting these standards were plotted onto a run chart each week. Educational weekly emails were sent to all Paediatric Trainees and Consultants highlighting areas of prescribing improvement that week.
Chart 1
70% of the prescribing standards audited were not met prior to the intervention. Targeted educational emails increase the proportion of prescriptions meeting national standards Improvement following six PDSA cycles was seen in 100% of prescribing standards assessed; 30% of prescribing standards were met across all six PDSA cycles The greatest scope for improvement remains in: writing prescriptions in capitals, signing and dating discontinued drugs.
Outcomes and Future Directions Paediatric prescribing is complex, departments should offer appropriate education to ensure standards are met A targeted approach to increasing awareness of common errors improves team prescribing practice Despite education, prescribing errors will happen and we should develop a blame-free culture to ensure mistakes are learned from Future directions: Prescription practise and personalised feedback for trainees, explaining common errors using examples References 1. BMJ (2020). 237+ million medication errors made every year in England | BMJ. [online] BMJ. Available at: https://www.bmj.com/company/newsroom/237-million-medication-errors-made-every-year-in-england/. 2. Conn, R.L., Kearney, O., Tully, M.P., Shields, M.D. and Dornan, T. (2019). What causes prescribing errors in children? Scoping review. BMJ Open, 9(8), p.e028680. 3. Davis T. Paediatric prescribing errors. Archives of disease in childhood. 2011 May 1;96(5):489-91
Introducing debriefing post-cardiac arrest at University Hospitals Dorset NHS Trust: A QI Project Dr M Charan, P Eden, L Ridout, Dr C J La, Dr R Potter and Dr N White
J Junior Doctor Survey
Problem
How stressed do you feel when you are at a cardiac arrest? (n=62)
A survey was sent to all junior doctors (F1-SpR) to gain qualitative data and develop an understanding of the experiences of an in-hospital cardiac arrest at UHD Trust. The key finding was that when part of a cardiac arrest team many junior doctors felt moderate levels of stress. The area of improvement that received the most support was of a debriefing session post-arrest. There were no documented debriefs post-cardiac arrest at UHD Trust prior to this project.
Not at all Slightly Neutral Quite Very
The implementation of the debriefing prompt on the online medical emergency form occurred on the February 1st 2021. Post-implementation, an aim to increase the number of documented debriefs that occur after an in-hospital cardiac arrest by 20%, between February 2021 and May 2021 was set.
Aim
A review of the medical emergency form where all cardiac arrests are documented was reviewed retrospectively (February 2021 to May 2021) and the number of debriefs completed and themes discussed was recorded.
Outcome Measure
how does that make you feel? (n=62) Disappointment Stressed Unable to process Exhausted Relieved it's over Other
50 Number of responses
Background
Resuscitation UK advise that a debrief should occur after an inhospital cardiac arrest to guide reflection, learning and psychological support[1].
Ideas for improvement
40 30 20 10 0 Debriefing session
Communication Hospital meeting Training
No change is possible
Other
Driver Diagram Junior Doctor Survey Lack of established debriefing documentation for cardiac arrest Resuscitation Team Increase the frequency of debriefs occurring after inhospital cardiac arrest
Meeting with key stakeholders to understand how a debrief can be implemented
Adherence to Resuscitation UK Guidance
Junior Doctors
Junior Doctor experiences of inhospital cardiac arrest
Trust wide meeting to discuss findings of QIP
Debriefing Model
Creation of a model fit for purpose locally
Literature review of debriefing models
Update the online medical emergency form
Working with IT to implement debriefing on online medical emergency form
Results
PDSA Cycles
Percentage change in frequency of debriefs pre and post-intervention
PDSA 1 Qualitative date via junior doctor survey (n=62)
PDSA 2
PDSA 3
Baseline measurements and key stakeholder meeting
Create and implement the debriefing prompt on the online form via I.T to be active on the 1st February 2021
PDSA 3: The Debriefing Prompt
PDSA 4 Retrospective collection of 4 months of data (February 2021 to May 2021) postimplementation and presentation at local audit meeting
100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0%
Themes discussed during debriefs 14%
24%
24% 22%
16% 53%
Communication Teamwork ALS Protocol
Pre-intervention Debrief
Post-intervention
No Debrief
Safety Areas of Improvement
Reflections and Next Steps 1. By introducing a debrief tab to the Medical Emergency Record from we were able to trigger the process of debriefing post-cardiac arrest. 2. The feedback from consultants and junior doctors from this QIP at a local audit meeting was very encouraging. This helped fulfil another improvement idea ascertained from the survey which was of a hospital meeting to discuss the QIP. 3. The debriefing tab will be introduced at a partner hospital once an online medical emergency form has been implemented to replace paper cardiac arrest forms. 4. The Resuscitation Teams have received formal training in debriefing. 5. A debriefing lead within the resuscitation team is being organised to monitor the debriefing process. References 1. Soar, J., Deakin, C. D., Nolan, J. P., Perkins, G. D., Yeung, J., Couper, K.,Hampshire, S. (2021). Adult advanced life support guidelines. Retrieved from https://www.resus.org.uk/library/2021-resuscitation-guidelines/adult-advanced-life-support-guidelines