BPSC 2022 conference - 160 posters - part 1

risto P tient et Con eren e is n in epen ent e ent esi ne t o s re e rnin rom ross t e Celebrat ing our 10th anniversary this year.

National online patient safety conference - 17th May online

Keynote Baroness Helena Kennedy KC

Shaun Lintern

Tim Spector

Dr Jenny V aughan

M ore here: risto p tients et om

Poster Competition 2022

Thanks to all 240 poster competition ent ran ts and to th e p resente rs of the 160 poste rs selecte d t o be p resente d at our ninth annual con fe rence on the 18 th M ay 2022.

P rojects f rom trusts ac ross the UK we re sha red th rough o ral p resentations fo ll owe d by qu e st i o n s by a j ud ge .

Thanks to Quality Imp rovement Clinic and QI C ear n for p roviding the fi rst pri ze for eac h of th e 15 categories – a 30 minute pe rsonal virtual QI coaching session to help th e winning p resente rs take the next step of their QI journey.

www.bristolpatientsafety.com

Poster Competition Group A Audit

Education and Training Prizes

Peri-operative capillary blood glucose monitoring in diabetic patients undergoing general anaesthesia

Authors: TrinoCruz Cervera, Maeve Curran, Jeffrey Chit Wong

Background

ØDiabetes is becoming an overwhelmingly common comorbidity in the peri-operative setting with 1015% of patients presenting for surgery having diabetes, equalling to over 323,000 patients per year, nationally [1]. Diabetes patients are at risk of having a longer term infective and non-infective complications [2]. Poor glycaemic control is therefore essential and will also help to reduce the overall disease management cost. Consequently, it was important to assess our compliance with local and national guidelines [1].

Results

6-12mmol/l

Methods

ØData was collected retrospectively, 250 patients were reviewed, 38 of which were eligible, diabetic patients undergoing general anaesthesia for a surgical procedure. The standards applied were set by the Joint British Diabetes Societies for Inpatient Care, and included capillary blood glucose percentage of time that diabetic patients have their peri-operative CBG between 6mmol/l and 12mmol/l (target 100%) [1]. Management of patients with CBG outside the desired range was also recorded.

1.Centre for perioperative care; Guideline for Perioperative Care for People with Diabetes Mellitus Undergoing Elective and Emergency Surery, March 2021

2.Klein, A.A, Meek, T., Allcock, E., Cook, T.M., Mincher, N., Morris, C., Nimmo, A.F., Pandit, J.J., Pawa, A., Rodney, G. and Sheraton, T., 2021. Recommendations for standards of monitoring during anaesthesia and recovery 2021: Guideline from the Association of Anaesthetists. Anaesthesia.

ØCBG was measured appropriately in 32% of patients in theatre and in 58% of patients in PACU. CBG was maintained within the appropriate range in 50% of patients; however in 21% of cases CBG was not documented. From those patients with CBG outside of the appropriate range (612mmol/l), three required starting of a variable rate insulin infusion (VRII) and one required hypoglycaemic treatment. Four patients were discharged from PACU with CBG outside of this range.

Discussion

Ø There was an overall poor adherence to CBG monitoring, particularly in theatre, although this may also be due to poor documentation. Two of the patients from PACU with a CBG >18mmol/l were not managed prior to discharge, these will be reviewed. After discussion, we have recommended several changes including; review of guidelines at clinical governance meetings, adding ‘is the patient diabetic? and has CBG been monitored?’ to the sign in or sign out checklist in theatre, implementing and consolidating discharge criteria from PACU and making these known via email, teaching and local posters. Increasing the availability of CBG and ketone monitoring devices should also be explored. We expect that these changes will improve perioperative CBG monitoring and we will be re-auditing in the following months.

Figure 2. Percentage of patients where CBG was maintained within range.

Compliance of BAD advice on the safe prescribing of Isotretinoin

Nada Khalil (FY2), Leah Mapara (Dermatology SpR), Randa Alhajar (Dermatology Consultant)

Background

• Oral Isotretinoin (Roaccutane) is a very effective treatment used for moderate and severe acne vulgaris. It is also being used for other conditions e.g. hidradenitis suppurativa, seborrhoea and rosacea.

• Careful assessment and close monitoring is imperative when prescribing this medication given its side effects and teratogenic nature. The British Association of Dermatology (BAD) have created clinical guidelines on the safe introduction and continued use of isotretinoin. There are 5 clinical audit points based

BAD Audit points

1. Female patients of childbearing potential receiving isotretinoin will have signed the ‘acknowledgement of PPP information’ form indicating that they have received appropriate information.

2. All patients will have had serum lipids checked prior to starting treatment and at least once during treatment.

these

that every specialist prescribing isotretinoin must adhere

Aims and objectives

1. Assess the safety of isotretinoin introduction in Northwick Park (NPH) and Ealing Hospital (EH) Dermatology clinics

2. Assess the safety of monitoring isotretinoin therapy in NPH/EH Dermatology clinics

3. Identify areas of improvement within clinical practice when prescribing and monitoring isotretinoin

4. Promote safe practices among clinicians when prescribing isotretinoin

Previous audit (Jan- April 2018):

• Based on 38 patients – 9 males, 29 Females from Northwick Park Hospital only

• Variable compliance with BAD guidance.

• 100% compliance with lipid levels monitoring

• Poorer outcomes with pregnancy testing 5 weeks after course completed and documentation of mood at baseline an during treatment.

Interventions implemented since last audit

3. All females of childbearing potential will have pregnancy tests before treatment and at monthly intervals and at 5 weeks after treatment.

4. The number of pregnancies occurring in patients taking isotretinoin with a target of 0% pregnancies as the standard to be achieved (note these must be reported on the yellow card system).

5. There will be documentation of mental health and mood state for all patients commencing isotretinoin, both at the assessment for treatment and at each follow-up appointment.

Results of re-audit

Methods

Audit population identified:

• Dermatology patients who had been prescribed isotretinoin between 01/09/2020-01/05/2021

• Exclusion criteria: missing clinical records, incomplete records

• Seen in Dermatology clinics at NPH/Ealing

Clinical records analysed and relevant information recorded:

• GCIS and EPRO for clinic letters.

• ICE for blood results

• Clinic pregnancy test book and EPRO for pregnancy tests (Also B-HCG due to Covid and tele appointments)

• Overall improvement since last audit in all audit domains.

• 100% compliance with audit points 2-4

• Need to ensure better documentation of mood disorder prior to starting treatment

To improve compliance further:

• Continue Roaccutane pharmacy led clinic with checklist

• SHO acne clinic for new patients– newly created guideline using 2021 NICE guidelines has been created to use in clinic.

• Hand out Roaccutane alert cards to patients

• Every patient should receive BAD leaflet – may help reduce drop out rate/reduce DNAs

• Upload pharmacy Isotretinoin check list on EPRO – all documentation in one place

1. SHO led acne clinic for new patients

2. Pharmacist led Roaccutane clinic using checklist

3. Transition from paper to electronic documentation

on

guidelines

to.

Improving Driving Advice Provided to Cardiology Patients at West Suffolk Hospital

Dr Ayesha Ahmed, Dr Adel Khalifa

Aims: To increase the adherence and provision of appropriate driving advice provided to patients on discharge from the cardiology ward at West Suffolk Hospital.

Initial Results

Post intervention, discharge summaries of 31 patients were assessed and it was seen that out of 31 patients, 25 had driving advice documented on their discharge letters whereas 27 had driving status documented on their clerking proformas.

Are you familiar with DVLA guidance after a cardiovascular incident?

We saw significant improvement in the adherence and provision of driving advice to cardiology patients and increase understanding of DVLA among the junior doctors. After introducing our template and hardcopies in the ward, the proportion of documented driving advice on discharge summaries increased from 4.5% (2/44) at baseline to 81% (25/31). We demonstrated that simple educational interventions and a standardised template improved the quality and quantity of provided driving advice.

Audit of Patients with Severe Ulcerative Colitis

Megan Rotherham, Peter Basford | St. Richards Hospital, Chichester

BACKGROUND

Between 15-25% of patients with Ulcerative Colitis (UC) will require admission for an Acute Severe Ulcerative Colitis (ASUC) flare at some stage during their disease It is potentially life-threatening and requires baseline bloods, stool culture with Clostridium difficile assay, radiological imaging and flexible sigmoidoscopy, with close monitoring after admission A significant proportion of admitted patients are likely to fail to respond adequately to intravenous (IV) corticosteroids and are likely to require medical rescue therapy or surgery

BSG guidelines indicate 67% of patients with ASUC showed a response to steroids, 29% required a colectomy and there is a mortality rate of 1% ASUC patients’ risk of VTE is 2-3 times higher than inpatients without IBD C difficile infection has been associated with a worse outcome in hospitalised IBD patients and needs prompt treatment with Vancomycin in additions to steroids Investigations, prescribing and management plans were assessed according to those deemed necessary by BSG

AIMS

The aim of this audit is to review the care of patients admitted at St Richard’s Hospital or Worthing Hospital for ASUC in accordance with the British Society of Gastroenterology consensus guidelines on the management of IBD In addition, the proportion of patients who were visited by specialist teams will be reviewed and the effectiveness of the Oxford Criteria at predicting the requirement for surgery or salvage medical therapy [1]

RESULTS

43 patients were identified with severe UC admitted between July 2019 and July 2020 Of these, 18 (41 9%) were female and 58 1% of patients (25) met Truelove and Witts criteria In total 19 patients required Infliximab and 14 patients required surgery

Within a 24 hour period

• 65% of patients had a Faecal sample sent

• 88% had an abdo x-ray or CT scan

• 19% had a Flexible Sigmoidoscopy

On admission

• 56% of patients received IV steroids

• 51% received VTE prophylaxis

Within 24 hours

• 88% had received IV steroids

• 86% had received VTE prophylaxis

DISCUSSION

BSG guidelines suggest that 67% of ASUC patients show a response to steroids, with 29% having a colectomy and a mortality of 1% This audit found 62 8% did not sufficiently respond to steroids, with 32.6% requiring a colectomy and a mortality rate of 0%.

Truelove and Witt’s Criteria identified 63.2% of the patients who required Infliximab and 83 3% of the patients who required surgery 80% of those who met the Oxford Criteria went on to require Infliximab or surgery

• This accounts for 21% of patients who required Infliximab and 7.1% of the patients who required surgery

OUTCOMES AND FUTURE PROJECTS

• Creation of a "Care Bundle" sticker for medical team to enter into the notes prompting necessary investigations and management on admission and for monitoring.

• Future investigation around Oxford Criteria at 72, 96 and 120 hours to explore impact of weekends on CRP and stool frequency documentation and impact on outcomes

The guidelines for management of ASUC have been set out by British Society of Gastroenterology (BSG) [1] The audit also used Truelove and Witt’s criteria and Oxford Criteria for assessing patient severity [2]

STANDARDS METHODOLOGY

Participants were included if they met Truelove and Witt’s criteria or if they were identified as having Severe UC requiring intravenous steroid treatment by a Gastroenterologist between July 2019 and July 2020.

Patients were also assessed according to the Oxford Criteria for the response to steroids at 72 hours Patients medical notes, drug charts, investigations, imaging and any endoscopy or surgery notes were reviewed to source the information

After 72 hours of receiving IV steroids 5 patients (11 6%) met the Oxford Criteria

For the 25 patients who met Truelove and Witt’s Criteria, 12 (48%) patients required Infliximab and 12 (48%) patients required surgery

18 patients did not meet Truelove and Witt’s Criteria, 7 (38.9%) patients required Infliximab and 2 (11.1%) patients required surgery

RECOMMENDATIONS

Additional training with regards to sending stool samples with C. diff testing, prompt IV steroids and VTE prophylaxis all within 24 hours

Improvement must be made in the number of patients who have a flexi-sig within 24 hours

Improvement required in the documentation of stool frequency and CRP testing at 72 hours to monitor steroid response

REFERENCES

1. Lamb CA, Kennedy NA, Raine T, et al. British Society of Gastroenterology consensus guidelines on the management of inflammatory bowel disease in adults. Gut 2019;68:s1-s106.

2. Moore AC, Bressler B. Acute Severe Ulcerative Colitis: The Oxford Criteria No Longer Predict InHospital Colectomy Rates. Dig Dis Sci. 2020 Feb;65(2):576-580. doi: 10.1007/s10620-019-05668-

6. Epub 2019 May 15. PMID: 31093812.

An audit and re -audit of adult venous thromboembolism risk assessment compliance with NICE guidelines in

the Medical for Older People department in University Hospital Southampton.

University Hospital Southampton

INTRODUCTION

Venous thromboembolism (VTE) is the third most common cardiovascular disease in the UK. 60% of VTEs are hospital-associated and cost the NHS £570,000 daily. The COVID-19 pandemic has highlighted the increased risks of VTE and reinforced the need for VTE risk assessment. As per the Department of Health, risk factors for VTE include age over 60, reduced mobility, dehydration and malignancy. All Medicine for Older People (MOP) patients have at least one of the aforementioned risk factors. A correct assessment prevents harm from VTE and also reduces the risk of bleeding from unnecessary pharmacological prophylaxis. The aim of this audit and reaudit was to assess the MOP departments compliance with completing the VTE risk assessment as per NICE guidelines [NG89].

METHODS

The University Hospital Southampton (UHS) Adult VTE assessment is based on the Department of Health VTE assessment and additionally requires input of weight and renal function in order to guide prescribing. 100 consecutive MOP patients across 5 different wards formed the sample population in May 2021 for the audit and then again in December 2021 for the re-audit. Data was collected from the UHS electronic record, CHARTs. Three standards were selected; VTE risk assessed on day of admission, VTE prophylaxis appropriately prescribed for weight and renal function and re-assessment within 24 hours completed. These findings prompted the intervention of teaching sessions on the importance of VTE prophylaxis prescription, delivered to the MOP junior doctor team at a local meeting.

Results

44% of patients did not have a risk assessment completed within 24 hours of admission. This decreased to 5% in the re-audit.

4% of patients did not have appropriate prophylaxis prescribed according to renal function and 7% for weight in the audit. In the reaudit, this was 4% and 9% respectively.

94.5% of patients had no re-assessment done within 24 hours in the audit and 99% of patients in the re-audit.

Conclusion

Prescribing according to weight and renal function and reassessment remain an issue. With this re -audit, we wish to create a 24 hour re-assessment reminder popup on CHARTs and make a VTE assessment sticker which can be placed in patient notes to improve this. No patient developed a pulmonary embolism as a result of inappropriate VTE prophylaxis prescribing.

Srishti Sarkar and Jessica Grayston, Hu Chan, Megha Bhandari, Tomilola Adepoju, Ibrahim Bodagh

Figure 1: Completion of VTE Risk Assessment within 24 hours of admission

Figure 2: Completion of appropriate prophylaxis prescribing according to renal function and weight

Figure 3: Completion of reassessment within 24 hours of admission

Investigating how often daily weights are recorded in acute heart failure patients

Introduction

Acute heart failure (AHF) is a leading cause of hospital admissions, accounting for nearly 70,000 admissions in the UK in 2019-20. AHF can present as new-onset or decompensated chronic heart failureA. Symptoms arise from a build-up of fluid in the lungs or body causing dyspnoeaand peripheral oedemarespectively. The mainstay treatment of fluid retention is diuretics. Both NICE and local trust (ICHT) guidelines recommend close monitoring of weight whilst on treatment. Daily weights are an objective measure of fluid balance and guide titration of diuretic dose. We noted that within an acute unit in a busy tertiary hospital these weight measurements were not recorded consistently.

Aims

1. Investigate how often daily weights are documented in AHF inpatients

2. Explore whether prescribing daily weights is associated with higher documentation rates

Target criteria & Standard

NICE Clinical guideline [CG187] Acute heart failure: diagnosis and management: 1.3.5 Closely monitor the person's renal function, weight and urine output during diuretic therapy.

ICHT Acute heart failure guideline: 5.6.1 Management of the haemodynamicallystable patient with AHF - 1. All patients should be weighed daily

Method

A retrospective analysis of 55 inpatients referred to the AHF specialist team between 1st November and 31st December 2021 was performed. Patients were required to fit stringent inclusion and exclusion criteria. For each patient, we recorded the total length of stay in days and the number of daily weights documented. As part of the secondary analysis, we hypothesised

drug chart would have higher documentation rates (ICHT uses Cerner EPR a type of electronic patient record). Therefore, we also recorded if were compared, between patients prescribed daily weights on the drug chart and those who were not, with an unpaired T-test.

Results

There were 32 patients who met our criteria (M:F 56:43%, age 77.7±2.5). (83% vs 46%, p<0.05), however only 25% of patients had this prescribed.

Discussion

Daily weights may not always be prioritised in busy departments andcan be missed in handovers, particularly when patients are moved to healthcare staff to measure and monitor this parameter, with the added benefit of allowing easy comparison of diuretic dose and effect. Studies have shown that inpatient weight loss in those with decompensated heart failure is associated with lower mortality, reduced length of stay and lower hospital readmissionB. This suggest that regular body weight measurements, which is a measure of success for diuresis, can improve clinical outcomes. Daily measurement also allows for setting a target of weight loss e.g. 0.5kg/day and can identify when diuretic dose resistance starts following prolonged treatmentC

Recommendations for change

This audit highlights there is scope for improving weight recording and has identified a novel method for addressing this. The act of writing in increasing the measurements rates. This simple and cost-effective change is easy to implement in all trusts that use both electronic and paper drug charts. We suggest advising doctors on the medical take, in the acute medical units and acute pharmacists of this simple addition when prescribing diuretics.

Limitations

A potential confounding factor in our data wassome patients refused to have weights measured, leading to an underestimation of readings. We focussed on one aspect of diuretic monitoring and ideally would have also audited how well renal function and urine output are recorded, as per NICE guidelines. Lastly, the generalisability of our data is limited due to the relatively small sample size, single hospital location and restricted selection of patientsreferred to the AHF specialist team. Future audits should aim to expand the cohort of patients and collect data points such as morbidity, mortality and readmissions rates to demonstrate whether increased monitoring of daily weights improves clinical outcomes.

Implementation and Re-audit

These findings form the basis of our quality improvement project, which is currently in progress. In the first PDSA cycle taking place over the month of February, the findings were shared with the cardiology team who, with the AHF nurses, started prescribing referred patients. In the second PDSA cycle we presented our findings to doctors in the acute unit, put a message in the medicine newsletter and placed posters around the hospital. In the nextcycle we plan to survey the nurses on medical wards to identify any barriers. Initial results are promising with daily weights rising from 46% to 70% and 67% of admission days in Feb (n=15) and Mar (n=8) respectively. Finding methods to maintain this long-term will be key.

Improving Awareness of Indications and Yield of Diagnostic Paracentesis

Background

Diagnostic paracentesis (ascitic tap) is indicated in all patients presenting with decompensated liver disease with ascites. This is to identify underlying aetiology of ascites as well as complications, including spontaneous bacterial peritonitis (SBP), which in particular carries a high mortality (1).

In decompensated liver disease, the first 24 hours is important for early intervention to reduce mortality and length of hospital stay, which is reflected in the British Society of Gastroenterology (BSG) admission bundle (2).

BSG guidance recommends that the following parameters should be measured in ascitic tap samples: fluid cultures, white cell count, albumin, protein, cytology. However all of these parameters are not always measured when samples are taken. This could therefore result in delayed identification and management of serious aetiology or complications of ascites, which in turn can increase hospital stay and mortality.

Aims

1. Retrospective analysis of all ascitic taps performed between May and November 2021 at Chelsea and Westminster Hospital

Audit data: patient demographics, indication of ascitic tap, requested parameters, time from patient presentation to ascitic tap being done, and outcomes

2. Baseline survey of junior doctors

1) To evaluate whether diagnostic paracentesis is being performed in a timely fashion

3)

Methods Results

Experience and confidence with ascitic taps, including technique, indications and contraindications, and knowing which parameters need to be measured

2) To evaluate whether all recommended parameters as per BSG guidelines are being measured in ascitic tap samples

1. Data collection:

All diagnostic paracentesis samples taken in May to November 2021 at Chelsea and Westminster Hospital were included (n=90).

Data was collected on patient demographics, indication of ascitic tap, requested parameters, time from patient presentation to ascitic tap, and outcomes

Most common indication was decompensated liver disease (83%)

Outcomes in patients diagnosed with SBP (n=11): Full treatment was given in 25%, mortality in 27%

In patients with suspected malignancy (n=11), cytology was not sent in 18%.

2. Survey of junior doctors: 35 responses from a range of grades (FY1 SpR) and specialties 37.1% were not confident in requesting all of the recommended parameters for ascitic tap samples

Only 51.4% correctly identified that diagnostic paracentesis should be done within 1h of a patient presenting with suspected SBP 94% would find it useful having a standardised order set on the hospital computer system for ordering all recommended parameters for ascitic tap samples

Lessons Learned & Next Steps

A large majority of diagnostic paracentesis samples were not sent with all recommended parameters as per BSG guidelines. This could result in a delay in recognition and management of both underlying diseases and life-threatening complications of ascites.

Planned interventions based on results:

1. Teaching sessions for junior doctors, in liaison with the postgraduate education team

2. Creating a standardised order set for the hospital computer system to order all recommended parameters for ascitic tap

Following the interventions, we will reaudit to assess for improvement in the following aspects:

Greater proportion of ascitic taps have all recommended parameters requested and measured

Shorter mean time from patient presentation to ascitic tap

Higher levels of confidence of junior doctors with performing ascitic taps

These interventions aim to raise awareness of the indications for ascitic taps and the parameters that need to be measured, as well as make this easier with the use of a standardised order set. The aim of this is to enable early recognition and management of underlying diseases and complications of ascites, which is important in reducing length of hospital stay and mortality in patients with decompensated liver disease (2).

Safiya Hashemi, Yueqi Ge, Devnandan Chatterjee ChelseaandWestminster Hospital NHSFoundationTrust

Documentation of Ascitic Paracentesis

Introduction

Abdominal paracentesis is a common procedure that is undertaken in patients with decompensated liver cirrhosis. Although the complication rates arelow, approximately 1.6% with complications ranging from local mild complications, up to significant bleeding and rarely death

The British Society of Gastroenterology (BSG) haspublisheda large volume paracentesis safety toolkit This quality improvement project aims to improve documentation of ascites drains to improve patients’ safety

From our baseline study, we have identified that 46.4% of the documentation satisfies the key elements recommended by the BSG’s safety toolkit Following this, we have worked with the IT department inimplementinganascitic drain insertion and removal proforma onour electronicdocumentation system (Quadramed). Parameters used were recommended by the BSG safety toolkit

Proforma Template

Name of persondoing the procedure

Designation

Confirmcorrectpatient

Presence of drainable ascites (clinically or USS)

Written consent

IV access

Albumin requested and on the ward

Therapeutic anticoagulation

Pre-drain weight

Surgical ANTT

Time of insertion

Site of insertion

Number of attempts

Colour of initialascites

For Has

Time of removal (max 6hours)

Stop diuretics for 24-48 hourspost drain

Optimize nursing care (show in documentation): Apply dressing. Leave in free drainage. Avoid clamping Keep drainbelowpatient.

Monitor (Show in documentation): Colour of fluid Drain output.Halfhourly patientobservationsduringdrain.

Notes/Comments

Fishbone Diagram

Lessons Learnt

• Since the proforma was introduced, 38.1% of the patients notes used the proforma for ascitic draindocumentation. Overall, compliance with the proforma was inadequateas the fill rate of the entireproforma was 53.9% on average.

• Management errors can occur in the absence of clear documentation of drainageplans. This is because not all healthcareworkers are experienced in paracentesis and there is no unified streamlined protocol to follow.

• Furthermore, implementing the proforma on its own into the IT system is not enough, as fill rate remains inadequate, this needs to be supplemented with increased awareness

Aims

1. To improve efficiency of documentation in ascitic paracentesis and ascitic drain removal

2. Decrease time needed for documentation

3. Improve safety and communication between medics and nursing team.

PDSA Cycle

• Identify problems

• Retrospective data collection for baseline data between 1st January 2020 and 30th April 2020.

• Implementation of the proforma on QuadraMed. Retrospective data collection of post-proforma implementation between 1st July 2021 and 30th October 2021.

• Data analysis of baseline data and post-implementation data. Conducted survey forward staff which showed improvement in satisfaction with plans and time of documentation and data accessibility on ward rounds.

• Planning of 2nd cycle to increase awareness of proforma implemented.

• To increase awareness of abdominal paracentesis’ management and importance of clear documentation of plans with further cycles to be carried out.

Driver Diagram

Results

The mean documentation compliance pre proforma was 46% and after the introduction of proforma was 53%.

Next Steps

Moving forward, our next steps consist of:

• Increasing awareness of the proforma.

• Measuring the length of hospital stay and complication rates.

Dr Mostafa Afifi, Dr Goon May Hong, Dr Nong Zhang, Dr Allen Roby

The management of deranged blood glucose levels in neurosurgical

patients taking dexamethasone

Introduction

Corticosteroids cause hyperglycaemia in patients with and without pre-existing diabetes, and evidence suggests most patients receiving high dose corticosteroids will experience hyperglycaemia. The majority of patients with brain tumours receive dexamethasone perioperatively to reduce oedema and the associated neurological deficits. Alongside the obvious potential complications of hyperglycaemia, in neurosurgical patients it can also trigger a cascade of systemic and local cerebral effects that are associated with: poorer surgical outcomes, increased complications, prolonged admissions and increased mortality. In the Wessex Neurological Centre, we anecdotally observed that a proportion of neurosurgical patients’ taking dexamethasone that had delayed discharges due to deranged blood glucose l evels (BGL), and there was an overreliance on the input of the hospital’s Inpatient Diabetes Outreach Team (IDOT) in the management of these patients.

Aims

• To identify the number of delayed discharges due to deranged BGL in neurosurgical patients taking dexamethasone, and the proportion of which were known to have preexisting diabetes

• To improve the neurosurgical team’s ward-based management of post-operative patients with deranged BGL by developing a tailored protocol with with the aim of reducing the number of IDOT referrals and delayed discharges

Primary outcome measures

• To define the proportion of patients with deranged BGL that are referred to IDOT, and/or have delayed discharge solely due to high BGL.

• The development of a safe and effective protocol approved by IDOT and neurosurgical teams using an evidence based approach

Methodology

We conducted multi-faceted PDSA cycles to delineate the impact of high BGL and how and where we could optimise BGL management in neurosurgical patients taking dexamethasone.

• PDSA 1 - A questionnaire to explore the perceived confidence of the neurosurgical senior house officers/advanced nurse practitioners in managing hyperglycaemia in neurosurgical patients taking dexamethasone. This enabled us to tailor our intervention of developing concise clinical guidance, and subjectively gauge the future impact or improvement with the planned intervention.

• PDSA 2 - Patient Pre-op/BGL/Discharge data: We undertook retrospective data collection of patients undergoing resection of brain tumour (excluding biopsies, and meningiomas) between January–February 2021 in a single UK based neurosurgical centre. Data collected included pre-operative HbA1c (Yes/No), Known diabetes (Yes/No), Deranged BGL (>2 readings of >12mmol/L in 24 hours) (Yes/No), IDOT referral (Yes/No), Delayed discharge (Yes/No).

• PDSA 3-Flow charts for the management of hyperglycaemia, were co-developed by the UHS Neurosurgical and Adult Diabetes teams based on Joint British Diabetes Societies –‘Management of Hyperglycaemia and Steroid Therapy, May 2021’.

Patient identification

We retrospectively identified 57 patients under the neuro-oncology team in a 2-month period. Exclusions were 4 meningioma resections, and 11 biopsies. Of the 42 patients undergoing resection of a brain tumour, 38 received post-operative dexamethasone and were included in analyses.

PDSA 2 - Patient BGL, diabetes

status

and the effect on discharge (Bar chart Right)

7/38 (18.42%) patients receiving postoperative dexamethasone had high BGL. 3/7 were new diagnoses of diabetes according to pre-operative HbA1c levels. 3/7 were previously known to have diabetes and 1/7 did not have diabetes. 3/38 (7.89%) patients had delayed discharges as result of high BGL.

PDSA 3- Managing hyperglycaemia in neurosurgical patients: ward-based management flow chart

Acknowledging our findings from PDSA 1 and 2, we initially developed written guidance to facilitate the neurosurgical team managing hyperglycaemia. However after discussion, the utility of a flow chart was preferred. Managing diabetes can be daunting for healthcare professionals. However, the desired impact of this guidance will allow the neurosurgical team to independently and safely manage hyperglycaemia in patients taking dexamethasone. This will reduce the clinical burden on the IDOT team, and empower the neurosurgical team. The aim is that this will directly result in reduced delays in treatment time for patients, by mitigating having to wait for IDOT review. The outcomes from our changes and the implementation of this guidance will be measured by evaluating future IDOT referrals and delayed discharges for this patient group.

Conclusions

Our preliminary findings elucidated a rationale for the development of further guidance in managing high BGL in neurosurgical patients taking dexamethasone. It is a common and predictable sequelae of the treatment, with potential to increase admission time.

Lessons learnt and reflections

We took a multifaceted approach which enabled us to identify multiple areas in which improvements could be made. It has helped me recognise the importance of a functioning MDT in the continuity of care of patients through from pre-assessment to discharge. The involvement of all stakeholders facilitated the sharing of ideas and the construction of an intervention that would benefit all. Pertaining to our unexpected finding that significant HbA1c results were going unactioned, I think that accountability as an individual and as a clinical team needs to be emphasised to maintain patient safety.

PDSA 1 - Questionnaire Results

12 healthcare professionals in neurosurgery responded to the questionnaire. Results indicated a scope for further education and guidance in order to increase confidence in managing hyperglycaemia and reduce reliance on IDOT.

Results of 3 (of 12) questions from the questionnaire for neurosciences SHO/ANP team regarding management of hyperglycaemia in neurosurgical patients. 1–Notatallconfident;5–Veryconfident

An unexpected finding -Pre-operative HbA1c measurement results 21/38 had HbA1c checked a pre-assessment or a recent HbA1c. 2/4 patients with known diabetes had there HbA1c checked. 4/21 patients who did have their HbA1c checked, were new diagnoses of diabetes but were not acted upon prior to admission.

Local standards: HbA1c should be requested for all patients with diabetes. However routine testing for patients not known to have diabetes is variable, and there is no current standard.

Verbal discussion with pre-assessment team elicited that in patients not known to have diabetes there is no formal escalation plan for high HbA1c

Guidance flow charts developed for the neurosurgical team in managing patients with hyperglycaemia taking dexamethasone. (Left)Patients known to have diabetes. (Right) Patients not known to have diabetes.

What next?

• Implementation and raised clinical awareness of the guidance and flow charts., after which repeat cycles of PDSA 1 –to gauge improvement in perceived knowledge and confidence of staff. PDSA 2 -To objectively measure the impact of the new guidance on IDOT referrals and delayed discharges. PDSA 3–Any further changes to the guidance or troubleshooting will be undertaken if required.

• The next aim will be to address the issue of ensuring elevated pre-operative HbA1c are escalated appropriately, in order to medically optimise patients before surgery and mitigate inpatient high BGL, and thus complications and prolonged admissions.

George Buckland¹, Susrata Manivannan¹, Antony Kaldas¹, Kathryn Hill¹, Paula Johnston², Mayank Patel²

1. Department of Neurosurgery, Wessex Neurological Centre, University Hospital Southampton

2. Inpatient Diabetes Outreach Team, University Hospital Southampton

Perioperative Glucose Control in Neurosurgical Patients,Godoyetal2012

By Ibukun Osuntoki, Aiknaath Jain, GbemiAjao and Issa Beegun

Are patients receiving their medications within an appropriate timeframe following their admission under ENT?

INTRODUCTION AND AUDIT RATIONALE AIM

A 50-year-old gentlemanpresented to hospitalwithchronic rhinosinusitisandwasprescribedtopicaldecongestants.

Due to a lack of availability of medication, his condition worsened, his hospitalstaylengthened,and he requiredsinusdrainageprocedures

Thiswas one of manycases in whichENTspecificmedicationswere notdeliveredpromptlyandapatientresultantlysuffered.Afterliaising with thepharmacyservice, we wereinformedthat manyENT medications were notstocked/ordered as apriority on thewards. Thiswasrelated to thefactthatthetheNationalPatientSafetyAgency (NPSA)andSpecialistPharmacyService,whoassesstherisks of delay or omission for drugs or drugclass,noteENT is alow-riskspeciality in terms of drugdelay or omission.

The aim of this project was to examine the extent of the delay in delivery of medications at Northwick Park Hospital and improve the ward availability of critical ENTdrugs.

DEFINITIONS

DoseDelay:Dose not givenwithin2hours of timeprescribed

DoseOmission:Dose not administered by the time of the next scheduleddose

(A dosedelay or omission is noted by a 7 on the drugchart at NorthwickParkHospital)

Standard: Drugs should be safely administered as close to the time noted on the prescription with little delay and no omission.

METHOD

The drug charts of all patients admitted under ENT at Northwick Park Hospital between September and October 2021 were reviewed (n=122 patients). If there was a delay of delivery or omission of a drug it was documented, along with the type of medication, prescribed dose and the length of time taken to the administration of the first dose.

RESULTS

23% of ENTpatients (n=28)admitted to NorthwickParkhaddrugseitheromitted or delayedduringtheirinpatient stay

Themostsignificantdelayexisted in antimicrobialagents. It took 13% of the cohort 30 hours to receivetheirfirst dose of antimicrobialagent. Onepatientwithaskull baseosteomyelitiswaitedthreedaysfor the firstdose of theirtopicalantibiotic. Furthermore, there existeddelays in the delivery of medications in multipleothergroups including steroidsandnasaldecongestants

There was an average of a 25-hour delay for over-the-countermedications.

DISCUSSION: THE RISK OF DELAY

ENTpatientssufferfromamultitude of seriousconditionsthatwhenleftuntreated, can notonlybesightthreateningbutalsolead to complicationssuch as meningitis,neurologicaldeficitanddeath.CertainENTmedications,such as topicalantimicrobialeardrops are paramount in thetreatment of theseconditions in theearlyphasesandalternatives,e.g.oralswitches, are not as effective or evidencebased.Furthermore,certainmedications,such as nasaldouches, are essential in theearly(24-48hr)post-operativeperiod to preventpost-operativecomplications,andtheireffectivenessdeclines as timeincreasesfromtheprocedure.

TAKE HOME MESSAGES

Although considered low risk, certain ENT conditions such as Otitis Externa and Chronic Rhinosinusitis have potential for significant deterioration if early therapeutic intervention is not achieved.

The low-risk stratification of ENT as specialty has contributed to poorer patient outcomes and extended hospital stays for our cohort of patients

Medical and pharmacy staff should review the risk of medications in the context of their patient groups and stratify more appropriatelyparticularly if the hospital has increasing volumes of patients under the specialty

Improving the Management of Rib Fractures and Compliance with the Rib Fracture Pathway

Dr Farzana Rahman, Dr N. Maxwell, Dr S. Shidane, Dr M. Bhagalia, Mr A. Abu

Introduction & Background:

Since 2019, there hasbeen anincreasein the number of patients with Rib fractures admitted to Whipps Cross, for local management at a district general hospital, than being transferred directly to the Regional Centre for trauma, Royal London hospital (RLH)

Rib fractures areamong the most commoncauses of thoracictrauma, associated with a high risk of morbidity and complications, primarily if not managed early and well1

Complications include atelectasis to severe pneumonia and mortality, which can beprevented to a degree by early and effective pain management as per evidence-based medicine 2

Methodology & PDSA Cycles:

o Conducted a retrospective data collection from January 2021 to September 2021

o Obtained PACS database of radiologically proven Rib fractures,

o Correlated databases with patient case notes online to collect data to compare management with recommended published pathway guidelines.

o Inclusion criteria: Patients presenting to Whipps Cross hospital, Age > 16 years old

Act: Reflect on results, Plan next cycle after improved awareness of Rib fracture Pathway

Study:

Analyse Data: Better adherence improves patient outcomes with Rib Fractures

Aims of Audit:

Plan: Identify current compliance with published Rib fracture pathway

Do: Increase awareness of pathway via posters in ED, Doctor offices, emails and teaching

§ Investigate the compliance with the published Rib fracture pathway.

§ Identify ways to improve the current pathway

Referrals Made:

1) Referrals to Pain Team:

40% were referred to the Pain team

70% -patients were referred when only prescribed paracetamol with no adjuvant medications e.g. PRN Oramorph prescribed

Only 15.5% of all patients were prescribed the PCA

Morphine

2) Referrals to ITU/ Anaesthetics: 75% were appropriate however 25% too premature.

3) Referrals to Trauma Consultant at MTC – RLH: 4 patients were transferred to RLH due to Poly trauma:

i. Of which 75% were referred to by GS SHOs rather than ED

delaying treatment times for patients.

Results:

Act: Reflect on results, provide pain scores in published new guidelines .

Study: Analyse data –lack of prescribing due to lack of assessment & understanding of pain ladders.

Plan: Identify reasons for ineffective pain control within 48 hours of admission

Do: Include standardised pain scoring for assessment of Pain –e.g., PIC Scores.

Act: Amend current pathway –include guidance in referrals, & trauma referrals/ Pain team and anaesthetics.

Study: Analyse data –current pathway focuses more on management than on acceptance of referrals.

Plan: Identify cause of non-compliance, Work with clinical effectiveness leads to improve published guidelines

Do:

Questionnaires to SHOs – that are responsible for accepting referrals

Discussion & Lessons Learnt:

1) Referrals:

o Currently in Whipps Cross –admitting more patients with Rib Fractures

o When patients have poly trauma –should be discussed with Trauma consultant/ referrals should be made (Ideally by ED):

§ Ensures patients that require transfer to RLH → transferred early,

§ If trauma consultant agrees for local management → To be managed at Whipps.

o Identified a need to include this within the Rib Fracture pathway

2) Radiology:

o CT Chest allows better understanding of the Rib Fracture injuries:

o Pneumothorax, haemothorax, flail segments etc.

o Identified a need to include guidance for when to request CT Chest within guidance

3) Pain management:

Initiating early treatment → Results in improved outcomes, shorter hospital stays, reduced risks of complications forming

Prescribing effective analgesia:

Follow current Tiers of management

Referrals to Pain Team – available 9-5:

o Ensure we are prescribing analgesia before referrals – many patients are easily managed with Tier 1 medications and only 15% were initiated on PCA

Proposed

• Increased awareness with current Rib Fracture pathway

• Including a standardised Pain score to assess pain to aid in prescribing

Next Steps:

• Re-audit to assess whether improvement with prescribing after sharing Rib Fracture pathway in ED, Gen surgery Doctor offices.

• Eventually working with Clinical effectiveness lead → Update the current Rib Fracture guidelines

References:

Kim, M. and Moore, J.E. (2020). Chest Trauma: Current Recommendations for Rib Fractures, Pneumothorax, and Other Injuries. Current Anesthesiology Reports, 10(1), pp.61–68.

Yazkan, R., Ergene, G., Tulay, C.M., Gunes, S. and Han, S. (2012). Comparison of Chest Computed Tomography and Chest X-Ray in the Diagnosis of Rib Fractures in Patients with Blunt Chest Trauma. Journal of Academic Emergency Medicine

Acknowledgements:

Thanks to the department of General Surgery and Anaesthetics at Whipps Cross Hospital

For Further information: Contact Dr F Rahman: Farzana.Rahman12@nhs.net

Figure 1: Rib Fractures by patient demographics.

Figure 2: % of Patients prescribed medications within 24 hrs

Figure 3: % of Patients undergoing XRs and CTs

Figure 4: % of Patients with additional injuries

Figure 5: Rib Fracture details

Poster Competition Group B Audit

Patient Safety Prizes

An Audit ofCOVID-19 Vaccination in Elective Surgical Patients

Dr Grace Hillsmith and Dr Emma Gravett. Supervised by Dr Bhaskar Dutta

Introduction

• Growing numbers of elective surgical patients have received the COVID-19 vaccination

• The Royal College of Surgeons have released guidance on vaccination in regards to elective surgery

• Consistent documentation of vaccination status is imperative to ensure patient safety

Aims

Prevent ambiguity for patients and staff

Prevent on-the-day cancellations

Improve documentation

To complete the audit loop:

•Reassessment of baseline data

•Comparison of baseline and reassessment data

RCS Guidance and Literature Review

• RCS guidance:

• Non-urgent elective surgery can take place soon after vaccination

• Essential urgent surgery can take place regardless of vaccination status

• Surgery should be separated from vaccination by a few days (at most 1 week) to reduce confounding symptoms

• Literature evidence suggests between 48 hours and 7 days delay between vaccination and the date of elective surgery

Methods

Retrospective audit

Proforma of questions to patients undergoing elective surgery

Assessment of notes including preassessment documentation, surgical and anaesthetic notes

Audit cycle

• Baseline (cycle 1) data was gathered for 34 patients over a 2 week period starting from 1st March 2021

• This data was presented at the Anaesthetic Safecare meeting , where it was decided to adopt a policy of a 7-day gap preand post-surgery for vaccination, and to also document vaccination status at preassessment

• Information on these new policies was disseminated to the anaesthetic department and preassessment clinic staff.

• Reassessment (cycle 2) data was gathered for 29 patients over a 2 week period starting from the 19th April 2021

Baseline Results

• 47% of patients had received their first COVID-19 vaccination

• Only 7.6% of patients had their vaccination status documented in preassessment notes

• 21% of patients were given advice on vaccination and surgery, however the advice given was very varied

• Advice ranged from waiting between 4 days and 6 weeks between vaccination and surgery

• 2 patients had their COVID-19 vaccination within 7 days of their surgery.

Reassessment Results

• 90% of patients had received at least one vaccine, with 38% being fully vaccinated

• Documentation has much improved, with 86% having vaccination status recorded in their preassessment notes

• 59% of patients were given advice, the majority of which was a delay of 7 days between vaccination and surgery.

• No patients had their vaccination within 7 days of surgery.

Conclusions and Recommendations

• Increasing numbers of elective patients are fully vaccinated as the vaccine rollout continues across the UK

• Implementation of the policy of a 7-day gap between vaccination and surgery has been successful, with the majority of patients receiving the correct advice

• Documentation of vaccination status has improved but is not yet 100%.

• We recommend introducing a specific question on the preassessment document regarding COVID-19 vaccination to improve documentation to 100%

References

• https://www.rcseng.ac.uk/coronavirus/vaccinated-patientsguidance/#:~:text=Non%2Durgent%20elective%20surgery%20can,vaccination% 20or%20the%20operation%20itself.

• https://assets.publishing.service.gov.uk/government/uploads/system/uploads/a ttachment_data/file/147832/Green-Book-updated-140313.pdf

Re-audit: NG89 Venous thromboembolismreducing the risk for patients in hospital

Dr. Vasiliki Bisbinas (FY2), Dr. Imogen Pulley (FY2), Hanna Tunbridge (Clinical Audit Lead)

Background: Venous Thromboembolism (VTE) is the primary cause of preventable deaths in hospital, (25,000 deaths/year in the UK with 55-60% occurring during or following hospitalization). Psychiatric inpatients may be at higher risk due to reduced mobility, poor fluid intake, restraint, catatonia, sedation and antipsychotic use. Evidence suggests anti -psychotic use may be an independent risk factor for developing VTE. Comprehensive VTE risk assessment completed on admission and reviewed regularly is necessary. The NICE audit standard is a 100% rate of VTE assessments on admission.

Aim: Ensuring staff adhere to the NICE guidelines when caring for patient’s who are at risk of VTE

Past compliance: 68% (Dec 2019), 76% (Sept 2019)

Materials/Methods: The sample was collected via Rio ePMA and included all patients who were discharged from the Trust’s mental health inpatient units during 1-30th September 2021 (n=58) and evaluated against an online audit tool devised using criteria taken from the NICE guidance NG89 created by the Trust’s clinical audit team.

Results:

Compliance for the 14 audit criteria:

Ø 6 >90% (green)

Ø 2 80-89% (amber)

Ø 6 <80% (red)

Discussion:

• Overall compliance improved since 2019 audit: 82%

• Consideration of VTE risk within 24 hours of admission in clerking documentation was accepted as assessment of VTE risk - on many occasions the editable letter for VTE assessment as per protocol was not completed and uploaded to the patient’s electronic file

• Only 3/48 patients were assessed as at risk of developing VTE so some questions were only relevant to a very small number of patients

Conclusion:

• Highlighting the importance of VTE assessment in psychiatry at Junior Doctor inductions

• Remind Junior Doctors of the need for the completion of VTE assessment on admission for all patients and throughout the admission as clinically indicated

• VTE has now been integrated into Rio - no editable letter/easier input

• Re-audit is recommended – (started April 2022)

Re-audit to optimise computed tomography kidneys, ureters, bladder (CT KUB) imaging in investigation of renal colic

Dr Adesh Ajmani, Foundation Doctor

Background Aim

Renalstones or calculiaremade of crystalloidandorganicmatrix.Thepassage of thesestonesthroughtheurinarytractcanresult in acuterenalcolicpain.This is acommonconditionand typicallyaffectspeoplebetweentheages 20-40;moreoftenaffectingmenthanwomen.Symptomsincludeabdominalpain in theflankregionwhichmayradiate to thegroinand is intermittently like spasms.Theymayhavefever,sweats,nausea,vomitingandhaematuria.Thegoldstandard to investigaterenalcolic is withnon-contrastcomputedtomographykidneys, ureters,bladder(CTKUB) in UK practice.Thisimagingmodalityworks by usingx-ray beamsthatrotate in acirclearoundthebodywhichallowsdifferentviews(axial,coronalandsagittal) to be generated.Therearerisksinvolvedwith CT scanningdue to theradiationexposure.Onlyessentialanatomicalareasshould be scanned to ensurethepatient is notexposed to excess radiation. In theinstance of CT KUB,onlytheupperpole of thehighestkidneyneeds to be scanned.Scanninghigherthanthispoint is notneeded.

An initialauditwascarriedout in 2017 to assess if patientsbeinginvestigatedforrenalcolicwithnon-contrast CT KUB at St HelensandKnowsleyteachinghospital(STHK)werebeingoverscannedandreceivedunnecessaryradiation.Theyhadfoundthat 26% of patientswerebeingscannedaspertheauditstandard.

Further,theaim of the re-auditconducted in 2019was to assess if therehasbeen an improvement in results of patientsbeingscannedaspertheauditstandard. To assesshowcurrent practice is compared to bestpractice.

Standard/Method Results

Local standard at STHKoutlines that 100% of CT KUB scans carried out should not exceed 10% excess scan length. Radiographers scan two scout views -lateral and coronal -from above the upper pole of the kidney to below the pubic symphysis. If the kidneys are not visible on the scout, then the radiographer should scan from the middle of the stomach.

Summary of audit standard

Title of guideline Non-contrast KUB (CURIT) guideline

Setting Local (STHK)

Standard Excess scan length above upper pole of highest kidney should not exceed more than 10% of total scan length

Criteria Coronal scout is used to plan the scan and visualise the upper pole of the kidney

Exception If kidney is not visualised on the coronal scout, then the patient should be scanned from the middle of the stomach

Target 100% of CT KUB performed for investigation of renal colic Suggested number

Patients who had CT Urinary tract without contrast between 6/5/2019 to 17/6/2019 were searched using PACS. This totalled 201 patients.

Systematicsamplingwasused to collectdatafroma samplesize of 100 patients.Their CT KUBscanwas measured in coronalsection.Thedistancebetween theupperpole of thehighestkidneyandthetop of the scanwasmeasured in mm.Thenthetotallength of scanwasmeasured in mm.This is shown in figure1

The percentage of over scan was calculated as follows:

Over scan =

As per the audit standard, no more than 10% was allowed. In cases where there was over-scan the coronal scout image was visualised to assess whether the upper pole of the kidneys could be seen. This is shown in figure 2 and 3.

excess scan length. 59 patients were over scanned. Of those 59, 32 had the upper pole of the upper pole of the kidney. 3 patients scans were unable to be measured because in these cases the upper pole of the highest kidney had not been scanned and cut off. One of these 3 patients had had a second series done to include the upper pole. The finding from this audit compared to the results from the audit in 2017 can be seen in the table below.

Therehasbeen a reduction in the number of patients being over scanned in practice compared to the results in the last audit. However, the audit standard target has not been met. Also, 1/3 patients that had been under scanned required a second series which meant the patient was exposed to higher levels of radiation. The recommendation is that the findings are presented at the audit meeting. This means positive feedback can be given but provides opportunity to encourage further vigilance and recap the trust guidelines. Should it be necessary, staff could receive further training.

Strengths and limitations of this audit:

reasonable sample size of 100 patients to ensure that there were a sufficient data X only included patients within a 6 week time frame X only 1 person was assessing the coronal scouts which allows for observer bias

Discussion Conclusion

Thisauditshowsevidence in thereduction of patientsbeingoverscannedwhen investigatedforrenalcolicwith CT KUB;morepatientsarebeingscannedasperthe standardcompared to theresults in 2017

Figure 1 Example of measuring the CT KUB scan in coronal view.

Introduction

RCP Guideline for Stroke recommends urgent CT scan for patients within 1 hour of hospital admission for suspected acute stroke1

Door to scan time is an important measure used to compare performance across stroke units nationally. An urgent CT head scan is vital to deliver appropriate treatment promptly, particularly in the context of thrombolysis (which has a narrow time window of 4.5 hours from time of symptom onset).

Delays in CT scanning for stroke patients

Dr T. Ambulkar, Dr. P. Meenamkuzhy-Hariharan Nottingham University Hospitals NHS Trust

Results

First audit cycle (February –March 2021)

Learning points

• Importance of raising awareness in frontline healthcare professionals about the importance of an urgent CT head (including indications for urgent scanning)

• Low threshold for clinical suspicion of stroke –if in doubt, escalate to a senior/stroke specialist

Future plans

• Continue to audit door to scan times and compare local performance with national data

• Raise awareness about the indications for urgent CT scanning in stroke patients

• Endeavour to improve data collection on qualitative reasons for scan delay (for e.g. recording reason for delayed scan in admission booklets)

PDSA Methodology

First audit cycle:

• 56.0% of all patients with suspected stroke scanned within 1 hour

• Most important qualitative reasons for scan delay:

• Others: delayed medical clerking/triage

• CT scan associated factors

• Complex clinical assessment

Second audit cycle (September –October 2021)

Methodology

• Random selection of 75 patients admitted to to the Stroke Department, Queens Medical Centre (Nottingham)

• 2 completed audit cycles:

First cycle data collection: February-March 2021

Second cycle data collection: September –October 2021

• Electronic information sources used: DHR/Medway/NOTIS/Nervecentre

• Data collection proforma used

• Percentage of scans occurring within 60 minutes were compared to percentage of scans being performed after 1 hour

• Potential qualitative factors that could contribute to scan delay were identified: Ø CT scan associated factors; difficult cannulation; complex clinical assessment

Second audit cycle:

• 46.7% of all patients with suspected stroke scanned within 1 hour

• Most important qualitative reasons for scan delay were identified as:

• Complex clinical assessment: atypical presentation of strokes (generally unwell, dizziness)

• CT scan associated factors: limited scanning facilities, scan requested promptly but performed late

Conclusions

There was a reduction in number of scans being performed within 60 minutes when the results from the second cycle are compared to the first cycle. However, not all patients included fit the criteria for an urgent CT scan.

Complex clinical assessment and delayed medical triage and clerking (in the Emergency Department) are the most important factors contributing to scan delay. Emphasis on improving these factors through educational seminars on stroke presentation and increasing collaboration between the Stroke department and the Emergency Department may help improve door to scan times.

o

References

1.RCP London. 2022. RCP guideline calls for suspected stroke patients to be scanned within 1 hour of hospital admission [online] Available at: <https://www.rcplondon.ac.uk/news/rcpguideline-calls-suspected-stroke-patients-be-scanned-within-1hour-hospital-admission> [Accessed 18 April 2022].

2.Nice.org.uk. 2022. Recommendations | Stroke and transient ischaemic attack in over 16s: diagnosis and initial management | Guidance | NICE. [online] Available at: <https://www.nice.org.uk/guidance/ng128/chapter/Recommen dations> [Accessed 18 April 2022].

3.NUH Hospital logo: www.facebook.com. 2022. Facebook [online] Available at: <https://m.facebook.com/nottinghamhospitals/photos/a.702100 206476604/3493007134052550/> [Accessed 22 April 2022].

Special acknowledgements

o Dr Sunil Munshi (Stroke Consultant, Nottingham University Hospitals NHS Trust)

Image 2: Informational poster distributed amongst junior doctors after first audit cycle

Professor Adrian Wills (Consultant, Nottingham University Hospitals NHS Trust)

Improving temperature management post-cardiac arrest in a District General Hospital Intensive Care Unit

Regina Askary, Ben Whittaker, Adam Revill

• NHSambulancesattend 30,000 out-of-hospitalcardiacarrests(OOHCA) inthe UK eachyear with a9%survivalrate.

• Return of spontaneouscirculation (ROSC) is achieved in approximately 30% with the majority beingunconscious and needingICU admission,and with only 30-50% being dischargedalive.

• Therapeutichypothermia showed promising results in significantclinicaltrialsandwas the management of choice for manyyears but the recent TargetedTemperatureManagement2 (TTM2)trial concluded that there was nobenefit to cooling patients to 36°C following OOHCA if the arrestwas due to cardiac/unknowncause.

• Our localguidance untilknow suggested thatpatients post-ROSCshould be maintainedat 36°C orbelow for the first 36 hours followed by preventionof pyrexia (defined as>37° inthe localguidance) for the following 36 hours.Regulartemperature monitoring is essential to achieve this

Aim Outcomes measured

The aim of this auditwas to comparecurrenttargeted temperaturemanagementatTorbay ICU with the hospital andnationalguidance, reviewing adherence to maintaining 36°C through invasive cooling and fever prevention to improve how we care for patients post-cardiacarrest.

Data collection

Theincluded dataruns from February 2020 to March 2022, collected via the Torbay ICUonline database.

Exclusion criteria:

• In-hospitalcardiacarrest

• Cardiacarrestsecondary to non-cardiaccauses

• Conscious patients following verbalcommands post ROSC

• Temperature<30°C on presentation

• Systolic BP <80mmHg despite adequatesupport (fluid loading,inotropes/balloonpump)

• Intracranial bleeding

• Severe COPD with LTOT

• Pregnant or presumedpregnant

1. Whether regular temperature management was recorded

2. Adherence to 36°Cfor 36h

3. If pyrexia was avoided for the following 36 hours (through use of invasive cooling and regular antipyretics)

Results

A total of 39patients were identified over the 2year period: 39participants withappropriate data for the first 36hours

18 patients who made it past 36h (up to 72h) requiring temperature management

89.7% hadt>36°C

61.5% hadt>36°C for at least2 continuous hours

30.8%received invasive cooling

38.5%receivedregularparacetamol

• 16.7%hadallhourlytemperatures recorded but most (77.8%)had them recorded the majority of the time (majority defined as>90%)

• 20.5% were 36°C orbelow appropriatelymost of the time.

• We were able to prevent t>37 °C in just 22.2% of patients who made it past the initial 36h.

How can we improve our care?

Recent guidance from ERC-ESICM has confirmed that avoidance of pyrexia (defined as 37.8°andabove) is the new aim post cardiac arrest

1. We propose to improve temperature monitoring in these patients, and reduce pyrexia through regular paracetamol and earlier initiation of invasive cooling

2. We are updating our hospital guidance in line with these recommendations to make this information freely available to staff.

3. Education for nursing staff and doctors will be undertaken through clinical effectiveness meetings, journal clubs, MDTs and reminders through admission paperwork and handovers for temperaturetargets when these patients are present on the unit.

Simple, point-of-care reminders improve VTE risk assessment and prophylaxis prescription in medical patients

Rohin K. Reddy1,2, Michele Mantega1, Zahra Arzoky1, Asjid Qureshi1

1 Department of Endocrinology and Metabolic Medicine,Northwick Park Hospital, London, UK

2 National Heart and Lung Institute, Imperial College London, London, UK

Aims

NICE guidelines recommend assessment of all patients >16 to identify VTE and bleeding risk, with thromboprophylaxis should be start ed within 14 h of admission.

We sought to improve VTE assessment and prescription rates by introducing a point-ofcare reminder by modifying inpatient lists via the electronic health record.

Methodology

2-cycle audit, evaluating the effect of addition of a reminder column todaily inpatient lists

Retrospective chart review was performed to calculate rates of VTE assessment and prophylaxis pre-and post-intervention..

Results and Lessons

During the baseline pre-intervention period, 68/81 (84%) of patients were appropriately assessed , and 73/81 (94%) were prescribed appropriate VTE prophylaxis.

In the post-intervention period, 23/26 (88%) of patients were assessed appropriately, and 25/26 (96%) were prescribed appropriate VTE prophylaxis.Appropriate VTE risk assessment increased by 4% and thromboprophylaxis prescription increased by 2% post-intervention.

Through seamless integration in existing clinical workflows, we demonstrate VTE assessment and prophylaxis can be improved via simple point-of-care reminders.

We aim to replicate this work in future cycles involving a greater number of patients across the Integrated Medicine Division at our institution.

Improving the Management of Anaemia in Solid Tumour Patients receiving Chemotherapy at a Tertiary Oncology Centre

Sina Yadollahi, Kim Teasdale, Shenthiuiyan Theivendrampillai, Luke Nolan, Jack Broadfoot Cancer Care, University Hospital Southampton (UHS) NHS Foundation Trust, Southampton, United Kingdom

Background

Theprimaryaim of theauditwas to determinethecurrentmanagement of anemia in cancerpatientsreceiving chemotherapy at UniversityHospitalSouthamptonandhow it measuredagainstcurrentnationalguidelines. Theauditwasdesigned to identifywhat we aredoingwellandwherethingscan be improved on if any.

Introduction

Anaemiaaffects up to 67% of cancerpatients. Anaemia is associatedwithfatigue,reducedquality of life andworseoverallsurvival. Liberal red bloodcelltransfusion(RBCT)leads to adverseoutcomesincludingtransfusion-associatedcirculatory overload(TACO).

NICEguidelinesrecommendrestrictiveRBCTanduse of transfusion-sparingagents.

NICE/ESMO/ASCO guidelines

Recommendtreatinganaemiawitherythropoiesis-stimulatingagents(ESA)andintravenousIron Recommendbaselineandregularassessment of ironstudiesduringchemotherapy Haemoglobin(Hb)transfusionthreshold: 70-80g/L or severesymptomsrequiringimmediatecorrection Singleunittransfusionrecommended in non-bleedingadults

Pre-assessment of TACO riskfactorsrecommended(BSH,ISBT,SHOT)

Aims & Methods

To assessandoptimiseanaemiamanagementandRBCTsafety in linewithNICE(TA323and NG24), ESMOand BSHguidelines.

Preandpost-interventionaudits of allpatientsstartingchemotherapy in Sept/Oct 2020 andMar/April 2021 (6monthfollow-up periods).

Interventions

Educational: multi-disciplinaryteachingsessions,postersandcomputerscreensavers.

IT: new pre-chemotherapybloodtestbundle,mandatorypre-RBCTriskassessment,andprompts in chemoreferral forms.

Governance: newSouthamptonGeneralHospitaltrustguidelinesandcancer-specificRedBloodCellTransfusion codes(via liaisonwithhospitaltransfusioncommittee).

Conclusions

Multi-disciplinary staff education and new standard operating procedures improved adherence to national guidelines, reduced RBCT and improved patient safety.

Who is your consultant?

1. Introduction

Recommendation 236 from the Francis Inquiry Report 2013 states that hospitals should reintroduce the practice of identifying the clinician that is responsible for a patient’s overall care A named nurse should also be nominated at each nursing shift for each patient 1 This principle requires clinicians to be accountable and ensure effective communication with patients and their supporters.

2. Aims and objectives

• The primary aim is to ensure that a patient’s stay in hospital is ‘coordinated, caring, effective and efficient’ with the responsible clinician taking responsibility for the patient’s overall care2

• Every patient should know who their named consultant is.

• Every patient should know the name of the nurse responsible for their care

• Relevant information should be clearly displayed eg: above the patient’s bed (2)

• All of the above is to ensure effective and accurate communication between the patient and their clinical team

3. Drivers

4. Methods

Baseline data collection

Baseline data was collected through the use of a questionnaire:

• Who is your consultant?

• How would you find out?

• Who performed your operation?

• Who is your nurse?

• Are you aware of your long term plan?

Other data was collected from the patient notes:

• Headboard information – correct or incorrect?

• Length of hospital stay

• Patient surgical status

Patients with dementia or cognitive impairment were excluded In total 43 patients were surveyed

Baseline data was used to propose and implement change – every patient should know who their Responsible clinician and named nurse are.

Implementation of change

PDSA (Plan, Do Study, Act) cycles were formed

PDSA 1: Education of junior doctors to ensure that headboard information is correct

Education of Junior doctors on the ward took place This was to ensure that patients are told who their named consultant is This also included ensuring the patients understood who is responsible for their overall care Junior doctors were provided with marker pens They were given the responsibility of ensuring headboard information was correct

The wards were re-audited using the same questionnaire, with the addition of the following question: “how satisfied are you with your care from 0 to 10. (0 is the worst and 10 is the best).”

5. Results

• Baseline data indicated that less than half of the patients knew who their named consultant was

• After implementation of PSDA 1, more than half of the patients knew who their named consultant was.

• The results are graphically summarised below

• Results have been further stratified to highlight the differences found between elective patients and emergency patients

Post-implementation data was further analysed

There appears to be a strong correlation between correct headboard information and patients’ awareness of their consultant

6. Discussion

Baseline data indicated that the hospital was significantly underperforming in line with the recommendations made in the Francis Inquiry Report There were significant improvements in performance after the implementation of PDSA1.

However, the standard set by the guidance is that every patient should know who their responsible clinician and named nurse is PDSA 1 did not lead to improvements that were fulfilling this standard – there were a significant proportion of patients unable to name their consultant

Without identification of a team leader ‘confusion can creep in’ for patients, ultimately impacting their inpatient experience Therefore, steps must be taken to improve the hospital’s performance

Limitations and challenges

• Small sample size – a larger sample size would increase the power of the audit and be more representative of the actual patient cohort

• Did not include medical/obstetric/paediatric patients.

• PDSA 1 utilised a bottom-up approach – the medical student carrying out the audit was responsible for educating and motivating the junior doctors on the ward Motivation and engagement with making changes was low amongst junior doctors

• High patient turnover and the fast-paced environment in the surgical assessment unit made implementation of PDSA 1 challenging – is there a different approach that is more suitable to this environment?

• “There are a lot of nurses” – many patients reported recognising nursing staff’s faces but not their names, often due to shift changes

• Often the headboard is blank – encouraging nurses to implement changes in the current bureaucracy is challenging

7. Future

• PDSA cycle 2: We will utilise a top-down approach – the consultant surgeons will be informed about the current findings of the audit during a departmental meeting They will be given responsibility to ensure junior doctors are motivated to drive the change

• PDSA cycle 3: Patients will receive an admission card, stating their responsible clinician and named nurse This is in accordance with the guidance, that states ‘relevant information should be appropriately displayed.’

• A re-audit will subsequently take place

• Future audits will include a range of specialties

Dr Jumaina Firdaws Ali, Mr Faisal Jawad Yahyaa Hassan, Widad Ramadan, Zohra Haiderkhan Figure

Figure 3: Proportion of patients able to name their consultant, stratified by headboard information

VTE Prophylaxis In Urology Patients - Preventing The Need To AnticoagulateThe Patient With Haematuria

Dr Alexander Morgan Kingston Hospital NHS Foundation Trust Corresponding address: a.morgan10@nhs.net

Introduction

Most hospitals in the United Kingdom have systems in place that ensure a patient's venous thromboembolism (VTE) risk is assessedon admission. Thirty percent of patients that are admitted under Urology via the emergency department present with haematuria.

Often anticoagulation is held. Failure to restart when bleeding has subsided can put patients at risk of the complicated and potentially catastrophic situation in which anticoagulation is needed to treat VTE in a patient with ongoing or at high risk of bleeding.

At our centre, a VTE prophylaxis assessment tool is used that must be completed for all patients on admission. Often Urological regular anticoagulation is intentionally heldor they are not started on prophylactic anticoagulation. Since this is only formally assessed at the beginning of their admission, we noticed that occasionally there were delays in their pharmacological VTE prophylaxis or regular anticoagulation being started.

Aims

Using the NICE guidelines on VTE prophylaxis: All patients to be assessed repeatedly and the correct anticoagulation decision to be made.

To assess whether prophylaxis, using a specifically designed section of the teams list, improved the quality of this prescribing.

Methodology

Data was collected retrospectively record and the normal teams patient lists.

The patients were assessed as to whether they had their VTE prophylaxis prescribed (both mechanical and pharmacological).

Results

The re-audit used the same methodology to see if there was an improvement in the quality of VTE prophylaxis prescribing.

We identified that a potential way to improve our prescribing was by adding an additional column to the teams patient list that encouraged the team to continuously assess the VTE prophylaxis used with each patient. Rather than just on admission.

Lessons learnt for continued improved VTE prophylaxis prescribing.

Suggestions made and discussed with team at local governance meeting

The percentage of patients prescribed pharmacological VTE prophylaxis appropriately remained similar 90% compared to 94%

What We Learnt

The addition of the new column has increased prescribing of mechanical VTE prophylaxis.

This addition of the new column has not improved our pharmacological prescribing of VTE prophylaxis.

Acknowledgements

We would like to thank the Urology team of Kingston General Hospital for their guidance through this audit.

References

(Overview | Venous thromboembolism in over 16s: reducing the risk of hospital-acquired deep vein thrombosis or pulmonary embolism | Guidance | NICE, 2018)

From discussing with the team, they felt that in general they were more aware of VTE prophylaxis prescribing for each patient. There was always some debate as to the best time to restart pharmacological VTE prophylaxis after episodes of haematuria. We suggested the following interventions to reduce delays in prescribing.

Encourage the patient to mobilise as soon as possible

Ensure mechanicalVTEprophylaxis is prescribed if indicated

Ensure patient remains well hydrated

Senior to assess each day and make the risk/benefit decision to whether or not to start pharmacological VTE prophylaxis

Poster Competition Group C

Full QI Project

Improving Care Pathways

Prizes

BACKGROUND:

Finding out the investigations to order for common neurological conditions and doing them right is a challenge.

We RACE and CHASE around for tests & tubes for blood and spinal fluid when investigating children for acute neurological diseases . Time is wasted , mistakes are made and children can be harmed

AIM & MEASUREMENT DEFINITION

For Acute Neurological conditions

“

Dina Hanna1, Jaspreet Kaur1, Nikki Davey2 1St George’s University NHS Foundation Trust, 2QIClearn

DIAGNOSTICS:

CHANGE IDEAS: Acute Neurology

PDSA cycles

Whattodo

Whentodoit

idea SpeaktoPaediatricneurologyconsultantsonmyodeaofflashcadsfor neurologicalinvestigations-2ndidea

NeurologicalInvestigationsflashcards-1

Circulatethecardofacertainconditionto2or3trainees Speaktothemfacetofaceorviawhatsappforfeedbackonthecardsandidea

Atarandomdayshiftorpointoftime Whentheyareoncallsotheyareavailableandcangivemepersonalfeedback

Wheretodoit Onlineplatformorviaemailorfacetoface Inthehospitalonthewardortheneurooffice

Whotodoit

Trainee-juniororseniorstartwith3traineesConsultantPaediatricNeurologists

Predictoutcome Easiertoorderthesamples–lessconfusionandimprovedknowledgeofwhat toorderMightchangeafewtestsoradjustthecards–willprobablythinkit’sagood idea

Datatocollect Repeatsurvey–doneinthebeginningwith2or3questionstocheckifthat providedbetteranswers Qualitativedatafromtheirfeedback

RUN CHART:

Baseline measure

Sampling after Change ideas

Acknowledgements: Jane Runnacles

IMPROVING DELAYS IN UPLOADING INTRAOPERATIVE IMAGES DURING TRAUMA SURGERY

Dr. Kajal Joshi, Mr. Alistair Scott Parker (Supervisor)

BACKGROUND :

Intra-operative images are an essential part of trauma surgeries, as they demonstrate the nature of the surgery, help in identifying intra-operative complications, and also form an important medico-legal record of the patient's fracture and surgery.

Reducing delays in uploading intra-operative imaging invariably helps the team make appropriate decisions on weight-bearing status, and streamlines discharge processes, without the need for unnecessary further check X-rays

AIM :

-To identify if there was a delay in uploading intra-operative images

-To quantify this delay by thorough data collection

-Liaise with radiographers team to combat any shortcomings or issues that they might face

-Create a system in which images were uploaded and available to view during the trauma meeting the next day by the next data collection cycle

METHODOLOGY:

DO : Collect records of all patients undergoing trauma surgery during a 2-week period. Review radiology software system next morning to check if intra-operative images have been uploaded on time before trauma meeting

PLAN : Find out if there are delays in uploading intra-operative images through data collection

Create a system in which intra-operative images are uploaded by the next day trauma meeting.

FINDINGS:

Cycle 1: October 2021 no. of surgeries requiring II: 31

Not uploaded on time: 12

Cycle 2: January 2022

no. of surgeries requiring II: 32

Not uploaded: 4

Uploaded on time: 19

Uploaded on time: 28

STUDY: Make a note of the number of intra-operative images that did not get uploaded on time.

Follow through over the next few days to check after how many days the images were uploaded

ACT: Liaise with the radiographers team to find out the issues they face while uploading images.

Discuss with the Radiographer Supervisor to come up with long term solutions for fixing the delays.

IMPLEMENTATION OF CHANGE:

The results of cycle one were discussed with the radiography team.

The issues raised by them were:

-PACS Port in trauma theatre was not working despite flagging it several times to IT services.

-Only one Wi-Fi enabled machine available, which was too bulky to operate.

Following the discussion, new Wi-Fi enabled machines were installed in theatres, which allowed images to be uploaded by the simple click of a button, instead of plugging it into a PACS port

LEARNING POINTS:

The importance of recording and uploading intra-operative images cannot be stressed enough.

It is an important medico-legal record that leads to significant delays in patient care, if not handled correctly

Working together and seeking opinions from other teams, namely, the radiographer team, and radiation supervisor, along with IT services shed light on the issues that they have faced, thereby leading to more efficient long-term solutions

The most important aspect of any QIP is maintaining the improvement that we have seen, hence, continuous monitoring via repeated cycles is a must

kajal.joshi1@nhs.net scott.parker2@nhs.ne

References:

Trauma & Orthopaedics North Devon District Hospital, Barnstaple

Facilitating

patient referrals by junior doctors and physician associates to the appropriate respiratory subspecialties

A.ODEKUNLE1, C.IOSIFIDIS1, N.ODELL1, S.CHOI1, J.HOLME1

1Manchester University NHS Foundation Trust

INTRODUCTION

One of the major duties of junior doctors and physicians associates (PAs) is referring patients to the necessary specialties and pathways. Doing this inappropriately or incorrectly may adversely affect patient safety, satisfaction and outcome of treatment. A report by the General Medical Council found that patients who were not satisfied with their referral experience were those that arrived at an appointment to see a doctor who was not expecting them or was unfamiliar with their case. In some cases, the referrals were lost entirely.1

AIMS

a.To facilitate referrals by junior doctors and physicians associates to the appropriate respiratory subspecialties.

b.To produce an easily accessible guide for referrals to the various respiratory subspecialties.

Sample population: junior doctors and physicians associates

Data collection: online self-administered questionnaire

RESULTS

The third cycle of data collection showed that there was only one subspecialty (out of 17) that the majority of participants did not know how to refer to. This was a significant improvement from 12 and 4 subspecialties in the first and second cycles, respectively.

With all our standards of measurement, there was a positive impact of our interventions with each cycle. The standards measured were:

I am confident referring patients to all of the above respiratory subspecialties (A)

I find it easy to refer to all of the above respiratory subspecialties (B)

Information available regarding referrals to the above respiratory subspecialties are up-to-date (C)and easily accessible (D)

There is a simplified guide on referrals to the subspecialties (E)

DISCUSSION

The following interventions were made after the first cycle: Production of a simplified guide explaining how to refer to various respiratory subspecialties. The guide was uploaded on to the Intranet, Induction mobile app, put on the Junior Doctors Briefings by the Chief Registrar and disseminated by emails to doctors and PAs.

CONCLUSION

This QIP has demonstrated a substantial beneficial impact as 75% of doctors and PAs that responded now feel confident in referring patients to the various respiratory subspecialties and 75% also agreed that a simplified, up-todate and easily accessible guide to referrals is available.

Fig.1.1 Percentage of responders who agreed that they are confident referring to the listed specialties in the 1st, 2nd and 3rd cycles

Fig 1.2 Percentage of participants who agrees and/or strongly agrees with the statements of our standards measured

Same Day Emergency Care Glangwili Hospital

Understanding the Problem

Same day emergency care have been successful in preventing avoidable hospital admissions in urgent care centres across the United Kingdom. However the utilisation and scope for SDEC in Glangwili General Hospital has not been fully optimised with only 5% of emergency attendances managed through this pathway whilst the national ambition is around 30%.

Measures: How will we know a change is an improvement?

The following measurements were agreed with historic baseline data pulled for the 10 weeks prior to the project commencing

The Theory of Constraints, data represented in the Pareto chart and Cause and Effect (fishbone) diagrams were used with the project team and wider stakeholders to understand the problem and identify the potential change ideas represented in the driver diagram below.

Changes: What changes can we make that will result in and improvement?

The project tested multiple change ideas identified by the project team and wider stakeholders in brainstorming meetings, process mapping and fishbone diagrams.

PDSA 1: Change the door of the unit to stop patients in beds being put in the unit. Adopt –learning: Stopped beds going into the unit but did not increase the number of patients going through the unit or aid identification of patients suitable for SDEC. Next steps to include: Testing a triage tool (AMB Score).

Improving SDEC flow will address key components of the 6 Domains of Quality in Healthcare:

Timely – patients will be assessed, treated and discharged on the day of presentation

Efficient & Effective – increasing flow through SDEC will reduce admission >24hours, releasing bed capacity and improving waiting times

Safety – reducing admissions >24 hours will minimise the potential for hospital acquired infections and deconditioning

Patient Centred – SDEC considers the individual needs and preferences of patients as well as the wishes of their families and carers

Involving others

The project team: Senior Sister ED, Staff Nurse CDU, Advanced Nurse Practitioner, Consultant Acute Physician, Physiotherapist, Occupational Therapist, Improvement and Transformation Lead and Quality Improvement and Service Transformation Practitioners.

A Stakeholder analysis exercise and fishbone diagram was used to identify other individuals and groups that would be key to the success of the project.

Engagement consisted of:

Regular meetings with the wider MDT/informatics/analysts

GP cluster meetings

QI collaborative team meetings

SDEC/CDU meetings with clinicians and managers

Staff survey and feedback

Co-producing patient posters and leaflets

The SDEC project is a co-design between partners- testing ideas and developing a model for SDEC together as equals.

Aim: What are we trying to accomplish?

To improve the number of patients managed through SDEC by 20% by March 2020

PDSA 14 Ramp 1: Multiple PDSA’s within 1 week. Rapid learning with Adopt, Adapt or Abandon approach. Learning: Ring fencing SDEC is key to enable full utilisation, G admissions alone are not enough, needs pull from the emergency department and need to explore WAST pathways.

Reflection and the next steps

Lessons Learned:

• Ring fencing SDEC is key

• Triage tool for SDEC (AMB Score) accurate in predicting same day care

Future Improvement Projects: Health Board wide SDEC project informed by the learning from the GGH project

Background

Achieving NICE transition-related standards of care for young people with long-term conditions A quality improvement project

S Barrow, O Wilkey , North Middlesex Hospital

Diagnostics Fishbone Diagram

Moving from paediatric to adult services is a difficult time for young people with complex health needs. Evidence suggests that effective transition between services can improve longterm outcomes. There has recently been a drive to refine and improve the transition process through the NHS Long Term Plan.

Aim

This quality improvement project aimed to better achieve the NICE Quality standards for transition for 6 sub-specialties in one paediatric department, across a nine-month period as part of the transition paediatric improvement plan.

Measurement

An initial gap analysis was undertaken using 11 NICE quality transition-focused standards of care to demonstrate current performance of services for transition for 6 sub-specialties: allergy, asthma, diabetes, epilepsy, HIV, and sickle

Change Ideas

• Regular transition workshops and progress meetings

• Implementation of the Ready, Steady, Go, paperwork

• Time-bound action points for each sub-specialty

• External talks from a transition improvement manager

• Joint transition clinics between paediatric and adult services for certain sub-specialities

• Application for funding for a new epilepsy transition specialist

Results Run Chart

Discussion

• Initial baseline measurement in April 2021, showed: 36% of standards were unmet , 18% of standards were partially met & 45% of standards were met across the 6 sub-specialties.

• Following implementation of change ideas, met standards increased to 58%.

• Specialties such as asthma & epilepsy showed significant improvement in partially meeting or meeting standards.

Reflections & Learning

• This QI project has enabled one paediatric department to better achieve NICE transition standards of care for young people with long-term conditions.

• Further work is needed to ensure young people & their families are actively involved in the design, delivery, & evaluation of services for transition (standards 1&2).

• Continuous work is required to ensure that transition-related standards of care are met for young people when moving to adult healthcare services.

Doctors Improving Referrals (DIRE) QIP

Background

Within the NHS, making referrals presents significant challenges for junior doctors. Delays to referrals have been documented to result in patient harm and junior doctors informally cite unpleasant experiences with making referrals. The aim of this study was to collect data on junior doctors’ experiences of making referrals, identify any barriers to referring, and the consequences of difficulties in referrals to both doctors and patients.

Methods

Junior doctors at the trust were surveyed on the referrals process, using a link on the ”Mind The Bleep” website (https://mindthebleep.com/improvingreferrals).

Results

284 junior doctors, with representation from every deanery in the UK and all training grades, responded to the survey.

A referrals “cheat sheet” and a comprehensive list of trust inpatient and outpatient referrals information were generated to address issues raised by junior doctors

Interventions

Conclusions

The interventions have been demonstrated has highly efficacious, are now recommended by the Imperial College NHS Trust simulation team. The interventions have been documented to improve patient care both locally and nationally. The cheat sheet has been downloaded X number of times

Figure 1 –Junior doctors’ confidence when making a referral

Figure 2 – Barriers to making referrals

Figure 3 – Consequences of referrals

Figure 4,5 – Excerpts from referrals cheat sheet

Figure 6 – Excerpts from referrals document

Benedict RH Turner, EV Thorley, A Doshi Ealing Hospital, London Northwest Healthcare Trust, UB1 3HW

Bringing posterior strokes to the fore –Improving stroke recognition

Ambreen Ali Sheikh1 , Athanasius Ishak1 , Sanja Zrelec1

1West Middlesex University Hospital, Kew Stroke Department, Twickenham Road, Isleworth, Middlesex TW7 6AF

INTRODUCTION: Between September 2018 - March 2020 there were 11 missed cases of stroke among inpatients (6 posteriorcirculation strokes, 5 anterior circulation strokes). 5/11 cases were deemed serious incidents and were all FAST screen negative (Table 1). A stroke survivor meeting was held, and some patients voiced concerns that screening methods did not correspond to their presenting symptoms.

Presenting complaintMisdiagnosed as Ataxia + Drowsy DKA

Incoordination

Vertigo + Hearing loss

Bilateral leg weakness

Nil acute

Nil acute

Nil acute Vertigo

Gastroenteritis

Table 1 –Serious incidents of missed posterior circulation strokes. All were FAST negative.

AIMS:

1. To improve detection of inpatient strokes so that none are missed by introducing a new stroke screening tool.

2. To introduce a stroke investigation and management protocol to improve timely stroke diagnosis and streamline transfer to HASU.

DO

PLAN

ü Promote use of the BEFAST stroke screening tool

ü Create a clinical guideline, as per the pan-London stroke pathway, about managing and excluding common stroke mimics and referring to HASU.

STUDY (April-September 2021)

Qualitative data:

ü “Easy to remember”

ü “ The pathway is clear & straightforward”

Quantitative data:

üAverage delay to diagnosis: 7 days vs 36 hours

ü4 inpatient strokes - none missed.

üNo NIHSS score on first review

CONCLUSIONS:

Ø BEFAST is a useful stroke screening tool

Ø Educational interventions can improve stroke screening

Ø Detailed neurological examination is essential

Ø Patient involvement is important for quality improvement

üWe created posters and placed these in key areas of the hospital & on the intranet.

üThe screening tool and guideline were presented at a grand round and at junior doctor teaching

üVirtual and in-person training for

ACT

üTraining is ongoing

üPlans for simulation training and inclusion as part of induction training

üEvaluation of impact of protocol

BACKGROUND

1 in 4 five-year-old’s have tooth decay with on average 3 or 4 teeth affected

CHANGE IDEAS

Getting Our Teeth Stuck into the Problem

Opportunistic Public Health Messaging within the A+E Department

Rosanne Verow1, Nicola Davey2, Richa Ajitsaria2 1 Barts NHS Trust, 2 QIC learn

DIAGNOSTICS

Tooth decay is the main reason for children to be added to the Child Protection Register for neglect in Tower Hamlet. Our Doctors look in throats every day but often don’t spot or address this problem

AIM & MEASURE

Aim: By the 1st March 2022 8 out of 10 children aged between 117 years old triaged to the paediatric A+E will have been asked the last time they visited a dentist.

Measure: Number of patients with a documented assessment in their notes of when they last visited a dentist.

PDSAs

10 PDSAs were performed during a one-month period. Six of the main interventions are shown below

Information Gathering

Action: Share information with the staff (see PDSA cycle 2)

Confirmed we should be directing patients to their dentist for tailored advice

Brainstorm with dentist

Action: Have leaflets printed on how to find a NHS dentist (see PDSA 3)

Information Sharing

Speak with parents and children

Action: Focus on excess admissions and health implications when discussing need

Share the problem and the project with the staff

Face to Face discussions around the problem, the aim and change ideas

Resources

Action: Print the leaflet in other languages

Information provided to parents

Didn’t know children (1-2yrs) needed to see a dentist. Having problems accessing a NHS dentist

Face to Face discussions in the A+E department

Teaching

Action: provide widespread departmental teaching to improve knowledge

Teach staff public health messaging around oral health

Led to multiple informal teachings. People motivated by health implications more then safeguarding

Email to all paediatric A+E staff updating them about the project.

Incentives

Action: Add a check box to the triage proforma to include ask about dentist

Motivate staff with fun competitive game

The forms offered clear advice and the staff felt empowered to give guidance

NHS leaflets in English printed on how to book a free NHS dentist appointment

Was the patient asked when they last saw a dentist?

They were receptive to the learning and clearly had limited knowledge in this area

Impact of PDSAs

Microteaching with 4 SHOs from different training backgrounds

Triage nurses could get up to 12 patients per shift. Nurses reached higher numbers than doctors

Created a tooth fairy leaderboard for staff who ask the most patients

REFLECTIONS & LEARNING

This was a multi disciplinary project that involved patients and carers. It shows that A+E is an ideal place for health promotion with staff interacting with large numbers of children every day.

Whilst we have not yet show a statistical change what we noticed was that staff started talking about oral health and based on self reported numbers and the amount of leaflets given out, a clear change has occurred within the department.

The next stage is to explore further with parents to see if increased awareness results in increased attendances to see a dentist.

RING THAT IRIBELL

A NOVEL DEVICE TO DECREASE INTERRUPTIONS IN CONTINUOUS IRRIGATION IN ENDOUROLOGICAL PROCEDURES

Charan Muraleedharan, Ryan Beazley, Christina Fontaine, Nicholas Burns-Cox Musgrove Park Hospital

Introduction

Theoperatingtheatre is abusyenvironment requiringsimultaneousmonitoring of multiple aspects in endourologicalprocedures. Large bags of irrigatingfluidneedregularmonitoring andchange by circulatingtheatre staff. Situationalawareness,communicationand teamwork are of theutmostimportance in ensuringcontinuous irrigation with minimal interruption;imperative for surgeonvisibility andthereforepatient safety.The IriBell is a noveldevicedeveloped to alert theneed to changeirrigatingfluidandtherebyreduce interruptions inirrigation.

Method

A five-pointgradedpre-IriBell questionnaire was used to assess theneed for thedevice. Iribell was implemented,andquestionnairerepeated.

Results

A total of 12 circulating theatre staff members completed the questionnaire. IriBell led to an 80% decrease in the number of stressful situations within the operating room, due to irrigation fluid. 92% (11) of staff found it easier to focus on different tasks during theatre with the use of the IriBell. 83% (10) felt irrigating fluid never ran out during cases, versus 0.1% pre-IriBell. It was also commented that the IriBell was of particular use during times of low staffing, or when there was a lack of experienced theatre staff. Furthermore, the majority of theatre staff found the IriBell easy to set up 92% (11) and easy to clean 92% (11).

Conclusion

IriBell has been well received universally resulting in a positive impact on staff stress, situational awareness and reduced interruptions in continuous irrigation -improving patient safety. We aim to roll out IriBell Trustwide.

Figure: Iribell device attached to drip stand and Neptune

How to get an Orthopaedic Surgeon to complete a TEP

“The TEP Check Method” A quality improvement project

By Rohit Chandegra, Jordan Bethel, BhupalShrestha, Mark Sykes and Simon Macmull

Introduction

TreatmentEscalationPlans(TEP)arepart of theadmissionsproforma for surgicalpatients. It is important thesearecompleted.Especiallywiththeincreasingly co-morbidadmissionswheredeteriorationscanoccur.

Secondly,giventheCOVID-19 pandemic and therisk of crossinfectionduringhospitaladmissions itis important that theseare done.During our nightsshifts we identifiedanumber of deterioratingpatientswhere theirTEP’s had not been completed. We demonstrate our qualityimprovementprojectwithregards to completion of TEPs.

Method

We carried out aprospectivecrosssectionalaudit of allpatientsadmitted under the orthopaedicteam. We looked at whether the TEPswerecompleted on admission, on thepost-takewardround orat all. We carried out 3completedPDSAcycles,eachovera1weekperiodwithmultipleinterventions in between. We should be100%compliantwithcompletingTEPs– itis an admissionrequirement

PDSA Cycle 1 Results

PDSA Cycle 2 ResultsPDSA Cycle 3 Results

Results - only 23% of TEPs were completed –Poor compliance

Interventions –

•Posters placed in the oncallareas for orthopaedic surgery

•text messages to all the orthopaedics junior and registrar team

Results - an 11% improvement of TEPs that were completed at admission –minimal improvement

Interventions –

•Posters placed in the oncall areas for orthopaedic surgery

•text messages to all the orthopaedic junior and registrar team

•“TEP Check ” -Escalation to the consultant body for monitoring on Post-take ward rounds

Results – a 90% compliance of TEPs that were completed at admission -Significant improvement

Interventions –

•Posters placed in the oncall areas for orthopaedic surgery

•text messages to all the orthopaedics junior and registrar team

•“TEP Check” -Escalation to the consultant body for monitoring on Post-take ward rounds

Conclusion

ThisQIPproved to be veryrelevant tothe COVIDpandemic.TherewerepatientswithintheOrthopaedic team who had caughtCOVID-19 duringtheiradmission. It is important that we are100%compliantwithfilling in TEPs.The 90%compliance in thesecond cycle wasveryimportant. We feelthat theconsultant“TEPCheck” on thepost-takewardroundproved to bethefactordrivingthecompletionofTEPs.

Future Recommendations

•More PDSA Cycles

•“No TEP, No admission to the Ward” interventions would ensure 100% compliance

•Further training for junior trainees and middles grades who have trained abroad and any doctors who may not be familiar with TEPs

Contact details

Rohit.chandegra@nhs.net/

Poster Competition Group D

Full QI Project

Improving patient safety

Prizes

Improving Central Venous Catheter (CVC) line documentation in Northwick Park Hospital Intensive Care Unit

Introduction

Insertion of central venous catheters (CVC) is one of the most common procedures to be performed in Intensive Care Units. Mechanical complications arise early after the insertion of a CVC and long-term complications, such as catheter-related infections, thrombosis and chronic venous stenosis, later in the course.1,2 CVC-related complications are associated with increased morbidity and mortality as well as increased costs.

High quality documentation and follow up of CVC insertions form the basis of reducing these healthcare related complications.

Aims and objectives

1.Establish how often CVC line and Vascath documentation were documented in accordance with NICE guidance at Northwick Park ICU.

2.Implement interventions to improve documentation in accordance with NICE guidance3 after interventions

3.Improve patient safety by reducing infection and complication rates related to CVC/Vascath insertions.

Results

1. 2. 3.

Methods

Data was initially collected on the 4th October 2021 using EPRO. We used NICE guidance3 and the London North West Trust paper CVC checklist to establish a gold standard framework for CVC line documentation. Data was then collected from all ICU inpatients with CVC lines on that date. Three interventions were implemented to improve documentation

A furthercycle took place on the 1st November 2021 to evaluate the impact of these interventions (n=15)

To establish whetherimprovementsweresustained,a third cycletook place on the 22nd November.(n=22)

Interventions

Teaching session on CVC/Vascath documentation

Development of template to aid documentation of CVC lines on EPRO

Poster displayed around ICU as reminder

Discussion

Post interventions, our 2nd cycle shows an improvement in 13 out of the 26 domains

Our 3rd cycle shows sustained improvement in 11 of these domains, and an improvement in 8 further other domains.

Areas where there was poorer compliance post-audit was related to there being no documentation on EPRO at all. This was generally seen when patients were referred to ITU initially and a CVC line was inserted prior transfer.

When the template was being used for documentation, there was nearly 100% compliance with documentation in all domains. Template most often used when CVCs needed changing on ITU or when a junior was involved. Template not use with locum doctors.

Confirmation of CXR was poor this is likely due to a lag between obtaining the CXR and remembering to document this on the system.

Further interventions:

1. Emphasise importance of a clear separate documentation of CVC insertions to ICU SpRs who accept ICU referrals

2. Address barriers to documentation e.g. time pressure or lack of computer availability in emergency situations

3. Highlight importance of documenting when CXR reported and if CVC safe to use

References

1. PoldermanKH, GirbesAJ. Central venous catheter use. Part 1: mechanical complications. Intensive Care Med 2002;28:1 17.

2. PoldermanKH, GirbesARJ. Central venous catheter use. Part 2: infectious complications. Intensive Care Med 2002;28:18 28.

3.Nursing Consultant, Intravenous Therapy Royal Marsden Hospital. Policy for the Insertion and Care of Central Venous Access Devices (CVAD) in Hospital. Royal Marsden NHS Foundation Trust Policy. 2016. 1748.

Project Introduction and Aims

Heart failure (HF) is oneof the mostcommon reasons for admission to hospital; itis associated withlongin-patient admissions, andhas a high inhospital and post-discharge morbidity and mortality Accurate fluid balancemeasurements are avital part of management with intravenousdiuretics for patients with decompensated heart failure and fluid overload. On our review of the data collection on Syon1 Ward (WestMiddlesexHospital), there was great variability andpoor recording of fluid balance. The SMART (Specific,Measurable,Applicable, Realistic, and Timely) aimof thisQuality ImprovementProject was to improve fluid balance recordingaccuracy from 65 to 75% on Syon1 (cardiology ward at WMUH) in two months.

Project Methodology / PDSA Cycles

Plan-Do-Study-Act (PDSA) cycles:

1. Assess the qualityof fluid balance monitoring on Syon1 ward compared to NICE guidelines standards onone morning ward round (06/09). Aim: Three weeks of promoting BMJ BestPractice Resources (free to NHS staff) on Heart Failure to Syon1staff(posters,electronicresources etc.).

2. Reassess the qualityof fluid balance monitoring on Syon1 ward compared to NICE guidelines standards onone morning ward round (23/09). Aim: Three weeks ofoffering BMJ BestPractice patient information leaflets to Heart Failure patientson Syon1 to highlight the importance of fluid balance in their recovery3

3. Reassess the qualityof fluid balance monitoring on Syon1 ward compared to NICE guidelines standards onone morning ward round (12/10). Aim: Three weeks ofoffering patient empowerment training to be more active in their own fluid balance recording,includingasking themto keepa written record of theirfluid input andoutput levels daily

4. Reassess the qualityof fluid balance monitoring on Syon1 ward compared to NICE guidelines standards onone morning ward round (02/11).

Project Results and LessonsLearnt After implementation of three separateinterventions of staffeducation, patient education, andpatient empowerment, median fluid balanceaccuracy improved from 65% to 80%over two months on Syon1 WMUH Patient education with patient informationleaflets and subsequent patient empowerment seemed to have the greatesteffect on improving the accuracy of fluid balance monitoring We also noted that itis considerably easier to measure fluid balance in those who are catheterised andonly receiving IV fluids,compared to thoseself-mobilising tothe lavatory and drinking independently We plan to use patient information leaflets more frequentlyto enable improved independence andempowerment

A multidisciplinary, patient empowerment approach to improve fluid balance records in patients admitted to a cardiology ward: a quality improvement program

Dr Guy Fletcher, Dr Alice Ditchfield, Dr George Ashton • Chelsea and Westminster Hospital Trust

Acknowledgement: Dr Mark Lethby, Care of the Elderly consultant supervisor

Reducing Time Taken for Treatment Escalation Plan Completion

THE PROBLEM

There are significant delays between a consultant decision regarding treatment escalation plan and formal completion of the DNAR/TEP form. Patients on the Care of the Elderly ward may remain without a formal TEP form for a significant period. In the event of deterioration, this can lead to difficult decisions to be made quickly out of hours, and suboptimal care.

PROCESS MAP

To reduce time from admission to the Care of the Elderly ward to formal completion of the DNAR/TEP form, in order to improve patient care and the legality of medical decisions, particularly those made out of hours.

RESEARCH

Focus group held with ward medical team, nursing team and auxiliary staff, ensuring staff at all levels of training from F1 to consultant were represented. A nursing handover was also attended.

PDSA CYCLES

MEASURES

Data was collected monthly as a snapshot and included time of first consultant decision regarding TEP, time of admission to ward, and time of TEP form completion.

This data was used to generate the following measures:

• Time from first consultant decision regarding TEP to TEP form completion

• Average time from admission to COE ward to TEP form completion

This was used to generate averages at the following data collection points:

• Pre-collection data: November 2021

• Data collection following PDSA 1: December 2021

• Data collection following PDSA 2: February 2022

RESULTS

Average time from admission to ward à TEP form completion:

• Pre-changes: 3.56 days

• After PDSA 1: 2.03 days (43% reduction)

• After PDSA 2: 1.94 days (47% reduction vs. pre-changes)

Average time from consultant decision à TEP form completion:

• Pre-changes: 1.96 days

• After PDSA 1: 0.58 days (70% reduction)

• After PDSA 2: 1.38 days (30% reduction vs. pre-changes)

PDSA 1

Plan: Change idea: Adding TEP status to clinical ……….handover list used by all doctors on ward

Do: November 2021 à allow 1 month to elapse to assess the impact and allow sufficient ward

…..….turnover

Study: December 2021 à Data collection & analysis

Act: Next step: allocated member of staff highlights incomplete TEP forms at handover

c

PDSA 2 P D S A

Plan: Change idea: Allocated member of staff ……….highlights incomplete TEP forms at handover

Do: January 2022 à allow 1 month to elapse to assess the impact and allow sufficient ward turnover

Study: February 2022 à Data collection & analysis

Act: Plan to extend QIP methodology to other medical ……….wards and continue to reaudit

TAKE HOME MESSAGES

47% reduction in average time from admission to Care of the Elderly ward to completion of TEP form.

70% reduction in average time from consultant decision to completion of TEP form after PDSA 1.

Simple and time-efficient changes can improve level of patient care and legality of DNR documentation without significant increase in staff workload.

The project highlights the valuable role of junior staff when empowered to speak up.

NEXT STEPS

Presentation of work at local faculty group meeting to further spread awareness of the project.

Continue to re-audit to ensure new standard maintained. Expansion of QIP to additional Care of the Elderly wards, then to all medical wards.

Improving call bell reachability in an acute older persons' ward

A gentle reminder in daily nursing handover (Safetyhuddle)increased call bell reachability to almost double

Background: Call bell within reach isan important part of quality of careand astandard in the RCP inpatient fall Audit.

Initial data collection showed 56% patients had call bell in reach indicating potential for improvement.

Aim:

Improve call bell reachability from 56% to 95% or more

Measurement

10 bed spaces reviewed3 times a weekfor 2 weeks (in the afternoon) before and after introduction of each change

Balancing measure of weekly falls data for the ward (all beds)

Changes :

First change: Stickers in medical notes as a reminder

Second change : Teaching session to nurses

Third change: A short video posted in closed social group

Fourth change: A gentle reminder (as a component of safety huddle) in daily nursing handover

Outcome:

First 3 changes any sustainable improvement

Learning:

Stickers can be easily ignored

Doctors' contribution in ensuring call bell reachability is important but nurses & HCSW have the most frequent role

Teaching is effective but it may not be able to involve all the staff especially when staffing is not consistent. Despite attending the teaching, implementation of gained knowledge from the teaching session may not sustain

Social media can be used to improve patient care provided

maintained but it was not an effective change for this project.

Reminding the staff of the importance of project was our patient care immediately being delivered afterwards

The 4th change which was a quick reminder to nurses/ HCSW during every morning & evening handover by senior nurses was successful in achieving significant & sustained improvement with >95% call bell in sight and reach Falls on the show any specific corelation with call bell reachability changes

AUTHORS:

Md F. Islam, M. Noor, C. Spice

Portsmouth University Hospitals NHS Trust

I need a weight!

Improving weight recording in the Paediatric Accident & Emergency Department , a Quality Improvement Project

Dr Katherine Styles, Dr Richa Ajitsaria and Nicola Davey

What’s the problem?

• Children are not routinely weighed in our A&E, a lost moment for health promotion.

• It also causes frustrating delays to prescribing.

• Even worse, some children are admitted to the ward without accurate weights leading to drug errors and disruption in their care

What’s currently happening?

• 23% of total patients, 27% of infants under 6 months are weighed

• In 3consecutiveshifts average 7 children per shift had delay to prescribing as no weight available

Aim:

1. Weigh 80% of all attenders

2. Weigh 100% of infants < 6 months

PDSA 1:Engagement

- Need to continue to engage senior nurse

- Engage junior doctors especially weighing infants

- Engaging Matron/ Consultants first workedsupportive, most senior- ordered new scales!

Results:

- Engagement - 1.1 Matron

- 1.2 Consultants

-1.3 Practice Development Nurse

“weight is NOT PART of the Manchester Triage system”

“the words triage and weight SHOULD NOT BE MIXED”

Understanding the problem: Fishbone diagram

PDSA 2: Swap triage chair for weighing chair

- Does the change persist?

- Need a different intervention for infants ?

- Faster prescribing for weight-based prescribing

- However, sitting on scales ≠weight

1. Overall weighing: Increased 19% to 75%

2. Infant weighing: Increased 19% to 78% I presented my QI project at our departmental governance meeting, increasing awareness and support.

3 children weight available for prescribing

- 1 did not

- 2 extra children weighed

PDSA

-Repeat reminders on shift

- Empower nurses to get doctors to weigh or request scales

- 2 doctors needed to be shown scales and how to use them

- Doctors weighed 5 infants on shift

- Engage junior doctors to weigh infants themselves at the end of their examination

-Information sharing in work WhatsApp group

- Day-to-day encouragement on ‘shop floor’

Conclusions: It hasbeenpossible to increase the number of children beingweighed in our A&E departmentusingquitesimplechangeideas which mostly focused on engagement.Most professionals were willing to try changeideas.

My learning: Being taught QI methodology completely changed my experience of QI projects. I realise how important it is to fully understand the problem first using diagnostic methodsthenmoving onto PDSA cycles.

3: Infant focus

IMPROVING THE SERVICE AT THE BREAST ONE-STOP CLINIC

Dr James Sheldon, Mr Mustafa Khanbhai and Ms Laura Johnson

Background

At the breast one-stop clinic (OSC), patients were asked a series of questions related to breast disease and breast cancer risk, by the clinician from a pro-forma. This included specific questions such as age of menarche, age of menopause, date of LMP, and patients would often need a long time to think about their answers to these questions. This was time consuming for the clinician and would often put patients under pressure to provide answers quickly, leading to some of the information being inaccurate.

Aims

To save time during the clinic appointment. To improve patient experience at the breast one stop clinic. To ensure patients provide the most accurate answers to questions asked.

PDSA Cycle

Re-design proforma. Implement new system on trial basis.

Gather feedback on new system

Analyse effectiveness of current system. Gather feedback on current system.

Methods

Over a one week trial period, all patients attending the one-stop breast clinic filled out a questionnaire in the waiting room, using questions adapted from the original pro -forma. Completed questionnaires were given to the clinician at the start of the consultation. Clinicians then completed feedback forms after the clinic, to assess the effectiveness of the new system.

Conclusions

Make further changes to proforma. Implement new proforma on permanent basis.

Results

§ 83% of clinicians found the new system saved time.

§ 75% felt that patients were able to give more accurate answers to the commonly asked questions.

§ 85% of clinicians felt it led to improved patient engagement during the consultations.

We see potential for this being implemented and used in all breast one stop clinics, with a patient questionnaire which is validated and recognised nationally to create standardisation across all breast centres. This trial saved time, improved patient interaction, provided more accurate answers to questions asked and should ultimately lead to better patient care and clinical outcomes.

Limitations

Not all patients understood the questions on the proforma. Language barrier for patients who could not speak English. Some clinicians didn’t adopt new system.

Next Steps…

Modify pro-forma further and repeat the trial. Education on new system before trial to increase compliance amongst clinicians.

Cancer patient summaries for safer on-call decision making

Nader Raafat1, Rosie Hattersley1 1OncologyDepartment,TorbayGeneralHospital,TorbayandSouthDevonNHSFoundationTrust,UK

BACKGROUND

Caring for cancer patients poses unique challenges to both the on-call team and ward juniors. They are often on unfamiliar and complex treatments, and have nuanced treatment escalation plans (e.g. resuscitation status, further oncoliogical intervention) that may not be intuitive. As a mainly outpatient specialty, there is no daily consultant ward round at Torbay, making it more difficult for ward juniors to escalate confidently and for on-call teams to understand a patient’s background, inpatient plan, and longer term trajectory.

METHODOLOGY:

Inpatient notes were audited at weekends for documentation of the following:

» Cancer diagnosis/treatment history

» Named oncology consultant

» Clear inpatient plan (incl. weekend)

AIMS

To address this, we set out to design an oncology admission proforma that would achieve the following:

Improve documentation

An aide-memoire to ensure all patients have sufficient documentation of core information discussed by a specialist in-hours, avoiding ambiguity for on-call teams.

Facilitate communication

» Treatment Esclation Plan (TEP)

» Reason for admission

» Current problems

Documentation needed to be in a clearly visible proforma or in the latest two entries to qualify. A total of 5 PDSA cycles were carried out. Cycles 3 and 5 were carried out to ensure improvements were sustained as juniors rotated.

Interventions:

Intervention #1

Staff of all grades surveyed for most pertinent information to include in proforma. Initial proforma drafted.

Intervention #2

Juniors and registrars surveyed for suggested improvements given initially low proforma uptake and absence of improvement.

Intervention #4

Ward clerks and nursing coordinators ensuring proforma printed in notes on admission.

Intervention #3

Results of improvement disseminated to staff.

Further modifications made based on registrar suggestions. Junior doctor changeover.

Intervention #5

Junior doctor changeover. Proforma printed on pink sheets to make it easier to find.

Lessons Learned:

Engaging stakeholders

As junior doctors we are often the most transient members of the ward team, so it is essential that more premanent staff (e.g. senior nurses, ward clerks) are consulted to ensure change outlasts doctor rotations.

Results:

A single source of information for ward juniors to escalate, make referrals, etc... Facilitates handovers after e.g. nights/ leave and enables on-call teams to quickly obtain relevant background for acute reviews.

Integrating into workflows Importance of iteration

Change is much more likely to be sustained independently of the individuals behind it when it is integrated into existing processes. By integrating the proforma into admission flows, friction was reduced and medical staff reminded to keep using it.

Initially, no domain was accurately recorded for all inpatients, and <=50% of patients had a clear weekend plan or valid TEP form. By the second iteration, proforma uptake was 90% and documentation rates were 90-100% across 7 out of 8 domains Following junior doctor changeover, proforma uptake fell to 30%, and TEP form completion fell to 50%. This was reversed following nursing/ward clerk collaboration, and maintained on subsequent audit (see table above).

The most significant improvement was in TEP form completion (Fig. 1), crucial given the importance of end-of-life care for this patient group.

The first and last versions of the proforma had the same skeleton but markedly different emphasis and layout, evolving as doctors started using it and finding issues.

Acknowledgements:

Many thanks to the oncology consultants at Torbay General Hospital and the Devon and Exeter Cancer Fund for their ongoing support. Vector art from vecteezy.com

Improving communication through List Documentation

Dr. Annabelle Hook (FY2) and Ms. Jemma Rooker (Consultant)

Introduction

Clear list documentation helps aid informed handover of patient care between teams. Lists that contain concise and relevant information can support informed decision-making processes. The trauma and orthopaedics (T&O) on-call list at GWH is used at the daily trauma meeting (TM) where the multidisciplinary team (MDT) are present and supports the identification of issues. Good lists aid safe handover of care between night and day teams highlighting outstanding jobs, reducing work duplication and time spent revisiting plans.

Problems

The previous custom built list system was no longer functional. This resulted in lists being saved in different places and/or under different filenames, lacking standardisation. Even when the old list system was in place, key information such as AMTS, bloods and time of arrival was infrequently documented on the list and as such, not readily available when asked for within the TM (without loading multiple programs). The information then had to be found afterwards. Finally, the old lists lacked frequently used contact details/bleeps, resulting in much time spent going through the switchboard to obtain these numbers.

Methodology & Plan Do Study Act (PDSA) Cycles

The quality improvement project was registered at the hospital. TM were observed, and discussions took place with a consultant to establishwhich parameters were needed, or not captured, with the current prompts on the old list Baseline data was collected considering the presence of these parameters on the old list. 13 consecutive days of lists were analysed. Parameters observed in TM as frequently not documented on the list: AMTS, blood results and time of arrival. Post each PDSA cycle change, 13 consecutive days of lists were similarly analysed.

Structure measures: Access to the list system, ability to safely store the list system on a computer system.

Process measures: Number of times each parameter documented on list. Specific parameters where improvements were desired: AMTS, bloods results and time of arrival documentation.

Outcome measures: Percentage of each parameter documented on the list. Number of pages needed to contain all parameters.

Balancing measures: New list being incorrectly completed resulting in parameters being unavailable during TM. More pages needed to contain all the parameters.

Aims

To create a new standardised list system containing relevant and useful information whilst being stored appropriately and consistently on the computer system. It was retrospectively measured by reviewing 13 days of consecutive lists post each change to analyse how many of the predetermined parameters were documented on each list. The aim was achievable and realistic as the new list was created to meet the needs of a specific department where the previous list system needed to be replaced. Project time frame was 6 months.

Secondary aim was to see improvement in list documentation of AMTS, blood results and time of arrival list documentation.

Parameters identified to be useful for the list: For all patients, list documentation of:

• Date

• On-call consultant initials per patient

• Location of patients

• Patient details (3 identifiers)

• Admitting problem

• Key history and examination

• Blood results

• Scan results

• Plan

Those for operation, list documentation of:

• Marked and consented (M&C)

• Eating Status

• COVID Status

• Number of Group and Saves

Those with Neck of Femur Fracture (NOF#) for operation, list documentation of:

• M&C

• Eating Status

• COVID Status

• Number of Group and Saves

• AMTS

• CXR completed

• Time of arrival

Other elements included readability and number of pages.

Flow Chart: To depict PDSA cycle actions. Results 64 lists analysed. Total of 661 patients across those lists. 111 non-NOF# operations, and 83 NOF# operations. (65th list (25th November) unavailable due to site-wide computer system upgrade, and alternative method used).

The average number of pages of the list decreased from 4.1 to 2. Finally, the readability of the list improved.

Run Chart: To depict % change of AMTS, time of arrival and blood results over time.

Key learning points and next steps:

A standardised list system is now in place and is consistently being used. Everyone has read and write access to this list (w ho requires it). It is stored in a safe and appropriate place on the computer system. The list contains prompts for useful and relevant information. A guidance document on how to use the list is available to ensure consistency of use during changeover periods.

Improvements seen: improvements were seen in a number of key parameters (Radar Chart 1). These include the documentation of: Blood results, AMTS and time of arrival (Run Chart). Improvements have been seen in the readability of the list and the number of pages used for each list.

Issues noted: changing to the new MS Word -based list system means that individuals can edit the list format depending who is on call. Whilst prompts are on the list for people to follow there are no mandatory fields that prevent partial completion of the document. If the computer system goes down, alternatives must be used. Next steps: complete data collection following Cycle 5 (the addition of the guidance document to the T&O introduction booklet). Monitor usage of the new list system. Aim to improve deteriorated areas (Radar Chart 2). Locally present new findings, and survey whether any further changes should be made to the new list system. Reflections: change does not equate to improvement. Multiple PDSA cycles are required to make incremental changes to work towards an aim. By involving the MDT early, support can be gained from the team and working together a list system can be created that benefits the department and meets its needs, whilst improving list documentation.

Limitations:It is important to highlight that not documenting a parameter on the list, does not mean that it has not been completed or is not available. The absence of documentation on the list means people must rely on human memory, or go back to check the original documentation, or open a different computer application. It is important to remember list documentation will always vary depending on the user and how busy each shift is. This is also affected by staffing levels and seasons. The list has been designed to include prompts for each of the useful parameters, but this does not mean they must be completed. It is important to remember that these results represent a baseline 13day consecutive period compared to each post-change 13-day consecutive period,this may not reflect all lists outside of these recorded time periods.

Example from PDSA Cycle 1: Introduction of new list system.

Easing the pressure: taking time out for reflection to engage staff and improve care

Kristina Thomson, David Fletcher, Rachel Major, Jackie Holley, Christine Herdman, Michele Dowling, Milton Keynes Community Nursing Service

Introduction

Milton Keynes District Nursing (DN) Service provides care at home for frail and vulnerable patients across 7 Primary Care Networks in Milton Keynes.Over the past year the service has worked to create a learning system where staff can reflect on practice, develop skills, and ensure that they provide consistent, high level care across all nine DN teams (approx. 130 staff).Due to the multiplicity of factors involved in the prevention of pressure ulcers, the team has been tracking the development of Category 3 pressure ulcers in service as a proxy measure for high quality care.

Since June of last year this work has been part of a QI Practicum across Central and North West London NHS Trust, which has provided the team with structure and a platform to develop and share their work. The aim of this work is:

To reduce Category 3 pressure ulcers developed in service by 10% by the end of June 2022.

The work took a whole service approach, and the service manager (sponsor) took an active role in the work throughout. It was overseen by a team led by one of the Practice Development nurses, supported by the Data Quality Officer, a Tissue Viability Nurse, B5 District Nurse, Health Care Assistant and Improvement Advisor.

Aims

While the stated improvement aim is to reduce category 3 pressure ulcers by 10% over the year to June 2022, the team wanted to achieve more than this:

• Create a safe, supportive environment where staff could reflect and learn new skills and knowledge to improve practice;

• Reduce unwanted variation in practice across the 9 teams working in Milton Keynes;

• Encourage staff of all grades to use data to inform and improve their practice.

Methods

The team has used Quality Improvement methodology to structure the work and track progress1.This has focused on a small number of PDSA cycles to track change and improvement:

•monthly workshops for staff -half day sessions each month where 2 teams come together to follow a programme for reflection, learning and improvement within a space that provides psychological safety for all staff;

•development of Quality Improvement Performance Portfolios (QIPPs) -team level performance reports produced each month to ensure teams can see how they are performing, and learn more about their patient profiles;

• mentoring -where staff with specific skill sets (e.g. tissue viability nurses) can support colleagues to develop skills, leading to earlier intervention and better patient care.

Results

Workshops have been at the heart of what we have done over the past year, providing both a safe space for reflection and learning, and a way for staff in different teams to get to know each other and discuss different ways of working. Better working across teams has allowed the service to work more flexibly, providing cover for caseloads at times of staff pressure, and allowing them to keep protected time for learning even at times of high operational pressure. Using team level Quality Improvement Performance Portfolios (QIPPs) has encouraged teams to take ownership of their own data and understand data relating to their own caseloads.

Earlier identification and intervention, higher levels of staff confidence and better working across teams has resulted in a drop of up to 40% in Category 3 PUs since we started our work last summer. Since we started our work in April 2021, the reduction in Cat 3 PUs has meant an average reduction in costs to the whole system from £54,000 in 2020 to less than £20,000 in the last three month period.2

We didn’t set out to make savings –but our work has released resource back into nursing practice ensuring a de facto return on investment. Earlier identification and better nursing care has meant less clinical time spent on investigating and reporting on incidents. This in turn means better caseload management and more time for clinicians to spend looking after patients.

Lessons Learnt

Two of our teams at a monthly workshop, where they have had time to explore their own data using the Quality Improvement Performance Portfolio. We’ve noticed some healthy competition between teams as they work to improve their team performance!

QIPPs provided a whole system overview of how teams were doing –great context for our work on pressure ulcers and emphasising the importance of a holistic approach to care.

What patients said about our service

• In complex systems, it may be difficult to measure the direct impact of our actions on performance measures. Take time to understand your system and develop meaningful measures over time.

• Improvement is a marathon not a sprint –you need to know why it is worth staying the distance. Dialogue with all team members gives them ownership of their improvement and development.

• Improvement work happens in context, not in isolation. Our teams used QI to provide structure to a range of initiatives we wanted to introduce. This structure helped us to see the big picture, think of our service as a system, and helped us to prioritise our activities. It’s also helped us to move from simply ‘doing’ to following through on the impact of our actions on our practice, professional development and patient experiences.

• Get data out of traditional performance reports and into formats that make sense to operational teams. Use it in ways that helps them to tell their own story, in ways that matter to them.

• Make time for reflection –it is a valuable investment, especially when under operational pressure.

• Better working practice releases resources and allows clinical staff to spend more time on direct patient care. We’ve made a start in tracking this, and we will be doing more as we continue to improve our practice.

• We need to do more to get service users and carers involved. As we move into continuous improvement, patient involvement is a key area for development. Roll on our next adventure in QI!

V.Kopanitsa 1, S. Flavell2, J. Ashby2, I. Ghosh 2, S. Candfield2, U. Srirangalingm2, L. Waters2

1. University College London (UCL) Medical School;

2. Central and North West London NHS Foundation Trust

e-nformed consent

Can Digitalisation improve the safety and quality of surgical consent?

Dr Laura Burney Ellis, Dr Amy Cleese, Ms Jennifer Barcroft , Mr Dafydd Loughran , Mr Edward St John, Mr David Phelps

Introduction

• Our unit conducts around 800 Gynaecology surgeries each year

• GMC guidance Decision making and consent states: ‘Give patients the information they want or need in a way they can understand.’

• Royal College of Surgeons Good Surgical Practice states: ‘Recognise that seeking consent for surgical intervention is not merely the signing of a form It requires time, patience and clarity of explanation.’

Lessons learnt

Aim:

• To evaluate whether patients understood the risks and complications of the planned procedure and whether they had adequate time to ask questions.

• Whether the use of a digital consent form improved the consent experience.

A questionnaire was designed, using a 5-point Likert Scale (strongly agree being most positive, and strongly disagree most negative).

Questions included: "I understood the potential complications of the procedure" and "I had adequate time and opportunity to ask questions”

Conclusion

Overall, consent-taking appeared comprehensive regardless of the method. However, e-consent appears more likely to provide a framework for patients to feel they fully understood the risks and complications and to have the opportunity to ask questions.

Initially, questionnaires themselves were available on paper and online via a QR code, however patients were much more inclined to take part when we took them through the questions in either format. This highlights the human interaction as key in the doctor -patient relationship, and emphasises technology as a facilitator in this process.

Identical questionnaires were used to assess both paper and electronic consent. Questionnaires were completed between one and seven days post-operatively.

Fifty anonymised questionnaires were collected from patients who had been consented using paper forms.

Data were collected from a tertiary London GynaecologicalOncology centre between October 2020 and July 2021.

Fifty anonymised questionnaires were subsequently collected from patients consented electronically.

'I understood the potential complications'

E-consent system Concentric was implemented, and one month's grace period allowed

Lessons learnt

Some staff members were more resistant to change than others; we organised a virtual teaching session on use of the e -consent system

Paper-consented

E -consented

Strongly agree Agree Disagree

'I had opportunity to ask questions'

Paper-consented E -consented

Strongly agree Agree Disagree

Digitalisation of healthcare can potentially improve not only efficiency but also the quality of our consent-taking discussion, empowering the patient to make a safe and informed choice References: 1. GMC Online. Decision making and consent. Available from: https://www.gmc-uk.org/ethical-guidance/ethical-guidance-for-doctors/decision-making

A Vital Question for ALL Critical Care Transfers

Dr Richard Healy & Dr Nour El-Shafei –Clinical Fellows, Wessex Neurosciences

The Scope of The Problem

NATIONALLY

• Insulin, hospitals and harm: a review of patient safety incidents reported to the National Patient Safety Agency (NPSA), 20112

• 16,600 incidents involving insulin were identified

• 24% reported harm to the patient

• 1,042 incidents of moderate harm

• 18 incidents with fatal and severe outcomes

• National Diabetes Inpatient Audit England and Wales, 2016

• One quarter of inpatients with Type 1 diabetes had a severe hypoglycaemic episode during their hospital stay (27 per cent).

LOCALLY

• Difficult to say exactly

• Probably a lot of unreported incidents

• Discussions with MetaVision Team to do this for all ICUs in the Trust

• Approval needed from GICU/CICU & PICU Clinical Directors/Matrons etc.

• Slow process before approval for change was granted

The NEW Checklist

The Future

Presented at Thames Valley and Wessex Critical Care Network quarterly meeting

• Regional transfer checklist will be changed to include the question… Insulin Infusion Required? YES or NO

• Anecdotal evidence from colleagues re similar problems

• CEPOD patients

• Reviewed Incident Forms relating to “Insulin” for a 6 month period:

• 9 reported in total (inc. ours)

• Most relevant:

• Bedside nurse turned off an IVI containing glucose as it had finished but did not replace it and left insulin running for 2 hours without glucose

Learning Points

• Insulin is dangerous

• A simple mistake & near-miss can go a long way to improve patient safety

• Checklists are very useful, but have their limitations

• They can still miss things

• We ALL need to be willing to raise concerns/suggestions as they are realised

• It is easy to rely too heavily on the Critical Care Technicians

• Think about all infusions running – are they all required for a transfer?

• Have a low threshold for completing Incident Forms

• A valuable learning resource – for all members of MDT

• Change takes time and can involve many hurdles

“Incidents involving insulin are frequent and cause considerable distress to people with diabetes and anxieties to their families and carers” 1