BPSC2022 Poster Group O - QI in Progress - Improving primary and secondary care - 2

18th May 2022 Poster Competition Group O QI in Progress Improving primary and secondary care - 2

Acute Management of Complex Airway Emergencies on a Respiratory High Dependency Unit J. Mayer, C. Hayden, V. Haile

Introduction:

Complex airway problems are life-threatening emergencies affecting up to 30% of tracheostomy patients(1), where initial management leads to identifiable harm in up to 75% of cases(2). Such situations are increasing in prevalence and recent initiatives stress the importance of guidelines and training (1). However, junior medics working on the respiratory high-dependency unit felt ill-equipped to manage these situations with 56% surveyed never receiving any training throughout their career. This poses significant risk to patient safety, particularly at a time when nursing ratios are stretched.

Aims:

To improve Medics’: Self-rated ability in managing complex airway emergencies (primary).

Self-rated confidence in managing complex airway emergencies (secondary).

Knowledge of complex airways and associated problems (secondary).

PDSA Cycles

Baseline data were collected via survey to respiratory juniors.

PDSA cycle interventions were as follows: 1. Teaching presentation during the respiratory educational meeting.

2. Simulation training with the respiratory physiotherapists.

3. Tracheostomy model in the respiratory doctor's office.

4. Addition of information poster's and "test yourself" materials alongside the tracheostomy model (in progress).

Follow-up data collection was carried out throughout the PDSA cycles via random sampling. The participants were asked to rate their ability and confidence from 1 - 10. The mean value was taken for comparison. This was followed by three knowledge based, multiple-choice questions. The percentage of participants who have scored 3 out of 3 has been used for comparison between cycles.

Previous Complex Airway Teaching:

Driver Diagram Balancing measures: -Incident form -Knowledge compared to confidence and ability.

Results: Confidence

Ability

Knowledge

Lessons Learnt and Moving Forward Presentation Simulation Tracheostomy Model Posters and ”Test Yourself” Material

By providing teaching, simulation sessions and easy access to educational materials, the junior medical team's ability, confidence and knowledge in managing complex airway emergencies has improved. This project highlights the value of training and education, particularly regarding a subject that is not consistently taught throughout undergraduate or postgraduate training. By improving the medical team's ability in managing complex airway emergencies, we minimise the risk to patient safety.

This project is ongoing with the fourth PDSA cycle currently underway. We are hopeful that we will be able to arrange teaching and simulation sessions at the start of new junior doctor rotations.

References: 1. McGrath BA, Wallace S, Lynch J, Bonvento B, Coe B, Owen A, Firn M, Brenner MJ, Edwards E, Finch TL, Cameron T. Improving tracheostomy care in the United Kingdom: results of a guided quality improvement programme in 20 diverse hospitals. British journal of anaesthesia. 2020 Jul 1;125(1):e119-29. 2. McGrath BA, Thomas AN. Patient safety incidents associated with tracheostomies occurring in hospital wards: a review of reports to the UK National Patient Safety Agency. Postgraduate medical journal 2010;86(1019):522-5.

Epub 2010/08/17

Falls Assessment and Prevention in the Health and Ageing Unit (HAU) in a Large Central London Teaching Hospital Emma Lewin, Ruth Evans, Maitri Shila Tursini Harriet Howard

Background and Aims

Falls are a common hospital presentation in the ageing population, with 30% of over 65s and 50% of over 80s suffering with at least one fall a year. A fall can lead to negative physical and psychological sequelae and falls are estimated to cost the NHS more than £2.3 billion per year. NICE has produced guidelines advising on the multifactorial assessment that should be carried out in patients presenting to hospital following a fall in the community, in order to prevent subsequent falls in the future and further hospital admissions.

The aim of this project is to evaluate how well the department at King's College Hospital was completing the multifactorial falls assessment as described in the NICE guidelines on falls prevention and identify specific areas for improvement.

Methods

A retrospective review of all inpatients, over the age of 65, admitted on a randomly chosen week into the Health and Patients were screened and included if they were identified as presenting with a fall or having a history of falls. Adherence to NICE guidelines for falls assessments was then checked.

Clinical notes were reviewed for evidence of the following by any of the multidisciplinary team: eight specific multifactorial assessments gait assessment, FRAX score, medications review, visual assessment, cognitive assessment, home environment assessment, ECG and lying-standing blood pressure (LSBP), and whether done correctly) Four multifactorial interventions increased package of care or adaptation of home environment, vision referral or intervention, referral to strength and balance training (including community physio), medication changes

Interventions

In between the two audit cycles, the following interventions were put in place with the aim of improving multifactorial falls assessments: 1. Teaching session to share findings with the department, remind of the guidelines and give suggestions on how to improve assessments 2. Creation of posters to put up around HAU as a visual reminder 3. Creation of an electronic proforma to be used to aid falls assessments and ensure all elements completed prior to discharge 4. Survey of staff on HAU to identify barriers to completing the assessment

Results Cycle 2

Four interventions were put in place with the aim of improving the quality of falls assessments.

The performance of the department was then re-audited for patients admitted in a random week in June 2021 following the interventions. The results were tested for statistically significant change using a chi square test.

Results Cycle 1

The data analysis demonstrated a completion rate of : >90% was demonstrated for ECG, assessment of home environment and medications review. <30% was demonstrated for lying-standing blood pressure, visual assessment and FRAX score calculation Therefore, teaching on how to perform these assessments and tips for making these easier were specifically including in a departmental teaching session.

E.g. signposting to the Sheffield FRAX score calculator, teaching on how to perform a bedside vision assessment and lying-standing blood pressure correctly

Demographics

Cycle 1 Cycle 2

Patients admitted HAU Patients with falls history Male:Female Age range

80 52 20:32 69-102

Conclusions and Next Steps

87 53 25:28 70-100

Statistically significant improvements demonstrated in gait assessment (83% to 89%), visual assessment (29% to 36%) and FRAX score calculation (21% to 34%) All other areas improved or were unchanged, but with no statistical significance Statistically significant improvements demonstrated in intervention of adaptation of home environment The staff survey demonstrated the following barriers to completing a comprehensive falls assessment: Limited time available to complete assessments Lack of clarity on which member of the MDT was responsible for completing the different assessments Not having all the elements required to complete an assessment (e.g. Snellen chart for vision assessment, height and weight measurement for FRAX score) Lack of knowledge on how to perform and interpret certain assessments (e.g. performing LSBP, interpreting FRAX score)

An assessment for risk factors/cause should be done for all patients at high risk of falls or admitted with a fall followed by any interventions deemed necessary This project demonstrates how surveying staff can help us understand why certain aspects of our practice are not being carried out consistently and how continuous education can improve our care for patients Next steps include plan to establish project as a rolling audit to continue reviewing and overcoming barriers to falls assessments

A Quality Improvement Project aimed at improving catheter documentation in electronic patient notes by implementing an Inpatient Catheter Chart form.

Dr. Ishtar Redman, Dr. Jennie Han, Dr. Edward Hoy

Introduction: Healthcare-associated infections (HCAI’s) are responsible for approximately 300,000 deaths per year in England, costing the NHS an estimated £1 billion per annum.1 The major predisposing factor for healthcare associated UTI is the presence of an indwelling urinary catheter and in the acute setting, the risk of developing bacteriuria increases by 5% each day in catheterised patients.2 We recognized that poor inpatient catheter documentation led to significant patient safety issues- delayed discharges, CAUTI’S, iatrogenic incontinence and catheter dependence- the need to be discharged with a catheter due to TWOC failure.

SMART OBJECTIVE: To improve catheter documentation in electronic patient notes by implementing an Inpatient Catheter Chart proforma which will be ICHNT senior clinical leadership sanctioned, hospital wide, mandated and created in accordance with both Trust and national guidelines.

AIM(S)

Primary drivers

Change ideas

Secondary drivers

Local Mfe meetings Education; JDs and Nurses Emails

100 % compliance

Disseminating information after nursing handover

Sustainability and consistency

Advocating for System change(s)

Education sessions targeting nurses, Fy1 doctors.

Software updateMeeting with CERNER education lead; to update electronic charts.

Update the trust-wide Catheter guidelines on our intranet.

Figure (1) Driver diagram depicting the primary and secondary drivers with change ideas.

Identify the reason(s) for poor catheter documentation.

Act Discuss need for an improvement in Catheter- documentation at local MFE teaching.

Gap analysis of the current catheter documentation on needed for Identify the crucial data CERNER catheter documentation

Figure (2) PDSA cycles 1

Gap analysis of the current catheter documentation as compared to the ICHNT 17 pieces of required upon catheter insertion as per Trust guidance.

Questionnaires to stakeholders to identify issues with documentation

Nudge campaign: Poster & Education session(s) targeting FY1/2 doctors and nurses on the first floor.

Questionnaires to doctors about issues with catheter and 2. documentation

• Delay in TWOCs • Unsure of clinical indication for catheter.

• Inappropriate removal of LTC causing urinary retention and pain.

• Incorrect/no size(s) documented as leading to urinary by-passing and bed wetting.

• Removed due to unknown indication, requiring re-catheterization.

• Realizing a patient has a catheter before discharge and arranging for TWOC as outpatient, or delaying discharge as needed to wait for TWOC. • Causing physiological dependence on catheters- patients being admitted continent, but subsequently discharged reliant on catheters.

Poster(s); educational posters in doctor’s office, bulletin boards on ALL first floor wards.

Patient safety

To achieve 100% catheter documentation on inpatient notes.

Qualitative data collected; NIC of 4 wards surveyed, how does poor catheter affect patient safety ?

Reflect on the results Focus group to determine which of the 17 data points are essential

Reflect on results Re-audit and analyze data

Present new findings to CERNER education lead

Results N=16; Gap analysis

Re-audit fol lowing 1st poster; 1st Cycle, N=13

Conclusions/Lessons Learnt:

2nd Cycle, N=18

18

12. No resistance to balloon inflation, no patient reaction or pain related to balloon inflation, free movement of the catheter once balloon inflated 13. Brand tip type, size, balloon size 14. Cleaning fluid used 15. Lubricant/anaesthetic gel used 16. If specimens were sent, and why 17. Attachments applied 18. Expected removal date 19. Post void residual

Future work- PDSA Cycle (3)

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•

Poor documentation can have clinical implications for patients.

•

Human factors cannot be ignoredChanging systems is far more effective than trying to change people.

•

Trust guideline is not being well followed – does this need to be updated?

•

Automated form would likely lead to better adherence to current guideline

16

15

14 13 N; NUMBER OF PATIENTS WITH CATHETERS

STANDARD DOCUMENTATION AS PER TRUST GUIDELINES 1. Reason for the catheterisation, on-going need for a catheter 2. Health status of the patient prior to catheterisation i.e. well, ill, febrile 3. If febrile – antibiotic cover 4. Discomfort i.e. retention 5. Indicated if a fluid chart is required 6. Allergy status (for example latex, gels and medication) 7. Consent obtained 8. Meatal or genital abnormalities observed, including discharge 9. If the insertion was easy or difficult and in men if obstruction felt at prostatic area, patient reaction to passing the prostate 10. Indications used to ensure catheter was inserted correctly (in men – amount of catheter inserted i.e. to the hilt) 11. Residual urine drained, colour, smell and, if necessary, dipstick and record the result

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10 9

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9

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0 1

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References: 18

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DATA POINTS REQUIRED FOR EACH CATHETER DOCUMENTATION (SEE KEY BELOW)

Figure (3) Line graph depicting the original gap analysis (blue), the first cycle of the audit after implementation of a poster (yellow) and the results of the second cycle (green).

P: Convene meeting with trust CERNER software lead.

D: Augment pre-existing software to include (7) data sets.

S/A: Re-audit the above and use results to update the trust wide guidelines on Catheter documentation in conjunction with the Urology team.

Drying for a Change: Environmental Inhaler Prescribing Dr. R Nolan

INTRODUCTION In the UK, Salbutamol is a commonly prescribed reliever inhaler to treat bronchoconstric@on in asthma@cs. 70% of inhalers prescribed in the UK are Metered Dose Inhalers (MDI), such as Ventolin.1 MDIs use propellants, containing hydrofluorocarbons which are potent greenhouse gases, to deliver medica@on into the lungs. Alterna@vely, Dry Powder Inhalers (DPI) u@lise a pa@ent’s inspiratory effort to deliver the medica@on. For instance, one Ventolin Evohaler (MDI) has the equivalent CO2 produc@on of approximately 175 miles in a car, whereas a DPI such as Easyhaler is around 7 miles.2 Therefore, the Bri@sh Thoracic Society encourage, where appropriate, to priori@se DPIs as they have a much lower carbon footprint with similar efficacy.3

PLAN In a Bath based GP prac@ce, a search was conducted via Systm One of pa@ents on the asthma register. The following inclusion criteria were chosen: asthma as sole respiratory disease, Asthma Control Test score of 20-25 inclusive, prescribed salbutamol and aged 18-60 inclusive. Those already on Salamol MDI were excluded, given the lower carbon footprint compared to Ventolin.4 Text messages were sent out invi@ng them to discuss switching their reliever inhaler from MDI to Easyhaler DPI.

AIM: To increase uptake of DPI to achieve greener inhaler prescribing at a GP practice

Illustration adapted from rightbreathe.com

DO Consultations were held with patients to evaluate their current understanding of inhaler environmental burden, assess their suitability for switching and provide education on DPI inhaler technique with video illustration from Asthma UK.5 The data was collated into an Excel spreadsheet.

STUDY Pre-intervention, 55 of the 168 patients identified were on DPI salbutamol and 113 on MDI. Of these 113 patients, 25 were on Salamol so excluded. Of the remaining 88, 22 expressed interest in switching via text response. 18 of these were successfully switched to DPI during consultations, hence post-intervention there was 33% increase in DPI prescription. 2 patients were unable to be contacted, 1 preferred to remain on a MDI and chose Salamol as a greener MDI alternative. The remaining patient chose to stay on their prescribed MDI. Additionally, only 4 patients were aware of safe disposal schemes at pharmacies. Of the patients contacted, none of them used spacer devices. Overall, this will save approximately 2970 miles in a car of CO2 production, per issue of salbutamol in these patients collectively.

Figure representing proportion of inhalers in cohort using MDI vs DPI inhaler before and after intervention

Limitations 1.Targeted well controlled asthmatics 2.DPI tend to be more expensive 3.Preventer inhalers generally are used more often by patients 4.Text message may have been missed by some patients 5.Primary care services already stretched with other issues

ACT PDSA 2 – teaching session to prescribers - PDSA 3 – Making it completed official policy PDSA 4 prescribing MDI Targe@ng higher where appropriate impact users

Lessons learned 1. Overall, patients were keen for environmentally friendly inhaler prescription 2. Most patients were suitable for switching 3.Single consultations were efficient enough to facilitate switch 4. There was little patient education literature available

CONCLUSIONS There was a positive response to DPI use in this small cohort group. We hope that with future cycles, as detailed previously, the percentage of DPI prescription will increase to improve inhaler prescribing carbon footprint.

PDSA 5 - Crea@ng References pa@ent informa@on leaflet & empowering pa@ents with NICE decision tool 6

1. Janson C, Henderson R, Löfdahl M, Hedberg M, Sharma R, Wilkinson A. Carbon footprint impact of the choice of inhalers for asthma and COPD. Thorax. 2019;75(1):82-84.

2. Inhalers: Further resources and informa@on — Greener Prac@ce [online]. Greener Prac@ce. 2022 [cited 5 March 2022]. Available from: hmps://www.greenerprac@ce.co.uk/inhalers-further-resources-and-informa@on 3. Bri@sh Thoracic Society. Posi@on Statement - The Environment and Lung Health 2020 [online]. 2020. Available from: hmps://www.britthoracic.org.uk/about-us/governance-documents-and-policies/posi@on-statements/ 4. GMMMG COPD Formulary Inhaler Op@ons [Internet]. 2022 [cited 17 April 2022]. Available from: hmps://gmmmg.nhs.uk/wpcontent/uploads/2021/11/GMMMG-COPD-Inhaler-Guide-September-2021-FINAL.pdf 5. Asthma UK, 2022. How to use an Easyhaler inhaler | Asthma + Lung UK. [online] Asthma + Lung UK. [cited 28 March 2022]. Available at: hmps://www.asthma.org.uk/advice/inhaler-videos/easyhaler/ 6. Nice.org.uk. 2022. [online] [cited 28 March 2022]. Available at: <hmps://www.nice.org.uk/guidance/ng80/resources/inhalers-for-asthma-pa@entdecision-aid-pdf-6727144573>.

Nil By Mouth: Safety or Sufferance?

R. Williams, I. Fabre, E. Muscat, K. Mohuiddin

1

4

Introduction Pre-op fasting decreases the volume and acidity of the stomach contents, therefore reducing the risk of aspiration.

Ensuring surgical ward staff understand the clinical NBM prevents unnecessary delays to procedures and excessive fasting of patients.

Results Foundation Doctors

100% 80% 60% 40% 20% 0%

Nursing Staff

100%

2

80%

Aim

60%

To reduce excessive fasting of patients by improving ward staff knowledge of NBM guidelines.

Oral intake cut-off times pre-op (NICE, 2020): Meals: 6 hours Milky drinks: 6 hours Clear fluids: 2 hours Medications: 30 minutes

3

40% 20% 0%

80% 60% 40% 20% 0%

Meal

Methods: PDSA Cycle 1: Ward staff survey

HCAs

100%

Milky Drink Cycle 1

Clear Fluids

Cycle 2

Meds

Cycle 3

Fully Correct Answers 45% 40% 35%

Cycle 2: Foundation doctor teaching + ward posters Cycle 3: Retained posters, guidelines

emailed to nursing staff + foundation doctor teaching

5

6

30% 25% 20% 15% 10% 5% 0%

Cycle 1

Cycle 2 F1/F2

NS

Cycle 3 HCAs

Interpretation Improvement between 1st + 2nd cycles for nursing staff and HCAs across individual nutrition options and complete answers;

Initial successful application of ward posters.

however, correct answers from both staff classes declined in the 3rd cycle.

Posters eventually removed, staff reallocation.

Reduction in fully correct answers from doctors between 1st + 2nd cycles; however, answers improved in the 3rd cycle.

A mixed response that may be due to staff turnover, position in the academic year and teaching uptake.

Next Steps Further cycles should be conducted within a shorter period of time to assess knowledge within each rotation of doctors.

Next intervention: visual prompt using bedside NBM signs with guidelines, and teaching sessions for foundation doctors on not only the guidelines, but also clear documentation in the notes for meal and fluid cut-off times.

7

Is this improving patient care?

It’s difficult to assess if knowledge is being applied, but auditing documentation in the notes may be an option. Also, despite best laid plans the vast majority of patients are on emergency theatre lists which are liable to order changes.

Miss.Krishna Murala, Consultant Obstetrician and Gynaecologist Mrs.Stephanie Larcombe , Transformation midwife Stephanie.Larcombe@ydh.nhs.uk

Project Aim: To reduce the overall incidence of PPH at YDH To reduce the overall incidence of post-partum haemorrhage (over 1500mls) in singleton pregnancies by 2% in order to align Yeovil District Hospital Maternity Unit with the best performing units in England and Wales (top 20%) by September 2020 Background YDH were identified as a outlier for postpartum haemorrhage above 1500mls in 2018/2019. The National Maternity and Perinatal Audit benchmarked PPH of 1500 or above at 2.9%. YDH rates were identified as 4%, 1.1 % higher. Blood loss between 500-1499 mls were also higher at 38%, the NMPA average 34.1% Post partum haemorrhage (PPH) and massive obstetric haemorrhage (MOH) are associated with maternal morbidity and mortality outcomes that have a negative impact upon the postnatal wellbeing of the woman and her family.

Reducing the incidence of postpartum bleeding above 500mls at YDH by introducing processes and strategies to identify risks factors, and respond to the cause will improve maternal and neonatal outcomes and the overall health and wellbeing of the woman and her family and ultimately reduce PPH over 1500mls.

Approach taken •

Staff SCORE Survey. Debriefs with staff,

Change ideas •

of digital scales in each labour room.

poster of themes from the survey/debriefs •

•

Measures of improvments included data

Measured blood loss through the introduction

•

Implemeneted a validated risk assessmnet

collection via notes audit, maternity dashboard

tool designed through two tests of change and

and maternity IT systems.

audit its use

Data plotted on run and SPC charts, outcome

•

postpartum haemmorrhage

and process measures used.

•

PDSA cycles to trial small test of change.

•

Weekly skills drills to embed the culture

MVP to collate patient experience of

•

Administration of syntocinon IV and tranexamic acid for all Caesarean sections

•

Learning from excellence template

Outcome and impact At this stage of the project the data shows that PPH rates has reduced to 3.3% .

Data audit has increasing compliance in using the scales to measure blood loss and use of the risk assessment ,regular skills drills are contributing to reducing PPH rates in the unit.

Learning & Next steps Service user feedback on their experienece of PPH as qualitative data has been powerful during skill drills to inform practitioners of the language we use when managing PPH and how we can improve on our practice for the women we care for.

We are confident that we will see further improvement in reducing PPH of 1500mls or above as we continue on our MatNeoSip journey, continued review of the risk assessment, weekly audit of the use of tools and PPH skill drills with staff on the labour ward and in mandatory training, will embed the use of staged management of PPH in theatres to make further reductions in PPH.

After

Action

Reviews

The trust was generating learning through various routes; including incidents, serious incidents, complaints, claims, audits, etc. However there was a gap in enabling the identification of timely reactive learning, and the inclusion of staff directly involved in incidents/events in the generation of learning. Below we conduct an After Action Review (AAR) on the implementation of AARs and the trust wide rollout using the four key questions that an AAR is centred around.

WHAT WAS EXPECTED?

WHAT ACTUALLY HAPPENED? Quality Governance Learning Assurance Coordinators were recruited to lead the AAR process and implementation.

We would have champions for the approach and people who promote it It becomes fully embedded with a Train the Trainer approach

A cohort of conductors have been trained with dates scheduled to train further conductors. 7 trust staff members have been trained as trainers.

The approach is widely recognized and valued not just a nice to have It is a positive multi- disciplinary approach where people feel welcome and feel able to be open

There was initial anxiety amongst some staff attending AARs. AARs were implemented in selected departments initially to trial the process and AARs are now utilised regularly within the Maternity and Paediatric departments.

Our departments champion it

Learning points have come out of every AAR held which bridge across individual learning, process improvements and trust wide learning.

It is a positive and inclusive approach We are able to create psychological safety in AARs We will achieve a cohort of trained AAR Conductors who use it formally and that it becomes something that people start to use informally as well, to structure conversations We improve the patient experience and safety because our staff are engaged in AAR and feel it is valuable

The time between the incident/event and an AAR being held varies significantly and are not always as timely/reactive as hoped. Some cases go to AAR within a matter of days, other times it can take a number of weeks.

AAR would be a timely and reactive learning tool.

AARs are frequently suggested/recommended by members of the executive team, as well as departmental leads in areas where AAR is well established.

The AAR approach compliments the new Patient Safety Incident Response Framework (PSRIF) as one of their recognised tools for learning.

AARs often have to be cancelled and rescheduled due to staff availability/staffing pressures.

AAR can often be seen as alternative to a Serious Incident instead of a complimentary method for identifying learning.

WHY WAS THERE A DIFFERENCE?

WHAT DID WE LEARN FROM THIS? AARs can be a successful forum for identifying learning from incidents/events.

Development of standardised staff guides and documentation paperwork.

A brief guide on AARs is now shared alongside the meeting invitations to familiarise staff with what an AAR entails prior to attending.

Supporting newly trained conductors and enabling them to observe an AAR being conducted within the hospital setting prior to leading their own.

AAR conductors are needed within every department to increase the opportunity for onthe-spot reactive AARs and to ensure each service takes ownership of AARs within their own area.

Produce a formal strategy for the ongoing implementation and embedding of the AAR process.

Increased trust wide communications to promote and champion AARs; including sharing learning points from AARs within the quarterly patient safety newsletter, creating a short week.

Raising the awareness of the new PSIRF amongst staff using existing trust communication routes.

Adapting the AAR training package to suit the needs of our Trust staff, including developing a clinical scenario to simulate an AAR in the hospital setting.

Our enthusiasm for AAR is catching.

Some AARs were held prior to the official trust wide launch so staff were unaware of what an AAR was.

Rollout and staff recognition of AARs is a slow and continual process as staff familiarity increases.

Staff will not be fully familiar and on board with the process of an AAR until they have either attended one, or trained as a conductor.

Staffing constraints and availability, particularly during the pandemic, has meant there can be difficulties in staff being released to attend an AAR. A very successful training package meant that staff were very supportive of AARs after completing the conductor training.

Newly trained conductors felt anxious about conducting their first AARs. Clarity about where this new process sat within/alongside other existing processes.

Staff were unfamiliar with the new Patient Safety Incident Response Framework (PSIRF) and its recommendation for the use of AAR as a forum for learning from incidents/events.

The high proportion of AAR attendees have felt able to speak freely within the forum.

Having a dedicated resource and trust leads in the form of the Learning Assurance Coordinators.

AFTER ACTION REVIEW

Training

Incidents

Events

Open and honest

Trust

Four questions

Expertise

Timely

No hierarchy

Events

Value

Collect and collate

Local

Drive

Collaboration

Actions

Ownership

Complaints

Right people

Audits

Projects

Systematic

Change

Trust wide

Connecting The Dots:

Improving discharge pathways and re-referral rates to community mental health teams in rural settings by connecting service users to local resources Dr Mazen Almaskati A Quality Improvement Project in progress with the North Cotswolds community mental health recovery team Introduction

Methods & Tools

We choose this project upon realising that a significant number of re-referrals of patients were from rural and often isolated areas. We embarked on this quality improvement project to explore methods to improve the support for these patients which is tailored to their needs and depending on resources available in their area whether that be from established organisations, the voluntary sector or peer support.

Fig 1: On average only 45% of referrals p/m from 2014 to 2022 were new patients

= new patient referrals

= Re-referrals

1. Literature search to understand initiatives with similar interests.

2. We collated a stakeholder map exploring dynamics of influence, impact and interest in our project.

3. We created an eight-question digital survey aimed at our caseload of adults aged 18-65 split between rural and suburban locations

Aim The aim of this project is to explore factors that contribute to the quality and longevity of patient discharge in rural settings from community mental health services. The project intends to explore the needs of community patients which contribute towards: • Enhanced recovery • Improved Quality of Discharge • Reduced service pressures • Fewer re-referrals to specialist mental health teams following discharge.

Lessons Learned Notably, results showed that 83% of respondents were unemployed, 58% identified access to transport and IT/internet as barriers to wellbeing, while 50% reported meaningful activity would sustain mental wellbeing. These results matched our understanding that rural living with lack of employment/access to transport/digital connectivity drastically impact feelings of isolation and although accounting for a minority segment in reported contributors to sustained recovery, significant affect discharge quality

Next Steps Identified focus areas: • Patient Environment • Communication & collaboration • Standardised discharge Fig 2: Stakeholder Map

Results Results showed that 91% of respondents lived rurally and 83% were under continuous care of the recovery team for over 2 years. 91% of respondents felt ongoing support was the most important contributor to mental wellbeing while ‘anxiety’ and ‘lack of confidence’ accounted for 75% of reported barriers to wellbeing

The following changes will be introduced: • Involve patients and employment worker in discharge MDT • Standardised discharge letters • Include IT/transport and employment information in discharge packs • Continue QI project data collection using focus groups and experts by experience

Fig 3: Factors preventing meaningful activity and mental wellbeing

Rural Suburban Urban

9%

91%

Fig 5: Proportion of patients in rural/suburban areas Fig 5: Proportion of patient employed/Unemployed

Measurements

Summary

• Referral/re-referral data trends • Demographic quantitative data • Service user feedback using survey • Qualitative Data from stakeholders e.g. GPs, focus groups/interviews

• Rural living can be a barrier to meaningful activity and mental wellbeing • Connecting patients to local resources, transport/employment are power tools in sustaining recovery

Fig 4: Important factors in achieving mental wellbeing

Improving maternal satisfaction with labour analgesia - a patient-centred approach

Dr Samuel Nava, ST3 Clinical Fellow in Anaesthesia, Dr Lesley Jordan, Consultant in Anaesthesia, Royal United Hospitals Bath

PLAN, PLAN, PLANà DO à STUDY à ACT Introduction

Labour is a unique physical and emotional experience that can have a lasting impact on parents' lives. An important role for clinicians, particularly anaesthetists, is to provide analgesia for women in labour and support shared decision making [1].

We have undertaken a quality improvement (QI) project with the aim of improving maternal satisfaction with labour analgesia in a District General Hospital Consultant-led maternity unit. Below we outline the steps we have taken so far and the QI tools we have applied. The project was commenced in conjunction with completion of the NHS Quality, Service Improvement and Redesign course locally.

Baseline evaluation – understanding the scope

The aim of improving maternal satisfaction is extremely broad. We started by attempting to understand more about the contributing factors to satisfaction or dissatisfaction with labour analgesia, demonstrated in the driver diagram seen below. We aimed to concentrate on the aspects that have the greatest influence on choice or effectiveness of labour analgesia and we began with a baseline evaluation of patient experience.

We created a unique patient survey with input from a range of different multi-disciplinary stakeholders and invited women to reflect on the positive experiences of labour. The survey was published on social media, open to parents who had been through labour and given birth at our unit in the previous year. We received over 250 responses in 3 weeks. The survey included a broad range of questions and asked respondents to rank the factors that most significantly contributed to their choice of analgesia.

Driver diagram and the Pareto Principle

The initial questionnaire provided a wealth of information about patient experience. The survey describes most frequently used forms of analgesia and the most cited positive or negative aspects of labour analgesia. Through a modified application of the 20:80 Pareto principle, we have identified the key contributors to choice of analgesia as effectiveness, risk and side-effects such as nausea, vomiting or dizziness.

The driver diagram outlines the overall aim, primary and secondary drivers.

We applied the results of the survey to the driver diagram and have progressed to plan a series of smaller quality improvement projects focused on the key drivers. We will apply small step wise changes though plan-dostudy-act cycles and frequent sampling.

Overall measurement of “satisfaction with labour analgesia” is difficult, however, we believe that by concentrating on more specific and measurable aspects of labour experience we can demonstrate quality improvement.

Stakeholder engagement

It became increasingly clear that this project would affect a breadth of individuals, from patients to members of the multi-disciplinary team. We have engaged high-impact and high-power stakeholders throughout and had positive input that helped in several ways: -

Understanding different perspectives. It has been invaluable hearing directly from patients and the Maternity Voices Partnership alongside our more medical perspective

-

How best to gain valuable information from a patient survey. The trust patient experience team guided and supported with their service evaluation infrastructure

-

Sustainability of change. With the aim of bringing lasting change, it has been important to engage senior leaders within the relevant departments to support sustained change

Action plan - Plan plan plan, now do study act!

We plan on a series of interventions: - optimising our epidural regimens and reducing failed or inadequate epidurals - increasing the availability of alternative analgesia such as remifentanil patientcontrolled analgesia - improving the availability of antenatal learning resources

High power Low power

Satisfy

Maternity Voices Partnership Patient experience team

Manage

Senior Midwives Senior Anaesthetists Senior Obstetricians

Inform

Monitor Pharmacy

Patients Midwives Anaesthetists Obstetricians

Low impact

High impact

Learning points - We spent a lot of time trying to understand the scope of the project before starting and strongly encourage a similar approach for anyone planning future QI projects.

- We found using a driver diagram helpful to structure our ideas and applied of the Pareto principle to a baseline survey as a method of targeting efforts towards the most important interventions.

- We have learnt about the importance of stakeholder engagement, not only in providing valuable input but also in supporting sustainability of change.

- heightening awareness of sustainability References

1. National Institute for Health and Care Excellence (2014). Intrapartum care for healthy women

and babies. Clinical guideline [CG190] Available at: https://www.nice.org.uk/guidance/CG190

A quality improvement project to continue increasing Learning from Excellence nominations at the Royal Devon and Exeter Hospital N West, F Birch, E Crehan, T Varley, H Diment, R Randhawa, J Tremlett, M Dineen, R Jaroenchasri

Introduction In the era of DATIX, it is easy to focus on suboptimal patient care, while numerous examples of excellent care go unnoticed (1).

Our established Learning from Excellence (LfE) initiative has created a system to report excellence, boost staff morale, and improve patient safety which we were keen to progress and develop from the already excellent standings.

Aim 1: To increase the number of nominations made by staff by 100% Planned interventions: Lanyards Coffee cups Posters and leaflets

Aim 2:

To create a platform for patients to make nominations Planned interventions: Joint patient/Staff form Integration into Electronic notes system (MyCare) Patient facing posters, leaflets

Our actions and progress We identified that nominations have generally since the last set of interventions, as shown by graph 1 We therefore chose to hold a Regional meeting with Derriford Learning from Excellence (LfE) team to learn from their excellence We championed integration of LfE between Royal Devon & Exeter (RD&E) and North Devon Hospitals, supporting the inclusion of patient nominations and creating new and improved nomination cards focusing on diversity and inclusion We worked with the Quality Improvement Academy (QIA) at the RD&E to gain support, funding, and approval of our intervention We collaborated with the national LfE team, gaining resources and key insight into how to build a successful project We built a nomination form for both patient and staff use Following this, we invited staff to give feedback on the form, with quotes shown in diagram 1 We then made informed changes to the form to make it clearer, easier to use, and more accessible Gained approval from the Chief Executive to move forward with putting this onto the Trust Website and the electronic clinician and patient notes system (MyCare) We developed advertisement in multiple ways including lanyards, posters and coffee cups

Graph 1: Number of LfE nominations from August 2021 to March 2022.

more user

be shorter and more

be more more eye

allowing patients to give thoughts

for wards and departments to make it quicker

Diagram 1: Quotes from staff survey on preliminary nomination form.

Challenges and future progression One limitation is by having an online form, both on the Trust website and on the electronic notes system, we eliminate form whilst the patient is in hospital using mobile devices/tablets.

We believe that having patient nominations will allow for a feedback loop of nominations a patient nominates a member of staff, inspiring them to nominate someone else. This will therefore boost nominations more sustainably.

Finally, our project so far has been focused on gaining more nominations and opening the platform up to patients, but not assessing the learning that can be extracted from this. In the future we aim to pull key themes and concepts from nominations to then feedback to managers and staff leaders to improve patient safety further.

Lessons learnt Understanding how to overcome the changing culture and ingrained practice of learning from negative experience Discussion with other hospitals in our region who have built the initiative within staff and patients proved very informative, and gave us the motivation and confidence to move forward with our own project The sustainability of the process of writing personal nomination cards is a key limitation, both in the physical process of having one person writing them, and the environmental impact of paper copies. To overcome this we plan to create digital nomination certificates This is an evolving project with new ideas being added all the time, and in order to get the optimum learning and therefore patient safety from it, we must continue developing and learning from our interventions With many thanks to QIA at the RD&E for their ongoing support.

Reference: Kelly N, Blake S, Plunkett A. Learning from excellence in healthcare: a new approach to incident reporting. Archives of Disease in Childhood 2016;101:788-791.

Assessing the utilization of CAM-ICU in the early detection of delirium in the General Intensive Care Unit G. Hunduma, S. Bathia, M. Shah, D. Richardson Background Assessing intubated patients for delirium is difficult which further emphasises the importance of ensuring that daily assessments are being performed in addition to ensuring that staff involved directly in the care of patients are competent in performing these assessments. Lack of daily CAM-ICU assessments results in delirium going undetected and therefore worsened patient outcomes and prognosis. The aim of this QIP was to perform a prospective analysis of the use of CAM-ICU on 30 intubated in the General Intensive Care Unit (GICU).

Objective

Methodology

• To assess and improve the detection rates of delirium from the day of patient admission into the GICU using the CAM-ICU • To assess staff competence and confidence in using CAM-ICU • To determine factors preventing effective utilisation of CAM-ICU

• The effects of the planned changes will be assessed using a combination of observation of new admissions on the Metavision software used in the GICU, and questionnaire of the nurses and doctors involved in their patient’s care.

• We planned an education session for staff with an aim of re-assessing the use of CAM-ICU after 1 month among the nurses and doctors involved in their patient’s care.

Results:

CAM-ICU results

Not assessed 30%

Positive 10%

The PDSA 1: • Newly admitted patients identified • Exclude patients with RASS>-2

Negative 60%

• Ask nurses if CAM-ICU has been performed within 24 hours of admission • Identify any discomforts with performing CAMICU

PLAN

DO

ACT

STUDY

Number of patients

with first CAM-ICU after 24 hours 17%

with no CAM-ICU performed during admisison 14%

with first CAMICU within 24 hours 69%

• Analyse data and determine limiting factors to CAM-ICU being performed • Identify patients tested positive for delirium and when CAM-ICU started

• Apply intervention of adding task of documenting CAM-ICU on ward round jobs list • Update staff in GICU • Collect data in preparation for PDSA-2

Discussion

Conclusion and Lessons learnt

• 69% had a CAM-ICU performed on admission compared to 33% who did not have CAM-ICU on admission. 87% had CAM-ICU performed anytime during admission.

• 10% from the sample tested positive for delirium.

• All the nurses felt they were confident in utilising the scoring criteria.

• Overall, CAM-ICU was well performed.

• Further improvements must be made in order to ensure all patients being admitted receive a CAM-ICU assessment within 24 hours.

• CAM-ICU performed within 24 hours enabled early detection of delirium • Early delirium treatment prevents worsening prognosis and unnecessary lengthening of ITU stay • Making it part of ward rounds job lists is an active method of reminding the team to perform CAM-ICU assessments