AE Leadbetter, RG Beckett, CL Marchand & SC Sturney
Bronchoscopy is essential for diagnosis and management of pulmonary pathology.
Procedural sedation and analgesia (PSA) practices vary, with minimal standardisation1.
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.
Departmental teaching increased awareness of procedural sedation and analgesia (Table 1).
Departmental teaching reduced overuse of midazolam and fentanyl (Table 1).
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.
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
What are the current prescribing practices?
PDSA 2
Retrospective review of all admitted patients over a 30 day period
Confirm if intervention has worked and identify any new areas for development
Review the data and hold focus groups to plan intervention
Retrospective review of newly admitted patients
PDSA 1
Targeted teaching (AMU & respiratory ward) and aide-mémoire poster
Compare findings with PDSA cycle 1
Focus on improving time to first dose VTE
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%)
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.
Authors Emergency medicine consultants Ehsan Hassan and Talia Barry
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.
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
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
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/
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).
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
Auditing the reporting of dental anxiety
software to ascertain whether an explanation/history of their anxiety was recorded. The medical history used on the Dentally
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.
to being too vague.
The results are shown in the pie chart below.
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
Add extra question to medical history tab on Dentally software asking patients to explain/elaborate on their anxieties
Question was added (Jan 2022)
Survey patients to see if addressing their specific anxieties allowed them to have better experiences in the service.
Re-audit reporting of anxiety and compare pie charts to see if reporting improved (April 2022)
Was explanation for dental anxiety recorded ?
Plan further PDSA cycles with a view to implementing the project regionally and nationally
and-phobia#causes-of-dental-anxiety-and-phobia.
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
Seline Ismail-Sutton, Rebecca Allan, Megan Howarth, University hospitals Dorset
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.
Cycle 1
Add prompt to clerking proforma to record driving status.
Raise awareness of issue with MDT.
Add reminder poster in ward office to discuss this as part of discharge routine.
2
New prompt to act as a continuous reminder for driving status to be recorded.
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.
Frequency of documented evidence remained low.
Discuss issue in morning MDT meeting.
Increase discussions via prompt on consultant ward round sheet.
Improved discussion rate, not all team members engaging.
New prompt on consultant ward round sheet to trigger discussion.
Improve team engagement via a more formal method.
Some improvement, some boxes unfilled, did not always lead to discussion.
Add box to clerking proforma to record driving status.
Review notes, assess if positive impact achieved, feedback from colleagues.
Add section to ward round proforma for prompt and documentation.
Review effect of each intervention, assess which to keep or remove.
Encourage this discussion to form part of discharge routine.
Reminder poster to discuss upon discharge and use existing guidance leaflets.
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 c onsider if these findings can be applied to community palliative care teams, and if driving guidance discussions are more suited to this setting.
Presentation and circulate email raising awareness of ongoing QI project.
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.
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.
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
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
• 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)
New Guideline (Jan-Oct 2021)
End Oct 2021: New Trust guideline created with input from pharmacy, cardiology, acute medicine, haematology and renal teams.
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.
Keywords e.g. ‘New Atrial Fibrillation’, ’AF’, ‘DOACs’ were used to make the guideline easily searchable.
• Improved awareness of existence of guideline and of guideline contents following education sessions
• Improved awareness of New Medicine Service
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
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%
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%
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.
Fig. 1. Quick reference flowchart for management of new AFDr 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
This is a QI project to evaluate the Creation of Treatment Escalation Plans for patients admitted to a general medical ward.
What are Treat escalation plans?
A Treatment Escalation Plan (TEP) is a form of advanced care planning and communication tool which is helpful in hospital for inpatients as they have the potential for acute deterioration and some may even be coming towards the end of their life. (1)
Why are TEPs useful?
There are situations in which doing everything possible may actually lead to more harm (suffering and distress) rather than 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 what should be done may not necessarily be the same thing. Thus this is the reason Treatment Escalation Plans should be discussed (amongst the clinical team and with the patient) and made based on personalised realistic goals whenever patients are admitted as inpatients. (1,2)
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 that interventions or referrals for more intensive care that are contrary to a person’s wishes or are futile or burdensome should not be undertaken. Equally in many patients who may have an agreed DNACPR, a TEP clarifies all the treatments 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)
Aim
The aim was for 100% of patients admitted as inpatients to medical wards should have a treatment escalation plan documented
QI Approval
Audit approval was sought and obtained from local clinical audit department and audit registered.
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;
-
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 recorded in an anonymised and password protected excel sheet
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 Treatment Escalation Plan on file. 54 patients did not have ay formal TEP available in their medical files. Thus only 40.65% of patients in this representative sample had a TEP available falling far short of the 100% standard set out at the introduction. (Figure 1)
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 demonstrated the need for more education on the importance of Treatment Escalation plans and their implementation.
Recommendations
A 3 pronged approach was utilised to improve the uptake and creation of TEPs;
1. Education
2. Reinforcement
3. Access/convenience
Action plan
The recommendations above were actioned using the following practical changes on the ward;
1. A presentation to ward doctors during ward based teaching
2. Moving forward regular presentations on the importance of TEP’s and creating TEPs during ward based induction for incoming doctors
3. A poster was created that highlights the importance of TEP’s and shows how to create one (reinforcing the importance of TEPS daily)
4. Create and place TEP pro-formas prominently in the doctors office so that they are readily available to be added to medical notes of new patients. This serves to provide ready access to TEP proformas. This thus increases convenience and reduces resistance to the adoption of TEPs
The action plan above was implemented for a month and following which the data collection was repeated to assess the efficacy of the recommendations
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. (Figure 2)
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 doctor rotation.
Future Improvements
1. To combat the rotation of junior doctors education on TEP should be integrated as part of local ward induction programs.
2. Education on TEPs and their importance should be extended to involve other members of the MDT (nurses, physiotherapists, ect.) to allow multiple members to reinforce one another in creating TEPs
Iddawela S, Prince R.
• Active surveillance of prostate cancer is a key aspect of long term management in primary care.
• A quality improvement project was undertaken to establish thesethresholds, set up monitoring pathways and invite patients to participate in annual reviews focussed on prostate cancer
Patients who have prostate cancer in a single GP practice in the West Midlands –identified those discharged
Patients were invited foran annual review, with an offer of an examination.
Monitoringand PSA thresholds established
• 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 regardingmonitoring 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
• 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
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).
Amissed fracture carriesthe 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.
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 theHB.
Deliver teaching to GPs and ENPs about wrist injuries, history taking skills, anatomy and scaphoid fractures.
To set up an advanced nursepractitioner led soft tissueclinicanda scaphoid pathway to ensure gold standard of treatment to aidearlier diagnosis in MIU.
A core working group established,led by an ANP. ANPled softtissueinjuryclinics were established.
Retrospective data analysis of wrist injuries (as phase 1)
Establish local MRI pathway for MIU
If scaphoidsuspected STI clinic 2/52
If still symptomatic and no obviousscaphoid fracture, request MRI MRI scan completed within 48hours
MRI report within 24hours (still in agreement stage)
The ANP team will address thiswith teaching the ENPs andthe 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.
Fattyliverdisease is oneof thecommonestcauses of abnormalliverblood tests(LFTs) and canlead to livercirrhosis in 1-3% ofpatients. Patientsandcliniciansareoftenfalselyreassuredthat itis leading to poor management.
In our analysis, ~30 % of patientswhohadabnormalLFTsare inappropriatelymanaged.
Only1 in 5 patients in our analysishaveariskstratification(FIB4) performed to assesstheirrisk of cirrhosis(NICEguideline). Based onour predictivemodelling atour GP practice, we estimatedthat only1 in 10 patientshaveaconfirmeddiagnosisoffattyliver and there is 170 undiagnosedfattyliverdiseases in patientswithderangedLFTs at our practice.
Our project focused on 3 separate workstreams and 5 interventions, each with their own PDSA cycle:
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
B.Improve the management of
Work streams / Aims
A. disease
B. Improve the management of deranged LFTs
C. Implement interventions in the early stages of NAFLD to prevent liver fibrosis
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 patient had repeat blood requested via call or text message
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
All patients were informed about management, complication and monitoring.
2patients were REFERRED to hepatology due to high risk of cirrhosis
C.Implement interventions in the early stages of NAFLD to prevent liver fibrosis
5.Re-call clinic
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?"
9 GP practices across 3 PCNs
"This is excellent work. Well done!"
"I scored her using your template!"
AbnormalLFTsare not wellmanaged in primarycare due to multiplefactors lack of time,awareness and localguidelines. After our rootcauseanalysis, we identifiedkeychangeswhichlead to improvedoutcomes:
Explainingcomplications (3xincrease)
Performingriskstratification (2xincrease)
Increasedreferral and identification of high-riskpatients
The toolkit(composedof an automatedFIB-4calculator,patient leaflet, and aconciseguideline) we had implementedwaswellreceivedacrossthree PCNs
Marie Jasim, 1
Bridget McManamon, 1
Benjamin Stone, 1
Rebecca Spiby 1
1 Torbay and South Devon NHS Trust
100% felt the workload was now more manageable
‘[great] result… I'm honestly delighted”
“Much better service now”
>50% increase in number of weekend phlebotomists ‘[it’s] definitely improved and made the weekend shift a much easier experience’
- 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.
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
- 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.
-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 improvementagainst 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
Can you think of instances when patients not being bled led to patient safety issues or delayed discharge?
Graph A Graph B
- 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.
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.
>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.
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 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 2 Results
• 52 admissions between May 2021 and June 2021.
• 39% with TEP form and 29% with CFS
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
Intervention 2
• Informal teaching from surgical registrars to clerking teams
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)
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.
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.
Between each cycle, staff education sessions, posters and policy change was implemented to ensure the operating surgeon requested the XR.
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.
To assess time between surgery and post-operative XR
To identify any reasons for delay To Streamline the protocol
R= Average number of days (NOD) between operation (OP) and XR request
X= Average NOD between OP and XR
Refining a novel trainee-led initiative during the COVID-19 pandemic
• 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
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. Indication for Review stated
2. Lead Consultant Listed
3. Patient attendance
4. Clinic Letter completed
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
Kathryn Mullan1, Ngozi Oketah1, Nicola Davey2 1 Royal Belfast Hospital for Sick Children , 180-184 Falls Road, Belfast BT12 6BE,2 QIClearn• 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 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
Develop a triage tool for High Impact Users (HIUs) at Bristol R The first step, outlined here, was to determine which factors increase mortality in this specific local
Ø We collected data on 250 patients FAs attending BRI ED between
Ø Six variables were chosen
Ø Data was collected from electronic patient gender and 5-year mortality was also recorded.
Ø Logistic regression modelling factors best predicted 5-year mortality
Scoring system to identify high risk frequent attenders
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 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
• 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.
Background:
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 fullyassessed 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 setstandards for acute surgical patientstransfer
Interventions:
o Presentation of results at SurgicalQuality 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
o Creation of easy-to-follow flow-chart including contact numbers of key staff members
o Education of key staff members
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)
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
Decision to transfer to arrival at site B 9:16h
Decision to transfer to procedure 43:38h
Decision to transfer to life saving op. 8:38h
CEPOD booking to procedure 12:23h
Findings:
Y. Hazemi-Jebelli, K. S. Weigel, R. Gunnell, M. de Wolf, M. Patel, A. Ogedegbe, A. Bhargava, D. K. Patten
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 iCoughprogramme.
Aims:
50% reduction in incidence chest infections over 6 months by implementing the iCoughprogramme.
Secondary aim: 1 day reduction in LOS.
Elements of the iCoughprogramme 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 iCoughwere implemented and upheld by the Ward Therapist, with the support of all ward staff, including nurses and HCA’s.
Baseline measures were collected including compliance with each of the iCoughelements 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.
“ I’m not as breathless climbing stairs”
Results:
“
“Using the power breathe at home before my surgery I noticed improvements in my breathing”.
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 PowerBreatheimplantation, 92% used it effectively –see patient comments in bubbles above.
Outcome measures :
Use of the PowerBreatheIMT resulted in a 33% improvement in Maximum Inspiratory Pressure.
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 iCoughprinciples.
-To support consistency with mouthwash use -a ward stock should be readily available.
-Powerbreathewas acceptable and easy to use by patients.
-Implementation of the PowerBreatheIMT 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.
Next Steps:
• Future funding is being investigated to use IMT as routine pre-hablilitationas 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 iCoughelements 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 abdo minal 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.
Even when I’m unable to walk, I feel like I can still exercise my lungs”Figure 1: iCough elements Figure 3; Patient diary
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
ARE DUE TO DOMESTIC ABUSE2 12% OF ED ATTENDANCES
1 in 7 men Will experience DV in their lifetime3
2 ARE KILLED BY THEIR PARTNER EVERY WEEK4 WOMEN
1 in 4 women Will experience 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. Training about DV and how to ask for all ED staff – which prepares them to recognise & ask & what to do
2. Culture of asking in ED by all staff so that it is routine
DV Bitesize teaching at end of Week 5
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)
1.1 Bitesize teaching
Only 1 doctor and 6 nurses attended. There was no change in the number of referrals the week following the teaching.
1.2 Simulation teaching for junior doctors & registrars 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 summary of the earlier case review findings
2.2 “Ask for Nurse Angela” Posters to be placed in the department so that DV victims know what to say to subtly alert staff. To utilise handovers to explain what a patient is alerting you to in asking for nurse Angela.
2.3 Screening questions to be incorporated into the social history of junior doctors doing the rapid first assessment of an ambulatory patient and into the nursing triages.
2.4 Prompt to be added to MTC booklet and incorporated to electronic MTC form to remind clinicians to ask about safeguarding including DV.
2.5 Reminder about DV in the nursing handover as part of ”The Big 5” to actively screen for DV in individuals presenting secondary to assault
3.1 DV contacts made more accessible by adding them to the widely used ”Induction” app so that 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 easier to follow and the next steps are obvious for staff to take depending on patient’s answers.
5.1 Private space for DV discussion to be allocated
Monitor the number of referrals in subsequent weeks
Monitor the number of referrals made to the safeguarding team in the following weeks and review how many were made due to the “Ask for Nurse Angela” scheme
Monitor the number of referrals made to the safeguarding team in the following weeks
Monitor the number of referrals made to the safeguarding team in the following weeks and review how many were MTCs
Monitor the number of referrals made to the safeguarding team in the following weeks
Monitor the number of referrals made to the safeguarding team in the following weeks
Monitor the number of referrals made to the safeguarding team in the following weeks and review how many had the new DV proforma fully completed
Monitor the number of referrals made to the 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.
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.
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 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
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
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.
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.
Figure 1: TWOC Checklist Figure 2: The Relationship between TWOC Success Rate & Patient Factors
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).
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.
Tracheostomy Model
Previous Complex Airway Teaching:
Posters and ”Test
Driver Diagram
Balancing measures: -Incident form -Knowledge compared to confidence and ability.
Results:
Confidence
Ability
Knowledge
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 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.
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
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.
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
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
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
Nextstepsincludeplan
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 bothTrust and national guidelines.
Qualitative data collected; NIC of 4 wards surveyed, how does poor catheter affect patient safety ?
• Delay in TWOCs
To achieve 100% catheter documentation on inpatient notes.
Poster(s); educational posters in doctor’s office, bulletin boards on ALL first floor wards.
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.
• 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 acatheterbefore 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.
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
12.No resistance to balloon inflation, no patient reaction or pain related to balloon inflation, free movement of the catheter once balloon inflated
Future work- PDSA Cycle (3)
P: Convene meeting with trust CERNER softwarelead.
D: Augment pre-existingsoftware to include(7) data sets.
S/A: Re-audit theabove and useresults to update thetrustwide guidelineson Catheterdocumentation in conjunction with theUrologyteam.
Conclusions/Lessons Learnt:
•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
References:
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 Societyencourage, where appropriate, to priori@se DPIs as they have a much lower carbon footprint with similar efficacy.3
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.
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.
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
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
ACT
PDSA 2 – teaching session to prescriberscompleted
PDSA 4Targe@ng higher impact users
PDSA 5 - Crea@ng pa@ent informa@on leaflet & empowering pa@ents with NICE decision tool 6
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.
Illustration adapted from rightbreathe.comIntroduction 1
Results 4
Pre-op fastingdecreasesthevolumeandacidity of the stomachcontents, thereforereducingtherisk of aspiration.
Ensuringsurgical ward staff understandtheclinical NBM preventsunnecessarydelays to proceduresand excessive fasting of patients
Aim 2
To reduce excessive fasting of patients by improving ward staff knowledge of NBM guidelines.
Oral intake cut-off times pre-op (NICE, 2020):
Meals:6hours
Milky drinks:6hours
Clear fluids:2hours
Medications: 30 minutes
Methods: PDSA 3
Cycle 1: Ward staff survey
Cycle 2: Foundation doctor teaching + ward posters
Cycle 3: Retained posters, guidelines emailed to nursing staff + foundation doctor teaching
Interpretation 5
Improvementbetween1st +2nd cycles for nursing staff andHCAs across individualnutritionoptions andcompleteanswers;
however, correct answers from both staff classes declined in the3rd cycle.
Reduction in fully correct answers from doctors between1st +2nd cycles;however,answersimproved in the3rd cycle
Next Steps 6
Initialsuccessfulapplication of ward posters.
Posters eventuallyremoved, staff reallocation
Amixedresponsethat may bedue to staff turnover, position in theacademicyearandteachinguptake.
Further cycles shouldbeconductedwithinashorterperiod of time to assess knowledgewithin each rotation of doctors.
Next intervention:visualpromptusingbedside NBM signs with guidelines,andteachingsessions for foundationdoctors on notonlytheguidelines,but also clear documentation in thenotes for mealandfluidcut-off times
It’s difficult to assessif knowledge is beingapplied,butauditingdocumentation in thenotes may be an option. Also, despitebest laid plansthe vast majority of patients are on emergencytheatre lists which are liable to orderchanges.
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, poster of themes from the survey/debriefs Measures of improvments included data collection via notes audit, maternity dashboard and maternity IT systems.
• Data plotted on run and SPC charts, outcome and process measures used.
• PDSA cycles to trial small test of change.
• Weekly skills drills to embed the culture
Change ideas
• Measured blood loss through the introduction of digital scales in each labour room.
• Implemeneted a validated risk assessmnet tool designed through two tests of change and audit its use
• MVP to collate patient experience of postpartum haemmorrhage
• Administration of syntocinon IV and tranexamic acid for all Caesarean sections
• Learning from excellence template
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.
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.
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.
We would have champions for the approach and people who promote it
It becomes fully embedded with a Train the Trainer approach
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
Our departments champion it
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
AAR would be a timely and reactive learning tool.
The AAR approach compliments the new Patient Safety Incident Response Framework (PSRIF) as one of their recognised tools for learning.
Quality Governance Learning Assurance Coordinators were recruited to lead the AAR process and implementation.
A cohort of conductors have been trained with dates scheduled to train further conductors. 7 trust staff members have been trained as trainers. 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.
Learning points have come out of every AAR held which bridge across individual learning, process improvements and trust wide learning.
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.
AARs are frequently suggested/recommended by members of the executive team, as well as departmental leads in areas where AAR is well established.
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.
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.
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.
Improving discharge pathways and re-referral rates to community mental health teams in rural settings by connecting service users to local resources
Quality Improvement Project in progress with the North Cotswolds community mental health recovery team
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.
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.
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.
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
•Referral/re-referral data trends
•Demographic quantitative data
•Service user feedback using survey
•Qualitative Data from stakeholders
e.g. GPs, focus groups/interviews
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
Next Steps
Identified focus areas:
•Patient Environment
3.We created an eight-question digital survey aimed at our caseload of adults aged 18-65 split between rural and suburban locations 9%
•Communication & collaboration
•Standardised discharge
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
•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
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.
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.
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.
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
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
- heightening awareness of sustainability
-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
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
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 LfEbetween 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 LfEteam, gaining resources and key insight into how to build a successful project
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. more user be shorter and more
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
allowing patients to give thoughts be more
more eye
for wards and departments to make it quicker
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.
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 h aving 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.
Background
Assessing intubated patients for delirium is difficult which further emphasises the importance of ensuring that daily assessm ents 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
•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 Metavisionsoftware 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:
The PDSA 1:
•Newly admitted patients identified
•Exclude patients with RASS>-2
•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
•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.
•Ask nurses if CAM-ICU has been performed within 24 hours of admission
•Identify any discomforts with performing CAM-
•Analyse data and determine limiting factors to CAM-ICU being performed
•Identify patients tested positive for delirium and when CAM-ICU started
• 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
An independent national conference, held annually and designed to share learning from across the UK.
Our programme includes nationally recognised speakers who are experts in their field. We also offer a range of workshops led by patient safety, quality improvement and medico-legal experts.
