BPSC2021 Winning Patient Safety and QI Posters

Bristol Patient Safety Conference is an independent national event designed to share learning

Thanks to all 216 poster competition entrants and to the presenters of the 160 posters selected to be presented at our eighth annual conference on the 16 th June 2021.

Projects from trusts across the UK were shared through oral presentations followed by questions by a judge.

Thanks to Quality Improvement Clinic and QIC Learn for providing the first prize for each of the 16 categories – a 30 minute personal virtual QI coaching session to help the winning presenters take the next step of their QI journey.

www.bristolpatientsafety.com

16th June 2021

Poster Competition Group A

Improving maternal, neonatal and paediatric care

First prize: In the Know or in the dark?- Keeping parents updated on their babies’ results

Presenter: Dr Jeanne Uhiriwe

North Middlesex University Hospital

Second Prize: Optimal Thermoregulation of the Pre- term Infant on Admission to the Neonatal Intensive Care Unit

Presenter: Pauline Hewitt

Gloucestershire Royal Hospitals NHS Foundation Trust

Problem

In the know or in the dark?

Keeping parents updated of their babies’ results

Jeanne Uhiriwe1, Akudo Okereafor 1, Nicola Davey2 1 North Middlesex University Hospital, 2 QIC Learn

Diagnostics

We tell parents we want to partner with them in their babies’ health. Imagine, then, how frustrating it is for the parent to find out that their baby had an abnormal result weeks prior, and they had not been informed!

Aim

Increase the number of times we know parents are informed of the outcome of their baby’s cranial ultrasound result through documentation within 72 hours of test. This should be achieved by 31 January 2021.

Chosen measure

Recording of Cranial ultrasound results as communicated to patients

Inclusions

All neonatal admissions at North Middlesex Hospital who have one or more cranial ultrasounds performed during their stay in the unit.

Exclusions

Patients observed, but not admitted to NNU, Postnatal patients with cranial ultrasounds, and babies admitted for < 72 hours.

Sampling method & frequency: Patient notes-review fortnightly

PDSA

Ideas to test

1. Collaborate with team currently changing proforma to add section to prompt checking if parents updated

2. Adding a section to the already existing cranial ultrasound form to trigger communication of results

3. Improve parental presence during ward rounds

4. Improve staff awareness of problem

Future PDSAs

Result

• Prior to the PDSAs, there were very few positive data points. Over the first 30 data points, there was only one recorded documentation, but over the next 30 , there were 6 recorded documentations of parental communication

A simple trigger on the existing form created the most change

Reflections

• The next aim would to reduce the time lapse between positive data points and have a more consistent result

Better communication is likely to be achieved with improved parental presence on the ward

If it doesn’t work, get rid of it. Having multiple places to document duplicates work, and doesn’t necessarily encourage uptake

Optimal Thermoregulation of the Preterm Infant on Admission to the Neonatal Intensive Care Unit

Pauline Hewitt, Lead Midwife for Delivery Suite & PERIPrem Lead Joanne Colliver, Consultant Nurse & Senior Advanced Neonatal Nurse Practitioner

Introduction

Mortality rates in the preterm infant are increased by 28% for every 1 degree decrease in the recorded temperature of a baby on admission to the Neonatal Unit. To optimise outcomes , at least 90% of preterm babies under 34 weeks gestation are required to have a normothermic temperature (36.5 -37.5C) measured within one hour of their admissionto NICU.

Gloucestershire Royal Hospital is enrolled in PERIPrem (Perinatal Excellence to Reduce Injury in Premature Birth), an 11 element perinatal bundle to reduce mortality & brain injury in preterm infants in the South West. At baseline audit, Normothermia compliance was found to be variableand a perinatal Quality Improvement project launched to optimise normothermia.

Outcomes:

ACT: Contribute to optimisation tool review as data capture recording subsets not reflective of overall compliance with required standard

STUDY: Collect data via optimisation tool Analyse data for trends

PLAN: Identify environmental barriers to optimal thermoregulation: cold towels

DO: Purchase towel heater Engage Trust's Estates department to consider environmental factors

Results & Lessons Learned:

This project highlights the importance of the perinatal team dynamic in improving patient safety in preterm infants.

By ensuring obstetric, midwifery and neonatal staff are working collaboratively as a highly functioning team, rather than separately, normothermia care is optimised.

Improved optimal thermoregulation was achieved through:

• Improved perinatal team cohesion and functioning

• Theatre staff ensuring optimal room temperature in the theatre setting

• Pre-heated towels available from a dedicated towel warmer on Delivery Suite

• Individual Transwarmer pads placed under the preterm baby to ensure optimal temperature control

• Monthly review of cases and continuous improvements made to factors impacting optimisation

On monthly data review, where compliance of 90% was not achieved, clinical patient factors were identified as the reason for noncompliance and not failure to consider the provision of optimal thermoregulatory care.

Learning from the design and implementation of the Optimal Thermoregulation Project will inform subsequent perinatal QI and contribute to improved patient safety.

16th June 2021

Poster Competition Group B

Medicines Management (1)

First prize: Gentamicin prescribing at a tertiary surgical centre: are we achieving proper usage?

Presenter: Dr Jerome Ling

Swansea Bay University Health Board

Second Prize: Antimicrobial stewardship: improving antibiotic prescribing practice in COVID -19 patients

Presenter: Dr Jessica Michael

North Bristol NHS Trust

Gentamicin prescribing at a tertiary surgical centre: are we achieving proper usage?

Introduction

To achieve safe and therapeutic treatment with once-daily dose gentamicin accurate documentation and appropriate serum-level monitoring is required. If the time gentamicin is dispensed is not documented, timing and interpreting gentamicin serum-levels becomes difficult. Whilst missed and delayed doses can lead to sub-therapeutic levels, improper serum monitoring can also result in toxicity.

AIM – to improve gentamicin serum-level monitoring through improving drug chart documentation.

Methods

• Data collected over 5 time periods in early 2021 on all general surgical wards at a tertiary surgical centre

• Drug charts where once daily gentamicin had been prescribed and dispensed at least once were included

• Assessed to ascertain if;

1)Dispensing time was documented for each dose of gentamicin given

2)Appropriate gentamicin serum level monitoring was performed

Intervention

Stickers(fig.2) were placed on the drug cupboards containing gentamicin to encourage and remind ward staff to document the dispensing times of gentamicin to aid serumlevel monitoring

Improvement

Post-intervention, 280 charts were assessed; 29 suitable for inclusion. 82% (N=24) had the dispensing times noted for all doses of gentamicin given. 86% (N=25) had appropriate gentamicin serum-level monitoring.

Initial Results

317 drug charts initially assessed; 54 suitable for inclusion. 65% (N=35) had the dispensing times documented for all doses of gentamicin, 80% (N=43) had appropriate gentamicin serum-levels.

It was found that when all gentamicin dispensing times are noted, a higher proportion of patients received appropriate gentamicin serum level monitoring compared to those patients where dispensing times were not always documented (Fig.1).

Improvement

The documentation of dispensing time for gentamicin was improved by 19%. A relationship was found between all dispensing times being noted and a higher proportion of those patients having correct gentamicin serum -level monitoring. Subsequently, there was also an improvement in the number of patients receiving appropriate serum-level monitoring of 6%. The eye-catching sticker, placed in a very visible and relevant location has shown to be an effective and simple intervention in improving patient safety .

Fig. 2

Dr Jerome Ling & Dr Damien Drury

Fig.

Antimicrobial stewardship: improving antibiotic prescribing practice in

COVID-19 patients

R.Scott, J. Michael, O. Martin, C. Sluman North Bristol NHS Trust

INTRODUCTION

Anti-microbialstewardship is an organisational approach to promotingandmonitoringjudicious use of antimicrobials, to preservetheirfuture effectiveness.[1]

Managingrespiratoryinfectionsduringthe COVID-19 pandemichasofteninvolved diagnosticuncertaintywithantibioticsfrequently commencedwhilstawaitingPCRresults.

Thepotentialbenefits of earlyintroduction of broadspectrumantibioticsmust be balanced against the risksassociatedwiththeiroveruse.

AIMS

1.Reduce inappropriately long prescriptions of broad spectrum antibiotics in PCR-confirmed COVID-19 patients.

2.Reduce the incidence of adverse events related to use of broad spectrum antibiotics in COVID-19 patients.

BACKGROUND

As junior doctors on a COVID-19 ward we noticed a cluster of Clostridium difficile cases and identified a wide variation in antibiotic prescribing practice as a possible cause.

Figure 1: Antibiotic review stickers used in Intervention 3 summarising NBT guidelines:

48 hour review of antibiotics prescribed for COVID-19

Antibiotics can be safely stopped in COVID-19 if patients have:

• A positive COVID-19 PCR result

• Symptoms and blood results (e.g. lymphopenia) consistent with COVID-19

• Chest X-ray or CT scan consistent with COVID-19

• Negative urine antigens, blood cultures or sputum samples/cultures

Prescriptionsexceeding 48 hours in theabsence of aneutrophilia,radiologicalchanges in keepingwith bacterialinfection or positivecultureswere consideredinappropriatelylong.

METHOD

• Datawascollected on238 COVID-19 patients across5wardsbetweenNovember2020 and March 2021.

• Drugschartswerereviewed for antibiotic duration.

• Patientinvestigationsavailable at48hrs, (includingneutrophilcount,culturesandchest imaging)werereviewed.

• Incidence of C.difficile infectionsrecorded.

Intervention 1: Junior doctor teaching sessions

Intervention 2: Educational posters

Intervention 3: Antibiotic review stickers on drug charts

RESULTS

• Overallreduction in percentage of inappropriatelylongantibioticprescriptionsfrom 38% to 33%

• There6C. difficile casesprior to interventions,all in patientswithinappropriately longantibioticprescriptions.Nonewererecordedpost-intervention.

DISCUSSION

GeneralChallenges:

•Theunpredictablenature of the COVID-19 pandemic-wardclosures,changes in populationsize and quarantiningalldisrupted data collection

•Interventions2and3limited by smallsamplesize due to reduction in COVID-19 patientnumbers.

Intervention 1

• Only showed a positive impact on wards where the entire junior team attended teaching(28A and 28B)

• Adverse timing of data collection prior to junior doctor rotation and the Christmas holidays may have contributed to the negative impact seen on Ward 9B and 26B.

Intervention 2

• Reduction in inappropriately long prescriptions from 35% to 25%.

• Implementedimmediately after Intervention 1 on 28A so hard to identify specific impact of posters.

• Consultants not included in teaching. Some juniors were hesitant to challenge seniors’ prescribing.

Intervention3:

• Reduction in inappropriately long prescriptions from 30% to 23%

Future impact:

Data presented to microbiology team to guide management in future COVID-19 waves:

1.Drug chart stickers to be rolled out by antimicrobial pharmacist

2.NBT guidance on stopping antibiotics in COVID-19 to be simplified for clarity

CONCLUSION

• Over one third of COVID-19 patients received inappropriately long antibiotics.

• Extended courses of broad-spectrum antibiotics pose patient safety risks, especially in the frail inpatient cohort.

• Simple measures such as posters, drug chart stickers and teaching sessions have shown to improve prescribing practice in COVID-19 patients.

% of Prescriptions Continued over 48hrs Inappropriately (Intervention 1)

16th June 2021

Poster Competition Group C

Medicines Management (2)

First prize: In The NAC of Time, Reducing Length of Stay (LOS), freeing up inpatient beds during COVID, with SNAP 12hr paracetamol overdose regime.

Presenters: Paul Flattery, Beatrice Bertolusso

Organisation: Hampshire Hospital NHS Foundation Trust

Second Prize: Improving the co-prescription rate of DOACs and PPIs

Presenter: Dr Kaveh Davoudi

Organisation: Taunton Vale Healthcare

IN THE NAC OF TIME

Reducing Length of Stay (LOS), freeing up inpatient beds during COVID, with SNAP 12hr paracetamol overdose regime.

Lead Authors: Paul Flattery, Beatrice Bertolusso Benjamin Rickett, James Norton, Channa Nadarajah, Jennifer Joiner, Helen Crossley.

• Paracetamol is the UK’s most common overdose drug, approx. 100,000 presentations to ED’s yearly(1)

• A national audit 2013/2014 highlighted MHRA/TOXBASE guidance compliance as low as 75%.

The Problem

WHY?

• Experience downstream and clinical incidents was giving the perception that compliance might be lower locally.

• Recent evidence for a shorter treatment protocol raised the question to use a 12hr (SNAP) management strategy compared to the traditional 21hr regime (2)

Aim

D

“Patients presenting acutely to the emergency department following an overdose of paracetamol are not given an antidote correctly in a timely manner in accordance with national guidance”

12hr SNAP

PROTOCOL

P D S A P

PDSA cycles

1 education alone, was conducted via formal and informal teaching sessions.

2 education plus protocol implementation for the 12hr SNAP regime.

Results

• Presentations with ≥1 management problem, reduced from 60% to 35% over our 5 month follow up.

36.1hr 33.09hr 23.57hr

• 10% of the emergency departments medication incidents were related to NAC prescribing / paracetamol overdose.

• 60% of patients had at least 1 problem with management

• Our average LOS reduced from 36.10hr to 23.57hr, this saved 194.44 inpatient hours (8 bed days)A

OF STAY (LOS) 1 2 20%

Discussion and Learning points

1.The LOS saved following cycle 2 is greater than simply completing NAC 9hr quicker. This supports our theory that initial delays/errors with these presentations were increasing patients LOS. This theory is further supported by the small reduction in LOS seen following education alone after cycle 1.

2.With bloods often taken by junior nursing staff or healthcare assistants on patient arrival we feel particularly proud of the impact our protocol and education drive has had across all the levels of the team in the emergency department.

S 74.19 % 0%

60%

40%

80% baseline cycle 1 cycle 2

% of patients requiring and receiving NAC on arrival as required by national guidance

Compliance with Paracetamol levels taken at 4 hours 35% 58% 95% 0% 20% 40% 60% 80% 100% baseline cycle 1 cycle 2

3.The implementation of the 12hr SNAP regime demonstrated a significant reduction in patient LOS

4.Our review was in-line with previous national audit 2013/2014 highlighting MHRA/TOXBASE guidance compliance to be as low as 75% (3) . Whilst our overall compliance never reached the same level, we feel the improvements made in practice to be a significant improvement in patient care.

Dr.

Kaveh

Davoudi, Dr James Shuttleworth, Dr Chris Merrett, Mr Fivos Valagiannopoulos

Background

• Direct oral anticoagulants (DOACs) are used for a range of conditions including venous thrombus embolism.

• DOACs increase the risk of upper gastrointestinal bleed (115 per 10,000 vs 50-100 per 10,000 in using NSAIDs) (1).

• Prescribing DOACs with proton pump inhibitors reduces this risk (2).

Aims

• To establish the co-prescription rate of DOACs and PPIs at the largest surgery within the Somerset CCG.

• To get into the top 10% of the CCG surgeries with the target co-prescription rate of 80%.

• To ensure sustainability of any improvement achieved.

Methods

• Using EMIS, all patients on DOACs over a one month period were identified and their prescriptions were checked

• 3 different interventions were carried out over a 6 month period

• The co-prescription rate was checked monthly to assess progress

December 2020: A warning was set up on EMIS reminding clinicians to look for PPIs every time a patient on DOACs was searched for (Figure 1).

Results

October 2020: 10 minute presentation about the risk of prescribing DOACs in absence of PPIs

February 2021: A warning every time a new patient was started on a DOAC (see Figure 2).

Conclusion

• We achieved a final co-prescription rate of 80%, improving patients safety.

• New Quality Outcome Frameworks (QOF) targets can be achieved through a simple series of interventions including presentations and EMIS warnings.

• We have liaised with the practice pharmacist to ensure continued monitoring of the co

Figure 1 illustrates the first EMIS reminder.

Figure 2 illustrates the second EMIS reminder.

16th June 2021

Poster Competition Group D

Care of the Older Patient

First prize: Prescribing of PPI cover with NSAIDs use in over 65s

Presenter: Dr Hazel Chon

University Hospitals of Leicester NHS Trust

Second Prize: Following the Fix: A proforma to promote post operative reviews of Neck of Femur Fracture (NOF) Patients

Presenter: Dr Alexandra Uren

University Hospital’s Bristol and Weston NHS Foundation Trust

INTRODUCTION

Prescribing of PPI cover with NSAIDs use in over 65s Dr

Hazel Chon, Dr Piranavan Kirupananthan

More than 30 million people consume non-steroidal anti-inflammatory drugs (NSAIDs) worldwide every day.1 Despite their beneficial effects, NSAIDs cancause a wide range of preventableharm to patients. Gastrointestinal complications, including gastriculcer,bleeding and perforation, are the most common side effects associated with NSAIDs 2 Elderly NSAID users are 4 times more susceptible to gastrointestinal bleed, making them vulnerable targets for hospital admissions because of NSAIDs induced major gastrointestinal adverse events.3 Approximately around 8500 hospitalisations in the UK were related to gastroduodenal ulcers annually.4 The annual cost of initial hospital treatment for acute upper gastrointestinal bleed is estimated to be £155.5 million in the United Kingdom

AIM

This QI project aims to achieve 100% in prescribing PPI cover for NSAID users aged ≥ 65 andimprove PPI compliance by 10% in two local GP practices over 8 months The aim of this project used the SMART framework to set a concise andachievable target. This project utilised the Model for Improvement to develop, test and implement changes leading to improvement The NICE guidelines recommend all NSAID users over the age of 65 should have PPI cover prescribed 5 Figure 1shows the driverdiagramused in this project Table 1 shows the qualitative and quantitative data collected Table 2 shows the measures used to generate stable growth for the project.3 PDSA cycles shown in figure 2 were used to test out changes on a smallerscale

RESULTS

In the first month, practice1had 92.6%(75/81)patients with PPI cover and 7.4%(6/81) with no PPI cover;practice2had 93.3%(56/60)patients with PPI cover and 6.7%(4/60) with no PPI cover Among those who had PPI prescribed, 12%(9/75)patientshad poor compliance in practice1 and 12.5%(7/56) in practice2.

Fig. 1 shows the driver diagram demonstrating the primary and secondary drivers with change ideas.

Table 1 shows the data collected for this QI project.

Table 2 shows the measures used to achieve sustainable growth for the project.

Fig. 2 shows three PDSA cycles performed.

Fig. 3 shows the number of hospital admissions related to NSAID induced GI adverse events in a local hospital from August 2020 to April 2021.

Table 3 shows the data collected from questionnaires in the 1st and 2nd PDSA cycles.

FOLLOWING THE FIX

A proforma to promote post operative reviews of Neck of Femur Fracture (NOF) Patients

Dr Alexandra Uren, Mr. Louis Hainsworth, Miss. Alanna Pentlow University Hospitals Bristol and Weston

Background

• NOF Fractures are a common serious injury in older people associated with high morbidity and mortality

• Current practice at Weston General Hospital requires these patients to be reviewed at 6 and 12 hours post-operatively

Aims

• To assess whether the introduction of a proforma would promote these reviews

• Ensure all important information documented –8 key points to be included in the review

Method

March 2020

• 20 patients notes reviewed who had undergone surgical management for a NOF fracture

• Only 50% had received postoperative reviews

• 0% had had pain level documented

• Post operative review proforma introduced to existing clerking booklet

Take Home Message

• 80% increase in the documentation of all 8 points when using the proforma

• Plan to introduce the proforma to junior doctor induction days to encourage its use

8 REVIEW POINTS

August-September 2020

• 30 patients notes reviewed

• Recorded time of reviews, level of reviewer, and how many of the 8 points recorded

Results

• 67% of patients received 6hour post-operative reviews

• 100% of the 6-hour reviews had all 8 necessary points recorded

• Of the the remaining patients NOT on the proforma – only 20% patient had all paints recorded

16th June 2021

Poster Competition Group E

Improving Primary Care

First prize: It’s red and lumpy”. Improving the process of reviewing skin complaints virtually in General Practice using patient submitted photos

Presenter: Dr Elizabeth Beasant

Organisation: GPST1 Cardiff and Vale UHB

Second Prize: Antipsychotic monitoring: A Quality Improvement (QI) project

Presenter: Dr Isobel Joy McFadzean

Organisation: Kingsway Surgery, Swansea

“It’s red and lumpy”. Improving the process of reviewing skin complaints virtually in General Practice using patient submitted photos

Project Methodology

• Process map created

• Baseline data collection to access scope of issue

• Brainstormed solutions/interventions at practice meeting

Study Act

• Data analysedand successful intervention adopted

Baseline data collected over 2 weeks.

-41 telephone appointments that were related to skin complaints - 46% of these appointment were given a second appointment- face to face, or called back at a later stage with the same initial problem

- Only 27% of appointments were asked to send in photos - Within the 27% that were asked for photos, many were not sent immediately. There was a combined delay of 18 hours for the photos to be received after being requested. 3 of the photos were never received.

Results

• Baseline data analysed

• Practice email account generated

• 1st intervention and 2nd intervention

Introduction

Due to practicing virtually and limiting face to face appointments in General Practice in the covid pandemic, many patient’s were calling regarding rashes or other skin issues. I found that patients would struggle to describe the issue and this made diagnosis and management very challenging.

The system in place for photos to be sent in proved quite inefficient and problematic for a number of reasons, many of which are listed on the process map.

Aims

The aim of the QIP was to improve the efficiency of the system of patients calling with skin complaints and sending in photos for review. The primary outcome was chosen as the percentage of appointments in which a photo was available at the time of the appointment.

1st intervention

2nd intervention

• Repeat data sets collected after each intervention. (Baseline then 2 complete cycles)

• Emailed clinical staff with the practice email address and encouraged them to use it

• Posters given to reception and asked staff to ask patients to email in photos at the time of booking their appointment

Secondary outcome measures that would demonstrate improvement included:

• A reduction in number of steps in the process map

• Reduction in additional appointments needed for the same issue

• Improving quality of virtual consults by encouraging more patients to send in pictures to review as additional information for their consult

Below: Process map prior to any intervention

- Orange represents sources of delay/wastage

• Appointments with photos available at time of appointment increased from 10% to 40%

• Secondary outcome measures as shown

• Process map steps reduced from 13 to 11. 8 sources of error reduced to 3.

Conclusion

Run Chart showing percentage of appointments in which a photo was available at the time of the appointment

1

% of appointments that had photos available to view at the time of the appointment

Median from (baseline data)

By having photos available at the time of consult, the virtual consultations were of better quality due to less diagnostic uncertainty.

• Less second appointments were needed which is beneficial for the practice and more convenient for the patient. Less face to faceappointments would reduce covid exposure.

• The process map showing 11 steps from 13 and only 3 sources of error from 8 highlights how much time could be wasted in the old system and the new system is streamlined and efficient.

• Errors remaining represent unavoidable wastage/delay from patient perspective- eg blurred photo or if the patient does not send a picture and IT issues (if the email does not come through).

Below: Process map after interventions

- Orange represents sources of delay/wastage

ANTIPSYCHOTIC MONITORING:A QUALITY IMPROVEMENT (QI)

ABSTRACT

BACKGROUND

A REVIEW INTO ANTIPSYCHOTIC MEDICATION WAS NEEDED FOLLOWING SIGNIFICANT INCIDENTS WITHIN THE PRACTICE.

METHODS

THE QI PROJECT USED AUDIT, THE MODEL FOR IMPROVEMENT & PLAN DO STUDY ACT (PDSA) CYCLES1 TO REVIEW AND MAKE SYSTEM CHANGES.

RESULTS

PDSA1: ADHERENCE TO PSYCHIATRY RECOMMENDATIONS INCREASED BY 9%.

PDSA2: 82% OF PATIENTS AGED >65 WERE MONITORED IN CLINIC.

CONCLUSION

A NEW PROCESS FOR ANTIPSYCHOTICS WAS IMPLEMENTED, AS PER NICE GUIDELINES,2 TO IMPROVE PATIENT SAFETY.

ANTIPSYCHOTICS

WHILST INITIATED BY SECONDARY CARE, PRIMARY CARE HAS THE RESPONSIBILITY TO MAKE DOSE ADJUSTMENTS & THE MONITORING OF THE MEDICATION.2.

COMMUNICATION BETWEEN THE SPECIALITIES IS USUALLY IN THE FORM OF LETTERS.

CLINICAL INCIDENTS

• MISSED DOSES

• INCORRECT DOSES

• PROMAZINE ISSUED INSTEAD OF PROMETHAZINE

• NO MONITORING

AIM

PRIMARY AIM: IMPROVE ADHERENCE TO PSYCHIATRY RECOMMENDATIONS BY 5% WITHIN 6 MONTHS.

SECONDARY AIM: INITIATE MONITORING CLINICS FOR PATIENTS PRESCRIBED ANTIPSYCHOTIC MEDICATION.

PDSA1

FIG.2: BAR CHART SHOWING ADHERENCE TO PSYCHIATRY RECOMMENDATIONS BEFORE & AFTER PDSA1

INITIAL AUDIT REVEALED 87% ADHERENCE TO THE MEDICATION RECOMMENDATIONS WITHIN PSYCHIATRY LETTERS. AFTER THE PHARMACIST WAS RECRUITED, THIS INCREASED TO 96%.

MONITORING

NICE GUIDELINES RECOMMEND ANNUAL MONITORING FOR PATIENTS PRESCRIBED ANTIPSYCHOTICS: HEALTH PROMOTION, BLOOD PRESSURE, BODY MASS INDEX, BLOOD TESTS +/-ECG.2

PDSA 2

INITIALLY WE HAD NO FORMAL PROCESS TO MONITOR THESE PATIENTS.

OUR PILOT FOCUSED ON >65’S & 36/44 (82%) OF THEM WERE REVIEWED IN CLINIC PRIOR TO THE COVID19 PANDEMIC.

DISCUSSION

THE QI PROJECT HELPED TO EDUCATE THE PRACTICE ABOUT ANTIPSYCHOTICS AND TACKLED MISCONCEPTIONS OF RESPONSIBILITY WITHIN CLINICAL MEETINGS.

OUR NEXT STEP INVOLVES CLINICS FOR THE

16th June 2021

Poster Competition Group F

Care of the unwell patient (1)

First prize: Recognising the deteriorating patient: Optimising lab to ward communication of abnormal blood results

Presenter: Dr Aya Abbas

NHS Frimley Health Foundation Trust

Second Prize: FRIDAYS – Make Every Day A Friday

Presenter: Dr Mark Hoey

Northern Health and Social Care Trust

Recognising the deteriorating patient: Optimising lab to ward communication of abnormal blood results

Abbas A*, Brackenborough K, Higton A(Supervisor)

Wexham Park Hospital

Bristol Patient Safety Conference 2021

*Correspondence to aya.abbas1@nhs.net

ü Background

An inquiry into all Serious Incidents (SIs) at Wexham Park Hospital between August 2019 - August 2020 coded as “involving the deteriorating patient” demonstrated that 44% (12/23) of all SIs were due to either delayed awareness and/or treatment of abnormal blood results. This exposed many areas in a multifaceted sequence of events where minor improvement could significantly alter the prognosis of these patients

ü Aims

1. To system map the process from recognition of anabnormal blood result in pathology to communication this to the responsible clinical team.

2. To identify the main areas where delays in this communication can occur.

3. To adapt and streamline the pathway for abnormal blood reporting to ensure efficient and timely action.

ü Methods

CYCLE 1- October 2020

PLAN: Allocated a team to shadow the biochemistrybiomedical scientist as they attempt to contact the wards to relay abnormalblood results

DO: 7 consecutive days; 10 hour shifts Observed and recorded the duration of time spent locating patients, the number of attemptsat calling respective wards and noted any failed communication

STUDY: Data analysed to highlight any trends of delay in phoning specific wards, incorrect labelling of patient locations on request forms and discrepancies in ward names between the clinical and pathology software

ACT: Information Technology (IT) team involved to correct location name mismatches and create pop-ups to prompt medical staff to confirmcorrect location when requesting ablood sample.New contact number list generated to allowlab to contact the 24/7 monitored nurse-in-charge (NIC) baton mobile instead of the unmonitored ward desk phones

CYCLE 2– March 2021

PLAN: Four mainmedical wards with IT systems discrepancies resolved Biochemical scientists (haematology now also recruited) invited to use the new NIC contact list to communicate abnormal results

DO: 7 consecutive days; 10 hour shifts.Lab staff self-recorded all abnormal result communication, i.e.perceivedpatient locations, number of attempts at contacting wards using amended software and NIC contact listandany failures

STUDY: Data analysed to investigateif these changes improved the efficiency of results reporting and highlight any residual issues relating to particular wards

ACT: Promoted furtherengagement of staff on wards that remained more difficult to contact

ü Conclusions and scope for further improvement

Communicating abnormal results involves a complexed system within the acute hospital setting with areas where human factors play a large roll. Many areas for improving safety and efficiency were highlighted from our systems map, and our second cycle showed that simply updating ward contact numbers and locations meant that 100% of abnormal results were communicated over the phone in a more timely manner.

Automated electronic alert systems are currently in their infancy for most pathology services and therefore it remains likely that the mainstay of communication will be direct verbal communication, either in person or via a telephone call between the laboratory and the clinical teams.1 However, automation in both alerting the clinical team and confirming actioned results would appear to be the end optimal goal for all abnormal results.

ü Results

Figure 1: System map of the process of abnormal bloods beginning at the decision to obtain a specific blood result from a patient, to acknowledgement of the abnormal blood result in pathology, to pathology communicating that result to the ward team responsible for the patient, highlighting potential areas for delay.

location of patients and the reasons behind any discrepancies. 4% were delayed to

errors.

ü References and acknowledgments

[Accessed 20th December 2020].

We

thank

Figure 3: CYCLE 1 Chart showing the relation between actual and request from

programmed software

Figure 4: CYCLE 2 Chart showing the same data after correction of ward name discrepancies on the pathology software.

Figure 2: The range of overall number of attempts vs time to contact all wards. CYCLE 1: Of these 54 results, 19% of communication attempts were eventually abandoned and the results subsequently uploaded online only. CYCLE 2: Of these 52 results, 100% were communicated over the phone, although 4 (8%) were unable to reach the allocated NIC number.

–

Make Every Day A Friday

Improving the out of hours experience

Background

Weekend on-call services in acute hospitals are potentially high-risk periods for patients. We learnt a significant proportion of on-call junior doctor time in our Medicine department was spent completing routine administrative tasks that should have been completed during normal working hours. Junior doctor experience at weekends was poor.

Methods

Aim statement: To reduce the number of out of hours requests for routine tasks to <20 per ward per month

Intended benefits: To improve out of hours staff experience.

More time released for medical and nursing staff to devote to direct patient care and improve patient safety

• Project team

• Baseline data collection

• Afternoon checklist introduced

• Scale and expand ward by ward

• Staff experience survey

Out of hours bleeps for routine tasks

Initial uptake of the checklist was low. The team found that perceived workload, Covid pressures, checklist availability and nursing engagement were responsible. Two folders for blank and completed checklists with an enclosed process map were introduced and replenished by the ward clerks. The ward sister became the champion for the project after colleagues reported a fall in nursing workload over the weekend periods.

Due to the successes above the project was expanded to the adjacent ward with plans to expand to all hospital wards and other trust sites.

Staff experience survey results

16th June 2021

Poster Competition Group G

Care of the unwell patient (2)

First prize: Introducing Blanket Screening for Human Immunodeficiency Virus in a Central London Emergency Department

Presenter(s): Matilda Fox and Rosie Pettit

Imperial Healthcare NHS Trust

Second Prize: Streamlining Venepuncture To Improve Efficiency and Patient Safety

Presenter(s): Dr. Sachin Wimalagunaratna

Royal Devon and Exeter NHS Foundation Trust

Introducing Blanket Screening for Human Immunodeficiency Virus in a Central London Emergency Department

AIM

Perform Human ImmunodeficiencyVirus (HIV) tests on 25% of Charing Cross Emergency Department (ED) attendees aged 16-59 in a 6 month period.

BACKGROUND

• HIV has a high morbidity and mortality when left untreated.1

• Additionally early diagnosis is cost effective 2 and reduces risk of further transmission of the virus.3

• NICE and BHIVA guidelines recommend EDs in high prevalence areas ( >2 cases per 1000 population) should screen all attendees age 1659.4, 5

• Charing Cross sits in an ‘extremely high prevalence area’, with 7.3 cases per 1000 population6 , making the implementation of blanket testing paramount.

METHOD

Phase 1: collection of baseline data using a staff survey designed to identify targets for future interventions.

Phase 2: Model for Improvement methodology used.7 Implementation of successive interventions in the department and measurement of outcomes.

PDSA

CYCLES

PHASE 1 RESULTS: PHASE 2 RESULTS:

Actual % of HIV test performed Aim of 25% of attendees

Baseline % prior to any interventions

DISCUSSION:

• Early increases in the proportion of testing following PDSA interventions were promising.

• We met our target for testing rates in December.

• A reduction in testing rates was noted in early 2021 which had a temporal relationship with the COVID-19 pandemic, suggesting departmental drive for testing was affected by external factors.

Important lessons we learnt:

1) Involvement of the MDT to see sustained change

2) Use of the behaviour insight “EAST” framework 8

3) The importance of calculating cost effectiveness early in order to fascilitateinterventions

4) Rotation of healthcare staff is an important consideration in sustaining change

REFERENCES

(1)WHO, 2020 “HIV/AIDS”, Accessed on 15/5/21 on: https://www.who.int/news -room/factsheets/detail/hiv-aids

(2)NICE, December 2016. " Putting NICE guidance into practice. Resource impact report: HIV testing: increasing uptake amoundpeople who may have undiagnosed HIV (NG60): https://www.nice.org.uk/guidance/ng60/resources/resource-impact-report-pdf-2727796141

(3)World Health Organisation, 2020 “HIV/AIDS”. Accessed on 15/5/21: https://www.who.int/news-room/factsheets/detail/hiv-aids

(4)British HIV Association, 2020. Accessed on 15/5/21 on: https://www.bhiva.org/file/5f68c0dd7aefb/HIV-testingguidelines-2020.pdf (5)NICE, 2016. Accessed on 15/5/21 on: https://www.nice.org.uk/guidance/ng60/chapter/Recommendations

(6) Public Health England, 2019. “Sexual and Reproductive health profiles – Hammersmith and Fulham https://fingertips.phe.org.uk/profile/ sexualhealth/data#page/1/gid/8000057/pat/6/par/E12000007/ati/202/are/E0 9000013/cid/4/tbm/1/page-options/ovw-do-0

(7)Institute for Healthcare Improvement, 2021. HowtoImprove [Webpage]. [Accessed 6th May 2021]. Available at: http://www.ihi.org/resources/Pages/HowtoImprove/default.aspx

(8)The Behavioural insights team, 2015 “EAST four simple ways apply behavioural insight” , Accessed on 15/5/21https://www.behaviouralinsights.co.uk/wp-content/uploads/2015/07/BIT-Publication-EAST_FA_WEB.pdf

1: Staff survey (September 2020)

2: Teaching of guidelines aimed at doctors in ED (November 2020)

3.HIV advocate nurse appointed (December 2020)

4.Posters aimed at staff to remind them to order tests (March 2021)

5. “Gamified” teaching for nursing staff (April2021)

6.HIV tests added to ‘Adult A&E Careset’ (May 2021)

Figure 2: Barriers to HIV testing identified by ED clinicians at Charing Cross hospital

Figure 3. Graph showing the percentage of ED attendees aged 16 -59 who were tested for

by month

Matilda Fox 1, Rosie Pettit1, Ernest Mutengesa1, Marcus Wright1, Anu Mitra1

Figure 1: Driver diagram developed at the start of our project to identify targets for change

Streamlining Venepuncture To Improve Efficiency and Patient Safety

Background:

• Obtaining blood samples is acommontask for clinicalstaff in hospital.

•Currently, time is often wasted searching through the ward for venepuncture equipment. This time could otherwise be focussed on patient care.

• Furthermore, with ournew electronic patient record,MyCare, the patient’s wristband andblood samplesshould be scanned onto the system beforebeing sent tothe lab.

•Adherence tothis scanningworkflowimproves patient safety,yieldsfasterresults and ensurestrust goalsare met

Plan Act

•Reflect upon results.

• Ride the wave of enthusiasm by ward staff forthe WoW as a one-stop blood-takingshop.

• Run reports on MyCare to analyse the adherence to scanningworkflow for our second aim

•Recognise the need to raiseawareness of the WoW and the benefitsofadhering tothe scanningworkflow.

•Presentresults at the RD&E Quality Improvement Academy monthlymeetings to gather feedback and ideas for progression of the project.

Conclusions:

• Gathering equipment for venepuncture is often a time consumingprocess in the wards

• With our WoW on the ward, mean time taken to prepare a bloods tray was reduced from 4 min 27 secs to 2 min 22 secs.Those who used the WoW resulteda further reduction in timeto 1 min 36 secs, achievingaim 1.

Future Work:

Cycle 2

Aims: By July 2021:

1. To reduce time taken to obtain a predefined list of venepuncture equipment by 50%.

2. To improve adherence to the scanning workflow in venepuncture by 50%.

Do

•Create a workstation on wheels (WoW) dedicated for blood taking.

•Contains venepuncture equipment, sharps bin, wireless scanner, label printer, and personal protective equipment.

•Place a bloods WoW on a surgical ward for 3 weeks.

•Measure time taken to prepare venepuncture equipment on the ward and compare to preintervention.

Study

Qualitative results

“Found it considerably efficient to have all the needed stock in a small contained unit.”

“Really easy, straightforward, everything was there …overall I think it’s a brilliant idea!”

“Didn't have everything in the ward cupboard, so had to go to the WoW. I was told by one of the nurses to get things from the WoW.”

Quantitative results

Pre-intervention

•Average time: 4 min 27secs (n=19)

• 50%reduction target: 2 min 13secs

Post intervention

•Average time: 2 min 22secs (n=20)

• Of thoseusing bloods WoW: 1 min 36secs (n=9)

•Create advertising campaign which promotes the bloods WoW and highlights the benefits of adherence to the scanning workflow.

•Analyse MyCarescanning workflow data to study progress towards achieving aim 2.

Dr.Sachin Wimalagunaratna, Dr.Oliver Small, Mrs.JoannaWalsh-Quantick, Dr.Michael Barrington,Dr.RussellEason, Dr Naomi Spencer

16th June 2021

Poster Competition Group H

Handover

First prize: Something for the Weekend: Improving Weekend Working Through Appropriate and High Quality Weekend Handover

Presenter(s): Dr Emma Kirby and Dr Naomi Wardrop

Royal United Hospitals Bath NHS Foundation Trust

Second Prize: Is anyone coming to handover?

Presenter(s): Stephanie Hill and Samuel Protheroe

Organisation: Hull Royal Infirmary

Something for the weekend: Improving weekend working through appropriate and high quality weekend handover

Dr Rachel O’Riordan, Dr Emma Kirby and Dr Naomi Wardrop

Background and Aims:

Despite shifts towards seven day working task demand out of hours is increasing. Like many hospitals, RUH junior doctor weekend ward cover for medical inpatients operates as a ward cover cross arrangement. A key component of this is effective handover, which is facilitated using an electronic pro-forma.Despite this standardised pro-forma two problems exist: highly variable information quality and high numbers of legacy tasks (tasks that for a variety of reasons are left to out of hours staff).

We aimed to improve the number of jobs entered on the handover system deemed as appropriate for an F1 from 60% to 90% in a 10 month period. It was hypothesised that in reducing legacy work and improving the quality of handover information junior doctors could prioritise more effectively and focus on direct clinical care.

Methodology & PDSA cycles:

Current F1 doctor’s were surveyed to ascertain perceptions of the current weekend workload. Data was collected prospectively from the electronic tool and tasks rated as appropriate or inappropriate by reviewers based on task suitability and information clarity. Several PDSA cycles were undertaken focusing on education and proactive weekend preparation as shown in Fig 1.

Outcome measures: Percentage of jobs entered onto the electronic weekend handover tool for F1 level deemed as appropriate. F1 doctor perception of weekend workload.

Process measures: Number of jobs entered onto weekend handover system. Jobs deemed as inappropriate broken down into 3 sections: inappropriate for F1 level, inappropriate for weekend (e.g. legacy tasks, investigations that will not happen over the weekend), inappropriate due to poor handover information or quality.

Balancing measures: Number of jobs handed for SHO review on the electronic handover tool. Number of unscheduled reviews required over the weekend collected from 3 medical wards.

Results:

A

Cycle 4: Electronic reminder message added to weekend handover system

Cycle 3: FRIDAY poster emailed to all junior doctors including detailed information

Cycle 2: FRIDAY mnemonic reminders put on computer workstations

Cycle 1: Teaching session on handover quality delivered to F1 doctors

An overall improvement from 61% to 89% in the number of jobs deemed to be appropriate was observed, alongside a decrease in t he number of jobs deemed as inappropriate due to poor handover quality from 21% to 9%. The run chart in Fig 2. displays the four PDSA cycles in addition to an email being sent to trainees from the foundation training programme director. Following PDSA cycles the electronic handover proformawas revised to include prompts for proactive weekend planning, the results following implementation of this are awaited.

The number of jobs handed over to SHO’s remained largely in line with number of F1 jobs handed over and there was no significant change in the number of unscheduled reviews required.

In a survey of F1 doctors in August 2020, only 18.2% of doctors felt weekend workload to be ‘manageable’. This increased to 44.4% when the survey was repeated in April 2021. In addition, the April 2021 survey showed that 55.6% of F1 doctors felt the appropriateness of jobs handed over had improved since August 2020.

Key Learning Points and Next Steps:

The impact of the revised weekend handover template is yet to be evaluated. The modest improvements demonstrated relied heavily on frequent reiterations through our PDSA cycles. This demonstrates the difficulties in changing handover practice which is heavily influenced by differing individual & team thresholds for weekend tasks. This will also vary from organisation to organisation and be heavily influenced by the structure and capacity of the weekend staffing team. The direct effect on patient safety is also difficult to measure. Moving forwards we need to look at processes which streamline our weekend care, better integrating senior ward rounds with F1 “on -call cover"; minimising duplication of work and out of hours task demand and thus improving communication, efficiency and patient safety.

It is important to note that for several months (November to February) there were significant increased pressures across medical wards due to the surge in the COIVD-19 pandemic. However, apart from a spike over the Christmas holiday period, a surge in the number of inappropriate handovers was not seen over this 4 month period and this could be interpreted as a success for the educational initiatives in focusing on effective weekend handover.

Despite handover and continuity of care forming part of the foundation professional capabilities there is a lack of formal teaching on effective handover, particularly prior to commencing F1. Resultantly, handover specific teaching and simulation will now be integrated into teaching during the foundation shadowing period with further teaching early into the F1 year.

Fig 1. PDSA cycles

Fig 2. Run chart showing percentage of jobs handed over that were deemed to inappropriate

Fig 3. FRIDAY infographic

(Fig 3.)

(Fig 3.)

Is anyone coming for handover?

Hull Royal Infirmary Stephanie Hill and Samuel Protheroe

PROBLEM:

Without a formal medical handover on weekday mornings, sick patients can get missed, doctors go home late and dissatisfied, and crash bleeps can be left unattended.

AIMS:

By the end of the 5-month project, reported stress of the night doctors will be reduced, their reported satisfaction will be increased, and more night doctors will leave on time.

PROCESS MAP:

Night doctor looks on E-Roster to find Long Day doctor

Night doctor goes to base ward of Long Day doctor

Night doctor identifies Long Day doctor on the ward

MEASUREMENTS:

• Perceived stress of night doctors regarding the handover process

• Perceived satisfaction of night doctors regarding the handover process

• Whether the night doctors left late, early or on time

Between the dates of 23/08/2020 and 10/01/2021 all night doctors covering the medical wards at Hull Royal Infirmary were asked to complete a questionnaire.

Questions asked:

1) Did you leave; on time, early, late?

If no volunteer found, night doctor leaves bleep unattended

If no Long Day doctor found, night doctor finds alternative doctor willing to hold bleep

FISH DIAGRAM:

Night doctor hands over bleep and goes home

2) On a scale of 1-5, how stressful was the handover process? 1 being no stress, 5 being very stressful.

3) On a scale of 1-5, how satisfied were you with the handover process? 1 being not satisfied at all, 5 being completely satisfied.

RUN CHART: REPORTED STRESS (1-5) OF NIGHT DOCTORS AFTER WEEKDAY HANDOVERS

PDSA CYCLES:

3.Monitor attendance Registers were put in place for the handovers and juniors made aware of this.

2.Introduce a formal handover. Standard Operating Procedure (SOP) written and agreed with consultants then shared with junior doctors.

1. Request that the long day SHO bleeps the night SHO in the morning to find them and take over bleep.

RESULTS INTERPRETATION

Baseline data found that on weekdays (n=25) the average stress score out of 5 was 2.7 and satisfaction was 2.5. On weekend days (n=13), where handover already exists, stress was on average 1.7 and satisfaction was 3.6. This difference conformed the hypothesis that improving the weekday handover process could reduce stress and improve satisfaction of the on-call junior doctors.

• Average stress score on weekdays reduced from 2.7 to 1.7.

• Average satisfaction score on weekdays increased from 2.5 to 3.2.

• Percentage of doctors leaving late reduced from 27% to 10%.

• PDSA cycles 1 and 2 contributed to this effect whereas PDSA cycle 3 did not and thus the intervention was not kept in place.

• Overall, initiating a formal handover saw a positive change in the results and should be endeavoured to be kept in place.

RUN CHART: REPORTED SATISFACTION (1-5) OF NIGHT DOCTORS AFTER WEEKDAY HANDOVERS

Leaving times reported for night doctors

16th June 2021

Poster Competition Group I

Education and Training (1)

First prize: Teaching clinical skills to medical students during the COVID-19 pandemic: A Quality Improvement Project

Presenter(s): Dr Anna Halstead, Dr George Williams, Dr Andrew Mcgaughey and Dr Grace Southern University Hospitals Dorset

Second Prize: Improving usability of a digital clinical decision support tool through PDSA cycles

Presenter(s): Harry Chappell, Dinesh Yoganantham, Joseph Read, Alexander Crawford Salisbury District Hospital

teaching clinical skills to mEdical students during the covid-19 pandemic

Dr. Anna Halstead , Dr. GEORGEWILLIAMS, DR.

ANDREW MCGAUGHEY & DR. GRACESOUTHERN

Introduction 3Results and analysis

The GMC sets standards and requirements for all UK medical trainees to ensure they have a minimum level of competence to practice safely. This includes basic clinical skills. During the COVID-19 pandemic, education was heavily disrupted for medical students, with many placements and clinical skills sessions being cancelled or converted to e-learning only. Practising clinical skills throughout medical school in a controlled environment is crucial for the students' development and to build their confidence. Without any formal clinical skills teaching, the students did not feel confident practising clinical skills on the ward.

Method

As outlined in the driver diagram (Image 1) we identified an achievable and sustainable intervention and decided on suitable measurable outcomes outlined in Image 2:

AIMS:

1. Improve the medical student clinical skills teaching

2. Increase medical student confidence in clinical skills INTERVENTION:

Design and implement an 8 week, weekly clinical skills programme for students to learn and practice skills in a controlled environment, based on the Southampton Medical School curriculum.

MEASURED OUTCOMES:

1. Student confidence - using a pre and post course questionnaire

2. Hours of teaching delivered

3. Weekly student feedback on each session, both written and verbal

By collating and analyzing the data from our measured outcomes, we ran three PDSA cycles with the primary aim of improving the medical students' confidence in clinical skills. The PDSA cycles are outlined in Image 3 below:

wards"

28 students attended the clinical skills teaching course that was run a total of three times over the academic year. We received excellent feedback throughout (Image 4), and there was an overall improvement in confidence of 72%having attended the course. Examples of the confidence difference for some of the individual skills are outlined in Image 5.

By correlating hours of clinical skills teaching to confidence level (see Image 6), we can see that generally the more hours spent doing clinical skills teaching the more confident the students become.

The data following our 2nd cycle showed that hours of teaching delivered decreased by 6.2 hours. On reflection, this was caused by logistical issues with room bookings, lack of models and equipment. These issues were addressed in cycle 3 and following a successful application for funding for more equipment and by improving communication with the clinical skills team, we managed to increase the number of teaching hours and saw our students' confidence improve to it's highest.

We also sent follow up questionnaires which showed that students had maintained confidence across all taught skills at three and six months and students unanimously reported the course gave them lasting confidence.

4 CONCLUSIONS& going forward

This project has clearly highlighted the importance of spending time doing clinical skills training in a controlled environment and the positive effect that it has on medical students' confidence.

Going forward we have set up a Whatsapp group to share opportunities to put the teaching sessions into practice on the wards. We will also be running refresher courses for the final year students to brush up on their skills before they start as brand new foundation doctors in August.

This has been a rewarding experience and it?s been great to watch us grow as a team and as teachers.

Image 1. (right): Driver diagram Image 2 (below) : aims, interventionsand measurable outcomes

Image 4: examplesof commentsfrom studentstaken fromweekly feedback forms

Image 5: Confidence in each named skill on a scale of 1-5 (1=least confident, 5=most confident). Before clinical skillscourse (blue) and after (orange)

"It made usmore confident topracticeon the

Image 6: Graph comparing thenumber of hourstaught (blue) and the overall confidenceof thestudents(red), out of 10 (10 being the most confident and 1 being the least)

"Great explanations; useful topractice"

Improving usability of a digital clinical decision support tool through PDSA cycles

H.Chappell, D.Yoganantham, J.Read, A.Crawford, C.Pettinger, R .Thakkar, E.Grace, N.Gupta, T.Rose, K. Glaister, S.Williams, S.Gray

Intro & Aims

Medical errors are a leading causes of morbidity and mortality globally.1 The majority of medical errors have been shown to be due errors of commission and errors of ommission.2,3

CQC and NHS England require that hospitals provide appropriate governance, training and resources for hospital staff. 4,5 Clinical guidelines are beneficial for patient safety, ensuring quality and consistency of care but may also cause harm.6,7 Microguide™ is a customisable platform which hosts selected trust guidelines and is used by over 50% of NHS acute hospitals 8 Our group aimed to improve the usability and functionality of this platform for foundation doctors at Salisbury District Hospital through “plan, do study act” (PDSA) cycles.

PDSA Methodology

The initial survey established current usage and issues users had. Two PDSA cycles have been completed, implementing a change and subsequent survey at each stage. Changes were implemented by the team directly and through communication with app developers.

Results and Discussion

There were 15, 14 and 16 responses to the initial survey, PDSA 1 survey and PDSA 2 survey respectively. Microguide was used by 98% at least a few times a week. The initial survey showed 93% found resources useful but only 20% found it easy to find to a desired resource.

PDSA 1 focused on user difficulties using the search function. A new search engine was implemented with ElasticTM search engine, the search engine used by GoogleTM 79% of responders noticed an improvement in search functionality

PDSA 2 focused on removing unnecessary layering of guidelines and duplicates. There was also editing and organisation to streamline the contents of guides. 63% noticed an improvement.

Between the initial survey and the PDSA 2 survey there was a 212.5% increase in the number of junior doctors finding guidelines "easy" or "very easy" to find

Sustainability

During our project, a sustainability plot was produced in conjunction with our hospital's Hospital Improvement team. This demonstrated areas to improve: infrastructure for sustainability; and adaptability of improved processes. We have subsequently worked to resolve these issues such that we believe we are now approaching our ideal state score for sustainability.

Time Trials

An initial time trial found it took F1 doctors on average 47 seconds to find the appropriate guideline for a clinical scenario

A repeat time trial after PDSA 2 found it now took F1 doctors on average 22 seconds to find the appropriate guideline for a clinical scenario

Conclusion and future directions

This shows Microguide is a frequently used and valuable resource. It demonstrates a model to effectively improve usability and the methodology could be applied to similar platforms. A third PDSA is ongoing with the microbiology department looking at implementing “systems based” antimicrobial guidance. All respondents preferred the proposed “systems based” format.

There is further scope for future PDSAs aiming to improve the mobile "App" version of Microguide and implementing future audit functionality to the guidelines.

16th June 2021

Poster Competition Group J

Education and training (2)

First prize: Increasing the rate of Learning from Excellence nominations at the RD&E Hospital during the COVID-19 pandemic by forming an alliance with the Quality Improvement Academy

Presenter: Dr Olivia Hartrick

Royal Devon and Exeter NHS Foundation Trust

Second Prize: Trainees Improving Patient Safety through Quality Improvement (TIPS QI)

Presenter(s): Gary Jevons, Sophie Green

Organisation: Trainees Improving Patient Safety through Quality Improvement (TIPS QI) (supported by HEE North West)

Increasing the rate of Learning from Excellence

nominations at the RD&E Hospital during the COVID-19 pandemic by forming an alliance with the Quality Improvement Academy.

Results

• In the NHS, developments in patient safety have focused on learning from errors. This approach neglects the opportunity to learn from the abundant examples of excellent practice. ‘Learning from Excellence’ (LfE) is a contemporary initiative which advocates a system to report excellence. This is a popular initiative, recommended in the 2019 patient safety strategy 1 However, nationally there has been variable rates of implementation success.

• Aim: We sought to increase LfEreports by 100% in one year at the Royal Devon and Exeter Hospital (RD&E) by forming an alliance with the foundation school Quality Improvement Academy (QIA).

• This academy provides a supportive environment for doctors to practice quality improvement. This project had the additional challenge of being conducted during the COVID-19 pandemic.

Introduction & Aim Methods

The RD&E LfEteam formed a partnership with QIA. We recruited a group of junior doctors to run a multi-faceted quality improvement project which aimed to increase excellence reporting at the RD&E. The team conducted three complete PDSA cycles, the first focusing on ward-based interventions and the other two on trust-wide interventions. These interventions included presenting at local meetings, creating a promotional video and screensaver which was advertised across the trust, engaging the chief executive to lead a ‘Twitter takeover’ and collaborating with the communications team to conduct a LfEpromotional week. Regular team meetings were conducted in a virtual setting and all interventions were conducted while abiding by the coronavirus protocols. Intervention success relied on good virtual communication with key stakeholders. Progress was analysedusing nomination run charts.

Focus:emergencydepartment,amedicalwardand asurgicalward. Intervention:series of formaland informaldiscussionswhichintroducedLfE. Result: In 3months,thenumber of nominationsincreased by 300%within ED and160% in surgery.

Focus:TrustWide. Intervention: The development of atrustapprovedanimatedvideoandscreensaver includinga QR code as adirectlink to the submissionform.Initial results identifiesadrastic increase in rate of nominations.

Focus:trustwide. Intervention:Trustapproved promotionalweek,restaurantstand and CEOtwitter takeover.Initial results identifiesadrasticincrease in rate of nominations.

• In 6months, we found an average298%increase in the monthlyLfEnominationswasobservedacrossthetrustfrom November 2020-April 2021

• The significantincrease in nominations in April2021(146) is aresult of thelattertwoPDSAcycleswhichincludedthe followinginterventions;the LfE promotionweek, CEO twitter takeover and publication of theLfEscreensaver.

Limitations

This QI project was conductedduringtheCOVID-19 pandemic. It was thereforeessential to followthe trust’s COVID-19 guidance.Thislimited our ability to drawfrom previousface-to-face QI interventionexperience and so we wererequired to adapt andfocus on innovativevirtual interventions. Furthermore,alargenumber of staffwere re-deployed to differentdepartments and manywardswereoftenmoved or closed.Thislikelyreducedtheimpact ofour firstwardbased PDSA cycle and so following PDSA cyclesfocused on trust widevirtualinterventionswhichproved to be alotmore successful.

Lessons learnt, future direction

• We foundthat an organisedandsystematicapproach to the qualityimprovementproject,involvement of appropriate stakeholders and regularvirtualtask-focusedmeetings sustainedthemomentum and maintainedtherate of success of thisproject.

• Usingamulti-facetedcumulativeapproachimprovedproject outcomes and sustainedchange.

• Anotherimportantoutcome of thisproject was thecreation of agroup of motivatedLfE ‘champions’ who arecommitted to continueLfEimplementation and sustainedchangewithin thistrust and acrosstheSouthwest.

O Hartrick, J Duckworth, M Dineen, A Pawar, M Edwards, T Atkinson-Seed, V Henderson, L Sigley, A Pankhurst, G Liversedge, N Mathieu, R Bethune

Figure 4. Promotional week photos.

Figure 3. Runchartof LfEmonthly nominations across the trust.

Figure 2. Learning from Excellence poster screensaver.

Figure 1.The model for Improvement and an outline of three completed PDSA Cycles2

Trainees Improving Patient Safety through Quality Improvement (TIPSQI)

Jevons; S Green; H Baird; C Whytock; K Newell; R Healy; E Abbot; J Dover; J Dalziel; D Krishnan; A Behbahani

Background:

• There is significant variation in exposure to, and training within QI concepts

• The Francis and Keogh reports1,2 highlighted junior doctors as “agents for change”

• Without formal QI training their potential to undertake improvement is limited

Aim:

• TIPSQI is a trainee-led organisation set up in 2013 with the aim of teaching QI methodology to all foundation year (FY) trainees within the North-West (NW) deanery, empowering them to undertake effective QI projects

Methods:

• Peer-led mentor system and “train-the-trainer” model

• Workshops delivered within the FY teaching programme reaching all 21 trusts within the NW

• Website developed (tipsqi.co.uk), including a TIPSQI project guide

• Teaching sessions developed for consultants supervising QI projects

• QI conferences arranged to showcase work of FY trainees

• In response to COVID-19 we converted to a virtual teaching model; all sessions provided virtually as well as organising a regional virtual QI conference to recognise the excellent QI work during the pandemic

-

Results:

• To date, we have reached over 3500 foundation trainees and 200 consultants across 121 sessions, and have delivered 3regional QI conferences

• We are supported by Health Education England North West with TIPSQI training being a mandatory deanery wide component of the FY curriculum

2020-21

- Conversion to virtual teaching model

- More virtual resources

- Two virtual conferences

• Through the use of pre and post self-assessment scores for the understanding of individual components of QI methodology, we demonstrated significant improvements in attendee understanding of key QI concepts (Figure 3); as well as achieving overall good feedback in the teaching quality (8.51/10) and relevance to training (8.24/10)

• Our virtual teaching programme received consistently positive feedback, equivalent to that of our “face-to-face” teaching

Future plans:

• Building an online project bank

• Expanding our sessions to higher trainees and to different regions within the UK

• Developing our online resources

Figure 3. Radar Chart to display pre- and post- assessment scores of all foundation sessions delivered up to August 2020

Figure 1. PDSA cycle to display development of TIPSQI

Figure 2. Driver diagram – Supporting FY trainees in Quality Improvement

“Really helpful session –interactive which was great”

“Brilliant, finally understand QI”

“Junior doctors are the eyes and ears of the NHS” Francis

16th June 2021

Poster Competition Group K

Improving processes and healthcare outcomes (1)

First prize: “Doctor...can you update the family please?...” A

Quality Improvement Project on Family Updates

Presenter(s): Amy Prideaux & Thanuja Thananayagam

University Hospital of Wales, Cardiff

Second Prize: A Quality Improvement Project to Improve

Access to Clinical Guidelines for Junior Doctors at the Royal Devon and Exeter Hospital

Presenter(s): Alice Mcloughlin, Fah (Rungphloy) Jaroenchasri

Royal Devon and Exeter NHS Foundation Trust

“Doctor...can you update the family please?...” A Quality Improvement Project on Family Updates

Dr Amy Prideaux and Dr Thanuja Thananayagam, FY1s at The University Hospital of Wales, Cardiff

Problem & Background

During COVID-19, hospital visiting was only possible for patients who were nearing end of life. This resulted in the ward receiving continuous phone calls from relatives and it became difficult to keep track of updates which had occurred. Some family members were becoming frustrated, and complaining if they hadn’t been contacted.

Driver Diagram

Aim

To increase the frequency of family updates given to relatives who were being treated on the COVID-19 ward by 50% in 6 weeks.

Team

All members of the MDT on Ward A7, University Hospital of Wales, Cardiff.

Measurement

Evidence of discussion with family member for staff members to fill in.

Data collected continuously for 6 weeks (3 weeks without intervention, 3 weeks with intervention).

PDSA Cycles Plan

-Identify problem

-Predict that the afternoon board round will increase the frequency of family updates

-Design whiteboard table

-Collect baseline data

Do

- Implement family update whiteboard

-Notify staff on ward

- Collect data

Study

- Analyse data

-Brainstorm ideas about the logistics of our intervention

Intervention Results

‘Relatives and Family Communication Board Round’

3pm daily

Quick run through of who has been spoken to and who still needs to be updated.

Re-visited ward 3 months later

Ward manager noticed there had been fewer complaints during the intervention. Patient folders now have an update sheet at the front, for staff to sign when and who they updated. Therefore a proven sustainable change and improved outcomes for staff and patients.

Lessons learnt

-Family updates and documentation requires continuous effor t from the whole MDT

-Effective and efficient feedback between staff members is required to ensure continuity between shifts

-Regular updates given to relatives will help ease their concern

Act

-Apply intervention of 3pm board round

-Update staff on the ward

-Collect fur ther data

Intervention

Aim met => Total number of phone conversations with family increased by 89% in 6 weeks following implementation of the communication board round.

Next Steps

-Perform QI project on new update sheet and compare results

-Allocate patient update advocate at start of shift

Acknowledgements

Dr Owen Seddon, Infectious Diseases Consultant

Next Steps

-Integration of family updates into SBAR handover tool

- Collect data on family concern and number of complaints made

A Quality Improvement Project to Improve Access to Clinical Guidelines for Junior Doctors at the Royal Devon and Exeter Hospital

A.Mcloughlin,

R. Jaroenchasri, B. Lane, S. Holloway, P. Gleed, H. Pringle, I. Kwek, A. Routsis, L. Taylor, Y. Mehta, S. Hasan, S. Smith, E. Richards, A. Kennedy, B. AbraduBerchie, P. Ramos Barbosa, A. Richards

Introduction

Medical practice is enhanced by guidelines that inform best practice, and clinical outcomes are shown to improve when guidelinesare implemented1 Junior doctors (JDs) heavily rely on accessible guidelines in clinical practice.

• JDs at the Royal Devon and Exeter Hospital (RD&E) report difficulty finding guidelines, which can impact patient safety and the provision of optimal care.

Aims

• To reduce the time taken for JDs to find clinical guidelines by 50% by June 2021.

• To increase the ease of use of clinical guidelines by 50% by June 2021.

PDSA Cycle 1

• PLAN/DO – a qualitative survey was circulated to JDs to evaluate the pattern of use and perceived ease of finding clinical guidelines. JDs and medical students (MS) were invited to find five common guidelines on the RD&E Hub whilst being timed STUDY:

○ 75% of JDs access guidelines multiple times per week

○ Average ease of finding guidelines was rated 2.5/10

○ Mean average time taken to find guidelines was 109s

• ACT – a clinical guidelines page was designed and launched onto the RD&E Hub, including commonly used guidelines.

PDSA Cycle 2

• PLAN/DO – to re-survey JDs after implementing the new clinical guidelines page on the RD&E Hub and test the ease of finding five common clinical guidelines STUDY

○ Average ease of finding guidelines increased to 8.7/10

○ There was an 81% reduction in time taken to find guidelines to a mean average of 21s

• ACT – a new clinical guidelines app called Microguidewas commissioned to further improve access to guidelines.

PDSA Cycle 3

PLAN/DO – to populate the new Microguideapp with clinical guidelines and test JD’s on finding common clinical guidelines within the app

• STUDY:

Average ease of finding guidelines on the Microguideapp was rated 8.75/10 There was a further 57% reduction in time taken to find guidelines to a mean average of 9s

• ACT –to advertise to wider staff population including physician associates and further JD’s

Ease of Finding Clinical Guidelines

Conclusion

This project identified an area of clinical practice lacking efficiency and negatively impacting junior doctors and the deliveryof optimal care. A simple yet effective intervention of collating guidelines onto a single page on the trust intranet was created leading to significantly improved access to clinical guidelines.

Furthermore, implementation of the Microguideapp improved speed of finding guidelines even more, surpassing our aims.

16th June 2021

Poster Competition Group L

Improving processes and healthcare outcomes (2)

First prize: Will I Finish Work on Time today?

Presenter: Dr Hajera Sheikh

North Middlesex Hospital, London

Second Prize: Transforming the task-board: Improving outof-hours task identification and prioritisation

Presenter(s): Daniel Butler, Elizabeth Alexander

Royal Devon and Exeter NHS Foundation Trust

Will I leave work on time today?

Dr Hajera Sheikh1, Nicola Davey2, Dr Emma Parish3 Homerton University Hospital 1, Quality Improvement Clinic2, Royal London Hospital 3

PROBLEM

Doctors rarely leave work on time. They frequently stay beyond the end of their shift; to complete clinical work, documentation, and other reasons.

This is contributing to burnout and doctors leaving the profession -meaning those who stay behind, stay even longer!

“Yes it’s a problem.”

“I don’t want to hand over crap”

“Everyone else is staying back”

“You find that the same people stay back each time”

“The whole point of a shift system is that you hand things over.” Some areas are a particular problem, eg postnates and special care.”

“What time is handover supposed to take place?”

“I feel lucky to have this job -on my terms –I don’t mind staying back”

“I’ve never finished on time.”

“It’s just a job, my work-life balance is more important.

DIAGNOSTICS

“I take handover on time, and I go home on time – The only reason to stay back is an emergency – other things can be handed over.”

“After a long day at work, the last thing I feel like doing is to stay back to fill yet another form to exception report.”

“I keep meaning to fill in a form for exception reporting –I forget the next day.”

“I’ve never filled in a form for exception reporting.”

AIM

All junior doctors to finish their shift on time or within half an hour, every time; by the end of January 2019.

Chosen measure: Details about a shift including time left, supposed end time, start time, handover delay, if delayed, causes of delay.

Inclusions: All daily shifts

Exclusions: Those where people left early due to appointments/study leave Sampling method & frequency: Retrospectively for shifts undertaken each week.

(9 junior doctors per day shift/4 per night shift)

LEARNING AND REFLECTION

• Achieved a reduction of time stayed at end of shift from 52 to 28min!

• Great QI learning opportunity – leading to ongoing discussion and improvement work within department.

• Doctors frequently staying beyond rostered hours, safeguards such as Exception Reporting are rarely used. Likely to be universal

• Seniors are not a barrier to leaving work on time, or to Exception Reporting. Active and exemplary engagement of consultants to explore solutions.

• Through the project, I was able to make a difference as follows:

• Management of postnatal wards

Joint MDT handover

Reduction of interruptions

Begin afternoon handover early

• Ongoing endeavour can be divided in 3 areas as follows:

Reviewing clinical workload (What we do)

Operational efficiency (How we do it)

Doctors views/attitudes (Psychology behind overstaying)

Transforming the task-board

Improving out-of-hours task identification and prioritisation

Daniel Butler, Elizabeth Alexander, Stefan Hudson, Amy Ward, Zoe Evans, Jacob Bruten, George Sylvester, Hussain Al-Jabir, Thomas Christie, CharleaWilliams, Chris Ward.

Background:

• The Royal Devon and Exeter Hospital uses a task-board system; an interactive electronic board where healthcare professionals allocate out-of-hours (OOH) tasks to on-call doctors.

• This task-board has recently changed significantly after moving from paper records to the implementation of ‘Epic’ software (a fully integrated electronic patient record).

• Survey data from twenty-six junior doctors rated the mean ease of reading and prioritising OOH doctors’ tasks as 3.7/10(10=Best, 1=Worst).

• Timelier reading and prioritisation of tasks would improve patient safety, as urgent patient tasks could be actioned sooner.

Aim: This project aims to reduce the time taken for junior doctors to read and prioritise fifteen tasks from the OOH task-board by at least five seconds per task.

Methodology:

• We used the PDSA cycle methodology to guide collection of quantitative and qualitative data and guide change.

• We timed juniors doctors reading tasks and prioritising tasks by finding specific patients from the task list.

• For example, once junior doctors read the tasks they are asked to highlight the patient with chest pain thus testing how navigable the task-board is.

PDSA Cycle 1: The Current Taskboard

P: Offline simulated taskboard wascreated and 15 patient tasks added.

D: The mean time taken to read and prioritise 15 tasks = 144 seconds (9.6 s per task).

P: Educational resource to optimise usage created based on doctors selfidentified needs.

D: Increase in levels of confidence and subjective competence.

A: 1. Improve the appearance of the task board

2. Educate doctors to optimise their use.

S: Qualitative data suggests:

1. Tasks to appear next to patient’s names

2.To be able to remove and reassign tasks.

A: An MDT of task-board users identified possible new designs incorporatingthe suggested improvements.

S: Junior doctors still desired a definite change to the task-board display.

PDSA Cycle 3: Proof of Concept

Task-board

P: The modified task-board mimicked the desired display modifications.

A: Finalisinga design idea with the ‘Epic’ software team, which can then be implemented

Learning points:

D: The mean time taken to read and prioritise 15 tasks = 58 seconds (3.9 s per task).

See figure 1.

S: Our proposed task-board satisfactorily reduced time taken to read and prioritise tasks.

Satisfying the entire MDT including nurses, site practitioners and software engineers was essential in creating designs for the future task board.

Current task-board

Proof of concept task-board

Conclusion: Our proof of concept cycle shows completion of our aim to reduce the time taken to prioritise tasks by 5.7 seconds per task.

Future Plans:

• Once visual changes are implemented we will run a fourth PDSA cycle to evaluate this change.

• We plan to share improvements with other trusts trialling taskboards within ‘Epic’ to facilitate safer patient care across multiple hospitals out of hours.

PDSA Cycle 2: Educational Intervention

FIGURE 1 - CUSTOMISATION OF THE ELECTRONIC OOH TASK - BOARD

16th June 2021

Poster Competition Group M

Improving patient handover and intensive care

First prize: Improving the culture of electronic handovers

Presenter: Cameron Gemmell

Taunton and Somerset NHS Foundation Trust

Second Prize: ‘Mind the step’ -down

Presenter: Declan Beattie

Northern Ireland Medical and Dental Training Agency (NIMDTA) - Belfast Trust

Improving the culture of electronic handovers

Introduction

• Royal College of Physicians guidance states handovers should have a standardised system of documentation to improve efficiency and patient safety1

• Handovers between the weekday and separate oncall weekend medical teams at Musgrove Park Hospital occur via an already established electronic record.

• Each patient record has a free-text box where a non-standardised handover is added.

• This results in little consistency and often insufficient information, for effective and safe task prioritisation.

Objectives

1. Develop a standardised handover template

2. Generate >80% use of uptake within the medical department

3. Template to be adopted by future annual cohorts

Methods

1. Pre-intervention email questionnaire and draft handover template model circulated via email to gather feedback & views on current system

2. Finalised template made available via ‘auto-fill’

Interventions to improve template uptake: email month period

Results

• 12.5% of pre-intervention survey respondents felt the current handover system worked well.

• 93.0% (358/385) of handovers in the final five weekends audited utilised the template.

• 94.1% (32/34) of survey respondents felt the template improved patient safety.

• Incidences discovered where a patient handover was created but the patient was not added to the weekend list, therefore risking missing weekend doctor review.

Uptake of standardised handover template

Discussions

• Changes to the electronic patient record system improved the consistency and perceived patient safety of handovers.

• Auto-fill function aims to increase longevity of template uptake amongst future junior doctor cohorts each year.

• As we continue to adopt electronic software into all aspects of healthcare, it is essential that we use this to our advantage and design out unnecessary potential errors which can jeopardise care.

Limitations / areas for future work

• Accessibility: doctors need to be manually given access to the template.

• Patients are not automatically added to the list

• Template can still be poorly/partially filled out.

• Priority/ escalation status options could be added.

Gemmell C, Rogers S, Davis J, Davoudi K, Hinds J, Ahmed J, Jenkins G

Ensuring the safe step-down andhandover of surgical ICU patients to ward level

BACKGROUND

• It is the job of the surgical F2/CT to review patients when they are discharged to the ward from ICU.

• These are complex colorectal and upper GI patients with high ICU admission rates post-operatively.

• The patients have high volumes of electronic notes from their time in ICU which can be difficult to summarise and information was often left out.

• We wanted to implementaproforma to facilitate simple, timely and safe transfer of informationto ward level and improve continuity of care between units.

Dr Declan Beattie Dr Ciara Murphy

AIM

The aim of the project is to improve patient safety on surgical wards following their discharge from ICU through implementation of a proforma completed in 80% of ICU discharges by June 2020

IMPROVEMENT METHODOLOGY

We implemented the initial proforma and completed further PDSA cycles based on feedback until the final proforma was confirmed.

OUTCOME MEASURES

80% of patients discharged from ICU had a proforma completed

PROCESS MEASURES

Percentage of proforma completed (acceptable standard 75%)

Focus groups were held with peers and senior colleagues to establish what important information should be included.

RESULTS

We used this information to design a simple proforma on one A4 sheet of paper.

We then retrospectively audited 20 ICU discharges against these points to see what information wasnot recorded. Some of whichincluded medication history, fluid balance and surgical complications – all highlighted as essential information by consultant colleagues.

Percentage of proformas completed for patients stepped down from ICU

• Following implementation oftheproforma 20 cases wereexaminedwith 90% having a proforma completed to an acceptable standard. Some areaswerestillnotbeingcompletedandhencea furtherPDSA cycle implemented.

• 8 morecaseswere examined whichhad 88% of patients having a proforma completed to an acceptable standard and a much-improved completion rate in areas of concern.

• We examined how the proformawasbeingcompleted and accepted 75% completion as our standard. The graph shows how each section wascompleted.

MOVING FORWARD

16th June 2021

Poster Competition Group N

Improving admission and discharge care pathways

First prize: Improving the Quality of Referrals from the NHS 111 Service

Presenter(s): Dr John Flemming

Epsom and St Helier University Hospitals Trust

Second Prize: Improving the pathway for patients’ follow-up on swab results in Gynaecology Department

Presenter(s): Eunkyung Lee, Ridhi Majithia

University Hospitals Plymouth NHS Trust

Improving the Quality of Referrals from the NHS 111 Service

Dr John Flemming , Dr Robert Tan - Epsom & St Helier University Hospitals NHS Trust

Background

In August 2020, our trust implemented a service for patients to ring 111 and be given an appointment to attend our Emergency Department if appropriate.

Patients can be directed to in-house services or outside of the hospital, including their own GP, pharmacies and others.

Within the Emergency Department, patients can be referred to an array of services.

The promptness of the appointment in the Emergency Department is meant to reflect the urgency of the presentation, based on information from the telephone triage.

Patients are seen by ED team within 30 minutes of appointment time.

Our Project

We conducted a weekly audit on a sample of ca. 30 patients referred to our ED by the NHS 111 Service, collecting data items such as Presenting Complaint, Outcome of Call (including urgency of referral), and appropriateness of referral.

Our cycle involved scrutinising each referral and deciding if the NHS 111 call handler made an appropriate decision. Each week, this was fed back to the call-handling service and several cases were discussed. All parties agreed on takeaway points (such as changing the decision -making algorithm).

After these improvements were implemented by the NHS 111 Service, the process was repeated in the following week, taking into account all constructive feedback given during previous feedback sessions. This recursive cycle built on all previous efforts with the aim of improving the patient experience each time contact is made.

Quality Control

To ensure that patients get the best experience from the NHS 111 service, we needed to address a few key issues in our project:

• Is an ED attendance necessary at all?

• If patients are referred to our ED, are they being sent to the correct subservice within it?

• Is the urgency of the appointment appropriate? Is it too soon or not soon enough?

• How can this process be best run to ensure top -quality patient care and efficient use of resources?

• How can we track our servic e improvements as they evolve over time?

Our efforts brought improvements to many aspects of the NHS 111 patient experience within our department.

The number of referrals judged to be “inappropriate” by the auditing clinician fell markedly over the audit period:

The proportion of patients to be seen within 1 hour rose over the audit period, and lessurgent appointments fell, showing that more urgent complaints were referred over time:

With thanks to: Dr Harriet Bedell-Pearce, Dr Jasmine Gandhi, Dr Hannah Gardiner, Dr Nadia Ibrahim, Dr Aamir Iqbal, Mr Marco Machado and Ms Emma Phillips

Improving the pathway for patients’ follow-up on swab results in Gynaecology Department

Dr Eunkyung Lee1, Dr Ridhi Majithia1, Dr Rachel Roberts1 1Derriford Hospital, University of Plymouth NHS Trust, Devon, United Kingdom

Background

At University Hospitals Plymouth NHS Trust, junior doctors on Acute Gynaecology ward are responsible for searching results of genital swabs undertaken. Both patient and swab details would be recorded in a book and we would then call patients to inform the results.

Sample of form :

However, we noticed a number of errors on the results system, as demonstrated in Figure 1. Evidently, junior doctors were taking or labeling samples in an incorrect way. As a consequence, patients were called to be re-swabbed and this led to delayed outcome and in some cases, no outcome at all if they were unwilling to re-attend the hospital.

The underlying problem was the lack of information available in the current swab form. For example, it did not have any information on who took the swab, who called the patient, and clinical reason for undertaking swabs. This further complicated communication with patients. In one case, we had a female patient with Group B streptococcus positive and therefore advised to inform her midwife at the time of the birth, when she had a miscarriage few weeks ago, causing significant distress to the patient. This highlighted how crucial it was to have a clinical background such as pregnancy status on the form.

Additionally, knowing the individual who performed the swab was equally important, as errors attributed to having incorrect swabs taken could have been prevented by identifying and supporting educational need in these individuals.

Methods

Noticing the errors in the swab results, we planned to study how colleagues in the department found performing swab procedures and following up on the results

We designed and distributed the survey, which consisted of questions involving accessibility and accountability of the current system

Following the implementation, we planned to study if the new swab form made the follow-up process more accountable and user-friendly

We created and distributed the survey after implementing the new swab form. The responses were gathered in regards to confidence in the new system

These errors leading to delay in the treatment of patients have significant ramifications and pose a greater risk to patients’ health and safety. In outpatient setting, secretaries reported swab results with approximately 6 weeks delay. This was wider health risk, especially Sexually Transmitted Diseases that required formal follow-up and tracking for the protection of public.

Objectives

[1]To prevent errors in the type of swab by identifying individuals who took the swab in incorrectly and supporting their educational needs.

[2]To reduce delays in informing patients of swab results by ensuring the continuity of reporting results, especially in the context of Sexually Transmitted Diseases.

[3]To mitigate distress caused by communication without having clinical background in order to establish sensitive communication and therefore improved patient-doctor relationship.

We created the first version of new swab form containing a row of boxes with extra clinical information that was not previously present

The survey responses helped us to recognize the root of the problem, being the current swab form having a lack of clinical information

We revised the swab form including additional clinical information such as pregnancy status. Recommended swab teaching for the new cohort of junior doctors

Patient ID: Swab type Clinical background Pregnant Results Actioned

Swab taker: (Initials) HVV / VVS Yes By :

Date taken: No

Outcomes

The pre-survey reported a lack of confidence in the current system on following up on swab results. The majority of junior doctors felt that the swab form was not easy to use with lack of clinical information. It was also found that continuity of follow-up process was challenging without knowing the individuals tracking and reporting the results.

A huge disparity was noted in terms of confidence and training level of junior doctors performing swabs. Therefore, identifying individuals who would require further training was helpful to made them aware of correct procedure and support their educational needs. This in turn reduced errors in performing swab procedure that patients can get correct results in a timely manner.

The post-survey found that implementing the new swab form prompted junior doctors to report results more efficiently and sensitively by having more clinical background of patients.

In the context of Sexually Transmitted Diseases, the new system improved patient safety outcomes as they could seek a treatment in a timely manner with appropriate contact-tracing.

Conclusion

We studied the responses of the survey and also reaudited the data, assessing error rates and delay in informing swab results to patients

Our Quality Improvement (QI) project has made a positive impact on improving the follow-up process of swab results in Gynaecology Department. We identified the root of problem in swab results errors and implemented a new swab form to improve accountability and accessibility of the current system. As a result, it led to significant improvement in terms of delay in reporting swab results, reducing errors and even enabling sensitive communication for patients’ safety.

Acknowledgement

We would like to thank Dr. Rachel Roberts (Obstetrics and Gynaecology Consultant) for her guidance and support.

16th June 2021

Poster Competition Group O

Care of the surgical patient (1)

First prize: Regional Quality Improvement Collaborative to Reduce Surgical Site Infection in Elective Colorectal Surgery

Presenter(s): Miss Sarah Biggs & Miss Lauren Dixon

Organisations: Gloucestershire Hospitals, , Great Western Hospitals, Royal United Hospitals Bath, North Bristol Trust, University Hospitals Bristol and Weston on behalf of PreciSSIon and West of England

Academic Health Science Network

Second Prize: Improving the confidence of ENT trainees in assessing and managing nasal fractures

Presenter(s): Dr Sachin Patel, Dr Syed Shah, Dr Zohaib Siddiqui

Maidstone and Tunbridge Wells NHS Trust

Regional Quality Improvement Collaborative to Reduce Surgical Site Infection in Elective Colorectal Surgery

S.Biggs, L. Dixon, B. Clayphan, L. Jordan, S. Dalton & A. Pullyblankon behalf of PreciSSIonCollaborative

Introduction

Surgicalsiteinfection(SSI)refers to woundinfectionsfollowinginvasive surgicalprocedures. SSI constitutesamajorhealthcareburdenaccounting for 14.5% of allhospitalacquiredinfections in the UK and an estimated 34226%increase in associatedcosts. It is alsoasignificantcause of patient morbidityincludingincreasedlength of stay, readmission,wound dehiscence,hernia,needforintensivecare, as well as death. SSIis more commonaftercolorectalsurgerywherewoundsarefrequently contaminated by bowelcontentandratesarereportedbetween8-30%.

ThePreciSSIoncollaborative(PreventingSurgicalSiteInfectionacrossa region) is acollaborationbetween7NHShospitals in the West of England with the aim of reducing SSI afterelectivecolorectalsurgery.

Bundle

Method

TheInstituteforHealthcare Improvement’s (IHI)BreakthroughSeries collaborativemodel was used.Quarterlylearningandsharingevents with QI coachingwereused to implementamutuallyagreed, evidencebasedwoundcarebundle in electivecolorectalsurgery acrossthe7hospitals.

Measures:

Public Health England SSI surveillance questionnaire was used to attain 30 day patient reported SSI data

Compliance with the bundle and questionnaire response rates were measured at each hospital

Develop a local measurement plan that aligns with the local improvement

To reduce surgical site infection in colorectal surgery by 50% by March 2021

Build capacity to improve both the culture and the learning system in the department

Implement bundle:

2% chlorhexidine

Use of wound protector

Repeat dose of antibiotics after 4 hours operating time Triclosan-coated sutures for mass closure and skin

Learn from and design reliable pathways of care

• Establish optimum data collection (phone/letter/email/inpatient data)

• Audit tool in theatre

• QI education

• Educate theatre staff and wider surgical team (consultants/junior doctors)

• Laminated signs in theatre

• Procurement of sutures: remove alternatives and monitor reordering

• Operation cards for colorectal cases

• Training for Anaesthetists and OPD re antibiotics

• Give responsibility for each component

• Develop and promote evidence based information

103 SSIs prevented

£234,000 Estimated saving

Results and Discussion

All 7 hospitals had implemented the care bundle by February 2020 and by February 2021 1,147 patients has received the intervention. Average SSI rate was reduced from 18% (n=903) to 9.5% (n=1,147), which is a 49% reduction in 30-day SSI after elective colorectal surgery across the whole region (data collection is ongoing). Patient response rate was 69%. Average compliance to each of the 4 bundle elements was high (70 – 95%) and a relationship between increasing bundle compliance and decreasing SSI rate was suggested. We have demonstrated that using a collaborative approach to quality improvement can be effective in improving patient outcomes on a regional scale.

Improving the confdence of ENT trainees in assessing and managing nasal fractures

Dr Sachin Patel, Dr Syed Shah, Dr Zohaib Siddiqui, Mr Iain McKay -Davies

Maidstone and Tunbridge Wells NHS Trust

Introducton

Nasal fractures are the most common type of facial bone fracture. 1 It is important they are examined thoroughly as they can be associated with complicatons such as skull base fractures and septal haematomas. Patents undergo a manipulaton under anaesthetc (MUA) to improve cosmesis or functon and this can be either under a general anaesthetc (GA) or local anaesthetc (LA).

Current practce within our hospital is that once a patent is seen by A&E, they are booked into our ENT SHO led urgent care clinic for review and then if deemed necessary they will be listed for a manipulaton of their fracture under a GA. There is no formal teaching regarding nasal fractures or how to manipulate them under LA.

Aims and Objectves

1)Drive improvement in the quality of care for patents with nasal fractures

2)Improve the knowledge and confdence of ENT trainees when assessing and managing patents with nasal fractures

3)Reduce the number of patents needing manipulaton under GA, instead performing the procedure under LA in our clinic

Methodology

A baseline questonnaire was completed by the trainees which included 5 domains, each scored on a 10 -point Likert scale (0= not confdent at all, 10 = completely confdent). The domains required them to subjectvely assess their confdence in identfying anatomy relatng to a nasal fracture, taking a focused history, examining a nasal fracture, assessing and recognizing complicatons and performing a manipulaton of a nasal fracture under LA on their own. The same baseline questonnaire was then repeated afer both of the interventons. 12 trainees completed all 3 questonnaires.

Plan -Do -Study-Act cycles:

1) Formal lecture

2)Objectve structured clinical examinaton (OSCE) style video that included history taking, examinaton and an MUA performed under LA on a real patent

Results

There was an increase in confdence across all domains subsequent to our lecture. Further improvements were again seen following our OSCE video interventon.

The greatest improvement was seen in how confdent trainees were in performing a MUA under LA. The baseline score improved from 1.25 to 6.8 post lecture and fnally to 8.6 afer the video.

6 patents with nasal fractures have needed manipulaton in our clinic. 5 were done under LA and 1 patent did not want it done under LA.

Conclusion

Our project has positvely impacted 3 groups:

1)The patents

- Reduced GA risk, tme in hospital and therefore COVID-19 risk

2)The ENT trainees

- Improved confdence surrounding nasal fractures

- Learnt a new procedure

3)The trust/department

- More theatre slots available

- Saved £2306.05 since January (GA £486.21 vs LA £21 per patent). Potental to save roughly £27,000/year (based on pre COVID -19 data as lockdown reduced the number of nasal fractures)

Future Work

We are currently running a concurrent project aiming to improve the documentaton surrounding history taking and examinaton of nasal fractures. We aim to implement a proforma.

Patents who undergo a MUA (GA and LA) are being given 2 week post procedure follow up questonnaires that include domains such as pain scores, improvement in functon/appearance and complicatons. Results from these will help us further improve our patent care.

16th June 2021

Poster Competition Group P

Care of the surgical patient (2)

First prize: Reducing the number of appointments for fibroepithelial polyps (FEPs)

Presenter(s): Dara Murphy

Oral and Maxillofacial Unit Ulster Hospital

Second Prize: Standardising Surgical Ward Round

Documentation

Presenter(s): Leila Ellis and Sophie Howlett

Torbay and South Devon NHS Foundation Trust

Reducing the number of appointments for fibroepithelial polyps (FEPs)

Dara Murphy, OMFS DCT2 Nicola McCurley John Hanratty

BACKGROUND

• The Ulster hospital Oral and Maxillofacial surgery (OMFS) unit is regional tertiary referral unit led by four consultants.

• We have an increasing need for further outpatient capacity due to a changing patient demographic with increased head and neck oncology and skins.

• The OMFS department currently has long waiting lists.

• Grift report1 states that the OMFS new: review ratio should be 0.74 our current ratio in OMFS 1.32. As a department we needed to look at ways to reduce review appointments

• Fibroepithelial polyps (FEPs) are a benign pathology with a high percentage of accurate diagnosis with a very low rate of misdiagnosis2.

AIM STATEMENT

By December 2020 70% of patients with a diagnosis of FEP attend two or less appointments

OUTCOME MEASURES

Percentage of patients who have attended two appointments or less for confirmed FEP pathology

PROCESS MEASURES

Number of appointments of each patient

IMPROVEMENT METHODOLOGY

Driver diagram:

PDSA cycles:

WHO BENEFITS?

No further time off work

Covid concerns

Access concerns re car parking/ childcare

Appointment can be used by someone else

Waiting list reduction

Cost of outpatient appointment

RESULTS

RUN CHART

Number of appointments given for a patient with the diagnosis of FEP

OUTCOMES 2019

16% of cases of confirmed FEP had 2 appointments or less

2020

77% of cases of confirmed FEP had 2 appointments or less.

NEXT STEPS

• Reaudit process to ensure change is sustainable

• Consider spreading: can a results letter be implemented in other spoke hospitals?

• Can we consider a similar approach for other pathologies?

STANDARDISING SURGICAL WARD ROUND DOCUMENTATION

BACKGROUND

Accurate, comprehensive, legibleand contemporaneous recording of doctor-patient interactionsis essential for patient safety, quality of care and medico-legal purposes The often fast-pacednature of surgical ward rounds cancompromisecommunication and promote inaccurate or incomplete documentation

AIMS

To standardise documentation of daily surgical ward rounds. To ease ward round preparation for junior doctors. To aide handover between all healthcare professionals.

METHODOLOGY

Three rounds of plan-do-study-act (PDSA) cycles were undertaken between November 2020 and April 2021 across the three emergency and elective surgical inpatient wards at Torbay Hospital.

CYCLE 1

• 11/11 MDT members rely on documentation as the main method for communicating investigation findings, clinical management and discharge plans.

• Useful for afternoon ‘safer’ meetings

• 4/19 entries used the jobs checklist encouraging review of plans for regular medications, diet, antibiotics, IV fluids, VTE and TEP, with junior doctors noting time as the main limiting factor.

• Infrequent use of prompts on the back page of the proforma including radiology reports (9/19), microbiology advice (0/19) and patient/carer communication (0/19).

6/7 junior doctors prefer to use continuation sheets for this additional documentation as fear elsewhere may be overlooked by the MDT.

• 2/7 juniors doctors reported the proforma was often not integrated in chronological order in the notes.

• Added discharge criteria text box.

• Incorporated checklist items into relevant sections of the proforma to improve usage.

• Redesigned the back page to replicate a continuation sheet to promote integration.

• Added colour border to facilitate locating the proforma in the patient notes.

INTERVENTIONS

Introduction of a daily surgical ward round proforma. Education sessions for F1 doctors and physician associates. Informal advertising to the wider surgical team

DATA COLLECTION

Retrospective analysis of 117 surgical ward round entries. Questionnaires and verbal feedback from junior doctors and multidisciplinary team members (MDT).

CYCLE 2

• Increased awareness of proforma across the whole team promoted use.

• Adjustments to layout based on feedback in cycle 1 were well received.

• Inconsistent availability of the proforma.

• 1 nurse noted that the dietary plan was often not completed which could lead to patients remaining on unnecessary dietary restrictions.

• Idea of introducing a cover sheet to be updated throughout admission with working diagnoses, investigation findings and poignant changes was dismissed as a source of additional work.

• Reduced engagement with questionnaires as a method of providing feedback.

• Optimised accessibility by adding the proforma to the shared network drive and reminding ward clerks to regularly print and store copies in clearly labelled drawers on each ward.

• Separated signature and contact detail prompts for the ward round preparation and real-time documentation, recognising that these sections may be completed at different times or by different individuals.

• Attended wards to collect verbal feedback from the junior doctors and MDT members.

QUANTITATIVE RESULTS

CYCLE 3

• Improved documentation of 6/10 parameters as outlined in Table 1.

• 6/6 junior doctors reported the proforma was preferable for ward round preparation and real-time documentation despite 4/6 finding a continuation sheet quicker.

• 15/15 MDT members reported the standardised structure of the proforma improved interdisciplinary communication with 13/15 also noting it was easier to contact the relevant doctor when needed.

• 2 junior doctors reported the particularly fast-paced nature of weekend ward rounds hinders use of the proforma.

• Discrepancies in preferences for elements thought to be useful to the MDT but inconvenient for junior doctors to record.

• Incorporated use of ward round sheet into surgical juniors induction manual including advice to carry multiple copies of the proforma during the weekend ward round.

• Continued education around use of the proforma as a guide to promote consideration of multiple aspects of patient care.

• Departmental presentation to share the impact of the proforma and encourage sustained use and ongoing improvements.

QUALITATIVE RESULTS

Table 1. To assess compliance with bestpractice standards, these 10 measurable parameters were selected for monitoring based on local Trust guidance and wider literature review Green =≥10% improvement from baseline, Orange =≥10% decline from baseline

CONCLUSION

• Introduction of a daily surgical ward round proforma improved the standard of record keeping of 6/10 measured parameters with less impact on those that have established documentation processes.

• Compared to the previouspractice of using continuation sheets, the proforma was preferred by junior doctors for ward round preparation and real-time documentation and by MDT members for facilitating interdisciplinary communication

Corresponding Author: Leila.Ellis1@nhs.net

Dr L Ellis, Dr S Howlett and Mr J Parvin

Figure 1. Current version of surgical ward round proforma

Figure 2. Word cloud highlighting free text and verbal feedback shared by junior doctors and MDT members