Bolton NHS FT Critical Care Extubation Checklist.

Dr Jonathan Reid, Dr Lawrence Pugh, Dr Sarah Thornton.

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.

What we learnt

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.

Anticipated benefits

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..

Future plans:

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.

Do they need a top up?

A QIP to promote the consideration of blood transfusions for patients with a NOF #

Dr Catherine James

Cardiff and Vale University Health Board, Wales, UK

Background

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.

Aim

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

Methods

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.

Results

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 **

Discussion

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

Improving the diagnosis and treatment of UTIs in the emergency department

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