Plan Do Study Act

•1. Change opening hours.

•2. Maintain new hours.

•Planned PDSA 4/5/6

Results

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

Conclusions

• 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

Communication Amongst the Multidisciplinary Team

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

Introduction & Aim:

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.

Methodology/PDSA Cycles:

• 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

Results:

• 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

Poster Competition Group G QI in Progress

Medicines Management

Prizes

an assessment of adequate PRN analgesia and associated laxative prescribing using HEPMA (Hospital Electronic Prescribing and Medicines Administration)

Introduction & Aim

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.

Method & Interventions

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.

Results

Cycle 1

•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)

Cycle 2

•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)

Cycle 3

•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)

Improvement

Conclusion

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.