BPSC2022 Poster Group M - QI in Progress - Improving care pathways - 1

18th May 2022 Poster Competition Group M QI in Progress Improving care pathways- 1

Improving safe sedation practices in bronchoscopy at a District General Hospital AE Leadbetter, RG Beckett, CL Marchand & SC Sturney

Introduction Bronchoscopy is essential for diagnosis and management of pulmonary pathology.

Procedural sedation and analgesia (PSA) practices vary, with minimal standardisation1.

Methods Retrospective review of 113 bronchoscopies and 59 EBUS reports between September 2019 September 2020 (May 2020 excluded due to COVID-19).

Identification of three interventions to improve PSA, based on BTS Quality Standards (2014)2.

1. Departmental teaching 2. Bronchoscopy suite poster Endobase

Re-audit of PSA practices post intervention.

Results Table 1. Sedation practices pre- and post- Intervention 1: Departmental Teaching Midazolam Use Bronchoscopy

Fentanyl Use EBUS

Maximum dose = 3.5mg 70yrs

Bronchoscopy

EBUS

Maximum dose = 50mcg

% cases exceeding maximum dose preIntervention 1:

5%

19%

4%

22%

% cases exceeding maximum dose post- Intervention 1:

0%

0%

0%

1.6%

Figure 1: Correct documentation of LA pre and post interventions 2+3 100 90

% correct documentation

80 70 60

1% lidocaine 2% lidocaine Instillagel

50 40 30 20 10 0

Pre-intervention

Following poster implementation

Following LA online field implementation

Conclusions Departmental teaching increased awareness of procedural sedation and analgesia (Table 1).

Departmental teaching reduced overuse of midazolam and fentanyl (Table 1).

Endobase 1. Gaisl T, Bratton DJ, Heuss LT, et al. Sedation during bronchoscopy: data from a nationwide sedation and monitoring survey. BMC Pulm Med. 2016;16(1):113. Published 2016 Aug 5. doi:10.1186/s12890-016-0275-4 2. BTS Quality Standards for Diagnostic Flexible Bronchoscopy in Adults (2014) https://www.brit[1]thoracic.org.uk/document-library/clinical-information/bronchoscopy/bts-quality-standards-for-flexible[1]bronchoscopy-2014/

CLOTS AND COVID

strategies to minimise thromboembolic complications Dr Zafraan Zathar, Dr Hanfa Karim; Dr Anne Karunatilleke, Dr May Yan and Dr Ziaudeen Ansari

BACKGROUND

COVID-19 predisposes patient to higher incidence of both arterial and venous thromboembolic disease (VTE)1. COVID-19 complicated by VTE is associated with higher mortality, morbidity and longer hospital stay1,2. Those with severe disease, as defined by critical care admission or non-invasive ventilation, are most at risk1.

AIM: Improve adherence to the evolving VTE prescribing practices locally and nationally, thereby, improving outcomes for COVID-19 patients.

METHODOLOGY

PDSA methodology was followed (Fig 1) to initially survey the prescribing practices over a 30 day period. Patients needing >40% FiO2 or bodyweight >80kg or other high risk factors for VTE (e.g cancer) were eligible for twice daily VTE prophylaxis.

Patients admitted to ITU or requiring respiratory support (i.e NIV) were eligible for extended VTE prophylaxis on discharge.

PLAN

DO

STUDY

ACT

What are the current prescribing practices?

Retrospective review of all admitted patients over a 30 day period

Review the data and hold focus groups to plan intervention

Targeted teaching (AMU & respiratory ward) and aide-mémoire poster

PDSA 2

PLAN Confirm if intervention has worked and identify any new areas for development

PDSA 1

DO

STUDY

ACT

Retrospective review of newly admitted patients

Compare findings with PDSA cycle 1

Focus on improving time to first dose VTE

Fig 1. PDSA cycles

RESULTS

100 80

LEARNING POINTS

91

80

75

86 86

60

Targeted teaching and flow charts are helpful interventions to ensure adherence to evolving clinical practice (Fig 2: 75% vs 91%) A different strategy is required to ensure we minimise time between admission to first dose VTE (Fig 2: 86% vs 86%)

% 40 20

GOING FORWARD:

0

0 Appropriate VTE prophylaxis

Eligible patients Time to first discharge on dose VTE extended VTE <14 hrs

Fig 2. Results from each PDSA cycle

PDSA 1

PDSA 2

As thromboprophylaxis is traditionally given in the evening, patients admitted after 6pm are not being given STAT dose.

In PDSA 3, we aim to target intervention at admitting teams to reduce time before first dose.

Ref: 1. Malas MB et al. Thromboembolism risk of COVID-19 is high and associated with a higher risk of mortality: A systematic review and meta-analysis. EClinicalMedicine.2020 Dec;29:100639. doi:10.1016/j.eclinm.2020.100639 2. Roberts LN, et al, Gray WK. Venous thromboembolism in patients hospitalised with COVID-19 in England. Thromb Res. 2022 Mar 24;213:138-144. doi: 10.1016/j.thromres.2022.03.017

NIV – a safer way of delivering the goods: North Middlesex Hospital Emergency Department Authors Emergency medicine consultants Ehsan Hassan and Talia Barry

The problem Emergency departments deliver NIV in the form of CPAP or BiPAP frequently. Staff delivering it may not be respiratory-trained nurses or doctors, things can go wrong.

We had a ‘never event’ where a patient was transferred on NIV with a closed 02 valve. Our department needed a ‘how to do’ guide on setting up NIV to reduce error and decrease stress for clinicians at a critical, timedependent moment and we needed to improve our documentation.

Results and reflection Improved documentation from 55% to 80% in first cycle, reflecting that the booklet was too long so was reduced from 4 to 1 page, a need for repeat reminders to embed process

Method A Plan Do Study Act cycle to introduce CPAP and BiPAP prescription forms in the resus area, an action group involving respiratory medicine, ITU and ED nurses and doctors, delivery of training in morning handover

References: https://www.england.nhs.uk/publication/never-events/ : https://www.britthoracic.org.uk/document-library/clinical-information/acute-hypercapnic-respiratory-failure/btsguidelines-forventilatory-management-of-ahrf/

The recording of dental anxiety in the emergency dental services: A quality improvement project Dr Govind Malhi BDS MFDS RCS (Eng) SmileTogether, Cornwall Aim

Introduction Dental anxiety can be defined as experiencing stress anxiety or fear when associated with a dental setting. Experiencing these symptoms while at the dentist is not uncommon. According the Adult Dental Health Survey 2009 (ADHS), 11.6% of the adult population in the United Kingdom have dental anxiety/phobia (Heidari, Banerjee and Newton, 2015). There are many of causes of dental anxiety. Common causes include traumatic dental experiences and previous trauma to the head and neck area. However, some not-so-common causes can include a fear of not being in control and agoraphobia (fear of being in situations where you feel you cannot escape) (Dental anxiety and phobia - Better Health Channel, 2021).

Improve reporting of dental anxiety so appointments can be specifically tailored to address patients anxieties and result in better patient experiences within the service and in dentistry as a whole

PDSA Cycle

Plan

A survey of patients in the Emergency Dental Service (EDS) in Cornwall came up with 3 common reasons for dental anxiety: Pain Fear of needles Childhood trauma/fear being passed on from parents

Add extra question to medical history tab on Dentally software asking patients to explain/elaborate on their anxieties

Auditing the reporting of dental anxiety

Act Survey patients to see if addressing their specific anxieties allowed them to have better experiences in the service.

software to ascertain whether an explanation/history of their anxiety was recorded. The medical history used on the Dentally

Do Question was added (Jan 2022)

Study Re-audit reporting of anxiety and compare pie charts to see if reporting improved (April 2022)

as to whether they suffer from dental anxiety.

An explanation was classed as a specific reason or event that caused the patient to develop anxiety related to dentistry i.e.

Future

to being too vague.

The results are shown in the pie chart below.

Was explanation for dental anxiety recorded ?

28% Yes No

Present findings of QIP within company to allow other clinicians to see value of increased reporting on dental anxieties and to allow propagation of further ideas on how to improve how we address dental anxiety Plan further PDSA cycles with a view to implementing the project regionally and nationally

72% References Heidari, E., Banerjee, A. and Newton, J., 2015. Oral health status of non-phobic and dentally phobic individuals; a secondary analysis of the 2009 Adult Dental Health Survey. betterhealth.vic.gov.au. 2021. Dental anxiety and phobia - Better Health Channel. [online] Available at: https://www.betterhealth.vic.gov.au/health/conditionsandtreatments/dental-anxietyand-phobia#causes-of-dental-anxiety-and-phobia.

Driving communication forward

Improving communication with palliative care patients about driving whilst taking opioids Seline Ismail-Sutton, Rebecca Allan, Megan Howarth, University hospitals Dorset

Introduction

Measurement definition

The number of people requiring end of life care is set to rise over the next 15 years [1], one of the most common symptoms experienced is pain. Opioid analgesics are often used to manage this.

Opioids have a negative impact on psychomotor skills and cognitive processing, therefore having significant implications for patients who drive whilst taking them. However, discussing this with patients is often overlooked. It is vital for patient and public safety that patients understand guidance for driving whilst taking opioids, and the legal consequences of not following this. Further, in a time where quality of life is vital, the opportunity to optimise it should be grasped.

Aim Increase frequency of documented evidence on recorded driving status and discussion on opioid driving guidance from baseline rate of 11.5% to 50% at the Macmillan Unit.

This should be achieved in the five month period between August 2021 and January 2022.

Chosen measure: documented driving status and discussion on guidance for driving whilst taking opioids.

Inclusions: All patients at Macmillan Hospice, Christchurch, with and ECOG 0-3 taking opioids.

Exclusions: Patients admitted with acute deterioration who did not improve, patients with an ECOG 4.

Data collection: Retrospective review of notes every month.

Diagnostics

Cycle 1 Add prompt to clerking proforma to record driving status.

Frequently rotating junior doctor team Perceived lack of importance

Frequency of documented evidence remained low.

Raise awareness of issue with MDT.

Discuss issue in morning MDT meeting.

Some improvement, some boxes unfilled, did not always lead to discussion.

New prompt to act as a continuous reminder for driving status to be recorded.

Add box to clerking proforma to record driving status.

Cycle 3 Increase discussions via prompt on consultant ward round sheet.

No trigger on ward round sheets

UHD leaflets not preprinted, increased perceived effort

Staff unaware of specific driving rules

Lack of teaching during induction

Presence and location of UHD leaflet unknown

Knowledge

Lack of documented discussions

Accepting habit of not discussing

Environment

Future PDSA cycles

Cycle 2 Add reminder poster in ward office to discuss this as part of discharge routine.

No reminder on discharge No prompt on checking proforma

Staff

Current PDSA cycles

Materials

Procedures

Encourage this discussion to form part of discharge routine.

Cycle 4

Cycle 5

New prompt on consultant ward round sheet to trigger discussion.

Add section to Review notes, ward round assess if positive proforma for impact achieved, prompt and feedback from documentation. colleagues.

Improve team engagement via a more formal method.

Presentation and Review effect of circulate email each intervention, raising awareness assess which to of ongoing QI keep or remove. project.

Results Baseline rate for documented driving status and driving guidance discussions was 11.5%.

The first intervention had the least improvement of 3.9% in both.

Improved discussion rate, not all team members engaging.

Reminder poster to discuss upon discharge and use existing guidance leaflets.

The second yielded the greatest improvement in documented driving status and driving rules discussion.

At the end of the third PDSA cycle, driving status and driving guidance discussions were documented in 65.2% and 60.9% of cases, exceeding our SMART aim.

Reflections Driving status box still frequently unfilled, possibly due to lack of team engagement.

Informal team discussion had little impact, more formal team discussions may be more effective.

Recording driving status did not always prompt driving rules discussion. Therefore, trigger may be better on consultant ward round sheet when more time available.

If so, it will be important to reassess and remove prompts on the clerking sheet to avoid unnecessary work effort.

Going forward, it will be useful to consider if these findings can be applied to community palliative care teams, and if driving guidance discussions are more suited to this setting.

[1] Etkind, S.N., Bone, A.E., Gomes, B. et al. How many people will need palliative care in 2040? Past trends future projections and implications for services. BMC Med 15, 102 (2017). https://doi.org/10.1186/s12916-017-0860-2

Atrial Fibrillation: Changing an Irregular Practice Dr Shu-Yi Claire Chan, Dr Jessica Macready, Dr Bridget Kemball Introduction

New atrial fibrillation (AF) is a common acute presentation on the medical take. Anecdotally, we noticed wide variation in the management of these patients at our hospital. An initial audit confirmed irregularities in management and follow-up. Based on the results of this audit, we were driven to develop a new Trust-wide guideline to ensure safe and standardised care for patients presenting with new AF.

Aims:

• Primary aim: To assess management and follow-up of patients presenting with new AF on the medical take • Secondary aim: To create a new clinical guideline, in collaboration with key stakeholders, for dissemination and use Trust-wide

Education (Nov-Dec 2021) PDSA education cycles occurred from Nov to Dec 2021, including education for the acute medical team, clinical fellows and foundation year 2 doctors.

Audit Round One (Aug 2020)

19 patients with new AF identified, of these: • 95% given appropriate rate control • 12% inappropriately discharged without anticoagulation (despite high CHADS-VASC score) For the 18 patients who survived to discharge there were discrepancies in follow-up: • 25% of patients were inappropriately discharged without referral for an outpatient transthoracic echocardiogram (TTE) • 44% were discharged with no follow-up Existing Trust guidelines outdated and difficult to find

• Improved awareness of existence of guideline and of guideline contents following education sessions • Improved awareness of New Medicine Service

Action Plan (based on round one results)

• Clear need for updated standardised guidelines • Clarification on follow-up: • Clear criteria for specialist follow-up • All patients should receive some form of follow-up given that many would be started on lifelong anticoagulation / rate control • Signposting to New Medicines Service (pharmacy counselling in the community)

Audit Round Two (Dec-Jan 2022)

Re-audit Dec 21 to Jan 22; 18 patients with new AF identified.

Rate Control • Most patients continued to receive appropriate rate control • Reduction in harmful outcomes: zero patients had rate control inappropriately withheld

New Guideline (Jan-Oct 2021) End Oct 2021: New Trust guideline created with input from pharmacy, cardiology, acute medicine, haematology and renal teams.

Anticoagulation • Improvement in patients receiving appropriate anticoagulation from 68% to 78% • Reduction in harmful outcomes (no anticoagulation or inappropriate choice of anticoagulant) from 16% to 6%

Fig. 1. Quick reference flowchart for management of new AF

Keywords e.g. ‘New Atrial Fibrillation’, ’AF’, ‘DOACs’ were used to make the guideline easily searchable.

Follow-up • Improvement in patients being appropriately followed up on discharge, from 53% to 89% • Improvement in patients being referred for appropriate outpatient investigations, from 74% to 83%

Conclusions

The new Trust-wide guideline showed good uptake and awareness among junior staff after education cycles. Re-audit indicated some key improvements in the management and follow-up of patients presenting with new AF. It also identified areas where further improvement is required (no change seen between rounds 1 & 2), including: • Clear rationale for inpatient specialist input • Clear documentation of stroke risk and bleed risk scores • Move to ORBIT rather than HASBLED for bleed risk scoring Further education of junior doctors, on these specific points, could be a focus for a future PDSA cycle.

Creation of Treatment Escalation Plans for patients admitted to a general medical ward Dr Sidharthan Ilangovan1, Dr Montana Jackson2, Dr Raj Tanday3 1

Junior Doctor, Barking Havering and Redbridge NHS Trust, 2 IMT, Barking Havering and Redbridge NHS Trust , 3 Consultant Endocrinologist, Barking Havering and Redbridge NHS trust

Introduction

Changes

This is a QI project to evaluate the Creation of Treatment Escalation Plans for patients admitted to a general medical ward.

The results of cycle 1 demonstrated that we were falling short of the expected standard when it comes to creating treatment escalation plans for inpatients as just under half of patients have TEP’s documented in their medical notes. This thus

What are Treat escalation plans?

demonstrated the need for more education on the importance of Treatment Escalation plans and their implementation.

A Treatment Escalation Plan (TEP) is a form of advanced care planning and communication tool which is helpful in hospital

Recommendations

for inpatients as they have the potential for acute deterioration and some may even be coming towards the end of their life.

A 3 pronged approach was utilised to improve the uptake and creation of TEPs;

(1)

1.

Education

2.

Reinforcement

Why are TEPs useful?

3.

Access/convenience

There are situations in which doing everything possible may actually lead to more harm (suffering and distress) rather than

Action plan

less and may not be in the best interest of the patient (or even in line with the patient’s own wishes). What can be done and

The recommendations above were actioned using the following practical changes on the ward;

what should be done may not necessarily be the same thing. Thus this is the reason Treatment Escalation Plans should be

1.

A presentation to ward doctors during ward based teaching

discussed (amongst the clinical team and with the patient) and made based on personalised realistic goals whenever patients

2.

Moving forward regular presentations on the importance of TEP’s and creating TEPs during ward based induction for incoming doctors

are admitted as inpatients. (1,2) 3.

TEPS daily)

Crucially, a TEP provides on-call hospital staff with immediately accessible guidance about how to respond to an individual in times of crisis, especially out of hours and at weekends. A TEP becomes particularly important when there is agreement

A poster was created that highlights the importance of TEP’s and shows how to create one (reinforcing the importance of

4.

Create and place TEP pro-formas prominently in the doctors office so that they are readily available to be added to

that interventions or referrals for more intensive care that are contrary to a person’s wishes or are futile or burdensome

medical notes of new patients. This serves to provide ready access to TEP proformas. This thus increases convenience

should not be undertaken. Equally in many patients who may have an agreed DNACPR, a TEP clarifies all the treatments

and reduces resistance to the adoption of TEPs

and care that should continue.(1,2,3) Current Guidelines

Currently there are no national guidelines dictating initiation of TEPs but there are many guidelines and clinical decision making aids available from NICE (i.e. Warwick model) to aid clinicians in TEP decisions. (3)

Cycle 2 Results

Aim

The action plan above was implemented for a month and following which the data collection was repeated to assess the efficacy

The aim was for 100% of patients admitted as inpatients to medical wards should have a treatment escalation plan

of the recommendations

documented Results

Over the 2 week period 66 unique patients were admitted to ash ward and their notes were analysed. Of the 66 patients 57 had a Treatment Escalation Plan on file. Only 9 patients did not have any formal TEP available in their medical files. Thus 86.36% of patients in this representative sample had a TEP available representing a marked improvement from the findings of the initial audit.

Cycle 1 Materials and Methods

(Figure 2)

QI Approval

Figure 1. Cycle 1 Results

Audit approval was sought and obtained from local clinical audit department and audit registered.

Figure 2. Cycle 2 Results

Timeframe 2 week period between 13/10/2021 – 27/10/2021 Participants Patients admitted to Ash ward a King Georges Hospital for this 2 week duration were used as a representative sample. All patients admitted to ash ward during this 2 week period were included in this study without any exclusions.

Methodology 1. Examination of case notes was the primary method used to identify if patients had any treatment escalation plans in place 2. Forms of treatment escalation plans accepted for this study are as follows; TEP Present

TEP Absent

TEP Present

TEP Absent

- Filled up treatment escalation plan proformas in medical clerking notes - Filled up treatment escalation plan proformas added on the ward (separately from the medical clerking booklet) - Detailed written treatment escalation plans not utilising the proforma

3. The patient notes were examined to locate the aforementioned forms of Treatment Escalation Plans and the data was

Conclusion

recorded in an anonymised and password protected excel sheet Our data indicated improving education (with regular passive reinforcement) and improving access to TEP proformas to allow quicker decision making and better adherence to guidelines does improve adoption and creation of TEPs. Potential Pitfalls Both QI cycles were performed within a 4 month period thus was not subject to the turnover of junior doctors. In past studies looking into implementing other forms of advanced care planning this junior doctor turnover has been found to be a point where improvements are diminished. (2) Therefore a 3rd cycle is planned for the future to verify if the results hold true despite junior

Cycle 1 Results

doctor rotation.

Over the 2 week period 91 unique patients were admitted to ash ward and their notes were analysed. Of the 91 patients only 37 had a

1.

To combat the rotation of junior doctors education on TEP should be integrated as part of local ward induction programs.

Treatment Escalation Plan on file. 54 patients did not have ay formal TEP available in their medical files. Thus only 40.65% of patients

2.

Education on TEPs and their importance should be extended to involve other members of the MDT (nurses,

in this representative sample had a TEP available falling far short of the 100% standard set out at the introduction. (Figure 1)

Future Improvements

physiotherapists, ect.) to allow multiple members to reinforce one another in creating TEPs

1. Paes, P. and O'Neill, C., 2012. Treatment escalation plans – a tool to aid end of life decision making?. BMJ Supportive &amp; Palliative Care, 2(Suppl 1), pp.A60.1-A60 2. Lewis C, Lefroy E, Cheung B. Treatment escalation plans: a review of patient and family discussions and communication between healthcare professionals. Future Healthcare Journal. 2019;6(Suppl 2):78-78.

Improving prostate cancer surveillance in primary care Iddawela S, Prince R.

PLAN • Active surveillance of prostate cancer is a key aspect of long term management in primary care.

• A quality improvement project was undertaken to establish these thresholds, set up monitoring pathways and invite patients to participate in annual reviews focussed on prostate cancer

STUDY

DO Patients who have prostate cancer in a single GP practice in the West Midlands – identified those discharged

•

Patients were invited for an annual review, with an offer of an examination.

•

Monitoring and thresholds established

• •

•

PSA

5/41 lost to follow-up – 2 from private sector 18/41 discharged 7/18 (39%) had no monitoring thresholds 1 patient – PSA above threshold, several occasions and missed 4/18 (22%) patients accepted invitation for review – only 2 consented for physical examination

ACT • NHS services contacted to reinstate follow-up • NHS consultants and/or services consulted regarding monitoring thresholds – including patients from private sector • Patients referred on urgent pathways for missed follow-up • Communication with clinical directors regarding transfer of care upon discharge • Mechanisms for practice recall and updating the cohort were enacted

KEY TAKEAWAYS • • •

Poor continuity of care in the private sector and difficulty re-establishing contact Need for clear and consistent communication between secondary and primary care at point of discharge Continual revisiting in primary care and offer of physical examinations in addition to PSA

Developing an advanced nurse practitioner led scaphoid pathway Sian Edwards and Louisa Morris Background

Phase 2 results Retrospective data analysis of wrist injuries (as phase 1) HISTORY TAKING 80%

75%

8% CONTEXT

MECHANISM OF INJURY

Aim of Audit To evaluate clinical standards by ENPs and GPs meet National guidance of potential scaphoid fractures.

To audit documentation standards to avoid any potential litigation against the HB. Deliver teaching to GPs and ENPs about wrist injuries, history taking skills, anatomy and scaphoid fractures.

To set up an advanced nurse practitioner led soft tissue clinic and a scaphoid pathway to ensure gold standard of treatment to aid earlier diagnosis in MIU.

68%

65%

Patients

Hand and wrist injuries are a common presentation to MIUs in the U.K, and scaphoid fractures account for 90% of carpal fractures.

Up to 16% of scaphoid fractures are not visible on initial imaging (Bickley, 2019).

A missed fracture carries the risk of avascular necrosis, leading to significant morbidity and costly corrective treatment, as well as the risk of litigation.

History taking, including mechanism of injury and time of injury is paramount.

TIME SINCE INJURY

HAND DOMINANCE

OCUPATION

Feel 89%

98% 86%

98%

88%

83% 57%

82%

46% 33%

38%

38%

38%

Methodology A core working group established, led by an ANP. ANP led soft tissue injury clinics were established.

PDSA 2 Establish local MRI pathway for MIU If scaphoid suspected STI clinic 2/52

Phase 1

If still symptomatic and no obvious scaphoid fracture, request MRI MRI scan completed within 48hours

A retrospective analysis of wrist injuries as per Nice and RCEM

MRI report within 24hours (still in agreement stage)

Phase 3 results

MRI REQUESTED 22 Scaphoid fracture, 1 DNA, 4 Radius fracture, 4

Bone bruising, 2

Phase 1 results

No fracture, 7

History taking

Other , 4

40 35 30 25 20 15 10 5 0 SHOULDER (IF

FINGERS 1-5

MC 1-5

REST OF CARPALS

AXIAL LOADING

SCAPHOID

ULNA

ASB

RADIUS

4 POINTS ELBOW

Wrist Performa N/V STATUS

40 35 30 25 20 15 10 5 0

Feel

Documented

PDSA 1 The ANP team will address this with teaching the ENPs and the GPs about wrist and hand injuries.

History taking skills Anatomy and physiology of the hand and wrist Clinical examination skills of the hand and wrist Investigation, diagnosis and follow up processes ENPs advised to audit their own clinical practice/documentation following the template used for this audit.

Optimising and improving the management of patients with abnormal liver function tests in primary care Yi-Hsuan Chiang, Linnuel Pregil, Dr Liuhao Wu

Background

Work streams / Aims

Fatty liver disease is one of the commonest causes of abnormal liver blood tests (LFTs) and can lead to liver cirrhosis in 1-3% of patients.

Patients and clinicians are often falsely reassured that it is leading to poor management.

In our analysis, ~30% of patients who had abnormal LFTs are inappropriately managed.

Only 1 in 5 patients in our analysis have a risk stratification (FIB4) performed to assess their risk of cirrhosis (NICE guideline).

Based on our predictive modelling at our GP practice, we estimated that only 1 in 10 patients have a confirmed diagnosis of fatty liver and there is ~170 undiagnosed fatty liver diseases in patients with deranged LFTs at our practice.

A. Achieved

disease

B. Improve the management of deranged LFTs Achieved

Achieved

C. Implement interventions in the early stages of NAFLD to prevent liver fibrosis

PDSA Cycle/ Intervention

Results

Our project focused on 3 separate workstreams and 5 interventions, each with their own PDSA cycle:

Re-call Clinic: Our recall clinic identified high-risk patients and all patients were appropriately managed with ~10% of the patients being referred to hepatology All patients were All patient had repeat blood 26 informed about requested via call or text message 2 management, 3 complication and 4 17 monitoring.

ACT

PLAN Audit and data collection Stakeholder identification Practice meeting Project planning

Refining interventions based on feedback: Improving patient leaflet Adjustment to local guideline Manual to Automating FIB 4 calculator Ad-hoc teaching sessions Step by Step guide Stakeholder engagement

DO Patient leaflet and posters Local guideline Re-call clinic (high risk patients) Teaching sessions Automated FIB4/Risk calculator

STUDY Questionnaires / Survey 1:1 interview FAQ and Feedback sessions Re-audit

Total DeNo Patient Recalled high-risk registered answer cancelled patient appointment

Risk (FIB4) Analysis The number of patients who had risk stratification (FIB4) score coded on EMIS increased by 2x after the introduction of our integrated FIB4 calculator

1. Patient leaflet

May-Dec May

?

>2x fold increase

April

compared to last year

Interventions knowledge

2 patients were REFERRED to hepatology due to high risk of cirrhosis

10 March

B. Improve the management of deranged LFTs 2. Local Guideline

3. PCN Teaching

9 1

1

1

2016

2018

2020

2021

13

Dec 22 (TBC)

Apr 22 -Automated FIB4 calculator incorporated into EMIS protocol + Teaching session + Guideline

Feb 22 - FIB4 calculator programmed on EMIS

2022

PCN teaching - Learnings, interventions and teaching sessions were shared with 9 GP practices across 3 PCN groups and we received overwhelmingly positive feedback from all the stakeholders "Really helpful presentations."

"Could you have this installed (FIB4 calculator) in our EMIS?"

C. Implement interventions in the early stages of NAFLD to prevent liver fibrosis 4. FIB4 Calculator

5. Re-call clinic

9 GP practices across 3 PCNs

"This is excellent work. Well done!"

"I scored her using your template!"

Conclusion Abnormal LFTs are not well managed in primary care due to multiple factors lack of time, awareness and local guidelines.

After our root cause analysis, we identified key changes which lead to improved outcomes: Explaining complications (3x increase) Performing risk stratification (2x increase) Increased referral and identification of high-risk patients The toolkit (composed of an automated FIB-4 calculator, patient leaflet, and a concise guideline) we had implemented was wellreceived across three PCNs. This QIP will be shared with all GP practices in North-East London so that other practices can replicate the project as part of their QIP.

Marie Jasim, 1 Bridget McManamon, 1 Benjamin Stone, 1 Rebecca Spiby 1 1

Torbay and South Devon NHS Trust

Improving patient safety, on-call working experience and junior doctor wellbeing through improved weekend phlebotomy provision: A Quality Improvement Project

BACKGROUND

“Much better service now”

100%

>50%

felt the workload was now more manageable

-

increase in number of weekend phlebotomists

‘[great] result…

I'm honestly delighted”

A working group of junior doctors and hospital representatives was formed (phlebotomists, laboratory staff, operations managers).

A mixed-methods online survey collecting quantitative and qualitative data was circulated to all junior doctors.

Data analysis identified the extent of the issue, and trends for targeted improvements.

A business proposal secured funding to trial an increase in number of weekend phlebotomists by >50%, and an increase of 2.5 to 4 working hours per phlebotomist.

A follow-up online survey identified whether implemented changes had a demonstrable effect, and areas for further improvement.

-

Can you think of instances when patients not being bled led to patient safety issues or delayed discharge?

-

-

-

-

-

Initially, 97% of respondents reported significant problems with existing weekend phlebotomy provision.

Doctors were spending a significant proportion of each shift identifying patients and taking bloods, at the expense of other tasks.

The majority of respondents identified patient safety concerns or delayed discharge as a result of delays in or the absence of blood test results (Graph A).

Following increased phlebotomy provision, all respondents surveyed felt the service had improved.

Average time taking to bleed patients improved from 97 minutes to 47 minutes (Graph B).

Further cycles are ongoing to maintain and continue improvement against changing needs of the hospital.

79% Improvement in junior doctor satisfaction with current provision

50 minute (48%) improvement in average time per doctor required to take bloods

Respondents answering 'yes' (%)

RESULTS

82

18

Before intervention After 1st intervention Graph A

Average time taken to bleed patients 125

Time taken (minutes)

-

Serious concerns raised: Unmanageable workloads for the on-call doctor team, who were already working at full capacity.

Patients were not being bled in a timely fashion to enable safe and effective care Discharge planning was being compromised

‘[it’s] definitely improved and made the weekend shift a much easier experience’

METHODS

Existing limited weekend phlebotomy service was incompatible with the number of patients requiring blood tests, which was impacting safe discharge and urgent out-of-hours care Junior doctors were therefore required to spend significant amounts of time taking blood.

100 75 50 25 0

BEFORE INTERVENTION AFTER FIRST INTERVENTION

Graph B

DISCUSSION AND CONCLUSIONS -

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There are significant challenges in providing optimum safe and efficient out-ofhours service, with limited resources. In a climate of increasing workload pressures, we are witnessing the impact of this on patient safety.

This project was an excellent demonstration of a truly multi-disciplinary team working together to provide better patient care.

Whilst this appears to be a cost-effective intervention that yielded measurable improvement, further work could include a cost-benefit analysis of employing additional phlebotomists balanced against timely patient discharges for those whose discharge was dependent on blood test results.

Discussions with other local hospital trusts to share ideas for safer out-of-hours service provision could also be beneficial.

A limitation of this data collection method is the self-selecting nature of the respondents.