Introduction
Wound management is an essential part of emergency medicine practice. Clinicians careforwounds ranging fromminor and simple lacerations or abrasions, to complex wounds (1). Approximately 4 million patients with a wound, are managed by the NHS per year. The annual cost of wound management in theNHSequates to £8.3 billion (2). During myemergency medicinejob, I noticed that, despite the high prevalence in presentation and cost to the NHS; junior doctors were not confident in woundcare. This was particularly apparent out of hours when staffing levels are lower, and seniors are often busy and unable to help.
Aims
1. To establish whether junior doctors felt confident in their ability to manage wounds in the Emergency Department
2. To establish if junior doctors were competent in wound care does their knowledge of woundcaremeet hospital guidelines?
3. To establish if junior doctors had access to quality resources they could use for help with wound management
4. To identify common knowledge gaps that can be targeted when creating future educational resources and training programs
Cohort study of junior doctors (F2 to middle grade, n = 22) working in different emergency departments in the UK (predominantly Worthing hospital).
Confidence in wound care management was assessed using a self assessment questionnaire where participants would gradehow confident they felt in different wound care scenarios.
Competence was evaluated using a series of single best answer questions (based on hospital and best practice guidelines) common scenarios that can present in wound care in the emergency department: dressing types and suitability, basic suturing techniques, risk factors for delayed healing and criteria for referral to a specialist plastic surgery centre etc. Answersfromallparticipantswere then combined to identify common knowledge gaps that can be targeted.
Participant's self-assessed confidence in different aspects of wound care Confident Unconfident
"Medical school adequately prepared me for wound care management"
Competence in wound care as per SBA score
Results
Only 20% of participants felt confident in wound care overall in the emergency department.
Participants felt least confident in knowing when a patient needed referral to plastic surgery (15%), and most confident in applying interrupted sutures to a wound (90%).
Only 5% felt medical school had adequately prepared them for wound care management.
Score greater than 50% Score of 50% or less Strongly agree
Only 33% scored higher than 50% in the competence SBA assessment. The lowestscore in the SBA was 0%, the highest was 75% The average score was 42%.
Know where to find help with wound care when seniors are busy
"A concise intranet resource for wound care management, that we could refer to out of hours, WOULD be useful" Very confident
1. Junior doctors are neither confident nor competent in wound care
2. Medical schools currently do not adequately train medical students in wound care
3. There are notsufficient online resources to provide accurate wound care guidance
4. Juniordoctors are not sufficiently supportedout of hours in wound care management
Have a reliable online resource they can refer to for help with wound care management
Only 40% were able to correctly list 3 woundcriteria that would mean a referral to plastic surgery should be made
Only 5% wereable to correctly identify iodine wash should be used with cation
63% wereable to correctlyidentify ONE dressing that should be used on a wound type (bleeding wounds). Only 18% were able to correctly matchall dressings towound type
>60% of participants said it took between 1-2 hours to receive a plan from the local plastic surgery centre once the referral had been made.
Only 32% felt they knew where to find help with wound care if seniors were busy or it was out of hours.
Only 4.5% felt they had a reliable online resource they could refer to for help with wound care.
73% felt a concise intranet resource to help with wound care would be useful
5. Junior doctors can correctly identify areas in wound care where their knowledge is lacking
6. Better education in woundcare is needed
7. Waiting for specialist advice from plastic surgery is excessively time consuming
Yes No
Next steps
Iam working withWorthing hospital A+Econsultants and advanced nurse practioners (ANPs) to create a concise, evidence based, online guide ; that junior doctors can refer to for help with wound care. This aims to be a comprehensive guide, but with special focus on the knowledge areas that were identified in this study to be lacking e.gplastic surgery referralcriteria.
In thefuture wehopeto design a complete wound care course that junior doctors will complete during their A+E rotations. This will include a series of teaching sessions from senior doctors and ANPs. On successful completion of the course junior doctors will be provided with a certificate.
Authors – Carey C1, Natarajan S2
Introduction
• Pre-DM isheavily linked to high carbohydrate intake
• Many are unaware of what dietary improvements can be made
• 1-to-1 consultations focused on reducing carbohydrate intake can improve pre-DM (1)
Aims
• Improve patients'understanding of pre-DM over 1–2 weeks
• Reduce carbohydrate intake using 1-to-1 dietary consultations
• Drivers of improvedknowledge about pre-DM and dietary interventions were identified (Fig1)
• Patients were identified and selected using EMIS reports(Fig2)
• A questionnaire was constructed based on the UKDDQ and used to interview patients
• Carbohydrate reduction advice was given verbally and a diet sheet produced by Unwin et al was provided
• A second call after 7– 14 assessed the impact of the advice
Conclusions
• Awareness of thecontribution of carbohydrates to pre-diabetes improved followingthe consultations
• Pre-diabeticpatients should be given verbal and writteninformation about lowering carbohydrate intake
On average, there are three major haemorrhage (MH) calls a week at the Royal United Hospital (RUH), Bath, UK. As junior doctors working in different departments, we observed varied practice and confusion about how to utilise the MH call. After several serious incidents at the RUH which involved significant delays in transfusion following a major haemorrhage call, we formed a multidisciplinary team (MDT) to address this issue.
Primary Aim: To reduce the time between MH protocol activation and the start of transfusion by 25% by December 2022. Secondary aims include improving confidence of staff in managing an MH call and improving staff knowledge of the MH protocol. Our study excluded obstetric MH calls as they had already developed a separate process.
Several steps were undertaken to understand the current system and measure current practice:
1)An MDT process map identified several areas of potential delay to transfusion (Fig 1).
2)Baseline measures of time from MH call activation to transfusion showed a mean of 38 minutes from March 2021-Oct 2021 (Fig 2).
3)A staff survey showed 85% had no training in MH calls and none could correctly identify the exact personnel on the MH team.
4)‘Point of care' (POC) simulation of MH was performed to evaluate human factors and latent safety threats and test the wholesystem. We identified that correct personnel did not attend call and no-one is routinely sent to collect blood products (Fig 3).
5) Key stakeholders (transfusion committee, patient safety committee and risk register) supported the initial interventions of development of a new MH algorithm and immediate amendment of personnel alerted by an MH call.
Difficult to maintain 1:1 teaching. Approached groups to deliver larger group teaching on algorithm on departmental study days
VR SIM and algorithm
1:1 virtual reality simulation combined with ‘tea trolley training’ in 3 ‘high MH frequency’ areas; MAU, SAU and ICU
Quantitative and qualitative data collected from participants.
Developed e-prescribing ‘care plan’ and mandatory elearning video
Large group teaching combined with trauma debriefing in partnership with our Trauma Risk Management team to recognise the emotional aspect of learning from MH. Quantitative and qualitative data collected from participants.
Collected quantitative and qualitative feedback
Initial VR simulation did not produce any significant change in our outcome measure (time taken to initiate transfusion). We were limited to how many people we could train due to our own work pressures. It was clear that to establish real change we needed to target larger groups of staff without disrupting normal working. However our secondary measures (below) improved substantially and qualitative feedback was positive. Staff survey quantitative data from VR training
Trust wide teaching with e-learning and e-prescribing package
Sustainability of our project required us to develop a trust wide mandatory elearning and e-prescribing package. This cycle is still in development.
Large groups taught in multiple departments such
Target whole hospital with e-learning and e-
Staff survey quantitative data from large group training
Whilst this intervention is still ongoing, we will continue to monitor transfusion audit data using SPC chart analysis. Current SPC chart analysis shows a decrease in variation around the mean although no definite shift in practice (fig 4).
Future plans include implementing a trust wide mandatory e-learning package to allow this training to be delivered to every staff member. We are also creating an e-prescribing package to reduce time taken to prescribe blood and reduce variation in practice. These strategies will ensure sustainability of the project. Audit data analysis will be taken on by the transfusion team and will be reported to the transfusion committee a nd patient safety committee.
Dr Rachel Nigriello, Dr Chris Waters, Dr William Mears, Ms Helen Maria-Osborn, Royal United Hospital Bath
In 2021, the MBRRACE-UK report into maternal deaths revealed that there has been no statistically significant change in the disparity of outcomes for black and Asian women since 2014 ; black women are four times as likely to die, during pregnancy or shortly afterwards, than white women, while Asian women are almost twice as likely to die . Sadly, these disparities continue and affect the babies of black and Asian women. Within the first four weeks of life Asian babies have a 60% higher risk of dying, while black parents are 45% more likely to experience this devastating loss than white parents.
Interventions to reduce stillbirth and neonatal death have had more effect on reducing the rates for white families and there are recognised inequalities throughout care in neonatal units with black babies suffering most (Sigurdson, 2019). Knight et al (2021) discussed microaggression and bias as factors contributing to poor outcomes in the UK, similarly in the USA, Suliman (2021) suggested that disparities occur as a result of racism within the care that is provided, not because of the race of mothers and their babies.
A 2021 report into maternity training provision indicated that less than a third of UK trusts provide cultural specific training (Ledger et al, 2021) which made the authors reflect on their own training in which exclusively white mannequins were used.
The authors entered a Quality Improvement (QI) competition, ‘1000 words for £1000’-write 1000 words about something that could improve care and win £1000 to put this into practice. We considered all white resuscitation dolls and text books (Mukwende, 2021), alongside non-inclusive language and lack of specific training as barriers to having open conversations and the ability to fully care for all babies – ‘Can’t see, can’t treat’.
After winning, we requested the purchase of black resuscitation dolls to adapt training. However, with support from Bournemouth University we were encouraged to take this further and lead a bigger QI project, developing a training package for midwives and evaluating current knowledge, attitudes, and measuring the impact of the training.
Midwife 2
In partnership with the Equality, Diversity and Inclusion lead, a training package was created for midwives. Topics covered include implicit bias, stereotyping and microaggression and the how these can impact care. Alongside this, clinical scenarios were explored, including jaundice, assessment of perfusion at birth and beyond, and reviewing ‘red flag’ advice for parents. By ensuring co-production, including discussions with Somerset Diverse Communities, we were able to present lived experiences of black mothers in maternity care and also ensure this training was culturally sensitive.
Anonymous pre and post-training surveys were developed using simple yes or no questions and free text answers to capture basic demographics, baseline understanding pre-training and evaluation of the training and midwives understanding post-training. Descriptive analysis was used for the statistics and thematic analysis was used for the free text answers.
Will this training change your practice as a midwife?
Do you feel that maternity guidelines are supportive and inclusive for all women and babies?
The 7 steps of QI, grounded in theory from the world-renowned Institute for Healthcare Improvement, is the approach utilised within our NHS Foundation Trust and was used in this project. As part of the Plan Do Study Act (PDSA) cycle of the 7 steps we ran a pilot training session to give time to make changes and improvements to both the training package itself and the data collection if required.
Midwife 1
76.1% of midwives within the trust were trained and positively 98% of midwives will change their practice following training with areas mentioned including documentation, advice to parents and assessment at birth. 42% of midwives said they would now feel confident to challenge stereotypes in practice and would take more time with their care. Similarly, 98% of midwives expressed they had gained new knowledge and understanding from the training. 96% of midwives felt that the APGAR scoring system was not suitable.
100% of midwives indicated that trusts should be doing more to ensure their guidelines are fully inclusive and felt that healthcare settings were impacted by bias. Midwives were asked if they felt there were any differences when assessing babies from different ethnicities, pre-training 46% felt there were no differences compared with 93% recognising these differences post-training. Surprisingly, only 62% of the midwives had heard of implicit bias before the training session.
The thematic analysis found three themes, a quote highlighting each has been includedShocked about inequality and impact of bias - “Ididn’trealisetherewassomuchinequality”
Midwife 4
Positive about change - ”founditreallyusefulandwillchangemypracticeinapositiveway” Midwife 5
Not ready to accept - “asamainlywhiteBritishgroupitisinevitable” Midwife 6
A key recommendation for practice from this project is that training equipment needs to be representative of the population and while training mannequins alone are not the answer, they do allow a starting point for conversations and understanding. Training, alongside these mannequins for maternity staff must include recognition of the rates of inequality, both for women and babies and impact of bias. Trainers need the knowledge to be able to give evidenced based answers to questions that are raised regarding assessment of babies from black and Asian backgrounds, as recommended by Healthcare Sa fety Investigation Branch (HSIB) in 2021 following the death of a three-month-old baby. We must consider language used and use of the APGAR scoring system as it stands today and ensure that care provided promotes equity. Continued poor awareness of implicit bias and its subsequent effect on patient safety must be understood to provide families with safe and personalised care (Parker, Corden and Heaton 2011; NHS England, 2016) and work to reduce unacceptable disparities. Maternity units need to look with fresh eyes at their guidelines to ensure they are inclusive, and training and equipment nee ds to be representative of the population.
Following the presentation of this project NHS England and NHS Improvement - South-West have purchased mannequins for all maternity trusts in the SouthWest region which is an exciting first step.
“Most valuable training I’ve had in a long time”
“Thank you for this, so valuable -it will make a difference if we all attend!”
“I feel braver to challenge bad care and racist comments” (post-training)
Midwife 3
The transitionfrom medical student to Foundation Year One (FY 1) doctor can be challenging,especially in a fast -paced specialty as GeneralSurgery. New FY 1soften face asteeplearning curve in acquiring ward-basedknowledge while providing patient care The aim of this project was to ease thetransition period for new foundation doctors in General Surgery by creating an electronic handbook and videoresource for both learning and referencepurposes.
We had a 66.7%response rate from the FY 1s for both the pre and post intervention surveys (n=6/9). The pre- implementation surveyshowed half the FY 1s ( 50% n=3/6) didnot feel prepared to work on General Surgery. One third of the FY 1s( 33.3% n=2/6)reported insufficient resources to answer common ward -basedquestions. Figure
The QIP is designed to continue over one year Data will be collected every four months to reflect FY 1changeover. The posterhighlights data collection from the first set of FY 1s.
AIM:
To improve efficiency in completing ward-based tasks to subsequently facilitate patientmanagement.
INTERVENTION:
Created an electronic handbook and pre-recorded video to provide easy access to important ward-based information.
MEASURED OUTCOMES:
Overall FY1 confidence: using pre and post intervention feedback forms Confidence in carrying out specific ward-based tasks and ability to answer ward-based questions
Free Text feedback for suggested improvements
We ran three PDSA cycles in -order to create the resources and measure the above- mentioned outcomes ThePDSA cycles are outlined in figure3 below
PDSA Cycle 1: Identifying the improvement focus.
PDSA Cycle 2: Formal Feedback PDSA Cycle 3: Evaluating project impact.
- Night Shift Guide
-Handover List
- Daily Schedule
-Clerking Processes
- Booking a patient to theatre
- Medications
- Requesting scans
- Chasing scans
- Making Referrals
- Discharge summaries
- Common bleeps/contacts
Figure 4: Ward-based tasks assessed in pre - and post-intervention questionnaires
post-guide
The pre-implementation survey was used to identify areas the FY 1shighlighted as important The topics with the highestvoteswere working a night shift (n=3), preparingahandoversheet (n=3) and the daily SAU schedule (n=3). All of thesetopics and more were included in the handbook and video.
Following the pilot introduction of the handbook a post -reference guide feedback form was sent. This showed 100% of the FY 1s had (n=4/6 agreed, n=2/6 stronglyagreed)improvedconfidence at work in all ward - based tasks assessed. An improvement in medianconfidencelevels on a5- point Likert scale was observed in all areas including: working night shifts, clerking patients, preparinghandover lists, prescribingmedication and fluids, and writing discharge summaries.
This QI projecthighlighted the gap in ward -based information given out to new rotating FY 1s and the benefit of having a formal resource to address the issue
We learnt the importance of the multidisciplinary teamwhendeveloping an information resource It elucidated the differentperspectives of how ward based tasks could be addressed.
Using afreetextfeedback box expanded the breadth of the qualitativedata in developing the project. Additionally, we found WhatsApp to be a more accessible platform to distribute resources and retrievefeedback.
Moving forwards there is scope to develop similar resources for otherspecialities including community-basedplacements and mandatory FY 1requirements such as the Horuse- Portfolio
This projectdeveloped our networkingabilities liaising with different members of the surgicalteam to source out information and time management skills
5: Overall level of confidence
Figure 6: Confidence improvements in individual tasks
Figure 1: Pages from the Electronic Handbook
Figure 2: Showing Aims, Intervention & Measured Outcomes
Figure 3: Depicts the three PDSA cycles
Dr Megan Foster, Dr Ryan Beazley
Junior doctors rotate regularly through different hospitals and trusts. We know that guidelines between hospitals differ, which makes keeping up with changes difficult. We recognise that at Musgrove Park Hospital (MPH), juniors are finding the trust approved guidelines difficult to access and understand, resulting in increased use of non-trust guidelines (i.e. google!).
Alterations made to the cards to improve usage: size, content, QR codes. Cards distributed to larger group.
We measured difficulty in both finding and understanding guidelines, rated 1 (easy) to 5 (difficult), alongside the usage of trust/non-trust guidelines per week.
Use
Non-trust guidelines
Our preliminary survey of 24 F1s found that whilst 100% aimed to use trust guidelines at work, 70% found them difficult to access and 50% found them difficult to understand. This led to the average use of nontrust guidelines 3-4 times per week.
Introduction of trust specific lanyard flashcards to 2 F1s, containing 12 topics voted by their peers.
1.For all F1s at MPH to have easily accessible and comprehensive guidelines by August 2022, as voted by pre and post intervention questionnaires.
2.To reduce use of nontrust guidelines to 0-2 times per week by August 2022.
1. Reduction of difficulty in both accessing and understanding guidelines.
2. Increased confidence amongst juniors, as voted by questionnaire.
3. Reduced use of non-trust guidelines from on average 3-4 times/week to 0-2 times/week.
1. Feedback suggested F1s were less likely to use the cards as they were ‘too bulky’ and some included useless information.
2. Questions raised as to the reliability of cards once trust guidelines are updated.
1. Reduce the size of cards and limit information.
2. Include QR codes on each card linking to the most recent guidelines (updated regularly by MPH).
3. Distribute the updated cards to all medical F1s at MPH for PDSA cycle 2.
In order to provide safe and high-quality care, it is imperative that staff ensure that they look after themselves physiologically and psychologically first.
This has been particularly important during the COVID pandemic. The huge burden of patient care and demands on staff, combined with new ways of working and unpredictability, has perversely meant this self-care has been often overlooked by staff. This leads to burnout& sickness and therefore impacts patient care.
The SCReaM Human Factors (HF) and Team Resource Management Programme at the Royal Surrey NHS Foundation Trust, as part of its remit,delivers multi-disciplinary Human Factors (HF) training. Part of our SCReaM HF training is ensuring that staff are placed at the centre of patient safety, requiring them to implement self-care as a priority.
To empower our delegates to translate their learning into practice, they undertake a pledge after their course -something that they have taken away from our HF training thatthey wish to try out to improve their working lives.
In March 2020, at the start of the pandemic, we aimed to empower staff to recognise and implement ways to improve their physiological and psychological wellbeing. We did this using the for and the previous QI work we had undertaken to translation of learning into practice after classroom training prior to the pandemic.
To accomplish this staff empowerment, we developed a number of change ideas and undertook PDSA cycles to adapt and improve delivery of our HF training during the pandemic. We transitioned from a classroom to a virtual format, refreshed both our course content and pledge sessions to increase the translation of self-care related learning into practice.
The measure that we used was the number of completed self-care themed pledges made after each course. We looked at the impact of our change ideas following March 2020.
Continue HF training during the pandemic
Delivery via a virtual platform to enable ongoing training during the pandemic
at home with no work interruptions. Several IT issues noted.
Difficult to facilitate interactive conversation in virtual environment.
Improve frequency of comfort breaks. Improve IT planning & support. Improve interactive discussion relating learning to daily working lives.
New structure to enhance interactive discussion about life on the frontline and to improve relevance of self-care to working lives
Give delegates to make the focus of their pledge selfcare
Changes to pledge mentor session
Alter structure and content of programme for increased short comfort breaks. Relevant self-care content to tailor to need during pandemic. Introduce course expectations to enhance safe
Delegates given peer examples of self-care related pledges. Used a professional duty approach
Smaller breakout groups for pledges with mentors
Increased interactive discussion and engagement.
Delegates wanting to put learning into practice regarding selfcare, but felt disempowered to.
Perception of whether awas acceptable
Some delegates found it more acceptable to undertake self-care based pledges in feedback. Missed opportunities in mentor groups noted by faculty
Increased self-care pledges made on course. Smaller groups enabled delegates to sound out self-care ideas and receive support in planning and actioning
Number of completed pledges before March 2020: 81
Number of completed pledges after March 2020: 99
Identify ways of improving acceptability use pledges to provide staff with an opportunity toe.g. peer examples of selfcare pledges during training and change of approach to self-care as a professional duty
Use mentor groups to capture opportunities and further enhance acceptability
Expand awareness of acceptability of self-care and challenging perception that self-care is a professional duty rather
We saw more than a five-old increase (5% to 28%) in pledges related to selfcare after March 2020, following implementation of our change ideas.
Change idea testing has allowed us to set up robust facilitative style HF trainingvirtually, enabling continuation of HF training opportunities during the pandemic.
Tailored mentor sessions increase the number and quality of self- control. Givingstaff the permission,that they believe to be required, is a priority to change their perception of self-care from Providing past examples of self-care themed pledges gave staff the acceptability that they need to on their own oxygen mask
Embedding the virtual model of training in the future alongside our classroom training to make HF training more accessible to a wider audience. We aim to empower staff to implement changes related to self-care. By celebrating the positive impact of the changes that people have noticed through their self-care pledges, this -care within the Trust.
We have reflected onpledge process and are developing further change ideas to look at barriers to completing pledges, particularly those related to self-care.
Aim
To ensure pa5ents with substance misuse and dependency issues are correctly informed of driving safety informa5on as per DVLA guidelines.
1.To assess and improve healthcare professionals’ knowledge and understanding of DVLA guidelines in rela5on to substance misuse.
2.To improve the recording of driving safety advice for pa5ents with substance misuse and dependency issues on discharge leGers.
• In 2019/20, alcohol-specific conditions were accountable for 347,761 hospital admissions in England, (equivalent to 2%).1 Twenty-seven percent of adults living in the North West consume more than the weekly recommended amount, making this the second highest region in England for excessive alcohol consumption.1 Drug use is also increasing in Greater Manchester; over the last decade, there has been a 74% rise in drug related deaths within the region.2 Hospital admission rates for alcohol-related conditions are around 53% higher in Greater Manchester than elsewhere in England.
• The DVLA requires individuals with certain medical conditions to self-report, as their ability to drive safely may be affected.3 The General Medical Council (GMC) states that it is a medical practitioner’s responsibility to ensure patients are aware of this requirement 3 The DVLA have published guidance outlining which medical conditions require DVLA notification which includes substance misuse/dependency issues.4 Previous research has demonstrated that there is poor awareness of these guidelines amongst healthcare professionals and patients. 5
Although 12 to 15% of all NHS A&E admissions are alcohol related, and drug use amongst adults increasing, previous research conducted has demonstrated a lack of awareness amongst both patients and healthcare professionals regarding the impact of substance misuse on driving safety.5 Although results from papers consistently show that UK doctors’ awareness of DVLA guidelines (in particular in relation to substance misuse/dependency) is limited, very few studies have been published, with many conducted over 5+ years ago. No recent studies, audits or QIPs on this topic have in the North West, although this represents the second highest region for alcohol excess.1
• Alcohol misuse
• Alcohol dependence
• Alcohol related disorders such as: hepa*c cirrhosis with chronic encephalopathy alcohol associated psychosis, cogni*ve impairment
• Alcohol related seizure
• Drug misuse or dependence
• Seizure associated with drug use
Plan
Baseline data collected to determine current practice within AMU with additional survey to establish healthcare workers’ knowledge and understanding of issues.
Educa5on of pharmacists who check TTOs with aim to flag missing safety informa5on to clinicians
Posters to raise awareness of DVLA guidelines placed near computers in AMU
Driving safety information question added to electronic discharge proforma
Proposed interventions for target-group formulated and timeframe over which to deliver (6 months).
Reflect upon results and determine effectiveness of intervention and strategize and adjust future interventions.
• Departmental teaching not that effective –numerous team members unable to attend. Will likely need repeated refreshers delivered at end of other teaching sessions especially due to rotation of staff.
• Group WhatsApp messages able to reach all team members.
• Appears more effective in reminding staff to check and document.
• Research has demonstrated poor awareness of DVLA guidelines amongst healthcare professionals in relaAon to substance misuse
• The survey results reflect this and this has translated into poor documentaAon of driving safety informaAon in discharge leEers
• Although change can be slow and takes Ame and perseverance, text reminders have shown a posiAve improvement
• Future PDSA cycles are necessary to gain a beEer picture of data overAme to determine which intervenAons are most successful in creaAng change
P S A D
Initial survey results
• Over 90% of healthcare workers have daily/frequent contact with patients with substance issues
• However almost three-quarters ‘rarely’ or ‘never’ enquire about driving-status
• Case-based questions concerning driving and substance misuse/dependency averaged a 44% incorrect response-rate
Baseline data
• Over a two month period, 60 patients admitted to AMU had DVLA reportable substance issues
• Only 2/60 (~3%) of discharge letters contained driving safety information
• The information for both letters was in relation to alcohol withdrawal-seizures
First intervention: Departmental teaching
Second interven5on: WhatsApp messages
Reminder WhatsApp messages sent on AMU WhatsApp group containing all AMU junior doctors
• Data collected following each interven5on.
• Daily acute-take list examined to detect pa5ents admiGed with substance misuse and/or dependency issues.
• Discharge leGers further inspected to assess for inclusion of driving safety informa5on for those mee5ng DVLA criteria
First intervention: Departmental teaching
• Marginal improvement
• Around 7% of discharge letters contained driving safety information for patients admitted and discharged from AMU over 14 day period
Second intervention: WhatsApp messages
• Data collected over 14 day period.
• 30% of discharge leGers for pa5ents contained driving safety informa5on for pa5ents discharged from AMU
References
4.
5.
DR OLIVER GEORGE, DR GEORGINA SANDERSON, IZZY ELKINGTON, DR THEA MORGAN & DR RICHARD CRAIG
Peripheral intravenous cannulation is essential for the treatment of many patients in hospital. Establishing intravenous access can be challenging 1. Repeated cannulation attempts and subsequent delays in obtaining intravenous access have significant implications for patient safety and experience 2,3. Patients with difficult intravenous access are frequently escalated to the anaesthetics team within the trust, forming an appreciable contribution to on call duties. In patients with difficult intravenous access, ultrasound-guided cannulation is associated with increased overall success rates and fewer complications compared to standard techniques 3-5
• Difficult intravenous access referrals to the anaesthetics team were surveyed using a two-part form, the first section completed by the referrer and the second by the individual receiving the referral. Initial data collection demonstrated 4.8 cannulation attempts on average prior to referral.
• Difficulty obtaining intravenous access was associated with delays to medication administration in 79% of cases (FIGURE 1), this included blood transfusions, intravenous antibiotics and fluid resuscitation.
• Further data collection demonstrated that anaesthetists used ultrasound-guidance techniques in 55% of patient referrals.
• Only 20% of referrers had attempted ultrasoundguided cannulation prior to referral (FIGURE 2).
• Of those that had not attempted ultrasoundguidance techniques, 31% had not received training, 31% reported that ultrasound equipment was not available and a further 25% reported both lack of training and availability of equipment (FIGURE 3).
Reduce delays to intravenous medication administration in patients with difficult intravenous access, and thereby improve patient safety. Our initial results highlight two key areas for improvement: (1) ultrasound equipment availability on the wards and (2) access to ultrasound-guided cannulation training within the trust.
A driver diagram, as outlined in FIGURE 4, provides a framework to explore factors that influence intravenous medication administration in patients with difficult intravenous access. Access to ultrasound-guidance cannulation training and ultrasound equipment form two of the primary drivers, reflecting the two key areas for improvement identified in our initial data collection. A Plan-Do-Study-Act cycle for establishing ultrasoundguidance cannulation training within the trust is illustrated in FIGURE 5.
Identification of patients with difficult intravenous access
Access to ultrasound equipment
Assessment
Documentation & handover
Equipment availability
Postgraduate training
Reduce delays to intravenous medication administration in patients with difficult intravenous access
ACT Following analysis, we plan to: (1) review the interventions and make adjustments as appropriate, and (2) share the results at relevant clinical governance meetings and with key stakeholders (described previously, see PLAN).
STUDY Following completion of further training sessions, we plan to re-analyse difficult intravenous access referrals to the anaesthetic team using the same two-part form as previously and compare these results to baseline. Our main outcome measure is the number of patients with delays to intravenous medication administration due to difficulty establishing intravenous access.
Routine use of intravenous access assessment tool on admission
Record alert on patient record
Increase awareness of equipment availability, locations and sign out processes Purchase new equipment / regular equipment checks and services
Undergraduate training
Ultrasound-guidance training for postgraduates
Ultrasound-guidance training
Escalation when unable to obtain intravenous access
Ultrasound-guidance training for undergraduates Multidisciplinary team training
Familiarity with equipment available
Escalation to senior team members
Referral to anaesthetics team
Ultrasound-guidance training for Multidisciplinary team
Opportunities to practice Referrals process
PLAN Using the driver diagram outlined in FIGURE 4, we considered factors that influence ultrasound-guidance training (postgraduate, undergraduate and multidisciplinary team training, and familiarity with equipment available) and identified relevant change ideas. Discussions with key stakeholders included: anaesthetics consultants and trainees, acute medicine consultants, chief nurse, midwives, vascular access practitioners, postgraduate and undergraduate medical education departments.
DO Established weekly ultrasound-guidance training drop-in sessions in Swindon academy:
• Available to postgraduate trainees, undergraduate medical students, nurses, midwives and Allied Health Professionals across all specialties within the trust.
• Portable wireless SONON® 300L ultrasound and standard cannulation model used.
• No previous ultrasound experience required; opportunity to practice and develop skills.
• Purchasing additional equipment for ultrasound training (cannulation and otherwise); same equipment as available on the wards to ensure transferability of experience.
• Low response rates to the surveys limited our data collection. Following discussions with the anaesthetics team and colleagues from each division within the trust, we have adapted our forms to improve future engagement. We are also working with the pharmacy team to collect further data from the electronic prescribing systems regarding intravenous medication delays due to lack of intravenous access to guide further PDSA cycles.
• Future PDSA cycles aim to focus on improving access to ultrasound equipment for clinical use. As outlined in the driver diagram (FIGURE 4), change ideas include:
(1)increasing staff awareness of the current equipment available for ultrasound-guided cannulation within the trust, (2) ensuring consistent availability of equipment and ‘sign out’ processes during the day and out of hours, and (3) purchasing additional equipment as required.
• Key learning points from this Quality Improvement Project include liaising with key stakeholders from each division within the trust and forming a business case for the purchase of additional equipment for training purposes.
BMJ Open 8, (2018). // 2. Fields, J. M., Piela, N. E. & Ku, B. S. Association between multiple IV attempts and perceived pain levels in the emergency department. J. Vasc. Access 15, 514–518 (2014). // 3. Liu, Y. T., Alsaawi, A. & Bjornsson, H. M. Ultrasound-guided peripheral venous access: a systematic review of randomized-controlled trials. Eur. J. Emerg. Med. 21, 18–23 (2014). // 4. Davis, E. M. et al. Difficult intravenous access in the emergency department: Performance and impact of ultrasound-guided IV insertion performed by nurses.
The COVID-19 pandemic has had an unprecedented effect on medical education in the past 2 years, affecting 2 cohorts of final-year medical students. In particular, a study completed by Choi et al1, found that, on average, 59.3% of the student cohort felt less prepared to start FY1. In particular, they felt that the postponement or cancellation of student assistantships had the largest impact on this.
Tolsgaard2 described a framework of “continue, postpone, adapt, drop, and add”, to consider how aspects of medical education could be changed. Taking this into account, a ‘Virtual On-Call’ simulation session was set-up at King’s College Hospital to develop a COVID-safe environment for in-person teaching. The sessions, facilitated by current foundation doctors, allowed final year medical students to experience an ‘on-call’ with case-based scenarios. Students were asked to review patient, by means of a case file, thus allowing them to consider the management of an acutely unwell patient. They also had opportunities to learn how to prioritize jobs, along with giving and taking handovers.
Establishing ‘VIRTUAL ON-CALL’
P• Set-up weekly simulation-based teaching sessions facilitated by juniors doctors.
• Design feedback form to measure pre- and post- session confidence levels of students
• Introductory talk given at Induction
D• Liaise with PGDME* about attendance
• Created WhatsApp group for facilitators
• Created QR codes for easy access to feedback form
LOGISTICAL:
• Low uptake of feedback forms
• Inconsistent attendance
S• Difficult punctual 5pm start time
TEACHING CONTENT:
• Identified out-of-date scenarios/materials
OUTCOME MEASURE:
• Global improvement in confidence levels
LOGISTICAL:
• QR code re-displayed with weekly WhatsApp reminders
A• PGDME staff to send weekly reminders
• Start time moved to 5.15pm
TEACHING CONTENT:
• Updated scenarios with up-to-date clinical guidelines
“
▻ To adapt an in -hospital simulated teaching program to a COVID-safe classroom setting and continue to provide equally high-quality teaching.
▻ To improve final year medical students’ confidence in managing the acutely unwell patient, prioritizing tasks, giving an effective handover, and knowing how to escalate.
▻ The level of confidence along with other data was collected using a pre - and post-session feedback form between August 2021 and April 2022.
▻ The QI project used the model for improvement methodology, there were 3 PDSA cycles completed within this period.
CYCLE 2: Nov 2021 – Jan 2022
P• Continue weekly VOC and feedback collection
• Implement changes identified in Cycle 1
D• Refresher introductory talk given at induction
• Changes implemented from Cycle 1
LOGISTICAL:
• Improved feedback uptake and attendance
• Difficulties with facilitator engagement
STEACHING CONTENT:
• Students wanted formal handover teaching
OUTCOME MEASURE:
• Nil adverse impact on confidence levels from changes implemented
LOGISTICAL:
A• Email sent to foundation/IMT doctors for recruitment, with certificate incentive
TEACHING CONTENT:
• SBAR handover teaching at start of sessions implemented
"Some of the notes could be replaced/information has worn off
P• Continue weekly VOC and feedback collection
• Implement changes identified in Cycle 2
D• Refresher introductory talk given at induction
• Changes implemented from Cycle 2
LOGISTICAL:
• Difficulty with real-time communication between facilitators/students
STEACHING CONTENT:
• Students wanted takeaway written material to support teaching given OUTCOME MEASURE:
• Continue overall improvement in confidence as reported by students
LOGISTICAL:
A• Virtual Noticeboard created to facilitate communication for real-time logistics changes
TEACHING CONTENT:
• A4 summary document drafted about SBAR handovers, job prioritization.
“ We had great facilitators who ran the session well and had great tips for us. I found having done the on-call session a second time I felt better and more confident.
“ [I would like] More practical advice e.g. how to contact colleagues, chain of escalation, writing a jobs list
Each question asked the students to rank their confidence in that particular skill on a scale of: ‘very unconfident’, ‘unconfident’, ‘neutral’, ‘confident’ or ‘very confident’. These answers were then allocated a numerical values from -2 to 2 respectively. An average was taken pre- and post- session for each cycle of students to demonstrate thetrend and allow comparison from cycle to cycle. Results demonstrated consistent improvement in confidence across all aspects. Due to the small number of students involved, it is difficult to prove statistical significance. Free-text answers also provided qualitative data and specified teaching content feedback.
WHAT WENT WELL:
• We were able to identify and adapt teaching content to student feedback, allowing appreciation of:
▻ Autonomy of managing simulated patient scenarios
▻ Reviewing practical aspects of on-call logistics with facilitators
▻ Effective handover techniques
• Effective use of technology to improve ease of organization and access to teaching materials/feedback
• Communication between VOC leadership team, facilitators, PGDME, and students to relay realtime logistical challenges and unforeseen delays
• Identifying methods to ensure consistent facilitator engagement across the year
• Feedback was student-focused, there is a gap for facilitators to feedback on barriers to effective teaching delivery
NEXT STEPS:
Introduce a feedback form for facilitators to identify barriers to delivery of teaching
Set-up real-time communication platform to triage logistical issues
Post COVID/ COVID-safe reintegration into hospital setting
PDSA 4: Formal handout sheet for distribution post-session (SBAR handover, prioritization)
• Bespoke therapist CO training
• Competency sign off
• Regular communication with teams / key stakeholders
• Data collection
• CO mandated for all visits
• Follow set escalation pathway
• Modification to escalation pathway
• CO mandated for initial visits only
• +vestaff feedback
• 67% CO compliance
• 89% followed escalation pathway –clinically reasoned if not followed
• Drop in CO compliance – 40%
• 90% followed escalation –proactive community Rx & no adverse outcomes
• CO Compliance ↑ 84%
• 98% followed escalation
•Providing CO training and clear escalation pathway provides benefits to staff and patients.
•Internal escalation pathway has enhanced MDT working within ICTs and Rapid Response.
•Evidence of earlier identification of deteriorating patients, leading to proactive community treatment and potential admission avoidance.
•Reduced response times for clinical support by using the right person at the right time.
Amend Low / Medium risk classification on escalation pathway
Amend when to mandate taking CO to support clinical autonomy
Test in another locality
•Upscale to all ICTS within Gloucestershire.
•Embed within therapist training matrix.
•Capture future data within Trust’s NEWS2 audit.
•Build on collaborative working with Urgent Care Directorate.
•Review need and benefit of advancing practice roles for therapists.
Language barriers in healthcare result in miscommunication between medicalprofessionals and patients. This can affect patient satisfaction and quality of care. This is particularly important in the emergency department triage setting, where the initial assessment determines the urgency with which the patient will be managed.
To assess the impact of an Arabic triage sheet on the perceived efficiency of the triage process.
Questionnaires were sent totriage staff and Arabic-speaking members of staff to gauge the effectiveness of current methods used to triage Arabic-speaking patients, and the disruptions to clinical practice and training caused by the pressure placed on Arabic-speaking members of staff to interpret on an ad hoc basis. An Arabic triage sheet containing pictorial depictions of common clinical presentations with the terms written in English and Arabic was then designed and made available in all A&E triage rooms at St. Mary’s Hospital. Afterastudy periodof 2 weeks,surveys were issuedto triage staff to qualitatively assess theimpact of the intervention on thetriage process.
87.5% of triage staff saidthey encounter an exclusively Arabicspeaking patient 2-4 times per shift, with 12.5% reporting 5-7 times per shift. 87.5% agreed that triaging Arabic-speakers is significantly slower than triaging English-speakers. Methods employed to communicate include language line, Arabicspeaking staff, family and online translation tools. The majority of Arabic-speaking staff reported that their clinical work is disrupted by having to act as an ad hoc interpreter. Following the introduction of the triage sheet, 100% of triage staff agreed that it made the triage process more efficient.
Despite not being a replacement for a thorough clinical history, an Arabic language triage sheet helped streamline the triage process and ease the pressure on Arabic-speaking members of staff. This model can be applied in other settings where an A&E department caters to a significant minority of non-English speakers.
Royal Devon & Exeter Hospital: Dr Luke Glover, Dr Simon Brackley, Dr Lucy Andrews, Dr Georgia Wright,Dr Lauren Eddy,Dr Miles Edwards,Dr Riordan Deehan Jackson, Dr Smruthy Chakka
Discharge summaries are vital for ongoing patient care and often contain important tasks for GPs ( Abrashkin et al 2012)
Delayedsending creates additional workload for GPs, hospitaldoctors and administrative staff and risks patient safety ( Kripilani et al 2007)
At our hospital, we have had numerouscomplaints regarding the impact of delayed discharge summaries on patient care
We aimed to increase the percentage of discharge summaries sent to GPs within 2 working daysto 90% across all departments by 14th July 20 22
22.6% of discharge summaries (12965/57367) were not sent within 2 working days
0) to present
We stratified these unsent summaries by location, specialty, discharge method, day of week and hour of day in order to target our tests of change
Cycle 1: Creating a "culture of completion" Intervention We engaged the medical problem, issued them a poster and asked that they encourage junior doctors to send RIP summaries at the time of writing death certificates
Result -6 week increase incompletion within 2 working days of deceased discharge from 50- 80% (run chart below -intervention at red line)
Cycle 1: Colorectal
Intervention -Changinguse of "lists" by colorectal doctors to include discharged patients with unsent paperwork within 30 days
Result - We realised our initial data collectiondidn't allow sole measurement of colorectal discharges. We also had poor take - up. We were grateful for starting on a small scale and learnt from this for our next cycle
Cycle 2: Respiratory
Intervention Learning from cycle 1, we targeted a respiratory ward (where our data allowed measurement) and engaged all doctors on the ward
Result -Though we now had 100% uptake, the intervention has as of now had no effect (run chart below change at red line)
75% of delayed summaries are signed but waiting for the final administrative step of clicking send
It represents the largest potential area of improvement
What we learnt - with the right approach there is the capacity to meet our target. "Soft interventions" like posters have temporary effects as their initial impact diminishes
Plan for Cycle 2: Our next intervention must be more robust. We plan to practically automate creation of deceased discharge summaries and have begun discussions with the ME's team
What we learnt - We asked therespiratory doctors who were ambivalent about using the changed list. We must make sure our next intervention is not perceived to increase work. Our cycle also coincided with changeover of doctors to different teams
Plan -Implement trust- wide changes to our EPR so summaries automatically send to the GP when signed
Result -We thought this was in process, but meetingthe trust's digital fellow, found that little progress had been made
What we learnt - Implementing change is difficult, with multiple factors at play. Early MDT support is critical
Engaging Stakeholders
Intervention -We attended two trust taskforce meetings where we presented our data & reasoning for the change
Result - We have the support of significant members of the medical staff and consultant body
Future plan: Pushing change requires careful thought about who is affected (patients and staff). After further consultation we hope to make this software change and measure its effect on a day- by- day basis
Our major advantage in this project is the extremely detailed continuous measurement we have managed to create and analyse
By engaging with stakeholders , we can combine the subjective feedback with the above data to target our tests of change
It is a big problem to tackle. Our parallel approaches to target different aspects, combined with small tests of change and learning from previous cycles gives us confidence in achieving our aim
There are multiple considerations for future cycles that we have learnt: the rotation of healthcare staff during testing (and later implementation), the balancing measures that need to be considered (e.g. workload in midst of a pandemic) and the importance of early MDT involvement and co mmu nication
Our Pareto chart suggests our most powerful change may be through targeting the signed unsent summaries, with the potential to exceed our target.We are currently in discussion with groups across the trust to make this happen
Figure 1: summaries (DCS) sent within 2 working days from 76% to 87%, although unmeasured at the time.
Figure 2: One example of the powerful nature of our data collection in this case the ability to see how many discharge summaries are not sent within 2 days by each hospital specialty.
Introduction
Falls have significant morbidity and mortality and these are more common and more likely to cause significant harm in NH residents. We have proposed that by improving education to NH staff, we can reduce the amount of 999 calls and reduce adverse patient outcomes. NH residents are more at risk of further falls as interventions and risk factor modification is more difficult.
Phase 1 We looked at the NH in SBUHB (Swansea and Neath) and all 999 calls between 1st Jan 2020 to 28th Feb 2022 where an Emergency Ambulance vehicle attended the scene. We looked at calls coded as Falls and could be Falls+ (Sick person, trauma injuries, convulsions/ fitting, Haemorrhage/lacerations,fainting). A survey was sent out to NH to see how the staff treated falls.
Phase 2 ENP/SpR delivered an education package to NH staff members encouraging staff to consider CWTCH
• Can we move them
• Will it harm them? (neck pain, back pain),
• Treat them – pain relief, dressing wounds
• Can – eat & drink
• Help – when to call 999). A survey was then performed showing whether staff felt more confident post intervention and whether this would change their practice.
Phase 1 4907 calls were made, 866 were coded as falls (17.65%), 1032 were potential falls (21.07%). Over the COVID-19 pandemic the calls for falls were higher than for COVID-19 (Graph 1). Of all calls, 60.45% were conveyed to hospital, 13.50% treated at scene, 26.05% referred to GP/ alternative services. The questionnaire showed 47% of NH do not have falls guidelines, all patients are kept Nil by Mouth & 88.24% of fallers are not moved. Emergency services are contacted 88.24% of the time. Phase 2 Education was delivered to all NH in Swansea (122 staff). Feedback showed 100% feel more confident in giving food and drink, moving patients and all found the session helpful with 90.98% less likely to contact 999. There is a clear educational need as 75.40% had not received prior training. RE analgesia, 96.72 % feel more confident but comments from staff felt that this could be improved upon.
Falls remain a significant burden on WAST and ED, with opportunity to reduce morbidity and mortality. NH do not have adequate procedures and a rapid falls intervention could have an impact as 39.55% patients remained at scene. Future directions include delivering the education package to all NH in SBUHB. OPAS at Morriston Hospital offer same day assessment for NH residents via GPs and is collaborating with WAST to provide a rapid response for falls and minor injuries in the community. We are working with local GP’s about providing PRN analgesia e.g. PENTHROX for fallers.
1.Older Person’s Assessment Service (OPAS), Morriston Hospital, Swansea Bay University Health Board (SBUHB) 2.Welsh Ambulance Service NHS Trust (WAST).Introduction:
Venous thromboembolism (VTE) accounts for about 5-10% of deaths in hospitalized patients and causes significant morbidity in non-fatal cases. In response to this, a key NHS quality requirement is to assess for venous thromboembolism (VTE) risk in 95% of all inpatients aged 16 and above.1 In the 2020/2021 year, the Whittington Hospital did not achieve this requirement and it was a priority for the Trust to increase VTE risk assessment compliance to a national standard of 95%. The Whittington Hospital uses an almost fully electronic system comprising multiple different online platforms; this includes the VTE risk assessment form, which is audited annually to assess whether the trust meets national quality requirements.
All medical documentation including clerking and post take ward round proformas are recorded on CAREFLOW*, electronic prescribing is done on JAC* and the VTE risk assessment form is done on ICE*. Hence, for the clerking doctor to admit the patient and complete VTE risk assessment and prescribing, they would have to open three separate systems. This is inefficient and ill-suited to a busy admissions shift and allows for multiple gaps where human errors can occur, compromising patient safety (eg: forgetting to prescribe VTE prophylaxis or prescribing inappropriate VTE prophylaxis.) (*These acronyms are various brand names of electronic software)
Aim:
The primary aim is to increase uptake of mandatory VTE risk assessments to the national target of 95% within one acute medical admissions unit and one acute surgical admission unit. The secondary aim is to increase the number of appropriate VTE prophylaxis prescribing.
Method:
Pre-intervention data was also collected for a week prior to the first intervention for baseline data. Feedback was also collected via a questionnaire regarding the existing VTE risk assessment system on ICE to identify key issues and to gather suggestions on how to further improve the current system.
QIP data was collected from each Wednesday and Friday over 18 weeks (11/8/2021-17/12/2021) to quantify the number of VTE risk assessment forms completed and the number of VTE prophylaxis prescriptions completed. VTE prophylaxis prescriptions were also assessed to check if the prescription was appropriate for renal function, weight or if the patient was already on other anticoagulation therapy.
Image 1: 2 mandatory ‘tick box’ prompts on CAREFLOW proforma
Insights and feedback from the preintervention questionnaire
• An anonymous, online questionnaire was distributed to doctors of all grades within the Trust via a generic mailing list. This questionnaire was also flagged up during a Foundation School teaching session. 19 doctors responded to this questionnaire.
• 73.7% of respondents reported that they did not find the separate VTE risk assessment form useful
• 89.4% of respondents reported that they do not regularly complete the separate VTE risk assessment form
Image 2: Integrated risk assessment form on proforma
ACT: Intervention did not improve assessments; did not circumvent issue of multiple systems/forgetting to complete form
STUDY: n=186 11/8/2021-27/9/2021
PLAN: Raise awareness through mandatory Foundation teaching session
DO: 11/8/2021
Anticoagulation teaching session and how to access the risk assessment form was carried out
ACT: Slight improvement but still below target of 95% assessments; did not circumvent issue of having multiple systems
STUDY: n=196 28/9/2021-14/11/2021
PLAN: Include 2 mandatory ‘tick box’ prompts on clerking/Post Take proforma (Image 1)
ACT: Significant improvement in completed assessments but still below target as only implemented in Medical proformas
ACT: Significant improvement in completed assessment; but still below national target of 95%. 1 2 3 4
DO: 28/9/2021
Modified version of the CAREFLOW clerking/post take proforma was released to include these prompts: Q1: Has VTE assessment been completed? (Yes/No); Q2: Has VTE prophylaxis been prescribed? (Yes/No)
STUDY: n=95 15/11/2021-7/12/2021
PLAN: Integrate VTE risk assessment form into the MEDICAL clerking/post take proforma (Image 2)
DO: 15/11/2021
Medical CAREFLOW proformas was modified to include VTE risk assessment form. ICE risk assessment form no longer in use.
STUDY: n=69 8/12/2021-17/12/2021
PLAN: Integrate VTE risk assessment form into both MEDICAL & SURGICAL clerking/post take proforma
DO: 8/12/2021
Surgical CAREFLOW proformas was modified to include VTE risk assessment form.
CONCLUSION AND KEY LEARNING POINTS
Streamlining systems and integrating the VTE risk assessment tool into the clerking and post take proforma improves overall patient care by enhancing appropriate VTE prophylaxis prescription. Following the 4 PDSA cycles, the overall VTE assessment improved from 20.0% to 85.5%. The overall appropriate prescription of VTE prophylaxis increased from 88.0% to 95.7%.
FOOD FOR THOUGHT: A WORK IN PROGRESS
-This QIP focuses on the medical and surgical acute admission units where patients are referred from ED and clerked by the Take team. Patients who are admitted onto these wards via other routes such as elective surgery, day cases or through maternity use separate proformas and the risk assessment tool has not been integrated in this. Modifying these proformas may help to further improve risk assessments to the target of 95%.
- The integrated risk assessment tool could also include other elements such as patient’s weight & eGFR to enhance safe VTE prophylaxis prescribing. However, the benefits of this must be balanced against creating an inefficient, ‘over bloated’ proforma.
- The final intervention should be re-audited to see if the improvements in VTE risk assessment and prescription are sustained after a longer period of time
Dr Nadia Eden1, Dr Mishka Venables 1
INTRODUCTION: A large part of medical practice is making sure patients are referred to the appropriate speciality in a timely manner. Difficulties in accessing those specialties can lead to delayed diagnoses, prolonged hospital stays and generally a poorer outcome for patients.
When we first started as F1s at Homerton University Hospital (HUH), a busy central London teaching hospital, we soon realised that there was no single point of access to find out how to refer to a specialty and that there were several different methods of referral and the only way to find out was through word of mouth.
AIM: to improve the process and ease of referring to specialties by 25% by August 2021
METHODOLOGY:
Plan:
to identify patterns and barriers to referral, preferred referral pathways and suggestions for improvement
Act: an online referral directory (see Fig 1) was created and distributed via the intranet, email, Whatsapp, F1 Induction talk and included in the updated Acute Care handbook
Feedback and suggestions of the current referral systems:
• The survey found that all doctors referred at least once a week and 50% of those were referring once a day
• On a scale of 1 to 10, 44.8% of doctors rated the difficulty in referring as a ≤5, (with 10 being extremely challenging)
Do: We designed a qualitative and quantitative survey as a Google Form and distributed it to all the doctors in the hospital via email
Study:
50% indicated that they would prefer a single unifying method of referring to specialties
The other 50% all suggested electronic methods of referring
”a document on how to refer to each specialty”
“It would be easier if there was one referral system for all specialties”
METHODOLOGY:
Plan:
To evaluate the effect of the referral directory and their experience of using it
• There was afairly even distribution of preferences for the 8different ways of referring:
• Neurology, ENT and Vascular were reported to be the most difficult specialties to refer to
• The process of referring to these specialties at HUH is via paper‘Yellow Boards’ or a phone call, neither of which arein the top three preferred methods of referring.
Act:
To convert the directory into a mobile phone app available to all doctors for free to improve ease of access to the directory (currently in progress)
"It’s amazing!! So so helpful, thank you for making it"
"Excellent resource!
Hugely helpful!"
“Significant stress and ping pong process. Very stressful as unable to provide cleat timeline or clarification to patients.”
• The improvementin ease of referral went up by 8.2% (from 44.8% to 53%scoring ≤5, with 10 being extremely challenging) with the implementation of the referraldirectory
• 82.3% rated the directory ≥4 outof 5 for ease of use
• 88.2%used the directory when they were unsure how to refer
Do: We sent a follow-up survey asking for people’s opinions on the directory i.e. how much it has helped them/suggestions for improvement
Study: 82.3% rated the directory 4 or above out of 5 for ease of use. Most common improvement suggestion was regarding ease of access to the directory.
"More easily available i.e. intranet or S drive. Could be a good app"
• We did not reach our 25% improvement target, likely due to multiple factors as follows:
o Access to the directory
Ø 82.4% were aware of the directory however, feedback on the surveyshowed there is still room for improvement:
o Phrasing/scaling of survey questions
Ø Our key question for measuring the outcome: “On a scale of 1-10, 10 being extremely challenging, how easy do you find referring to adifferent specialty?
o Poorer response rate for 2nd survey
Ø 40 people responded to the 1st survey and only 17 to the 2nd one
Feedback from Cycle 2 Survey
"Added to more place and posters around the hospital"
• We did not meet our target of improving the process and ease of referring by 25%
• According to our survey, the next steps to try and achieve this would be improving access to the directory
• We are looking into creating an app to be ready to use in time for the new starters in August 2022
% of doctors that rated the difficulty of referring </ to 5 (with 10 being extremely challenging)
At Whipps Cross Hospital, every patient should have the correct named consultant for the appropriate encounter on CRS. This reduces inappropriate workload, helps to ensure investigation results are actioned by the correct person, it means other health professionals are aware of the correct team to contact, and is essential for appropriate clinic follow up on discharge. All of these relate to patient care and are important for patient safety.
The Surgical Access list is updated at least daily and reflects the most accurate method of determining which general surgical (GS) patients are admitted under which consultant. This is often not reflected on CRS and can affect patient care as described above. We compared the surgical access list to CRS for any given week. Data collected between 9th to 16th June showed that only 76% of GS in-patients had the correct responsible consultant named on CRS. Our aim was to improve this to 100%.
Continue to collect data, continue to educate juniors rotating onto general surgery about ensuring named consultant surgeon is correct
Collected data at two to four monthly intervals to see if improvements in percentage of correct responsible surgical clinicians made and sustained
Identify barriers to the correct responsible surgeon being named on clinical documentation – noted that mainly errors were occurring from patients admitted through ED
Liaised with Switchboard, ED matron, rota-coordinator and junior doctors, emphasis on ensuring the day consultant was the admitting consultant throughout the on-call week
Percentage of correct named general surgical consultants
Week beginning 9th June: 76% correct
Post intervention, week beginning 28th June: 100% correct Intervention repeated after junior doctors rotated to ensure they were aware of how to change named consultant if incorrect on CRS
Week beginning 2nd December: 89% correct
Communication between the surgical department and other departments including ED and medical staffing is key to ensure good handover and accurate responsible clinician documentation. As junior doctors rotate through the specialty, it is important for them to be informed about ensuring each ward patient has the correct surgical consultant on CRS, and how to change this if incorrect.
Further QI projects to check percentage of correct named consultants, to review if named consultant on discharge is correct and if not, impact on clinic follow up/ follow-up investigations.
Dr Louisa Morris, General Practitioner and Clinical Lead for Quality Improvement, Prince Philip Hospital, Llanelli. Louisa.morris@wales.nhs.uk
• Prince Philip Hospital (PPH) Llanelli is a 223 bed DGH within Hywel Dda University Health Board.
• PPH ‘Front of House’ consists of Acute Medical Assessment Unit (AMAU) and GP led Minor Injuries Unit (MIU)
• Pressures on existing services were analysed using retrospective data collection from Feb 19Feb20 (pre COVID-19)1
• New challenges Mar 20 onwards resulting from COVID-19 and social distancing requirements
• Medical Same Day Emergency Care (SDEC) proposed in order to address current pressures and improve patient care.
• Business case (Oct20) for pilot funding from Welsh Government (WAG) until 31 Mar 21.
• HB continued funding thereafter.
• Engagement with key stakeholders.
• Initial location & staffing model agreed
• GP led model agreed.
• Patient selection based on clinical conversation, AMB3 score / NEWS4 score and set pathways.
• PDSA 1: Phase 1 pilot: 16-19 Nov 20 (8 hrs/day Mon-Fri).
• PDSA 2: Phase 2 pilot: 7 Dec 20 – ongoing (10hrs/day Mon-Fri).
• PDSA 3: Initial pathway based model moved to a process based model with defined exclusions.
• Patient feedback via central service accessed by QR code.
• Planned next PDSA cycles:
• PDSA 4: Introduction of Advanced Nurse Practitioner (ANP) from Apr 22.
• PDSA 5: Publicity campaign aimed at key stakeholders e.g. Primary Care / Ambulance / 111
• PDSA 6: initial triage of all medical referrals to hospital by SDEC clinician.
total seen in SDEC.
Primary Drivers: Reduce Overcrowding in Hospital.
Stream patients away from front door
Welsh National Metrics for Ambulatory Emergency Care were used to set aims2
•1. Phase 1 pilot (Nov 20)
• 2. Phase 2 (Dec 20)
• 3. Process based model (May 21)
•4. Introduction of ANP (planned April 22)
•5. Publicity camp
•1. Change opening hours.
•2. Maintain new hours.
•Planned PDSA 4/5/6
From 5 April 21- 4 April 22 (Q1-Q4):
• Total patients seen in SDEC = 1098
• Average proportion of acute medical take seen in SDEC over 24 hr period 21.2% (see Fig 1) - Q1: 17.1 % - Q2: 16.2%
- Q3: 18.3% - Q4: 31.1%
• Average acute medical take seen in SDEC during hours of operation 36.51%
-Q1: 30.6%
-Q2: 28.0%
-Q3 30.7%
-Q4 53.7%
• On average 96% of patients were discharged on the same day.
• Average length of stay was 160 min.
• Most discharged with no follow-up. Other exit strategies are GP follow-up/ Hot Clinic / OPD / Acute Response.
• Patient feedback has been 100% positive to date with staff feedback overwhelmingly positive.
Secondary Drivers:Early senior doctor review Rapid access to investigations Community management where possible Improve patient experience
• 1. Open 8hrs/day
• 2. Open 10 hrs/ day
•3. Exclusions rather than inclusions
•1. Data analysis
•2. Data analysis
•3. Data analysis
• SDEC is currently operating in line with national metrics.
• Progress hindered and data skewed by recruitment issues and COVID related sickness leading to frequent short notice closures and interruption to service.
• Possible missed opportunities identified including:
- default referral to medical team
- patients arriving outside SDEC hours
- those with length of stay < 24/48/72 hrs.
• Numbers steadily increasing as service beds in.
• Not possible to draw conclusions relating to influence of SDEC on overall inpatient length of stay due to variability in admissions data over last 18 months.
• Ongoing PDSA cycles include the introduction of an ANP from April 22 followed by a poster based publicity campaign and complete triage of all medical referrals.
• Need to focus on PROMS as the central feedback service ( accessed via QR code) has yielded low numbers.
• Nationally SDEC is now an integral part of Urgent and Emergency Care plan.5
• Next steps include a business case for ongoing funding for a proposed 12 hr / 7 day service however staffing is a significant challenge in current 5 day service.
References:
1. Data collection (FoH) Feb 19-Feb 20
2. Developing Ambulatory Emergence Care in Wales – Advice to Health Boards 2018 (pdf)
3. https://www.rcplondon.ac.uk/guidelines-policy/acute-care-toolkit10-ambulatory-emergency-care
4. https://www.mdcalc.com/national-early-warning-score-news
5. https://gov.wales/6-goals-urgent-and-emergency-care-policyhandbook-2021-2026
Ryoon Wha Kang1, Joanna Mort1, Abigail Obeng1, Nive Theivendran1, Saima Sheikh1, Gavin Fong1, Edward Hewertson2
2. University Hospital Southampton NHS Foundation Trust, Medicine for Older People consultant and QI lead
The mainstay of communications between doctors and the multidisciplinary team (MDT) is the bleep system. All bleeps should be answered in timely manner, as the urgency of the bleep cannot be determined. However, the increase in bleep load can compromise patient care, because doctors are interrupted during ward rounds, procedures or breaking bad news.
The aim was to define urgent and non-urgent tasks for doctors and encourage the use of the Microsoft (MS) Teams amongst the MDT for communicating non-urgent tasks, leaving the bleeps for urgent tasks only.
• Introduced the MS Teams to doctors and the MDT
• Monitored the active users on the MS Teams and the bleep traffic data
• Satisfaction survey was done to doctors and the MDT regarding the MS Teams usage
• The MDT was not clear on which junior doctor to contact on the MS Teams or which bleep to use
• The morning meeting for junior doctors was started to ensure each consultant had an assigned junior doctor, available on the MS Teams and bleep
• The bleep load was still heavy and engagement on the MS Teams varied due to individual junior doctor preferences or the importance of the MS Teams not clearly stated from the induction
• Monitored reasons and frequency of bleeps throughout the day
• Urgent and non-urgent tasks were defined
• The bleep list for the MDT was updated
• The bleep traffic and the MS Teams engagement data were recollected
• The average number of urgent bleeps during a day was 29.4 and non-urgent bleeps was 61.5, across 10 teams, although there was a significant variation number of bleeps between each team
• The busiest teams with the highest bleep burden struggled to record data due to the high workload and bleep load
• 100% expressed preference of using the MS Teams over bleeps and 60% of them felt that at least 30 minutes of their time was saved per day.
Conclusions:
• Robust inductions for doctors and the MDT is the key to promote the use of the MS Teams for non-urgent tasks, hence to reduce the bleep load for urgent tasks
• Enough lap tops or devices are required amongst doctors and the MDT to access the MS Teams conveniently
• The culture has to be changed in order to move onto the new communication platform
Dr Matthew McMillan & Dr Alexandra Burgess
(Hospital Electronic Prescribing and Medicines Administration),has recently been introduced to our District General Hospital.It was noted that patients’analgesia use was poorly reviewed on a regular basis, and there is no way to notify a prescriber if patients are regularly accessing PRN (as-required) analgesia. Previously All-Wales paper drug charts were used, which had a distinct PRN section.
Aim: To assess how well prescribers identify apatients’use of PRN analgesia, and the necessary escalation of the WHO analgesic ladder and whether laxatives were prescribed with opioid analgesia, due to the increased risk of delirium in older adults.
3 data collection cycles were carried out for all medical inpatients at Singleton General Hospital between February and April 2022. Medication was reviewed using HEPMA, to determine:
1)PRN analgesia prescribed?
2)Is the patient accessing it >3 times in a 24hr period?
3)Con-current laxatives prescribed for those on opioid based analgesia or any patient >65years old? Between each data collection cycle, a new intervention was implemented.
Intervention 1: Posters were designed and placed on each medical ward as a cue to a review and change analgesia when appropriate “Prescribe. Review. Now!”. This poster was circulated electronically to all the medical doctors in the hospital. Intervention 2: A presentation on collected data, the WHO analgesic ladder and laxative prescribing was created, and circulated to all prescribers.
•167 inpatients surveyed, 58% female, 42% male,meanage of 78 (±13.4).37% (n=62) had appropriate prescriptions of both analgesia and laxatives. 31% (n=52) inadequateanalgesia, 19% (n=32) inadequate laxatives, and 13% (n=21) inadequate analgesia and laxatives. (Figure 1)
•159 inpatients surveyed,65% female, 35% male,mean age of 77 (± 15.7).58% (n=92) had appropriate prescriptions.19% (n=30) inadequateanalgesia, 15% (n=24) inadequate laxatives, and 8% (n=13) inadequate analgesia and laxative.(Figure 2)
•157 inpatients surveyed, 62% female, 38% male, mean age of 78 (± 15.7). 68% (n=107) had appropriate prescriptions. 12% (n=19) inadequate analgesia, 14% (n=22) inadequate laxatives, and 6% (n=9) inadequate analgesia and laxatives. (Figure 3)
Adequate analgesia and laxative prescriptions on HEPMA improved by a total of 31% (p<0.005), over 3 cycles and 2 interventions. After each intervention there was a significant statistical improvement in prescribing analgesia and laxatives. However, there is still room for further improvement, especially in ensuring adequate laxative cover is prescribed for all patients either >65 years old, or those on opioid-based analgesia. Visual reminders on wards of regularly checking PRN medication showed to be an effective intervention to improve patient care and safety.
• Hospital admission and surgical intervention are well-documented risk factors for thromboembolic events1
• Systems exist to ensure patients are prescribed appropriate venous thromboembolism (VTE) prophylaxis on admission. However, surgical patients may require alteration of their VTE prophylaxis.
• Without ongoing measures to monitor VTE prophylaxis, surgical patients may be at increased risk of omitted VTE prophylaxis.
• Local guidelines recommend that if VTE prophylaxis is withheld, this should be documented2
• Guidance given to new foundation doctors suggests that VTE prophylaxis status should be a routine part of ward round documentation3. However, this is rarely monitored.
To audit and improve documentation of VTE prophylaxis in surgical ward round notes
Baseline data: We examined ward round entries on 3 wards and recorded how many times VTE prophylaxis was documented over a period of seven days.
PDSA cycle 1: Intervention targeted at F1s working in general surgery, highlighting the importance of checking and documenting VTE prophylaxis when preparing ward round notes.
PDSA cycle 2: Intervention extended to registrars.
Intervention involved both written and verbal explanations of our project to the target group. Post-intervention data was collected one and three weeks after each cycle.
Planned to target our intervention towards general surgical F1s as they are most commonly responsible for ward round documentation
We found peer to peer intervention resulted in a mild improvement in VTE documentation. For PDSA cycle 2 planned to extend our intervention to registrars
Message sent to F1s on general surgery about the importance of checking VTE prescriptions and encouraging documentation
Examined ward round notes 1 and 3 weeks after the intervention, and recorded how many times VTE mentioned. This was compared with baseline data
• Baseline data showed poor documentation of VTE amongst surgical specialties. Amongst medical specialities, VTE was documented in at least 75% of notes samples.
• General surgery had the lowest incidence of VTE documentation.
• After PDSA cycle 1, there was a moderate improvement in VTE documentation.
• This varied greatly between individual doctors.
• Specialities with no intervention saw no change in VTE documentation.
• Results following PDSA cycle 2 in progress.
LIPID MANAGMENT FOR SECONDARY PREVENTION OF CARDIOVASCULAR DISEASE IN TORBAY HOSPITAL
Authors: Merson S1, Nakou D2Hypercholesteraemia refers to the elevated levels of low-density lipoprotein (LDL) >3mmol/L or non -high-density lipoprotein (non-HDL) >4mmol/L It is usually the result of unhealthy lifestyle choices It can also bedue to faulty genes, known as familial hypercholesteraemia, something to be considered when total cholesterol >7.5mmol/L or LDL> 4.9mmol/L.Hypercholesteraemia isan importantrisk factor for atherosclerosis and subsequently for cardiovascular disease (CVD) 1
This project aims to improve the care of the patients who are admitted on Coronary care unit (CCU) and Cardiac painunit (CPU) in Torbayhospital with acute coronary syndrome (ACS) inline with national guidance for lipid management in secondary prevention of CVD
• Present findings andactions at Cardiology
Departmental meeting- Consensus opinion was thatthe management of secondary prevention in CVD should be the remit of GPs
• Cardiology nurses asaboveand write in on improved blood tests recording sheet
• Emergency department and Medical receiving unit to request lipid profileblood test for all ACS patients.
• Junior doctors to add instructions for GP in the care plan summary (CPS)
Current strength:
• 94%(30/32) were prescribedahigh intensity statin (66%), or lower dose statin or ezetimibe with appropriate rational (28%).
Areas for improvement:
• 34%(11/32)had repeat lipid profile.
• 45%(5/11) achieved reduction of non-HDL>40% from baseline.
• 17%(1/6) with reduction of non-HDL<40% GP was advised to consider adding ezetimibe 10mg daily and then PCSK9i.
Please add the following to CPS for all ACS patients.
ALT/AST-
Non HDL Cholesterol -
LDL Cholesterol -
(LDL cholesterol may not be available in which case fine to just mention non HDL cholesterol)
GP-please measure full lipid profile and AST/ALT again after 3 months (non-fasting). High intensity statin treatment should achieve reduction of non-HDL-C > 40% from baseline. For this patient aim for Non HDL Cholesterol of less than …………………….
If this is not achieved after 3 months then please follow the National Guidance for Lipid Management for Primary and Secondary Prevention of CVD
NHS Accelerated Access Collaborative » Summary of national guidance for lipid management (england.nhs.uk)
Plan: February 2022
• Patients admitted to CCU and CPU with ACS between 01/07/21-30/12/21 with LDL
≥ 3mmol/L
• 32 patients in total
• Male to female ratio 2:1
Do: Is the following happening?
• Prescribeahigh-density statin: Atorvastatin 80mg daily.
• Repeat lipid profile after 3 months
• Achieve reduction of non-HDL>40% from baseline in 3 months
• If non-HDL<40% add ezetimibe 10mg daily or monotherapy if statin intolerance
• If non-HDL remains >2.5mmol/L consider injectable therapies (Inclisiran or PCSK9 inhibitors)
Optimisinglipid management isan essential component of secondary prevention of CVD.
Initiating highdose statins is performed well in Torbay
Improving further monitoring and management is challenging, factors include:
• Transient and rapidly changing team of junior doctors who populate the CPS.
• Hand over between secondary and primary care.
• Timely blood tests and medication reviews.
In June 2022 review CPS and follow up lipid profile and management for patients with ACS discharged in March
If GPs are not consistently followingfollow up guidelines then considercardiology based follow up
PDSA cycle 1
• Gentamicin is a common inpatient antibiotic with a narrow therapeutic window.
• Achieving safe gentamicin levels requires accurate, individualised prescribing adjusted for weight, height and renal function.
• This drug is commonly incorrectly prescribed with previous studies showing an error rate of 70% within our trust. Incorrect prescriptions leads to increased risks of toxicity and renal failure.
• A gentamicin dose calculator therefore could help reduce errors in gentamicin dosing, improving patient safety.
.
• Assess if a mandatory Gentamicin Prescribing plan with integrated dose calculator and peer education improves gentamicin prescribing.
1. Correct gentamicin doses (adjusted to weight and height) prescribed in 77% of patients after implementation of the prescribing plan compared to 30% previously.
2. Adjusted body weight used in all patients ≥20% IBW and 5% increase in up-to-date weight documentation.
3. 98% of levels were taken one hour pre-next dose if poor renal function compared to 92% previously.
Ø The Gentamicin calculator has therefore, improved prescribing accuracy.
.
• 472 prescriptions analysed between 04/01/21 to 23/02/21 prior to calculator implementation against the following quality standards:
Ø Correct dose prescribed.
Ø Up-to-date weight and adjusted body weight in patients ≥20% ideal body weight (IBW).
Ø Gentamicin levels measured 20-24hrs post first dose and one hour pre-dose if reduced eGFR (<60).
• Implementation of mandatory electronic prescribing plan with integrated dose calculator.
• Peer-peer education about the gentamicin care plan at departmental meetings.
• 241 adult prescriptions between 01/10/2101/12/21 analysed after interventions.
.
• Increased up-to-date patient height/weight documentation.
• Pull-through of gentamicin calculator dose onto electronic prescription charts automatically to reduce chance of error.
• Improved accuracy of gentamicin levels monitoring by increasing education, including nursing staff, on when to take levels for each individual patient.
• Small changes can result in significant improvements to accurate prescribing
.
• Multidisciplinary team education is key to maintaining changes implemented –increase education to include other MDT members
• Prescribing care plans can help reduce human error and maintain patient safety.
Prescribing
Dr Alexander Morgan, Dr Matthew Edmunds, Dr Yorissa Padayachee, Dr Rajalakshmi Valaiyapathi
Imperial College Healthcare NHS Trust
Corresponding address: a.morgan10@nhs.net
•The British Heart Foundation predicts 920 000 people are living with heart failure (HF) with 200 000 new cases diagnosed annually, resulting in significant morbidity and mortality
•The European Society for Cardiology (ESC) published updated guidance on prescribing in heart failure with reduced ejection fraction (HFrEF) in August 20211
•An important change was the addition of a 4th prognostic medication – the sodium-glucose co-transporter-2 (SGLT-2) inhibitor which has been shown to improve morbidity & mortality associated with HF
To assess compliance of prescribing in accordance with 2021 ESC heart failure guidelines
The first seminal trials in heart failure demonstrating the clinical effectiveness on outcomes in patients with heart failure with reduced ejection fraction in HFrEF. Taken from Cardiovascular Medicine editorial online2,3,4
Limited awareness of the new ESC guidelines
Highlight new guidelines to the SHOs and ANPs
Informal teaching by SHOs and guideline summaries produced
Low confidence in more complex prescribing
Discussion with experts on the topic
To identify areas where improvements could be made and enact changes to improve patient morbidity and mortality by the appropriate and timely initiation of prognostic medications.
Heart Failure Consultant Led Teaching Program
Unfamiliarity with the newer SGLT2 inhibitors
Focus on SGLT2 inhibitor prescribing confidence
Heart failure pharmacist led teaching program
QIP presentation at Heart Failure MDT highlighting our compliance so far and gain ideas for future improvements
• Repeated PDSA cycles showed consistent increases in adherence to ESC guidelines and greater prescriber confidence
• Reduction in quality of prescribing during round 3
• This coincided with the changeover of junior doctors.
• There was still persistent improvement vs baseline.
1. Empowering juniors (through teaching) and promoting them to take initiative in starting these medications improved the initiation of prognostic medications and resulted in sustainable change.
2. Combined working between different grades and members of the MDT has led to improved co-operation, quality of prescribing and longevity of change.
Percentage Increase in Numbers of Patients Prescribed a SGLT2 inhibitor. Admission vs Discharge.
3. Further work is needed to ensure quality of prescribing continues after changeover of medical staff
4. Up-titration of medication remains low. This will be the focus of future PDSA cycles.
Acknowledgments:
Thank you to all the Heart Failure team at Hammersmith Hospital. Special thanks to Dr Carla Plymen, Dr Punam Pabari, Dr Graham Cole and Tom Cooper for their teaching and guidance.
Preceding influenza pandemics have had diagnostic and treatment ambiguity surrounding the need for antibiotics in treating bacterial coinfection for a viral disease. In the time of COVID-19, similar issues have meant that patients presenting with respiratory symptoms are often treated empirically with antibiotics whilst awaiting COVID-19 results. A recent metaanalysis1 found that bacterial co-infection at presentation was estimated to be 3.5%, however, 71.9% of the patient population still received antibiotics. To tackle antimicrobial resistance, a 2020 WHO Bulletin2 highlighted the need for daily antibiotic de-escalation considerations and a research agenda for diagnostic tools that differentiate between bacterial and viral infections. Serum procalcitonin (PCT), as an acute inflammatory marker, has proved effective in guiding antibiotic prescribing in respiratory tract infections by limiting antimicrobial use without compromising patient safety outcomes3,4 Thus, there is a similar role for it to be used in antibiotic prescribing in COVID-19.
AIM:
1.Encourage PCT value use in diagnosis of superadded bacterial infection in COVID-19
2.Improve antimicrobial stewardship by employing PCT-guided antibiotic prescribing for COVID-19 patients
• Data collection occurred between Jan - Nov 2021
• Inclusion Criteria: Adult patients >18 years of age, admitted from A&E with COVID positive swabs on admission
• Exclusion Criteria: Patients transferred from other hospitals with known COVID positive status
• N.B. For overnight ED admissions, the PCT days were subtracted by 1 to accurately represent PCT requests/reviews
DATA ANALYSIS:
• The use of Day 1 PCT increased between pre-intervention (64.18%) and post-cycle 2 data (78.00%).
• Overall antibiotic use following medical review was reduced by 19.69%.
• There was an increase of 24.16% in references to the role of PCTvalues in clinical decision making noted.
• The average number of days of antibiotics prescribed for patients with a low PCT value was reduced from 3.44 (+/-1.85) to 3.27 (+/-0.92), by a total of 4.9%.
• For patients requiring day 3 PCT tests due to a high day 1 PCT, compliance increased from 33.3% to 45.5% between preliminary and post PDSA2 data, and from 16.7% to 40% for day 5 PCT.
• There was a clear increase in requests and use of PCT values from preintervention to post-PDSA 2. However, there was an unexpected reduction in compliance of PCT guidance in post-PDSA 1, due to several reasons:
• PCT had not yet been adopted by all medical / post-take consultants
• Despite it being added to the EPR system, this was not widely known
• There is an importance of both changing, and disseminating information about changes to truly impact clinical practice
• There were also some technical barriers initially, involving the failure of the EPR system to display PCT results that were "add-ons”, thus impeding PCTguided antibiotic changes
• We were unable to show a clear association between PCT result and decisions to stop/continue antibiotic treatment due to small sample sizes, and the complexity of concurrent clinical symptoms that override PCT value decisions alone.
DATA COLLECTED:
PROCESS MEASURES:
- Whether Day 1/3/5 PCT values were available
- Documentation of PCTguided / clinical override prescribing
OUTCOME MEASURES: - Days of antibiotics prescribed
BALANCING MEASURES:
- Patient deaths
• However, if we were able to extrapolate this data to a wider population, even the small reduction in antibiotic course length, may translate to significant monetary savings and improved antimicrobial stewardship.
• Prescribing cues to be implemented based on PCT values itself (e.g. for earlier reviews / to re-consider prescriptions)
• Implementation on other wards / departments (e.g. ED)
• Use of scoring-based prescribing to include other facets (e.g. as in CURB)
• Urinary tract infections (UTIs) are the most common bacterial infection seen in general practice, representing an estimated 1-3% of all consultations.
• Antimicrobial resistance is increasing globally, as well as in the UK.
• Appropriately requesting mid-stream urines (MSUs) for culturing, and correctly prescribing antibiotics, are important both for patient safety and antimicrobial stewardship.
• Educating patients about UTIs is an important aspect of management.
• The expansion of telemedicine during the pandemic provides new avenues of providing patient information, including electronic patient leaflets.
1) To increase the number of MSUs that are being performed as per NICE guidance (NICE CKS: Urinary tract infection (lower)).
2) To improve correct antimicrobial prescribing for UTIs at the practice (PHE antibiotic prescribing guidelines).
3) To improve patient education regarding UTIs in line with NICE guidance. Specifically, to increase the percentage of patients given advice regarding safety netting, consultation recall, self-care, and avoiding UTI recurrence.
• The percentage of MSUs that were appropriately requested increased from 64% to 91%/92% post intervention.
• Percentage of patients who had MSUs successfully processed (requested, taken, cultured, followed up) increased from 45% to 65%/83% post intervention.
• Correct antibiotic prescribing increased from 73% to 93%/88% post intervention.
• Percentage of patients receiving advice about how to take an MSU, safety netting, appropriate recall, self care advice, and UTI prophylaxis all increased across both dat. collection periods, average scores increasing by 33% and 68.6% across the two periods.
• Project aims discussed with practice team
• Interventions discussed at practice meetings
• Background data collected to assess scope of issue
• Data analysed to determine effect of intervention
• Interventions adopted
Intervention 1
Intervention 2
• Baseline pre-intervention data collected and analysed
• Intervention 1 performed
• Intervention 2 performed
• Post-intervention data collected (repeat sets collected to assess two different time periods)
• Teaching session following baseline data collection, with open-table discussion about previous MSU requesting or antibiotic prescribing misconceptions. Follow-up reminder session 4 weeks later.
• A new UTI text message generated on AccuRX with link to RCGP ‘Treating your infection’ leaflet on UTIs. This text contains all the advice we should be giving patients (as per NICE guidelines).
• UTI text message and leaflet translated into Turkish, Portuguese, Spanish, and Somali
• UTI Induction handover teaching to incoming FY2 doctors
• UTI management prompt posters installed in practice
• Teaching on MSU requesting and antibiotic prescribing with open-table discussion about previous misconceptions improved practice.
• AccuRX texts are a simple and time-efficient way of providing patients with information about UTIs that can be easily applied to other practices with similar software.
• Telemedicine must not be restricted to those fluent in English and future work is looking to address language barriers in current patient education.
• Further rounds of data collections will determine if UTI management ‘prompt sheets’, further teaching sessions, and UTI management texts in other languages can all help to sustain the change seen in the initial interventions
The Problem
• The Covid Pandemic has resulted in fewer elective patients physically attending pre-op clinic to discuss their anaesthetic options; low-risk patients are assessed over the phone.
• Conversations with patients highlighted many weren’t retaining key information on the risks and benefits of their anaesthetic.
Aims
• Establish the discrepancies between what patients were consented for and their recollection of this – were information leaflets helping?
• Improve patient engagement in the process of consent.
RCOA Standard
“Those undergoing elective surgery should be provided with information before admission, preferably at pre-assessment or at the time of booking, but the duty remains on the anaesthetist to ensure that the information is understood.” (2017)
Method – Plan & Do
• A simple questionnaire was designed and 30 patients approached on the day of their elective surgery and asked to complete it.
• Information was gathered on whether they could recall the anaesthetic they were having, the risks and benefits of this and whether they had found the posted information leaflet useful (2022).
• A mix of quantitative and qualitative data was obtained, including information on the grade of anaesthetist gaining consent and the type of surgery being performed.
• This was undertaken over a 6 week period and the results charted and analysed.
Discussion - Study & Act
• The data was presented and discussed at the departmental QI meeting.
• This highlighted an issue with patient engagement with the process of anaesthetic consent, contributing to a lack of awareness of the risks.
• An information poster was designed and displayed in patient-facing areas with the help of Pre-Operative Clinic and Day Case Unit teams.
Conclusions & Next steps
• Although most patients recalled the type of anaesthetic they were receiving, many (43%) retained no risks of it whatsoever.
• The majority of patients are reading their information leaflets but many don’t feel that the volume of information was relevant to them and that these decisions were in the hands of their anaesthetist
• This has highlighted an issue with patient engagement with anaesthetic consent and a lack of awareness of the risks
• It is hoped that the posters will engage patients and encourage them to take an active interest in their anaesthetic.
• Potential for further data collection within anaesthesia, as well as involvement of the rest of surgical division in gauging patient engagement in consent.
Bibliography
1. AAGBI: Consent for anaesthesia 2017. 2017. doi:10.1111/anae.13762/full. https://www.aagbi.org/sites/default/files/AAGBI_Consent_for_anaesthesia_20 17_0.pdf.
2. Patient information leaflets and video resources | The Royal College of Anaesthetists. rcoaacuk. https://rcoa.ac.uk/patient-information/patientinformation-resources/patient-information-leaflets-video-resources.
With thanks to…
Dr Rebecca Barker and the Pre-operative and Day Case Unit teams at Sherwood Forest Hospital NHS Trust
“Reading through the pro’s and con’s of anaesthetic options didn’t seem relevant to me as it’s not something I can control”
“I’ll just go with what my anaesthetist tells me – they know best!”Dr Beth Hancox and Dr Migara Seneviratne Sherwood Forest Hospitals NHS Foundation Trust
Half of all reported violent incidents in healthcare settings occur in the emergency department (ED) (1 ) The British Medical Association have reported that over 40 % of doctors have seen physical violence or verbal abuse in the workplace (2 ), making this is an occupational hazard
The anxiety and stress endured by patients and carers is typically compounded by long waiting lists, which can fuel hostile behaviours towards staff (3 ) Workplace violence can result in lack of confidence, anxiety, increased use of alcohol and post- traumatic stress disorder (4 ), which highlights the importance of reducing this threat in the ED It was clear from our Datix system (the NHS system for reporting incidents) that staff were experiencing frequent episodes of violence and aggression from visitors to our emergency department, with likely underreporting of levels . As such, our primary objectives were as follows:
(a) To assess the extent of violent and aggressive behaviours within the department over a 4week period
(b) To remind colleagues of the importance of not accepting these behaviours as or an acceptable part of daily work
(c) To implement changes to the patient experience with a view to reducing the incidence of aggression towards staff in our department
Summary of Stage 1 of the Quality Improvement Project:
Data analysis revealed that the highest incidence of workplace violence in the emergency department occurred in the reception area
A working group was established to develop interventions that would enhance the patient experience in the waiting room and reduce violent acts
Interventions included:
Information on current waiting time
Artwork describing the triage process
Providing information in multiple languages
Structural adjustments to the main waiting area
Information on levels of violence and aggression toward NHS workers
Workplace violence was defined as "any incident in which an employee is abused, threatened or assaulted in circumstances relating to their ( 2)
Numerous safety crosses (Figure 1) were displayed around the three central areas of the department : (a) the reception (b) adults ED and (c) paediatric ED All staff members in the emergency department were made aware of this visual data collection tool and were asked to record all incidents of violent behaviour Staff were requested not to duplicate their entries on multiple safety crosses
Data analysis (Figure 2) revealed that the highest number of workplace violence events occurred in the reception area, which allowed us to prioritise interventions that would reduce violent behaviour in this specific area
To this end, a working group was established along with help from NHS Patient Experience Group (PEG) to identify factors that contributed to patient experience within the ED The PEG, reception staff, nursing staff and a group of local sixth form students (London Academy of Excellence, Tottenham) helped design interventions (Figure 3) to reduce violent acts in the reception area.
The focus of work going forward should be to address the contributory factors but also to highlight that violence is an unacceptable part of the daily staff experience
Primary interventions have been made including the use of posters/artwork in the main waiting area which clarify the ED procedure, alongside more generic additions (plants, water fountain, clocks and waiting time board)
Our work is currently in progress and shall be re- audited in 6 months after all interventions have been introduced
Background
-
-of-hours patient care is provided by a doctor not normally working or training in the specialty. It occurs widely across the NHS, particularly in surgical specialties, and has implications for both patient safety and doctor wellbeing. Due to increasing general medical workload in our Trust, a decision was made some 15 years ago to reallocate found ation doctors from Trauma & Orthopaedics(T&O) and Ear, Nose and Throat surgery (ENT) to out-of-hours medical ward cover. This left one core surgical trainee or equivalent providing emergency cross-cover for all surgical specialties, including General surgery, Urology, Vascular surgery, ENT, T&O and Spinal surgery, resulting in an overwhelming and often unsustainable workload. Compounded by the pressure of providing emergency cross-cover for multiple unfamiliar specialties this situation led to negative trainee surveys, GMC reports and numerous Immediate Safety Concerns (ISC) and Exception Reports.
This project aimed to improve patient care and post-graduate training through optimisingjunior doctor staffing in both the medical and the surgical directorate. Business cases were generated using data from GMC surveys, Exception Reports and recent ISCs, and presented to the Trust Board, highlighting the concerns and suggesting sustainable solutions. In essence, funding to hire a number of additional junior doctors would be required to create a new tier in the surgical out-of-hours rota. Recruitment of surgical clinical fellows would enable a split of T&O and Spinal surgery from the rest of the surgical out-of-hours workload. Recruitment of medical clinical fellows was also needed in order to repatriate foundation doctors back to their home specialties. The business cases were approved, and a new out-of-hours rotawas created and implemented in August 2021.
Qualitative evidence was gathered by surveying affected junior doctors before and after the change to assess its impact on doctor well-being and training as well as perceived patient safety. Quantitative analysis of Exception Reports and ISCs submitted during this period was also used as evidence to demonstrate improvement.
The survey results following the change were overwhelmingly positive, showing a significant improvement in workload and rest breaks (Figure 1) and continuity of care for patients. Job satisfaction improved, with 81% of surgical junior doctors reporting they would recommend their job, compared with only 42% prior to the change (Figure 2). Foundation doctors in T&O reported higher levels of confidence and enhanced learning due to more consistent exposure to the specialty (Figure 3). There have been fewer Exception Reports (Figure 4) and no ISCs raised outof-hours in surgery since July 2021, compared with eleven in the previous 18 months.
We have learned that historic short-term fixes such as the reallocation of foundation doctors to provide service provision within other departments can have detrimental long-term effects. This improvement project has shown that the use of data to demonstrate longstanding problems can help advocate for funding and systemic change that improves the welfare of patients and doctors alike.
Exception Reports for Working Hours within the Surgical Directorate
Background:
During the COVID-19 pandemic, there has been a significant increase in the number of mechanically ventilated patients across critical care units.
The 4th National Audit project of the Royal College of Anaesthetists(NAP4) found that over a quarter of the cases discussed involving major airway complications occurred at the end of anaesthesiaor in recovery.
NAP 4 found that an unstructured approach to airway management complications led to poor outcomes.
The problem:
The COVID pandemic presented challenges of high volumes of mechanically ventilated patients, as well as large numbers of redeployed staff of varied critical care experience. This heightened the risk at extubation, andhighlighted the need to optimise a structured approach to it.
Aims:
We aim to provide a checklist to be used when extubating all intubated patients to help anticipate and prevent complications in patients on critical care. We aim to aid staff members preparing for extubation, carrying out the procedure and looking after patients post-extubation..
Plan:
Critical care MDT surveyed to evaluate confidence in being part of extubation team, and perceived benefit of a checklist.
Do:
The checklist was initially designed by a team of medical and nursing staff Study: The Critical care MDT was then surveyed to evaluate the usage and merits of the checklist..
Act:
The original checklist was re-designed based on the qualitive feedback and experience of using the checklist
More than 1 in 5 critical care staff members did not feel confident being part of an extubationteam
All staff surveyed (n=22) stated that they thought that a checklist would be of at least some benefit, with 82% stating that they would find it very beneficial Based on feedback and experience, we created a one sidedchecklist uniform for all patients, guiding the MDT through preparation, the procedure, aftercare and complications.
Throughout this project, we have experienced the challenges of a dynamic work environment with escalating volumes of mechanically ventilated patients and a high turnover staff with varying critical care experience. We anticipate that this checklist will both improve the safety of extubationand confidence of staff members to participate safely in an extubationteam.
We plan repeat cycles to evaluate the usage of the poster.
We are open to collaborating and sharing our findings with other critical care departments for the further development of this resource and further improvement of patient safety.
Neck of femur (NOF) fractures are a common serious injury in older people & are associated with a high morbidity & mortality.
Maintaining post-operative haemoglobin (Hb) aids mobility & rehabilitation, helpingpatientsto return to their feet quicker.
Therefore, current practice at the University Hospital of Wales involves patientshaving day one post-operative bloods to consider their need for a blood transfusion.
Wales Fragility Fracture Network suggest that patients who have undergone surgical repair for NOF fracture should have their post-operative haemoglobin (Hb) maintained above 90g/L, and above 100g/L for those with a history of ischaemic heart disease (IHD) 1. Therefore, the main aim of this study was:
To promote the consideration of blood transfusions for NOF # patients to optimise their post-op Hb
Data was collected retrospectively from the notes of general orthopaedic traumapatientswho had sustained a NOF fracture during the period of 01/02/2022 – 28/02/2022.
Data recorded included type of operation, if day one post-operative bloods were taken and whether there was any medical note about Hb/transfusion within 24 hours of operation.
The intervention was an information poster placed in the orthopaedic on-call room, theatre office and wards (01/03/2022) in addition to a WhatsApp message in the junior doctors group.
This quality improvement project was still in progress at the time of poster submission, with the second cycle being carried out from 01/04/2022 – 28/04/2022 to assess for any improvement following the intervention.
1st Cycle: 2nd Cycle:
25 patients, 100% had Day 1 post-op bloods taken. However, 40% did not have them documented.
18 patients, 89% had Day 1 post-op bloods taken. Improvement, with 78% having bloods documented. 18% more patients being considered for transfusion.
Has your post-op NOF# patient had their day 1 Hb checked?
40% of patients who underwent surgery following a NOF # fracture in February, had no day 1 post-op Hb documented in their notes
Please ensure post-op bloods are documented + transfusions are considered **
A simple intervention helped to improve the consideration of blood transfusion for 18% more NOF # patients.
However, 22% of patients, still did not have their Day 1 post-op bloods documented. Therefore, we cannot tell if these results were reviewed and whether the need for a blood transfusion was considered, based on their Hb.In addition, in the 2nd cycle 2 patients had no Day 1 post-op bloods taken at all.
Other interventions such as adjusting the NOF # proforma or a sticker in patient notes to prompt consideration for transfusion may help to further optimise patient's post-op Hb.
1.Wales Fragility Fracture Network. (2018). Post-operative haemoglobin guidelines. Available at: https://www.networks.nhs.uk/nhs-networks/wales-frailty-fracture-network
Introduction:
From November 2019 - Jan 2020 Yeovil District Hospital prescribed the most UTI antibiotics in the South West
A pharmacy review found a significant amount of the antibiotics were Pivmecillinam prescribed in ED TTO packs
Possible causes included:
1. Patients with genuine UTIs attending ED instead of their GP for treatment due to lack of appointments
2. Patients being inappropriately prescribed antibiotics who did not have UTIs
We decided to investigate to whether people were being prescribed UTI antibiotics according to trust and national guidelines.
Guidelines:
Based on NICE quality statement 2015 (1)
1. Adults aged 65 years and over should have a full clinical assessment before a diagnosis of UTI is made
2. Healthcare professionals should not prescribe antibiotics to treat asymptomatic bacteriuria in adults with catheters and non-pregnant women
3. Healthcare professionals should not use dipstick testing to diagnose UTI in adults with urinary catheters
Method:
All urine dipstick tests done in yeovil ED between 01/05/2020 - 01/08/2020 were reviewed to establish:
1. What proportion were not indicated i.e. were performed on adults > 65 years old or adults with catheters?
2. Did these non-indicated dips lead to inappropriate antibiotic prescription in people with asymptomatic bacteriuria?
3. When antibiotics were prescribed did the antibiotic choice correspond to our trust guidelines?
4. When inappropriate urine dipsticks where performed, who requested them?
Interventions
•PDSA 1: Doctor focussed - poster in department, teaching for doctors, adding a UTI antibiotics indicating form to TTOs
•PDSA 2: Nurse focussed - teaching for nurses
•PDSA 3: Presentation at ED clinical governance meeting
Did we improve?
Conclusions
•Our interventions did not reduce inappropriate urine dipstick testing
•Our interventions may have reduced off-guideline antibiotic prescriptions
•Our interventions may have reduced overall antibiotic over treatment for UTIs
Dr Tian Huang, Dr Rebecca Rodrigues, Dr Ziya Motala, Dr Thushanee Ramajayan, Dr Zoe Bleything
L Samara, H Abdulgawad
At the Great Western Hospital, the on call team are responsible for clerking emergency gynaecology patients. This includes both junior doctors and advanced nurse practitioners with a wide spectrum of gynaecology experience. During post take ward rounds it was noted that areas of the gynaecology history, were not well documented. As well as areas of the examination, such as whether or not swabs were taken. Both of which delayed efficiency of ward rounds as repeat questioning was required. Additionally, for early pregnancy patients, documentation of rhesus status and previous !-hcg results is vital for decisions on management. Accurate, clear and comprehensive clerking is essential to improve the quality of management plans and efficiency of subsequent reviews.
• The results demonstrated an improvement in documentation of history, examination and investigations as well as improved confidence amongst junior clinicians in clerking patients.
• The proforma also helped to prompt more senior reviews in complex patients prior to the consultant ward round.
• The use of a specific emergency gynaecology proforma improved the quality and consistency of clerking documentation.
Future plans:
• Teaching on emergency gynaecology clerking at induction
• Further improvements to the proforma based on feedback
1. To improve clerking documentation, including gynaecology history, examination findings and results of investigations
2. To improve junior doctors’ confidence in gynaecology history taking
am more confident in taking histories in emergency
following
S. Theivendrampillai, F. New, B. K. Somani University Hospital Southampton (UHS) NHS Foundation Trust, Southampton, United Kingdom
Endourological procedures are minimally invasive surgeries used in Urology primarily to diagnose and treat urological diseases. It implies the use of special instruments which are introduced into the urinary system and allow antegrade access to the urinary tract. For such procedures entering the urinary tract and breaching the mucosa, bacteriuria (BU) is a definite risk factor. Pre-operative urine microscopy, culture and sensitivity (MC&S) is recommended for all endourological procedures as per European Association of Urology (EAU) guidelines1.
AIM:
The quality improvement project was conducted to determine the rates of urine MC&S prior to endoscopic urological procedures and its relevance on post-operative urinary tract infectious complications.
It is important to diagnose and treat patients for urinary tract infections prior to to the endoscopic urological procedures to prevent serious adverse outcomes. The project was conceived to identify whether the Urology Department were keeping to the standards and to identify how patient safety and care could be improved.
Data was collected retrospectively of patients undergoing endourological procedures from November 2019 - March 2020
We analysed the results of urine MC&S, and whether the results were acted upon, the endoscopic procedures undertaken, and outcomes related to infectious complications post-operatively.
After analysing and presenting the data of the baseline first cycle at the local clinical governance meeting, recommendations were proposed to improve patient care, safety and outcome.
A second cycle was undertaken between June –September 2021 after changes were implemented.
Recommendations Actions taken
“Every patient should have a urine MC&S prior to procedures as per guidelines to improve patient safety and care”
• Departmental teaching session
• Pre-assessment Team made aware of the updated policy
• Urine MC&S requested for patients during their pre-assessment
• Posters in pre-assessment clinic rooms
• Pre-assessment Team to chase results and inform the on-call Urology team for positive MC&S results
Cycle 1:
• 5/54 had urine MC&S prior to surgery
• 11 (20%) patients developed post-operative urinary infection, 2 of which required admission for urosepsis. Cycle 2:
• Following the interventions, standards of care and safety improved significantly.
• 39/65 had urine MC&S sent at pre-assessment.
• 8/39 (20%) grew positive cultures and treated for prior to the surgery.
• 7 (10%) patients had infectious complications post-operatively.
Overall, there was a poor compliance of pre-operative MC&S for endoscopic procedures during the first cycle, potentially leading to avoidable adverse outcomes.
• Although not every patient had pre-op urine MSU, there was a marked improvement from 9% to 60%.
• There was an overall reduction in post-operative infection from 20% to 10%.
• Greater portion of patients were identified with positive urine cultures prior to their procedures.
• And thus, there is good evidence that pre-op urine MSU is required.
Should pre-operative urine microscopy, culture & sensitivity prior to endoscopic Urological procedures be made mandatory: Results of a QIP at a Tertiary centre.
Authors: Sameer Nagi, James Speed, Hannah Thomas, Sian Beasant, Peter Jackson, Dr Adam Hickson
Introduction
Approximately 1.2 million NHS Hospital and Community Health Service Staff are in employment of whom 52.4% are professionally qualified clinical staff. Having collective interests among healthcare professionals (HCPs) has shown to improve teamwork leading to greater job satisfaction, improved healthcare outcomes and reduction in time of hospitalisation particularly in surgical teams.
Aim
To evaluate the use of a publication of articles written by different HCPs related to surgery in understanding other
This was a single centre, longitudinal study.
Plan: Collate a peer-reviewed series of articles by different HCPs each month. Upload online to intranet alongside a feedback survey.
Do: Dissemination of online feedback surveys, quantitative and qualitative feedback for each edition collected.
Study: Surveys used a 5-point Likert scale with a confidence interval of 95% one tailed test. Mean and standard deviations were calculated for improvement in knowledge, insight and interest in other HCP roles. Values for the 1st publication were used as a baseline, the 2nd publication results were compared with that of the first to generate p values. The 3rd publication results were compared with the 2nd edition to calculate p values. Improvement points and comments suggested by readers were noted.
Act: Coupling both the qualitative with quantitative results, suggested changes would be introduced for the subsequent edition e.g. for the 2nd edition. The PDSA cycle would then be continued for each subsequent publication.
Conclusion
Circulation of the surgical gazette can increase knowledge, insight and interest into other HCP roles. These are known factors that can improve teamwork.
Reflection
Was able to involve different HCPs for a common goal. Learnt the difficulty of trying to quantify qualitative changes. If I was to repeat this, I would look to control more variables with the use of big data & consider a pre-survey.
