BPSC2022 Poster Group L - QI in Progress - Improving primary and secondary care 1

18th May 2022 Poster Competition Group L QI in Progress Improving primary and secondary care - 1

Service Evaluation to Improve Staff Experience When Triaging Dental Emergencies C.J. Ung and A. Rai Dental Core Training King’s College Dental Hospital

BACKGROUND

RESULTS

CONCLUSION

The COVID-19 pandemic has resulted in profound changes in dental service provision in both primary and secondary care settings. King’s College Dental Hospital has served as a prominent urgent dental care hub in London, and has lead to an increased volume of patients seeking access to emergency dental services.

First Cycle Results The majority of clinicians reported that telephone triaging is a stressful experience due to limitations in the triaging system, specifically a lack of acceptance criteria. An updated triage pro-forma which includes clear acceptance criteria was created to facilitate information gathering. Improvements and relevant advice addressing reported concerns were disseminated during a departmental staff meeting. Clinician experience was re-measured to evaluate the impact of said improvements on staff experience.

There is a need to telephone triage patients to assess suitability for treatment. Improvements can be made to the telephone triage system which can potentially reduce stress levels in staff members. Clinicians responded positively to the new form and the inclusion of access to a generic email have made the process easier.

The huge demand has resulted in the need for triaging of incoming calls, enabling identification of patients who are clinically appropriate for treatment, who are then assessed and treated on the Acute Dental Care (ADC) Department. Patient details are collated daily from the dental emergency telephone line to be triaged by clinicians.

Triaging can be a stressful experience for staff and many see this as the least enjoyable part of their day.

PROBLEMS IDENTIFIED/ SUGGESTIONS

First Cycle Lack of prompts on form/ postcode issues

NEW TRIAGE FORM

Unclear criteria

NEW GUIDANCE & CLARIFICATION

Second Cycle Lack of facial contact

AIMS • To improve staff satisfaction and reduce staff anxiety and stress during the dental triage process.

• To ensure patients are appropriately triaged to be seen on ADC.

METHOD Survey designed to measure clinician experience and obtain written feedback.

Pilot survey distributed – confirmed need for improvement and led to improvements in survey design The quality improvement method utilised the plan, do, study, act model for improvement Changes for improvement implemented after reviewing responses Questionnaire was redistributed to the same cohort of clinicians to re-measure clinician experience.

CHANGES IMPLEMENTED

ACCESS TO GENERIC EMAIL FOR PATIENTS TO EMAIL PICTURES

Fig. 3 Responses show a small reduction in those reporting triaging as a stressful experience (6 and High stress experienced by staff

AWARENESS OF STAFF WELLBEING SERVICES

Language barriers

GUIDANCE FOR USING LANGUAGE LINE

Fig. 1 Fig. 2 Feedback from clinicians and The new pro-forma for the relevant changes made to information gathering. the system.

Second Cycle Results Clinicians reported positive responses to the changes implemented, in particular the availability of prompts on the triage sheet and access to a generic departmental email address for liaising with patients, which has helped to improve patient communication and streamline the triage process.

over) after the implementation of changes

Whilst the reduction in clinicians reporting triaging as a stressful experience is reassuring, the results are indicative that further measures could be taken to address outstanding concerns and demonstrates scope for further improvement.

REFERENCES 1.

2.

n.d. Plan, Do, Study, Act (PDSA) cycles and the model for improvement. [ebook] NHS England and NHS Improvement.

Available at: <https://www.england.nhs.uk/wpcontent/uploads/2021/03/qsir-plan-do-study-act.pdf> [Accessed 16 May 2021].

Dawson, J., 2014. STAFF EXPERIENCE AND PATIENT OUTCOMES: WHAT DO WE KNOW?. [ebook] NHS Employers.

Available at: <https://www.nhsemployers.org//media/Employers/Publications/Research-report-Staffexperience-and-patient-outcomes.pdf> [Accessed 16 May 2021].

“Simplifying Safeguarding Month” Changing culture in the Emergency Department Natalie Whitton (Consultant), Davina Ding (CTF)

Background

Methods

Safeguarding in ED is important and a product of adequate training and professional curiosity. From the problem statements below, a multidisciplinary and multimedia theme-based educational programme was organized.

Educational Barriers • Busy department with unpredictable workload • High staff turnover with COVID-19 limitations • Poor staff compliance with level 3 safeguarding training • Lack of dedicated departmental safeguarding support Service Provision Concerns • Estimated 5% increase in safeguarding concerns from the previous year according to the Office of National Statistics.

• Safeguarding on hospital risk register as a high CQC* priority

Methods/Media

Specifications

Formal sessions

Nurse, SHO and Registrar weekly departmental teaching

Informal discussions

Daily reminders/updates at doctor and nurse handovers

‘Tea trolley’ teaching

Multidisciplinary, small focus groups

‘bogBlog’

Posters on the back of staff toilet doors (Figure 1)

Social media

Facebook, Twitter

Direct e-mail

'All ED staff’ list used

Visits by wider safeguarding team

Members of Adult Safeguarding, IDVA** and Learning Disability services available in the department

Before and after surveys were conducted to obtain cross sectional data on staff attitudes towards and compliance with safeguarding training and practices.

Results • • • •

Despite compliance with mandatory training, staff lacked confidence in their delivery.

100% of staff surveyed had received information from one or more of the methods utilised. (Figure 2) Common attitudinal barriers towards safeguarding identified (Figure 3) Overall improvement in staff confidence (Figure 4)

How confident are you with....

40 staff - Where have you seen information on safeguarding?

Capacity, MCA and MHA

Tea trolley

Patients who abscond

Teaching

Who the IDVA is and role

Handover

Asking parents and children about…

facebook FOAM

Asking patients about domestic abuse

facebook ED

Referring an adult with safeguarding…

emails

Referring a child to MASH

bog blog

0 0

5

10

Figure 2

15

20

25

30

35

Before safguarding month

0.5

1

1.5

2

2.5

3

3.5

4

4.5

After safeguarding month

Figure 4

Impacts and Considerations Senior staff were able to identify common themes regarding staff delivery of safeguarding consequently consider solutions to rectify highlighted issues.

• The need for dedicated departmental safeguarding support and training • The need for consolidation of available resources for ease of access • Replication of this educational month to enable collection of quantitative data It was also concluded that the use of theme-based, opportunistic departmental teaching creates an educational forum of discussion and is an effective method of delivering teaching in the unique ED environment.

Figure 1

Figure 3

Digitalising and Improving the Handover Process for Urology at a North West London District General Hopsital

INTRODUCTION:

AUTHORS: LUCY FOX, SARAH BROWN, HAMA ATTAR

The clinical handover process is an essential part of providing continuity of care. Issues surrounding handover can lead to avoidable errors and can affect patient safety. Our Urology department noticed significant problems with the handover process including patients not being added to the inpatient list, and therefore not being seen on the ward round, lack of or inaccurate clinical information, and poor communication between general surgical teams covering Urology out of hours. The current standard was a simple list of inpatients including their name, hospital number and location.

Our aim was to improve the clinical handover process using a three-pronged approach: • Increase the confidence of clinicians in accepting and giving handover • Ensure all Urology admissions were added to the list to avoid patients being missed • Improve the clinical information available to enhance continuity of care and patient safety.

Plan, Do, Study, Act (PDSA) Cycles were led by a team of junior doctors who undertook a questionnaire to determine healthcare professional’s views on the current Urology handover process and to identify issues that need to be addressed.

IMPROVEMENT JOURNEY:

Figure 1: The Current Standard

Cycle 1: The current standard was replaced by a word document list (WDL). This included clinical information, blood results and outstanding jobs. Time inefficacy and lack of access and confidence in using this list proved to be significant issues.

Cycle 2: The word document was replaced by a digital list using the Electronic Patient Record ‘Cerner’.

This built on the Cycle 1 list, however moving online allowed for clinical details to be pre-populated and autofill of blood results, which improved the efficiency of the handover process.

However, clinician access remained an issue.

Cycle 3: A general access list was created using the Care Team Handover on Cerner so that all medical staff could access the list, enabling them to add patients and their clinical progress.

Figure 2: The final list using Care Team Handover

DATA:

Figure 3: Improvement in how often patients were missed with implementation of WDL

RESULTS: Cycle 1: Our questionnaire showed patients were not added to the handover list ‘often’ 20% (N=2 of 10) or ‘occasionally’ 50% (N=5 of 10) of the time. This improved to ‘rarely’ with the implementation of the WDL, 75% (N=6 of 8), shown in Figure 3. However, the WDL was time consuming to update and unfortunately 44.4% (N=4 of 9) did not feel confident adding patients to the list (shown in Figure 4). There were also clinical governance issues relating to saving and accessing the WDL. There was increased confidence in handing over and a preference for clinical details being available.

Figure 4: Lack of confidence In using the WDL was an issue

Cycle 2: Feedback studies showed improved access and use of the Cerner list but patients were still being missed, particularly when admitted out of hours. Data showed that only 71% (N=5 of 7) of general surgical doctors had access to the Urology List, which was most likely the cause of patient’s being missed therefore it became clear that a general access list was required.

Cycle 3: Our final questionnaire showed that 100% (N=9 of 9) of general surgical doctors had access to edit the list and 100% (N=15 of 15) of the urology team reported that patients were rarely missed off the list.

Figure 5: Care Team Handover List gave all general surgical team members access

Lessons: The new Urology inpatient list and handover process ensures that patients are handed over and continuity of care and patient safety has improved as a result. There has been a significant improvement in patient’s being added to the list particularly when admitted out of hours and the care team handover list has provided all general surgical doctors access to the Urology List.

Considerations for the future: We could further improve by giving new general surgical doctors compulsory Cerner training on how to add patients to the Urology List and how to edit this list. This would hopefully avoid changeover period causing a lack of continuity in accurate handover.

Improving Patient Care for those with Difficult Peripheral Intravenous Access in Blackpool Victoria Hospital Authors: Dr Mohannad Abuomar (ACCS trainee), Dr Harry Alker (FY2 trainee) Contributors: Dr Gareth Hardy (ICM/EM Consultant), Tessa Walmsley (anaesthesia associate), Dr Anukiran Ravichandran (ACCS trainee)

Introduction and aims

Peripheral intravenous cannulation (PIVC) is the most common invasive clinical procedure required in hospitalized patients in whom 10-24% is reported to have difficult venous access (1,2). Blackpool hospital has a cohort of patients with a high prevalence of identified independent risk factors for difficult IV access e.g., intravenous drug users (3), leading to delays in peripheral venous access and therefore investigation and critical medication administration. We aimed to achieve: improved patients' experience, 50% reduction in calls to anaesthetics for assistance with difficult PIVC and 50% reduction in the number of vascular access related clinical incidents in the hospital.

Clinical Incident data

Figure 1

Details No harm: Minimal harm:

Near miss: Waiting managers:

Methodology + PDSA cycles

Figure 2

50% Reduction of: -Cannula calls -Incident reports Improved Patient Satisfaction

5 Engaging with community vascular access team and addressing unexpected results.

4 Objective data collection (Figure 2)+ USC teaching faculty set-up.

3 Engaged with stakeholders proposing service set up.

2 Pilot study on USC - 10 trained with good performance and patient feedback.

Suboptimal treatment in resuscitation Contrast Delayed transfer to theatre

Surgical wards:

Emergency Department: 22% CT scanner: ITU/Anaesthetics: Delivery suite:

Ideas to ensure this happened

We needed to ensure...

Which required...

A team who take ownership of difficult IV access

-Pilot study on small group -Training acute response team (ART) members

Everyone's responsibility +/- service setup

Address unexpected results

Staff survey (Figure 1)

Results and Lessons Learnt

Medical wards:

Driver diagram To achieve our aim

1

Missed/delayed administering: (IV antibiotics, IV fluids, peripheral TPN, electrolyte replacement, insulin infusion for DKA, analgesia and bloods

Wider regular USC teaching

Consider alternative peripheral access with longer dwelling time

Use of ultrasound guidance had been successful in the pilot study therefore a wider ultrasound teaching and sign-off process was developed. IMT2 and FY2 training program teaching has been established and we aim to have this available for future trainees also. Following 7 teaching sessions of 32 candidates the number of calls to anaesthetics dropped by over 50% (Figure 3). Vascular access service remains necessary and the project results have been shared with the community vascular access team to support their business case.

- ART to feedback performance and patient satisfaction FAILED

-Teaching faculty -Adopting online curriculum https://sonocpd.com/ -Creating phantom limb -Adjusting sim suite set up -Booking rooms for teaching -Sending out advertisement -Implemented into trustbased teaching program targeting all IMT2/FY2 doctors

-Midline utilisation data -Raise midline awareness -Share results with community vascular access team

Number of anaesthetic calls for PIVC assistance over time No. of calls

Note drop in calls

3 teaching sessions

We learned that with departments stretched already, placing an extra service on them was too much to ask. Therefore, spreading the skill of USC throughout the hospital was a productive alternative.

We had trouble gaining feedback from trainees due to requesting a paper form. Alternatively, we would have liked to use a QR code for this.

Contact details: mohannad.abuomar@nhs.net, harry.alker@nhs.net Acknowledgements: Emma Wiper (Quality improvement programme manager), Dr Ben Pope (ACCS trainee), James C.R. Rippey (Senior Clinical Lecturer at University of Western Australia + creator of online curriculum)

Figure 3

teaching sessions 2

2 teaching sessions

2-week cumulative intervals References: 1. Rodriguez-Calero M et al. Risk Factors for Difficult Peripheral Intravenous Cannulation. The PIVV2 Multicentre Case-Control Study. [Internet]. 2020 [cited 20 April 2022];9(3):799.

Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7141318/ 2. Rodriguez-Calero M et al. Defining risk factors associated with difficult peripheral venous Cannulation: A systematic review and meta-analysis. ScienceDirect.

2019;49(3):273-286.

3.

Drugs.

Lancashire County Council.

Available from: https://www.lancashire.gov.uk/lancashire-insight/health-andcare/health/lifestyle/drugs/

PINCH: Patient INformation to Control Haemostasias A QIP on improving epistaxis outcomes Dr James Murdoch

Introduction

Aims

Epistaxis is a prevalent ENT emergency seen in the emergency department.

The high incidence is compounded by the frequent re-attendance rate of its sufferers.

Many patients return due to lack of knowledge or confidence in managing epistaxis.

• •

•

• Improve patient education around management of epistaxis by providing patients with a patient information leaflet.

• Improve self-management of this condition, which in turn helps reduce morbidity and readmission.

Methods

A questionnaire was designed by doctors and other stakeholders in the department, focusing on patient confidence in management of epistaxis. A Likert scale was used to measure their responses.

Throughout February 2022: • Patients admitted with epistaxis were given the questionnaire.

• They were then provided with the patient information leaflet.

• The questionnaire was repeated after they had read the leaflet.

Results

Data from the questionnaires was assimilated and analysed using a combination of excel and SPSS • Analysis showed a significant difference in self-reported confidence in managing epistaxis.

• As the sum of the positive ranks are larger than the negative ranks, it can be deduced that patient confidence in managing epistaxis improved after the implementation of the patient education leaflet

Conclusion

Self-reported confidence in managing epistaxis Before intervention

Providing patients with a patient information leaflet improves their confidence in managing epistaxis.

After intervention

14

NUMBER OF RESPONSES

12 10

Further actions

8 6 4 2 0

1

Not confident at all

2

3

4

5

Very confident

• Ensuring a constant supply of leaflets in accessible locations around the hospital to ensure lasting change.

• Future cycles of this QIP to be carried out to establish whether this intervention reduces admissions to hospital with epistaxis

Can visual aids help identify patient status on ward lists?

A preliminary quality improvement project.

Rhian Bevan, Dolapo Thompson & Dale Thompson. Royal United Hospitals Bath

AIM

BACKGROUND

• Ward lists are importance sources of information transfer between members of the clinical ward team • Large volumes of information on ward lists can make it difficult to identify key information or the clinical status of patients • This difficulty is compounded by high turnover of staff, requiring frequent transfer of large quantities of information

Create a visual aid using colour codes to quickly identify patient clinical status and improve information sharing between the clinical team on ward lists.

PLAN

DO

• Improve identification of key information on ward lists • Survey to assess stakeholder needs/view of problems: Qn: Are you able to quickly identify when the clinical status of a patient has worsened?

Qn: Is the current list design appropriate/sufficient in helping identify patients who are MFFD?

Never Sometimes Yes

19%

RED: Worsened clinical status AMBER: Awaiting investigations/theatre GREEN: Medically Fit for Discharge (MFFD)

• Short teaching sessions provided to stakeholders on planned change • Implement traffic light visual aid on ward lists for 8 weeks on surgical wards • Re-survey stakeholders to determine if planned intervention has been successful

No

4%

Sometimes

42%

Yes

54%

81% n = 27

ACT Allocation of colours to clinical status

Improving ability to identify patient status on ward list

• Create a ‘traffic light’ code focusing in 3 main patient categories:

Colour printers

Available time to update list with new system

Consistency in colour coding

Legibility of colours on paper printout

PDSA CYCLE1

Availability of colour printers Viewing list on projector when colour printer unavailable Simpler colour codes that are practical Liaising with a ‘champion’ stakeholder

STUDY

Quantitative results

CONCLUSIONS • A colour coded traffic light system may be a useful tool in helping to identify key patient information on surgical lists • Consistency is key when implementing a reliable change • Difficulty implementing a change in a shifting clinical environment. Importance of a consistent stakeholder.

FUTURE WORK PDSA CYCLE2

1) Identify a ‘champion’ stakeholder to improve consistency of change 2) Further reduce colour codes to simplify and reduce admin burden: RED: Requiring ongoing medical input GREEN: Medically Fit for Discharge

10%

Qn: Were you able to quickly (on first glance of the list) identify MFFD patients/worsened clinical status patients with the colour codes?

Qn: Did you find the colour codes useful in updating the list?

n = 10

90%

Sometimes No

20%

80%

Qualitative results

Yes

Yes Indifferent No

“If you were updating the list when a patient had distinctly improved or deteriorated, the traffic light system was a clear way of ensuring this would be communicated to the team” “More effort to update the list but also easier to hone in on MFFD or unwell patients. However, it wasn’t always updated fully so not all MFFD/unwell patients were highlighted which made me trust the system less”

Multicentre Survey of inpatient wards to identify Private spaces for Psychiatric Assessments James Booker1 (presenter), Nathan TM Huneke, Tariq Islam & Vicky Cleak 1Department of Liaison Psychiatry, Southampton General Hospital, Tremona Road, Southampton, UK | Email: jb18g20@soton.ac.uk

Introduction • Liaison psychiatry services provide diagnosis and treatment services for patients admitted to the general hospital setting with concomitant physical and mental health needs.

• Despite this, patients can be acutely unwell with mental health illness and approximately 5.2% of patients reviewed are ultimately transferred to a psychiatric hospital.(1) • During psychiatric assessments, the interview often involves discussing personal information, which patients may feel uncomfortable disclosing in ward bays.

• Locally, we have observed that access to private spaces for assessments is not always possible and this may have an impact on accurate risk assessment and management.

Aim This survey aimed to identify the current availability of private spaces for psychiatric assessments on inpatient wards in general hospitals.

Methodology • Multicentre cross-sectional survey design of inpatient wards based at four general hospitals.

• Wards were identified that the adult liaison psychiatry department commonly received referrals from. A single-assessor attended each hospital and surveyed the Nurse In Charge (NIC) during normal working hours.

• On each ward the nurse in charge (NIC) was identified and a brief verbal explanation of purpose and importance of the survey was given. If the NIC consented to being involved in the study, they were then sequentially asked the following questions: 1. Is there a designated private space on the ward to have sensitive conversations with patients? (Yes/No) 2. If so, is a private space always available? (Yes/No) 3. How likely is a conversation to be interrupted at this location? (never, unlikely, neither likely or unlikely, very likely, always)

Results

• The Psychiatric Liaison Accreditation Network (PLAN) guidelines recommend: “Where clinically appropriate, the team has access to, and use of facilities that offer dignity and privacy to conduct assessments.”(2)

• Present the results at the trust-wide mental health meeting.

• Analyse the data to identify if private spaces impact patient care.

• Measure the availability of private spaces and its importance.

Act

Plan

Study

Do • Carry out a multicentre survey across the same NHS trust.

• Wards where a private room was not available had a higher incidence of interruptions.

• This could result in communication failures and patients withholding sensitive information.

Lessons Learnt Ø This PDSA cycle has highlighted the lack of availability to private rooms that liaison psychiatry teams have when assessing patients in general hospitals and has presented this to hospital management to facilitate trust-wide changes inpatient wards. Ø The lack of private rooms increases the risk of patients being interrupted during assessments which put patient dignity at risk and may lead to substandard care. Ø To rectify this hospital management should assess the feasibility of allocating private rooms on each inpatient ward in general hospitals. Ø Further PDSA cycles plan to reassess the availability of private spaces now that the issue has been highlighted to hospital management and provide teaching to nursing staff to emphasise the importance of preserving private rooms on wards.

1.

2.

Christodoulou C, Fineti K, Douzenis A, Moussas G, Michopoulos I, Lykouras L. Transfers to psychiatry through the consultation-liaison psychiatry service: 11 years of experience. Ann Gen Psychiatry 2008 71. 7(1):1–7.

Baugh C, Blanchard E, Hopkins I. Psychiatric Liaison Accreditation Network (PLAN) Quality Standards for Liaison Psychiatry Services, Sixth Edition 2020.

Physical Health Assessment and Documentation in Acute Psychiatric Inpatient Wards Dr Aayenah Yunus1, Dr Sahana Balakrishnan1, Dr Xi Mian Quah2, Dr Moses Anene3 1F2,

Nottingham University Hospitals Trust, 2. F1, United Lincolnshire Hospitals Trust, 3 Consultant Pyschiatrist, Lincolnshire Partnership NHS Foundation Trust Correspondence: aayenah.yunus1@nhs.net

Background Patients with severe mental health illness have a lower life expectancy of 13-30 years compared to the general population, with a significant proportion of excess mortality secondary to physical conditions1, including dyslipidaemia, diabetes, and cardiovascular disease3. Acute inpatient psychiatric admission provides an excellent opportunity to screen for physical illnesses and to effectively manage these to reduce morbidity, improve patient outcomes, and increase cost effectiveness2. We found that absence of up-to-date information hindered our ability to make management decisions.

Aims • • • •

Improve assessment and documentation of physical health assessments Target compliance- 100% of patients being offered physical examination, blood tests and ECG withing 24 hours of admission If not completed, a reason should be documented in the patient’s notes Implement sustainable interventions to improve compliance in our unit

Communication

ECG Machine unavailable

Do

Clinical poster

Email all ward staff

Draft staff information email

Act

Highlight outstanding tasks

Identify shortfalls

Create guideline poster

Daily ward reminder

Patient away from ward/in session

Nighttime disturbance

Patient declined

Lack of visual reminders

Method

Physical health screening not done within 24 hours of admission

Mental health documentation takes precedence

Lack of education on importance of screening

To obtain a baseline measurement, we retrospectively reviewed current inpatient notes (n=30) and collected data from their physical healthcare folder, digital patient notes (Rio) and blood test result reporting system (WebV) using a standard proforma.

The process was repeated by retrospectively collecting data for new patients for each PDSA cycle over a 2-week period.

Few staff trained to perform screening

Doctors unaware of outstanding assessments via handover

Review inpatient paper notes and systems

Optimise task handover

Patient asleep/agitated

New admission not communicated to doctors Lack of task allocation between doctors and physical health nurses

Increase staff awareness

Study

Patient

Environment

Plan

Establish baseline

Out of hours admissions/multi-site cover

System

Staff

Results Documentation rates improved from 18.5% à 50% for ECG and from 20% à50% for blood tests, however there was a marginal decline in documentation rates for physical examination from 34.8%à 33.3%.

Physical Examination % done within 24 hours of admission

90 80 70 60 50 40 30 20 10 0

100

100

90

90

% done within 24 hours of admission

100

% done within 24 hours of admission

Blood test

ECG

80 70 60 50 40 30 20 10 0

0

1

2

3

80 70 60 50 40 30 20 10 0

0

Cycle

1

2

Cycle

3

0

1

2

3

Cycle

Conclusion and recommendations Barriers identified included lack of awareness of the guidelines, suboptimal handover between clinical staff, and limited resources during out of hours shifts. Our interventions addressed these issues by improving awareness of the guidelines and by increasing communication between all clinical staff by establishing a daily reminder to discuss outstanding investigations.

Our project yielded effective sustainable improvements in patient care, which can be expanded on in the future. We recommend that the dedicated daily ward round reminder continue, as well as the aide-mémoire poster be posted in all clinical areas as an important and effective tool to summarise guidelines and supplement other interventions.

References 1. DE Hert M, Correll CU, Bobes J, et al. Physical illness in patients with severe mental disorders. I. Prevalence, impact of medications and disparities in health care. World Psychiatry. 2011 Feb;10(1):52-77.

Park A, McDaid D, Weiser P, Von Gottberg C, et al. Examining the cost effectiveness of interventions to promote the physical health of people with mental health problems: a systematic review. BMC Public Health. 2013;13(1).

3. Osborn D, Burton A, Hunter R, et al. Clinical and cost-effectiveness of an intervention for reducing cholesterol and cardiovascular risk for people with severe mental illness in English primary care: a cluster randomised controlled trial. The Lancet Psychiatry. 2018;5(2):145-154.

Background

Improving the Accessibility of Essential Equipment on the Surgical Assessment Unit

IV access and blood samples frequently form clinical management plans. On the surgical wards, the junior doctors perform these and need to be prompt when dealing with acute situations like sepsis, perforation, bowel ischaemia and acute bleeds. The treatment rooms should facilitate quick identification and collection of basic items to minimize delays to patient assessment and treatment. Across the four general surgery wards in Queen Alexandra Hospital, Portsmouth, each treatment room is different with equipment difficult to locate and reach. This wastes time in critical situations and daily ward jobs.

Aim By decreasing the time taken by junior doctors to identify and collect vital equipment from the surgical treatment rooms we aim to reduce delays in patient assessment and treatment.

Method 15 Junior Doctors were asked to enter the Surgical Assessment Unit treatment room to collect the equipment needed to gain IV access using a cannula, obtain samples for routine bloods, blood cultures, and blood gas syringe- as they would do for a deteriorating patient. The use of cannulation packs which have some of the items pre-packed was allowed. The doctors were advised to use their usual method to gather the equipment and to leave it unopened.

Items to Collect: Alcohol wipe, tourniquet, cannula, syringe/adapter, purple & yellow blood bottles, aerobic & anaerobic blood bottles, needle, blood gas syringe, gauze, extension cannula sticker and saline flush.

Some of the doctors worked on the SAU and some were treating outlied patients (so were less familiar to the treatment room layout).

The doctors were timed from when their ID card granted them access to the room until the time they exited.

The treatment room drawers were then re-organized. The equipment needed for cannulation and venepuncture were organized into one column and in order of use. The blood gas syringes and remaining items were in the neighbouring column, with new, clear labels applied.

Results Average Time Taken To Collect Items (s) Before Intervention After Intervention 106

78

After the intervention, the average time decreased by over 25% and SE decreased from 12.6s to 8.9s showing the doctors had become quicker in the more organized treatment room.

Additionally, the range before the intervention was 199s (min 60s; max 259s) and after the intervention it had nearly halved to 104s (max 147s; min 43s).

Lessons Learnt We sampled junior doctors who were caring for outlied patients on the surgical assessment unit. These doctors were unfamiliar to the treatment room layout and naturally took longer to locate the equipment. We invited these doctors to participate with the rationale that every doctor should be able to enter and identify the key equipment they need. Often in critical circumstances, the doctors assessing and treating the patient are not based on that ward, so would need to be able to use the treatment room for its purpose, with minimal delays due to disorganization or counterintuitive layouts.

Next Steps For the second PDSA cycle we will reorganize the remaining three surgical wards in a similar layout with the same labels.

After 2 months we will time doctors again. This is an appropriate time to acclimatize to the new layout and will be before junior doctors rotate to their next rotation.

Recommendations Based on a 25% improvement after organizing one treatment room, we recommend standardizing the surgical treatment rooms to a similar layout, where cannulation and venepuncture equipment are grouped together. This would mean doctors based across the surgical wards would spend less time searching for basic equipment, and in the event of a deteriorating patient, would be able to access equipment to gain IV access and blood samples quickly. Standardising would reduce discrepancies between the wards and take a doctor less time to acclimatize to each room’s layout. We found arterial blood gases particularly poorly labelled and would recommend all equipment to have a designated area and clear label which would further reduce time spent searching for an item that may be out of stock completely.

Ellen Cornish, Kirsty Cole.