Have you seen the !-hcg?: Improving documentation of emergency gynaecologyclerking through implementation of a proforma

L Samara, H Abdulgawad

Introduction

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.

Method

Results, Conclusions and Future Plans

• 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

Aims

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

INTRODUCTION:

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.

METHODOLOGY:

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.

INTERVENTION:

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.