BPSC2022 Poster Group N - QI in Progress - Improving care pathways - 2

18th May 2022 Poster Competition Group N QI in Progress Improving care pathways- 2

Improving the Assessment of Patients >75 years admitted under General Surgery: Focusing on Treatment Escalation and Frailty Scoring Jocelyn Cheuk, Alice Raban Introduction

Treatment Escalation Plan encompasses decisions surrounding Do Not Attempt Cardio-pulmonary Resuscitation (DNACPR) and patients' ceiling of care. Previous research highlighted that survival to discharge following CPR is 15-20% and this figure is much lower amongst elderly and frail patients. Appropriate DNACPR decisions following discussion with patients and their family members can facilitate a natural and more dignified death. The Rockwood Clinical Frailty Scale (CFS) is a holistic and global clinical measure of a person’s level of function and vulnerability two weeks prior to their deterioration, which can help facilitate TEP discussions. This quality improvement project was set up following recognition that completion of TEPs and CFS documentation is lower in some specialties such as General Surgery.

Aim

>70% patients >75 years old with TEP & Rockwood Clinical Frailty Score (CFS) documented

Initial Audit •71 admissions of patients >75 years old between Oct and Nov 2020 •44% with TEP form and 37% with CFS

Intervention 1 •Placed copies of TEP forms into the surgical

.

assessment proformas and highlighted the Frailty Score box already in the proforma.

•Qualitative survey regarding surgical team’s thoughts

Cycle 1 Results •66 admissions between Dec 2020 and Jan 2021 •62% with TEP form and 51% with CFS

.

Qualitative survey: •barriers to completion identified •58%: senior review is the most appropriate time for TEP. 92% supported inclusion of TEP forms into clerking proforma Intervention 2 •Informal teaching from surgical registrars Cycle 2 Results •52 admissions between May 2021 and June 2021.

to clerking teams

•39% with TEP form and 29% with CFS

.

Summary Results from Cycle 1 were promising and demonstrated that visual aids have an impact in prompting early completion of TEP forms and CFS scores. Results from Cycle 2 demonstrated no impact and several limitations were identified: • Sample size was smaller than previous cycles • Timing of intervention coincided with significant Covid-related changes to the structure of the surgical team.

There is no doubt that there are significant benefits in early completion of TEP forms and Rockwood CFS scores.

The comparative success and failures of methods trialed helped identify learning points and guide future interventions in this ongoing quality improvement project.

Future Directions • Rollout of ReSPECT forms within the trust • Formal teaching with input from geriatric team • Online training via Clinical Frailty Network • Encourage documentation of TEP discussions in discharge summaries

Quality Improvement Project: Reducing The Delay Between Hip Hemiarthroplasty Surgery and Post-Op Check X-Ray Authors: Dr. Kaustabh Sen (FY2 Clinical Fellow), Mr Andrew Gardner (Specialty Registrar, Trauma and Orthopaedics), Miss Lydia Jenner (Specialty Registrar, Trauma and Orthopaedics), Miss Jemma Rooker (Consultant Trauma and Orthopaedics)

Aims

Introduction Approximately 28,000 hip hemiarthroplasties are performed for fracture each year in the NHS. The Getting it Right First Time (GIRFT) initiative recommends a post-operative x-ray (XR) to ensure satisfactory position of components and to assess for an iatrogenic fracture.

To assess time between surgery and post-operative XR

To Streamline the protocol

Methods/PDSA cycles Consecutive patients were identified through the National Hip Fracture Database.

Electronic patient records and radiograph systems were scrutinised for date of XR request, date of postoperative XR and date of discharge.

A total of three PDSA cycles over an 18-month period were performed.

PDSA cycle1 (pt=35) R=1.7 X=4.4

Not idle between cycles Between each cycle, staff education sessions, posters and policy change was implemented to ensure the operating surgeon requested the XR.

PDSA cycle2 (pt=55) R=1.5 X=4.3

PDSA cycle3 (pt=50) R=1 X=3.1

R= Average number of days (NOD) between operation (OP) and XR request X= Average NOD between OP and XR 5

Lessons learned:

To identify any reasons for delay

4.5

NOD between OP and Xray request

NOD between OP and XRAY

4.4 4.3

4

Requests on admission or at time of surgery was associated with a quicker time to post-operative XR. In the third PDSA cycle, when the mean number of days (NOD) between operation (OP) and XR was 5 days, the mean length of stay (LOS) was 12 days.

When this was >5 days, the mean LOS was 16 days.

Streamlining post-operative XRs reassured hip fracture patients the operation was successful and was associated with a shorter hospital stay.

Continued proactive XR requesting is vital in this cohort of patients to avoid risks of prolonged bed rest and hospital stay.

Author contact: kaustabh.sen@nhs.net

3.5 3.1 3

2.5

2 1.7 1.5 1.5 1

1

0.5

0 CYCLE 1 (PT=35)

CYCLE 2 (PT=55)

CYCLE 3 (PT=50)

Pandemic Pandemonium in Paediatrics Post-discharge Refining a novel trainee-led initiative during the COVID-19 pandemic 1

1

1

2

Kathryn Mullan , Ngozi Oketah , Nicola Davey

2

Royal Belfast Hospital for Sick Children , 180-184 Falls Road, Belfast BT12 6BE, QIClearn

BACKGROUND

•

Established in response to the pandemic, a trainee-led outpatient clinic aimed to provide postdischarge care to children and young people while reducing pressures on consultant-led clinics

•

Since its launch, service users identified communication breakdown at various stages in referral, booking and follow-up management as detrimental to its success

DIAGNOSTICS

AIM & MEASURE

Process Map

All children attending Trainee Review Clinic will undergo timely clinical review with outcome letter completed & communicated with all parties (from baseline 10%) by February 2022 Determined by 4 criteria: 1.

2.

3.

4.

TRC Protocol TRC Booking Proforma

TRC Troubleshooting Session TRC Appointment Cards

TRC Clinic Code TRC Letter Template

Indication for Review stated Lead Consultant Listed Patient attendance Clinic Letter completed

CHANGE IDEAS

PDSAs

Trainee Review Clinic Protocol

RUN CHART

REFLECTIONS & LEARNING Using the Model for Improvement, frequent, small change ideas allowed us to identify successful interventions

The run chart illustrates improvement leading to meaningful change at patient and service level

Targeted interventions resulted in a safer, more efficient service. The was a 50% reduction in the clinic’s Did Not Attend (DNA) rate

Ongoing feedback guides strategies for change in post-discharge care. Future work will capture patient experience with patient-centred outcomes

Developing a triage tool to predict mortality among High Impact Users in an inner-city Emergency Department Authors: Jasmine Schulkind (CT1), Lily Stanley (ED SpR), Mya Dilly (ED SpR), Sally Buckland (HIU Co-ordinator), Raoul Chandrasakera (HIU Co-ordinator), Paul White (Associate Professor, Applied Statistics)

1

WHY?

• A frequent attender (FA) is anyone who attends ED ≥5 times per year (RCEM).

• At Bristol Royal infirmary (BRI) ED ~1% of attendees account for ~10% of ED • • •

2

attendances per year.

FAs at BRI ED have a 5-year mortality rate of 20.6%.

The BRI High Impact User (HIU) team was established to support the FA population through Personal Support Plans (PSPs).

Because of the high % of FAs there is a need to triage patients to determine who to prioritise for a PSP.

AIM Develop a triage tool for High Impact Users (HIUs) at Bristol Royal Infirmary (BRI) ED, using predicted mortality.

The first step, outlined here, was to determine which factors increase mortality in this specific local population

3

HOW?

Ø We collected data on 250 patients, randomly selected from 1780

4

FAs attending BRI ED between Jan 2016-Jan 2017.

Ø Six variables were chosen as potential predictors of mortality. Ø Data was collected from electronic patient notes. Data on age, gender and 5-year mortality was also recorded.

Ø Logistic regression modelling was performed to determine which factors best predicted 5-year mortality.

Ø This wasn’t a clinical research study therefore did not require NHS research ethical approval.

Scoring system to identify high risk frequent attenders

6

5

WHAT WE FOUND Attendances and Mental health problems: • 14/15 very high attenders (>15 attendances per year) had mental health (MH) problems.

Attendances, mental health problems and mortality: • FAs with MH problems who attended 10-20 times per year (n=22) had a much higher mortality rate (31.3%) than those in the >20 attendances group (n=6) where 5-year mortality was 0%.

• Data suggests patients with mental health problems have different risks from those without.

Therefore two different scoring systems to predict mortality were developed

7

Limitations and Conclusion

• This is a small-scale project using a specific cohort of HIUs and so our findings are not generalisable.

• This is an under-researched and poorly understood population. We hope ED departments will use these findings to collect data on their own HIU populations.

• Our next step is to pilot the scoring systems and prospectively collect data.

CATEGORY: QI IN PROGRESS

Taking the long way to theatres: assessing delays in trust internal transfer of acute surgical patients Y. Hazemi-Jebelli, K. S. Weigel, R. Gunnell, M. de Wolf, M. Patel, A. Ogedegbe, A. Bhargava, D. K. Patten

Background:

Data collection:

Over the COVID-19 pandemic acute surgical services at our trust were moved from running at two sites to running to a single site. This was done in order to protect Site A elective operating capacities.

This quality improvement project was inspired by cases whereby significant time delays resulted in poorer patient clinical outcomes Aims: o To assess the times and delays in the transfer of an accepted and fully assessed acute surgical patient o To identify the risks of patient safety and outcomes resulting from delays in transfer o To identify if there is an existing trust policy / guideline(s) in place o set standards for acute surgical patients transfer

PLAN

Interventions:

ACT

o Presentation of results at Surgical Quality and Safety Governance meeting o Setting standards for transfer methods and time limits o Creation of formal transfer proforma to be filled in for every transferred patient, including clear instructions on the steps required

The following data was collected from clinical notes, electronic patient records, radiology, endoscopy and theatre software for a 3-month period: 1. Demographic information 2. Time & Date seen by A&E 3. Time & Date referred to surgical team 4. Time & Date seen by surgical team 5. Diagnosis 6. Time & Date decision to transfer 7. Type of transfer i. Ambulance ii. Blue light ambulance iii. Independent transport on following day (TCI)

DO STUDY

8. Time & Date arrival at Site B 9. Time, Date & category of CEPOD booking 10. Time & Date first procedure* after arrival 11. Nature of first procedure after arrival 12. Complications 13. Discharge date *first procedure at secondary site as marker of delay

Any IR 11 Data collected 206

Incl in analysis 187

Ambulance transfer 127 Blue light transfer 36 TCI 23

I&D 22

Any endoscopy 10

Laparotomy 19 Operation 78

Procedure 99 Other op 8 Complications 37

Deaths 7

Appendicectomy 27 Lifesaving Procedure 15

o Creation of easy-to-follow flow-chart including contact numbers of key staff members o Education of key staff members

Site A to Site B transfer Guidance 1. Does patient require ongoing care on an acute surgical ward?

Yes

2. Is patient stable for transfer?

No

Yes

3. Does the patient require transfer to Site B theatres within 1 hour? (eg ischaemic bowel)

No

4. Does the patient require surgical intervention at Site B within the next 24h?

Yes

No

Can the patient be stabilised for transfer with resuscitation?

Patient can stay at Site A under medical care

Patient to be transferred under category 1: Immediate transfer

No

Patient to be transferred under category 3: nonurgent transfer

Yes

Patient to be transferred under category 2: Urgent transfer

No Yes

Take patient to theatre at Site A

Resuscitate patient at Site A

Inform Site A theatres:

Reassess if patient is stable for transfer and continue at question 2

XXXX (in hours) XXXX (out of hours)

Inform Site A consultant

Please Inform: Site B Take SpR: #XXXX Site B CEPOD SpR: #XXXX Site B theatres: #XXXX

Please liaise with: Team at Site B: SpR #XXXX, SHO #XXXX Nurse booking LAS

Please liase with: SAU regarding bed space: #XXXX Site manager Site B if necessary: #XXXX Please document: time decision for transfer made, time decision to operate made, type of transfer indicated, time LAS informed Please ensure patient is added to Site A surgical list and transferred to Site B surgical take list when patient has left Site A ED department

Average time between: Decision to transfer to arrival at site B Decision to transfer to procedure Decision to transfer to life saving op.

9:16h 43:38h 8:38h

Please call Site B on call SpR when patient has left department

CEPOD booking to procedure

Intervention:

Findings:

12:23h

Introduction of the iCough programme at RUH Bath in patients undergoing elective colorectal surgery to reduce post-operative pulmonary complications.

Author: Mrs Nina Stuckey Surgical Team Lead & Clinical Specialist Physiotherapist Co-Authors: Miss Ella Cottle Physiotherapist & Miss Petra Silverwood Physiotherapist

Introduction Postoperative pulmonary complications (PPC’s) are common, associated with increased length of stay (LOS), morbidity and increased healthcare costs postoperatively(2,3) ‘iCough’ is an evidence-based pulmonary care programme shown to reduce PPC’s (1) It has 6 elements shown in Figure 1 Recent research shows Threshold Inspiratory Muscle Trainer (IMT) devises e.g PowerBreathe ( figure 2), are superior to Incentive Spirometry (4), with increased impact on inspiratory muscle strength demonstrated by Maximum Inspiratory Pressure (MIP). We therefore chose to implement these as part of an iCough programme.

Aims: 50% reduction in incidence chest infections over 6 months by implementing the iCough programme.

Secondary aim: 1 day reduction in LOS.

Methodology: Elements of the iCough programme were implemented for patients undergoing elective major colorectal inpatient surgery between March - August 2021.

Patients were given the PowerBreathe IMT device set to 40% of MIP in preoperative assessment with instructions on use. Both ward staff and ITU therapists were provided with specialist training on iCough practises to enable consistency in the delivery of iCough.

Patients were provided with a daily goals logbook to enable active engagement in iCough.

All elements of iCough were implemented and upheld by the Ward Therapist, with the support of all ward staff, Figure2. PowerBreathe device including nurses and HCA’s.

Baseline measures were collected including compliance with each of the iCough elements as well as ongoing compliance which were fed back to the team as well as use of IMT device.

Outcome measures: - Maximum Inspiratory Pressure (MIP): Baseline ( pre-op clinic), Day 0 (pre-op), Day 1 and Day 3 post-op.

- Number of postoperative chest infections and LOS ( from electronic data and note review) Regular feedback supported learning and improved compliance resulted from several tests of change such as patients being told to bring in mouthwash, including this item on the ward stock list, putting up coloured routes on the ward to aid mobilisation targets and several adaptations to the patient diary tests.

Figure 3; Patient diary

Figure 1: iCough elements

“Even when I’m unable to walk, I feel like I can still exercise my lungs”

“Using the power breathe at home before my surgery I noticed improvements in my breathing”.

“ I’m not as breathless climbing stairs”

Results:

80 patients were included. Only 54% received an IMT, due to Covid19 delays.

Learning from testing resulted in reliable implementation of the basic iCough elements.

See figure 4 for process measures: compliance with mobility, mouthwash, head elevation and implementation of PowerBreathe IMT.

PowerBreathe IMT effectiveness: Of the 54% of patients with PowerBreathe implantation, 92% used it effectively – see patient comments in bubbles above.

Outcome measures :

Use of the PowerBreathe IMT resulted in a 33% improvement in Maximum Inspiratory Pressure.

Baseline Mean MIP 53.3 cm H2O

Day 0 preoperative Mean MIP 71.1 cm H2O

Day 1 postoperative Mean MIP 55.3 cm H2O

Day 3 postoperative Mean MIP 58.3 cm H2O

Figure 4: Compliance with mouthwash, head elevation and IMT

As expected MIP reduced following surgery, but remained higher than the pre IMT level and started to improve by day 3 ( figure 5) No patients developed a documented chest infection over 6 months. (Baseline rate March - August 2019: 3 chest infections) Length of stay reduced on average 0.5 days

Lessons learnt : -

The Ward Therapist Role was integral to maintaining the implementation of iCough principles.

To support consistency with mouthwash use - a ward stock should be readily available.

Powerbreathe was acceptable and easy to use by patients.

Implementation of the PowerBreathe IMT resulted in increased inspiratory muscle strength as demonstrated by increased MIP. This increase in respiratory muscle strength is likely to have resulted in the decreased postoperative complications shown.

Figure 5: Mean Maximum Inspiratory Pressure following IMT

Next Steps: • • • • • • • •

Future funding is being investigated to use IMT as routine pre-hablilitation as well as having therapy presence in the pre-operative clinic.

Future funding is being explored for mouthwash to become regular stock on the ward.

Information decimation to other surgical areas to enable wide opportunity of access to the benefits of iCough.

To collect further qualitative feedback from patients to further investigate the benefits of implementing iCough.

To collect staff feedback on ease of implementation.

Development of education videos for patients and staff to increase involvement of preoperative nurses and increase sustainability and decrease dependence on therapist.

Implementation of electronic recording of iCough elements and monthly reports for ease of feedback and monitoring of compliance.

Development of ‘enhanced recovery co-ordinator’ role to oversee training, compliance and spread to other specialities.

Acknowledgement: Sister Claire Drury, RUH Colorectal Ward Staff, Mr Stephen Dalton, RUH Colorectal Enhanced Recovery Lead, Dr Lesley Jordan, Consultant Anaesthetist and Patient Safety Lead.

References: (1) Cassidy, M.R., Rosenkranz, P., McCabe, K., Rosen, J.E. and McAneny, D., 2013. I COUGH: reducing postoperative pulmonary complications with a multidisciplinary patient care program. JAMA surgery, 148(8), pp.740-745.

(2) Canet, J. and Mazo, V., 2010. Postoperative pulmonary complications. Minerva anestesiologica, 76(2), p.138.

(3) Kulkarni, S.R., Fletcher, E., McConnell, A.K., Poskitt, K.R. and Whyman, M.R., 2010. Pre-operative inspiratory muscle training preserves postoperative inspiratory muscle strength following major abdominal surgery–a randomised pilot study. The Annals of The Royal College of Surgeons of England, 92(8), pp.700-705.

(4) Owen, R.M., Perez, S.D., Lytle, N., Patel, A., Davis, S.S., Lin, E. and Sweeney, J.F., 2013. Impact of operative duration on postoperative pulmonary complications in laparoscopic versus open colectomy. Surgical endoscopy, 27(10), pp.3555-3563.

DOMESTIC VIOLENCE IN THE EMERGENCY DEPARTMENT: MAKING IT EASER FOR CLINICIANS TO ASK (A QIP in Progress) EILIDH GILCHRIST (FY2), KATIE THOMPSON (JCF), ELIZABETH OGUNDIYA (FY2), JULIE-ANNE HEWITT (FY2), DR SOFIA RAHMAN (EMERGENCY MEDICINE CONSULTANT, NHS KCH)

Introduction: Domestic violence (DV) is often a hidden crime and is globally under-reported. In a survey done by the Office for National Statistics in 2021, 5.5% of adults aged 16 to 74 years (2.3 million) had experienced domestic abuse (DA) in the past 12 months.1

12%

ARE DUE TO DOMESTIC

2

1 in 7 men

ABUSE2

Will experience

WOMEN

DV in their lifetime3

OF ED ATTENDANCES

ARE KILLED

1 in 4 women

BY THEIR PARTNER

Will experience

EVERY WEEK4

DV in their lifetime3

The Problem: NICE state that “People presenting to frontline staff with indicators of possible domestic violence or abuse (should be) asked about their experiences in a private discussion.”5 However, a case review of Kings College Hospital ED found that over a 3 month period 30% of those presenting having been assaulted with a head or facial injury were not asked about the perpetrator and 90% of them did not have safeguarding referrals, even when their partner was documented as the perpetrator.

Furthermore, 100% of the females who had been stabbed and presented as a major trauma call (MTC) had been stabbed by their partner.

Aim: This project aims to identify barriers to asking about DV and address these through the implementation of interventions to improve the rates of screening for domestic violence in high risk patients.

Diagnostics: A survey was sent to all staff in the ED called “Staff’s views on what would make it easier to ask patients about intimate partner violence (domestic violence) in the emergency department: returning a total of 36 responses from a variety of nurses and doctors who work in the department. Their answers were used to create both a cause and effect diagram (Figure 1) and a driver diagram (Figure 2) and determine potential change ideas.

Measured outcomes : the number of domestic violence related referrals made to the ED safeguarding team.

1. Bitesize teaching

Improving staff knowledge & confidence in asking about domestic violence

Training about DV and how to ask for all ED staff – which prepares them to recognise & ask & what to do

2. Training days/simulation for nurses, doctors etc incl communication stations & how to ask in difficult pt 3. Attendance at DV meeting once mandatory for all rotating junior doctors 4. DV staff advocates within dept

To improve rates of screening for domestic violence by all ED staff in patients presenting with injuries secondary to assault

Culture of asking in ED by all staff so that it is routine

6. EPR/symphony trigger/proforma to fill in for assault

Improving knowledge of where to find & ease of use of domestic violence guidelines & proformas

DV guidelines & proforma easily accessible

Improving environmental & structural resources

Ensuring staff have a private space to ask intimate questions (i.e. not curtains) Ensuring staff have the time to ask & take the appropriate next steps

ACT Teaching to be repeated at a time more convenient to doctors and nurses and simulation training targeting junior doctors and registrars.

1

Figure 3: The first PDSA cycle performed

DV Bitesize teaching at end of Week 5

Figure 4: Run chart reflecting the number of DV referrals received by the ED safeguarding team on a weekly basis6 References: 1.

Office for National Statistics (ONS). (2021) Domestic abuse prevalence and trends, England and Wales: year ending March 2021. Published online: ONS https://www.ons.gov.uk/peoplepopulationandcommunity/crimeandjustice/articles/domesticabuseprevalenceandtrendsenglandandwales/yearendingmarch2021 2. https://rcem.ac.uk/wp-content/uploads/2021/10/Management_of_Domestic_Abuse_March2015.pdf 3. https://www.mankind.org.uk/wp-content/uploads/2020/03/50-Key-Facts-about-Male-Victims-of-Domestic-Abuse-and-Partner-Abuse-March-2020-final.pdf 4. https://www.ons.gov.uk/peoplepopulationandcommunity/crimeandjustice/articles/homicideinenglandandwales/yearendingmarch2018#how-are-victims-and-suspects-related 5. https://www.nice.org.uk/guidance/qs116/resources/domestic-violence-and-abuse-pdf-75545301469381#page10 6. http://www.ihi.org/resources/Pages/Tools/Quality-Improvement-Essentials-Toolkit.aspx

10. Phone numbers & how to contact on guidelines, posters & via induction 11. Proforma shortened to only the most indicative questions with clear & concise next steps using MDT feedback 12. Allocating a private space to ask 13. Written questionnaire to be given to patients to complete themselves 14. Clear defined points in patient journey where they should be asked

Plan Do Training about DV and how to 1.1 Bitesize teaching ask for all ED staff – which prepares them to recognise & ask & what to do 1.2 Simulation teaching for junior doctors & registrars

2.

Culture of asking in ED by all staff so that it is routine

3.

DV guidelines & proforma easily accessible

4.

DV proforma appropriate to time available to staff & clear about guidance

5.

Ensuring staff have a private space to ask intimate questions (i.e. not curtains)

DO 20 minute "bitesize" teaching session provided on the shop floor

STUDY Only 1 doctor and 6 nurses attended. There was no change in the number of referrals the week following the teaching.

8. QR code leading to proforma & guidelines

Figure 2: Driver diagram based on the staff survey6 1.

PLAN Teach all ED staff how to recognise and ask about DV and what to do when they identify DV.

7. DV page to be inserted into MTC booklet

9. DV proforma to be made an electronic EPR form

DV proforma appropriate to time available to staff & clear about guidance

Figure 1: Cause and effect diagram based on the staff survey6

5. Posters raising awareness & reflecting dept performance/newsletter

Study Only 1 doctor and 6 nurses attended. There was no change in the number of referrals the week following the teaching.

Use a survey pre and post teaching to asses confidence in asking about DV and monitor number of referrals in the subsequent weeks 2.1 Presentation to the team about the QI with Monitor the number of referrals in subsequent summary of the earlier case review findings weeks 2.2 “Ask for Nurse Angela” Posters to be placed Monitor the number of referrals made to the in the department so that DV victims know what safeguarding team in the following weeks and to say to subtly alert staff. To utilise handovers review how many were made due to the “Ask to explain what a patient is alerting you to in for Nurse Angela” scheme asking for nurse Angela.

2.3 Screening questions to be incorporated into Monitor the number of referrals made to the the social history of junior doctors doing the safeguarding team in the following weeks rapid first assessment of an ambulatory patient and into the nursing triages.

2.4 Prompt to be added to MTC booklet and Monitor the number of referrals made to the incorporated to electronic MTC form to remind safeguarding team in the following weeks and clinicians to ask about safeguarding including review how many were MTCs DV. 2.5 Reminder about DV in the nursing handover Monitor the number of referrals made to the as part of ”The Big 5” to actively screen for DV in safeguarding team in the following weeks individuals presenting secondary to assault 3.1 DV contacts made more accessible by adding Monitor the number of referrals made to the them to the widely used ”Induction” app so that safeguarding team in the following weeks key contacts for the management of DV are readily available and therefore quicker to access 4.1 DV proforma review to ensure that it is Monitor the number of referrals made to the easier to follow and the next steps are obvious safeguarding team in the following weeks and for staff to take depending on patient’s answers. review how many had the new DV proforma fully completed 5.1 Private space for DV discussion to be Monitor the number of referrals made to the allocated safeguarding team in the following weeks

Figure 5: Table of future interventions according to which secondary driver the intervention targets, “Act” reflection to be completed following each intervention.

Results: A baseline measurement was done for 5 weeks, showing lots of variability in the number of DV safeguarding referrals made in the ED. PDSA 1 (figure 3) was implemented at the end of week 5, with no changes in the number of safeguarding referrals, so the teaching is to be repeated and changed to a time more suitable for both doctors and nurses. Future PDSA cycles to be implemented as above and studied with continuous reflection on interventions which make a difference.

Lessons Learnt: • The importance of screening for DV in the emergency department • The value of involving staff and actively asking them where the barriers to asking about DV lie • When dealing with a large-scale departmental problem requiring cultural change, many interventions of different natures targeting different groups will need to be made. This can take time, require communication with many different teams and will require constant re-evaluation.

Improving the Quality of Trial without Catheter (TWOC) on the Elderly Care Ward H. Sutton, T. Bobmanuel, G. Slabbert Portsmouth University Hospital NHS Trust, Portsmouth, United Kingdom

Introduction Urethral catheterisation is a common procedure, performed predominately to monitor urine output and relieve urinary retention which may be due to a number of underlying factors.

Trial without Catheter (TWOC) is a process that involves the removal of a catheter from the bladder and the subsequent monitoring for the passage of urine. A failed TWOC has detrimental consequences to patient safety as it increases the risk of urinary tract infections, mobility of the patient is impaired and ultimately leads to prolonged admissions.

Aims

Results

1. Assess the success rate of TWOC in the elderly care ward 2. Determine if the TWOC process is carried out in line with best practices 3. Identify any issues preventing healthcare professionals from using best practices for TWOC and the impact this has on TWOC success

Data was collected for 12 patients and the TWOC success rate was 67% (8/12).

Patients at baseline mobility and who had regular bowel movements had the highest TWOC success rate with 70% of patients with regular bowel opening and 100% of patients at baseline mobility being TWOC’d successfully.

However, only 2 patients were at baseline mobility due to the medical state and frailty of the patient. The full analysis of the data is demonstrated in Figure 2

Methodology Data was collected prospectively for patients undergoing a TWOC procedure between September-December 2021.

Electronic patient records and documentations were interrogated to identify the success rate of TWOCs, collecting data on various variables that could result in a failed TWOC such as regular bowel opening, baseline mobility, review of medication that can contribute to urinary retention, exclusion of possible UTI and BPH. Interventions were implemented in the form of a sticker containing check boxes for the factors that need to be considered prior to a TWOC – see Figure 1

The QIP revealed there was no standardization or uniformity in the TWOC process on the ward despite the success rate observed. Further cycles are essential to assess patient outcomes and improve standardisation and level of care.

Figure 2: The Relationship between TWOC Success Rate & Patient Factors

Figure 1: TWOC Checklist

Conclusion In summary, our data revealed that there is a lack of standardization for TWOC in geriatric patients. With further cycles, we will identify if the TWOC checklists help to improve the standardization and success rate of TWOC.