Patient Safety Journal Vol 1, Issue 1 by munglani

Vol 1, Issue 1, ISSN 2632-363X

March 2019 Vol 1, Issue 1, ISSN 2632-363X

PATIENT SAFETY JOURNAL

for better, safer care

Quality Improvement: combining digital technology with innovative learning

> Learning from Deaths > Patient Consent After Montgomery > Refer-to-Pharmacy > Criteria Led Discharge 1

> Winter is Coming > Shock through the heart, and youâ&#x20AC;&#x2122;re to blame > Caries Prevention

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15th May 2019 Engineer’s House, The Promenade, Clifton Down, Bristol, BS8 3NB www.bristolpatientsafety.com Delegate places £219 to book visit www.bristolpatientsafety.com/book

National Quality Improvement & Patient Safety Poster Competition Deadline 10th March 2019

If your entry is shortlisted you will be invited to present your poster at the conference on 15th May 2019 and qualify for a discounted delegate rate of £159. Submit your entry online here www.bristolpatientsafety.com/poster-competition

Programme Preview Keynote Speaker Building a Just Culture at Mersey Care NHSFT Mr Joe Rafferty, Chief Executive, Mersey Care NHS Foundation Trust

Featured speaker A multi-professional approach to medication safety Dr John Dean, Clinical director for quality improvement and patient safety, Royal college of Physicians (RCP)

The impact of the criminal law on healthcare Dr Jenny Vaughan, Consultant Neurologist, NW London Hospitals NHS Trust and Medical Law Campaigner The Psychology of Quality Improvement Anna Burhouse, Quality Improvement Consultant, Director of Quality Development RUBIS.Qi Identifying delirium and implications for patient safety Dr Claire Copeland, Clinical Director Ageing & Health, Forth Valley Royal Hospital and member of the Scottish Delirium Association ImproveWell, empowering staff to communicate their ideas for improving care Peter Gray, Service Improvement Lead, Royal Cornwall Hospital Trust A QI project on reducing neonatal hypothermia; the challenges of sustaining improvement Claire Evans, Junior Doctor

Workshop A: Practical Tools to Support QI evaluation Lou Hall, Programme Manager: Evaluation, SWAHSN Workshop B: Sharing learning on improving care for mothers and babies Ann Remmers, Maternal and Neonatal Clinical Lead, WEAHSN Workshop C: Learning from Suicide claims Dr Alice Oates, South London and Maudsley NHS Foundation Trust Workshop D: Innovation in Healthcare Tricia Woodhead, Health Foundation Quality Improvement Fellow and Improvement Advisor Workshop E: Managing Concerns about Individual Performance Dr Sally Pearson, NHS Resolution Select two out of five workshops Full programme and to book visit: www.bristolpatientsafety.com

PATIENT SAFETY JOURNAL

Vol 1, Issue 1, 1 ISSN 2632-363X

for better, safer care

Patient Safety Journal This a record of the proceedings and learning shared at the Bristol Patient Safety Conference. Journal purpose, to improve safety and care through: • sharing approaches to improvement at all levels in a healthcare setting including system-wide change • accelerating the sharing of ideas and tools that have been successfully put into practice • celebrating practitioners’ quality improvement work and barriers overcome

Contents Learning from Deaths: Implementing Structured Judgement Reviews across the West of England Dr Mark Juniper, Kevin Hunter, Melody Moxham 5-7 Quality Improvement - combining digital technology with innovative learning Nicola Davey, Tom Kenny, Laura Longley 8-15 Refer-to-Pharmacy: outcomes of hospital to community pharmacy referral’ Alistair Gray, Clinical Services Lead Pharmacist, East Lancashire Hospitals NHS Trust 16-19

Editor-in-Chief Dr Tricia Woodhead Senior Editors Miss Anne Pullyblank Dr Mark Juniper Professor Wai Tse Publisher Katherine Dougherty, KJD Communications Copy Editor Ravi Munglani Designer Lesley Lee Design Website www.patientsafetyjournal.com

Criteria Led Discharge: A Systematic Review and Patient Safety Dr Liz Lees-Deutsch MSc BSc Dip HSM RGN

20-24

Patient Consent After Montgomery, Practical Guidance for Doctors James Badenoch QC 25-28 Winter is Coming: Improving Antibiotic Prescribing for Sore Throats Dr Rajan S. Pooni, Dr James McKinnon 29-36 Shock through the heart, and you’re to blame: Reducing DC Cardioversion Errors using a checklist and simulation training Dr Nathan Riddell and Dr Nico Swetenham 37-49 Caries Prevention: dietary counselling and fluoride intervention. A multi-centre quality improvement project (QIP) within Primary Care Dental Practices Dr Jonathan Davies, Miss Julia Harris 50-53

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Introduction from the editor Dr Tricia Woodhead It is six years since a small group of us set out to design the first Bristol Patient Safety Conference. Our aim was to provide an annual forum that would promote quality improvement in our healthcare system locally, as well as provide a networking opportunity to share and encourage that work. Having initiated our foundation doctors QI programme in 2010 we were very aware of the value of presenting, publishing and sharing to everyone; but also of the challenge of funding, travelling to and indeed gaining abstract acceptance at the small number of international meetings. We wanted a local opportunity for everyone starting out on or leading our QI journey. Our aim was to share success, add skills through our workshop format and develop connections and a community of professionals skilled in making improvement.

The Bristol Patient Safety Conference is definitely about seeing, hearing, saying and doing. We are adding reading via this journal. We have asked presenters of both plenary and workshop sessions to provide us with a short piece on the key messages and insights they would wish us to add to what we saw, heard and experienced in May 2018. Our aim is to refresh our memory, restore some of the insights we gained, perhaps with a new insight that has developed as we have sought to share, and put them into practice. We hope to regenerate our energy to learn, discuss and most importantly to work with others to steadily and purposefully improve the work we do each and every day. Reading is something you often do on your own, but the written word gives a common resource to a team with which to challenge themselves and seek greater understanding.

This journal is a new addition to that same aim. You may be familiar with the ‘Cone of Learning’ the concept attributed to Edgar Dale an educationalist is as follows; we remember 10% of what we read, 20% of what we hear, 30% of what we see, 50% of what we hear and see, 70% of what we say, 90% of what we say and do (especially if it’s teaching!). This, like all theories, is disputed by many but the fundamental point is that humans learn in different ways and need a combination of experiences to maximise the gain in their knowledge and understanding.

We hope that by reading you will not just refresh your own memories of the conference in 2018 but will find opportunities to share with others and start preparing to join us in 2019.

We hope that by completing the ingredients of ‘learning pyramid’ for our community of improvers they will learn, live and lead improvement even more effectively. Abstract submissions for the poster competition are open until 10th March 2019 Our programme for the day is on the second page of the Journal

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Learning from Deaths: Implementing Structured Judgement Reviews across the West of England Dr Mark Juniper1, Kevin Hunter2, Melody Moxham3

Summary The West of England Academic Health Science Network has a strong patient safety portfolio. As part of our work on improving patient safety we partnered with the Royal College of Physicians in late 2016 to pilot, and be an early adopter of, their Structured Judgement Review (SJR) process. Using our experience in delivering collaborative projects, we approached all acute hospitals in the region to work together to improve the way we learn from deaths in healthcare. Our aim was to standardise the Mortality Review process, share learning, identify outcome themes and facilitate region-wide quality improvement (QI) initiatives.

Introduction The purpose of mortality review is to learn from deaths and to identify areas of practice that can be improved. Standardising this process enables organisations to compare data, to share the lessons they have learned and to establish improvement work more widely across the healthcare system. The Structured Judgement Review (SJR) methodology was developed by Professor Allen Hutchinson and validated in the Yorkshire & Humber AHSN by the Improvement Academy. The SJR process has been adopted by the Royal College of Physicians (RCP) to standardise the approach to mortality review in all hospitals under the National Mortality Case Record Review (NMCRR) programme. The West of England AHSN worked with the RCP and the Improvement Academy to roll out the SJR process across all acute hospitals in the West of England.

Methods The West of England AHSN used a collaborative approach to adopt a region-wide

SJR process. We used the Institute for Healthcare Improvement Breakthrough Series Methodology, and launched our Collaborative in September 2016. We established a network which involved senior leaders from all organisations. They initially met together and shared their established processes for mortality reviews. All organisations agreed to work together to establish SJR as a common methodology. Non-executive and Executive Directors were invited to initial meetings to ensure organisational buy-in at a senior level. All Trusts were involved from the outset, but a step-wise approach was taken with three trusts acting as early implementers, to refine the methodology, to understand some of the barriers to implementation and to gain confidence in the use of SJR. Regular contact between the leads was established in the form of a monthly telephone conference and a quarterly face-to-face meeting. Initially this involved sharing the challenges faced and how these had been best overcome.

Consultant in Respiratory and Intensive Care Medicine at The Great Western Hospital in Swindon, Clinical co-ordinator (Medicine) at National Confidential Enquiry into Patient Outcome and Death (NCEPOD) since 2012

Head of Patient Safety & Programme Delivery, West of England AHSN

Patient Safety team, West of England AHSN

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Adoption of SJR at the 5 remaining Trusts was accelerated as a result of the shared experience. This enabled early implementation when the National Learning from Deaths guidance was announced in March 2017. After the roll out of the SJR process, Clinical Leads from across the region have continued to meet on a regular basis to share progress and their learning from implementation. This has involved reporting on the number of reviews undertaken in each organisation as well as identifying common themes from across the region The NMCRR programme currently applies to in-hospital deaths. The Collaborative has been supported by two GPs who have contributed to discussions on how to take out-of-hospital learning forward. The two Mental Health Trusts in the region have joined the group and the group has also had Public and Patient representation. As part of the Collaborative the West of England AHSN has also supported the development of resources for member organisations including operational process maps, educational material and an implementation toolkit. These have been shared between the organisations involved in the collaborative as well as with the RCP. Early in the implementation across the West of England, Trusts signed up to a best practice framework, which, whilst not mandatory, detailed some of the key processes and actions that the group felt were important to adopt. These included: • ensuring reviews are completed by clinicians not immediately involved in the care of the patient • mixed teams and specialties undertaking the reviews to share the work and the learning • reviewing systems issues such as bed moves or delays in admissions, as well as clinical care 6

• liaising with Bereavement and Patient Services teams to ensure concerns of family members are included in the review • providing feedback to colleagues on care that was given.

Results The SJR process has been found to be effective in ensuring full reviews are focused on relevant cases. From April 2017 to November 2018, data shared suggests that 4046 deaths have been reviewed by the SJR process in the West of England region. Of the deaths reviewed, in 96%, the care received was rated as good, very good or excellent. Only 0.2% of deaths were considered to be avoidable. The value of a collaborative approach was evident throughout the implementation process. Clinical leads shared experience and ideas in areas such as how to screen patients to decide which cases needed SJR, how to involve bereaved families, and giving feedback to colleagues when areas were identified for improved clinical practice. Sharing of data between organisations has also provided a mechanism for external quality control. This has included shared conversations about the quality of care received, common areas for improvement and assessment of whether deaths were avoidable. The aggregated data for the West of England has identified the need to improve end of life care across the region. Local approaches to improvement such as a “poor prognosis letter” (sent to GPs when patients are identified as nearing the end of their life) have been shared. A region-wide improvement project to implement the ReSPECT process1 (Recommended Summary Plan for Emergency Care and Treatment) has also been established.

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The next stage of the learning from deaths collaborative work in the West of England has recently been agreed. This will be to act as early implementer of the Medical Examiner (ME) role, learning from the pilot work that has already taken place in Gloucestershire.

Conclusions The IHI Breakthrough Collaborative Series model creates a structure that enables organizations to learn from each other and to improve together. The opportunity for key implementers from Trusts across the region to share and learn from each otherâ&#x20AC;&#x2122;s adoption, has facilitated the introduction of a standardised mortality review process in the West of England. The findings from mortality reviews help to inform organisations about the care they are providing, and to develop quality improvement projects from these findings. Trusts have found the collaborative approach extremely valuable and find the conversations with colleagues from different organisations informative and reassuring. The most significant region-wide learning on the planning and management of a patientâ&#x20AC;&#x2122;s end of life before their deterioration has led to a further region-wide solution, the ReSPECT process, being planned for adoption.

Acknowledgements Thanks to colleagues from the Royal College of Physicians, and Yorkshire & Humber AHSN Improvement Academy who we worked closely with throughout this project. Thanks also to the Clinical Leads and staff from the following trusts: University Hospitals Bristol NHS Foundation Trust, North Bristol NHS Trust, Royal United Hospitals Bath NHS Foundation Trust, Great Western Hospitals NHS Foundation Trust, Gloucestershire Hospitals NHS Foundation Trust, Weston NHS Trust, Taunton & Somerset NHS Foundation Trust, Salisbury NHS Foundation Trust, Avon and Wilshire Mental Health Partnership NHS Trust and 2Gether NHS Foundation Trust.

Conflict of interest disclosures Disclaimers and conflict of interest policies found at: http://www.patientsafetyjournal.com/policies.html

Article submission and acceptance Date of Receipt: 14.12.2018 Date of Acceptance: 23.1.2019

Contacts/correspondence Melody Moxham, West of England AHSN, South Plaza, Marlborough Street, Bristol, BS1 3NX melody.moxham@weahsn.net

Intellectual property & copyright statement We as the authors of this article retain intellectual property right on the content of this article. We as the authors of this article assert and retain legal responsibility for this article. We fully absolve the editors and company of Patient Safety Journal (PSJ) of any legal responsibility from the publication of our article on their website. Copyright 2019. This is an open-access article distributed under the terms of the Creative Commons Attribution Licence, which permits unrestricted use, distribution and reproduction in any medium, provided the original work is properly cited.

References ReSPECT process: https://www.respectprocess.org.uk

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Quality Improvement – combining digital technology with innovative learning Nicola Davey BPharm (Hons), MPhil, PG Cert, MRPharmS1 Tom Kenny BM, MSC-PH, MBA, MFPH1 Laura Longley, BA (Hons)1 Keywords Improve ONE Thing, Patient Safety, digital learning, social learning, empowering junior doctors, online learning, blended learning, QI tools and techniques, QIClearn™, Quality Improvement

Summary • Interest in robust improvement methods continues to be high amongst those attending the Bristol Patient Safety Conference. Knowledge and experience of using the model for improvement as change method of choice appears to be increasing year on year in this region. • New learners need help to select a challenge that is small enough to allow them to gain confidence in the use of QI tools and techniques and complete a project in the short time frame afforded in their training. • The idea of failing safely and learning quickly is appealing and this can influence people in their decision to undertake a QI project in place of an audit. • The use of a simple measurement tool to select a suitable challenge for a QI project appeals to many and appears to help identify when projects are just too big to tackle on their own. • Whilst staff in healthcare are interested in digital leaning, the term holds different meanings to people. In the healthcare arena relatively few people are aware of the different skills that must be brought together to create an innovative and effective virtual learning environment e.g. validated learning materials, deep Quality Improvement Clinic Ltd.

learning design expertise, reliable, versatile, and affordable learning platforms, and effective measurement tools to evaluate learning outcomes. The skills that are required to teach, facilitate, and mentor learners in the online space and in blended learning that spans both classroom and online

Introduction 2018 is the third year that the Quality Improvement Clinic has delivered a workshop at the Bristol Patient Safety conference. The workshop was delivered to over 60 people. In this session participants were invited to focus on how to ‘Choose ONE thing’ to work on as they learn how to use the model for improvement as a change method and begin their quality improvement journey. Using a paper-based exercise they were able to explore some ideas for improvement and use simple measurements to discover whether any of their ideas were small enough for their first Quality Improvement (QI) project. They were also shown how this exercise can be easily undertaken on QIClearn™, a digital online social learning platform. This allows learners to share their work and receive feedback in real time with their peers and mentor, even when they are unable to get together face to face. QI knowledge and experience amongst learners is often varied at such workshops,

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with the majority of people not having experience in using the model for improvement . This range presents facilitators and mentors with a challenge. One way that we address this challenge is to undertake a rapid baseline assessment with every set of learners that we encounter. This gives us vital insights to inform our approach, allows us and others to recognise expertise that they can draw on in the room, and gives us an opportunity to demonstrate how we use the model for improvement in our own daily practice. With this in mind, the workshop offered different things to these different audiences. For those new to QI it offered insights into the challenge of choosing something small enough to work on, for those more experienced it offered insights into the use of the simple measures we promote in QI. This helps learners get off to a good start with their own QI journey.

Introducing new ways of learning There are many barriers to learning robust change methods and getting started with quality improvement. Those we encounter from our learners include: • Getting released from work to attend teaching • Finding time to practice using QI tools and techniques • Having easy access to exercises small enough to enable micro-learning and practice Those we encountered in teaching include: • Creating learning exercises that really help people get started with QI • Enabling learners to connect and learn with one another quickly and easily • Making learning fun and engaging

To overcome some of these barriers we have explored new, innovative ways of teaching and learning, that have been used successfully in other professional groups, to transform the way learning is accessed and the number of people it can reach. In doing this we have discovered new ways of doings things in the digital environment and in turn we have been able to incorporate some of these back into our face to face teaching, providing additional enrichment of the learning experience. Digital innovation can help organisations systematically plan and implement programmes to improve learning and transform services. Whilst well established in other industries, we know that this is also true for healthcare, with patients being the ultimate beneficiary of staff development. Curatr™ is one of a new generation of software platforms that provide digital social online learning, both as stand-alone, and as part of blended learning offers (mixes of online and face to face). Such platforms utilise existing apps offering flexible and reliable functionality. Critically, programmes created on these platforms can be accessed by learners using smart phones, tablets, laptops, and desktop computers allowing users to overcome some of the traditional barriers such as firewalls.

Methods A baseline measure of knowledge in the room was undertaken. This was achieved by eliciting a description of the model for improvement from those who knew it. The description of the model for improvement provided the measurement definition against which everyone was asked to rate themselves and the results were recorded in a simple histogram. This exercise was devised by the Quality Improvement Clinic and has been refined over several PDSA cycles. The current

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format has been used with over 40 groups. A short demonstration was then given of the similarities and differences between audit and PDSA test cycles. Using learning system software alongside expert learning design and tried and tested teaching materials offers flexibility to the teacher, learner, and their peers. In this workshop we used an example with learning design and teaching materials created by the Quality Improvement Clinic and digitised by QICLearn™. In the workshop participants were able to undertake a paper based exercise in order to help them ‘Choose ONE thing™’ that they could improve (form 1). The paper based exercise uses a simple scoring system that

allows participants to rate up to three ideas. Having completed their selection and scoring in the workshop, participants were invited to discuss these with their peers before sharing some of them with the larger group. This activity was also demonstrated on the online platform where learners can enter each of their ideas and ratings (form 2) and gain rapid feedback from their mentor and peers to help them refine their choice of project before they move on to the next stage: ‘Improve ONE thing™. The rationale behind the design of this exercise was also discussed and participants were asked to provide at least one piece of feedback before leaving the session.

Form 1: Worksheet for face to face exercise and table discussion

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Form 2: Webform for online completion and discussion with peers and mentor

Results Knowledge and experience amongst the two groups of using the Model for Improvement (27 had not seen or used it, 34 had used it or use it well) was the highest in our teaching experience to date (n=43 groups over 3 years). Those with lower scores (1 & 2)

were invited to look to those with higher scores for expertise and, in return, those with higher scores were invited to share their experience in the subsequent exercise.

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Scores for 2018 were significantly higher than that experienced at the Bristol Patient Safety Conference in 2016 (17 not seen or used it, 5 used it or use it well), and also those that we see in the many other groups that we teach.

Thematic analysis of ‘take away’ messages

Stop before you start

60 feedback comments were posted by participants as they left the session. The majority of participants offered extremely positive feedback, with the majority focusing on the ‘Choose ONE thing’ exercise. A small number of people felt that the session did not meet their expectations: a small number of participants were clearly looking for more advanced QI learning, whilst another small group had expected more in the way of digital learning.

Keep it simple

Knowing to start microscopic!

Keeping ambitions small when embarking on first QI journey

Microscopic – start with the minutiae (when we are always told NOT to sweat the small stuff), the small stuff matters! ONE LITTLE THING – pitching a problem small enough to fix

Best learn - doing the “one little thing”

Small is beautiful

Qualitative feedback regarding the Model for Improvement and PDSA included:

Gaining in small chunks first

Small change = big difference

‘First time I’d heard of the Model for Improvement & PDSA cycles’.

Small changes = BIG improvement

‘Really, really useful! I feel now I can use this to make a positive change within a short space of time rather than a full audit’ ‘Good to hear about the model for improvement – will try to use this’ ‘PDSA repeat – have covered and used lots of times’ The concept of learning from failure is one that many high performing trainees find difficult to embrace. The comparison between the PDSA and Audit cycle led to a discussion about failing safely and learning fast that participants appeared to engage well with. The Choose ONE thing™ exercise using the worksheet generated a significant amount of discussion, with scores across the range from minimum (0) to maximum (8). Those scoring 0 were invited to share their choice with the group and explore their rationale for scoring. Those with a higher score were invited to do likewise. Participants were also invited to consider what it would take to increase a score from 1 to 2 or from 0 to 1, and whether this was realistic. 12

the approach of branding “One small thing” “One little thing”. Very transferable Using measurement to bring objectivity to project choice improve Scoring as way of deciding whether your idea is achievable

Multiplication tool for choosing one thing!

Little thing scoring system

Project scoring system!

Appreciation of personal sphere of control How difficult it is to do most projects – almost all need input from others and is outside my control

Revaluate problems that are ‘too big’

Great way to know if one should pursue a project

Taught me a new concept

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In the face to face workshop this exercise chimed with new learners and more experienced learners in equal measure, some of the latter expressing interest in using it with their own mentees.

method than their counterparts in other parts of the country. This explanation holds some credibility as this region has a longer and more consistent track record of training in these methods than many others in the country.

Similar themes were observed in conversations recorded between mentors and learners participating in a QI programme in the QIClearn™ online space.

For those new to the model, the use of the method as a way of assessing knowledge in the room was appreciated, whilst the explanation provided of the similarities and differences between PDSA and Audit was appealing to trainees who have struggled with the completion of audits in short placements.

Discussion Whilst benefits of using robust change methods such as the Model for Improvement (Langley et al. 19961) are acknowledged at a national level, our experience of teaching front line staff in over 40 groups from a range of healthcare settings suggests that practical experience of applying the model is limited. Having run the same exercise in workshops at the Bristol Patient Safety Conference in 2016 and 2018, we are able to say that many more participants in the 2018 workshop were aware of the Model for Improvement and had used it at least once than in 2016. There could be a number of reasons for this finding. One hypothesis could be that many of the same people attended both workshops, although the registration profile and a show of hands in the workshop suggest that this is not the case. Another hypothesis is that the participants, who are predominantly trained in the South West of England, are more familiar with this

The thematic analysis of feedback on the individual exercise suggests that the ‘Choose ONE thing™’ selection tool resonated with new and more experienced learners alike. The use of a simple scoring system can help people focus on challenges that are within their reach. The scoring itself offers a powerful demonstration of measurement for improvement in action. It is evident from the ‘take away’ messages posted by participants at the end of each session that their exposure to this using the ‘Choose ONE thing™’ exercise generated learning and practical insights that they may be able to apply to their own QI projects. The conversations posted in the QICLearn™ blended learning programme suggests that the same scoring method when applied using digital technology resonates with learners in online learning environments in a similar way as the face to face environment. The ‘Choose ONE thing™’ exercise has been designed for use by new learners. To date these have typically been individuals participating in workshops including people working in the Care Home sector and clinicians including doctors in training, nurses, midwives, emergency practitioners, paramedics, physios, and occupational therapists. More recently it has been used with executive and senior staff to explore their definition of ‘teams’.

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Transferring tools and exercises to an online environment is not always straightforward or successful. The ‘Choose ONE thing™’ exercise was originally designed and tested with people as they embarked on their QI learning journey during face to face workshops and in one to one coaching. Whilst teaching in this way is dynamic and exciting, healthcare organisations are finding it increasingly difficult to release staff to participate in programmes that take them away from the clinical environment for significant blocks of time. There is also a growing appreciation that knowledge acquisition of QI tools and techniques do not necessarily translate to gains in service improvement. Advanced digital learning systems allow learners to engage and interact with a wide range of activities in smaller ‘portions’. Known as micro-learning in the learning community, this approach has been shown to appeal to learners who have or are able to acquire digital literacy. Innovative learning systems such a Curatr™ allow learners to access micro-learning via their smart phones, tablets, laptops or desk tops. Whilst not suitable for all, the combination of high-quality content curated by experts in learning design and delivery using appealing and accessibly technology has been successfully adopted in other industries. ‘Choose ONE thing™’ evolved through the experience and learning acquired using it in the face to face environment and then the digital space, with new ideas generated in one environment being tested back in the other and vice versa. The social aspects of learning that would otherwise occur in face to face settings take place through conversations posted online in ‘chat’ and via short videos that participants and mentors record and upload quickly and easily from smart phones. Learners download worksheets and post their completed work back into the learning space where their peers 14

and mentors see and discuss it. Expert facilitation enriches conversations through constructive challenge and enquiry and this ultimately increases the confidence of learners to take their next step. In our experience digital learning encourages sharing of best practices, breaks down barriers, allows for a shift in culture, empowers learners, and gives them the confidence that they have a QI project that will make a difference. QICLearn™ helps learners capture their learning journey and facilitates sharing their story with their wider practice community – this approach can also increase stakeholder buy in and ultimately support spread and adoption. Finding ways of demonstrating new technologies to those who are interested in learning about digital innovation is challenging: As with QI, diversity of audience knowledge is often high, and so we have more to learn about how to do this in a way that meets the wide range of interests and needs. At QIClearn™ we are already seeing the benefits of using innovative digital technology to walk beside our learners as they take their first steps in exploring scientifically informed change methods. However, its traction within healthcare has yet to be established in most parts of the healthcare system. The Topol Report2, ‘Preparing the healthcare workforce to deliver the digital future’ commissioned by Health Education England made the following observations in their Interim report (June 2018): Technology will be increasingly useful in providing education and training at scale. The development of online courses, podcasts and Massive Open Online Courses (MOOCs) or Small Private Online Courses (SPOCs) is likely to become important to reinforce or supplement face-to face teaching. The use of augmented reality/virtual reality and immersive environments will also have a role, especially in those areas which are difficult to cover in the workplace and as their cost becomes more affordable. In summary, the potential to reshape and improve healthcare using new technologies is huge, but without a highly trained workforce, confident and competent to use these new systems, in partnership with the patient and the carer community, their full impact is unlikely to be realised…

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Acknowledgements

Contacts/correspondence

Dominique Le Touze for co-facilitating the workshop, Laura Longley and Rachel Hammel for the design of QIClearn™ Online programmes, QICLtd for the workshop materials and activities, Curatr™ for the learning system (HT2Labs). All learners who have participated in face to face and online workshops and programmes with Quality Improvement Clinic and QIClearn™, The organisers, partners and sponsors of the Bristol Patient Safety Conference.

Nicola Davey, Vine Cottage, Shedfield, Southampton, SO32 2JE Nicola@qualityimprovementclinic.com

Conflict of interest disclosures Nicola Davey is founding director of Quality Improvement Clinic. QICLearn™ is an innovative enterprise and subsidiary of Quality Improvement Ltd. Tom Kenny is a director of Quality Improvement Clinic Ltd.

Article submission and acceptance Date of Receipt: 04.11.2018 Date of Acceptance: 14.12.2018

References Langley GJ , Moen R , Nolan KM et al. The improvement guide: a practical approach to enhancing organizational performance. San Francisco : Jossey-Bass ,1996.

The Topol Review, Preparing the healthcare workforce to deliver the digital future: Interim Report June 2018 – A Call For Evidence, June 2018. https://www.hee.nhs.uk/sites/default/files/documents/Topol%20Review%20interim%20report_0.pdf

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Interview with Alistair Gray

‘Refer-to-Pharmacy: outcomes of hospital to community pharmacy referral’ Alistair Gray, Clinical Services Lead Pharmacist, East Lancashire Hospitals NHS Trust, speaker at Bristol Patient Safety Conference in 2016 Alistair, please could you give us a quick description of Refer-to-Pharmacy Refer-to-Pharmacy is the world’s first fully integrated hospital to community pharmacy electronic referral system. What I mean by this is that the referral software has direct links with the hospital’s patient administration system (PAS), which means there is no re-keying of any patient demography (a single identifier automatically populates the referral with all required details) and there is an interface with the hospital’s discharge letter system. This means that once a referral has been made, a copy of the patient’s Transfer of Care letter is automatically sent to the patient’s community pharmacy when the patient is discharged (upon receiving the electronic signal from PAS that the person has left the hospital). The community pharmacist receives the same letter as the patient’s GP at the same time What are the key benefits to the patient? There are two benefits: improved medicines safety and improved medicines adherence. In the last 12 months, there have been over 150 reported outcomes from the community pharmacists completing a referral where unintentional prescribing errors have been identified on the first GPs’ prescription postdischarge. In most cases this is due to GPs inadvertently issuing repeat prescriptions for medicines that have been stopped or changed in hospital. An example was when an elderly lady had been admitted to hospital with a

gastrointestinal bleed due to her taking an oral anticoagulant (rivaroxaban). This was stopped and the Transfer of Care letter sent to the GP (and community pharmacist via Refer-to-Pharmacy) detailed the reason for cessation. The lady’s repeat prescription was not amended though and was sent to the community pharmacist in the usual way. In the past, this would have been dispensed and the lady would likely have restarted the tablets with potentially devastating consequences, as the pharmacist would have been unaware of the hospital episode and the medicine changes. On this occasion the pharmacist spotted the discrepancy and contacted the GP. The doctor immediately requested the medicine not to be dispensed and the patient had a safe outcome. With regards to improving medicines adherence, many of our referrals are to steer our patients into evidence-based medicines adherence consultations with their community pharmacists (New Medicine Service (NMS), Medicines Use Review (MUR)) which have been shown to improve how patients use their medicines to get the best form them and stay healthy at home. An analysis of our readmissions data suggests that at least 100 fewer patients are being readmitted to hospital each year as a result of being referred to their community pharmacist. What are the logistical implications of implementing this system for the key stakeholders, including the trust? The system has been working for over three years now (it went live in October 2015) so many of the development challenges

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feel like a distant memory now and we are just concentrating on getting the best from the system. The most persistent challenge is the behavioural changes required by the hospital pharmacy team to ensure every eligible patient is referred, and at the community end that every referred patient is appropriately managed. This is partly because staff change over time at both ends and need inducting and training into the correct processes, and also because of human factors requiring people to work in a slightly different way to what they will have previously done.

When you spoke in 2016 you had recently launched the service – what are the facts and figures of how far you have come since then? The system went live on 29th October 2015 and has just passed its third birthday. In those three years over 23,000 referrals were made; the current monthly amount is around 800. We track the referral types and the outcomes so we can tell a story with the data. These are the referral types made from go-live to 31.10.18: • Blister Pack (Monitored Dosage System) referrals: 8504

We are tackling both. In the hospital for people who are admitted and eligible for a Hospital Admission Notification to be sent (e.g. blister pack users, care home residents, where there is a real utility to a community pharmacist knowing their patient is in hospital so they can pause their dispensing processes – saving time and preventing medicines waste) we have introduced a step into our Medicines Reconciliation checklist which prompts a referral to be made. This checklist is printed into the ‘Drug History’ section of each patient’s admission documentation and is filled out by the person completing medicines reconciliation who invariably has a mobile device so they can make a referral instantly. We use a separate second checklist on discharge to ensure that patients eligible for NMS or MURs are referred.

• Medicines Use Review referrals: 5722

We also have an audit tool which shows from which wards patients have been referred, and also what has happened to them when they have been discharged. One of our pharmacy technicians checks this weekly and contacts community pharmacists if they are highlighted as receiving a referral but not yet acknowledging it. Of the 200+ referrals made each week, only a handful meet these criteria so it is not time consuming.

• 1005 prescription items not dispensed (@ £10/item approximately)

• Care Home patients: 3458 • Information-only referrals: 2714 • New Medicine Service: 2186 • Domiciliary Home Visits (not to community pharmacists): 637 In March 2017 we upgraded the system to allow Hospital Admission Notifications to be made, allowing community pharmacists to pause dispensing for e.g. Care Home residents or blister pack users admitted to hospital. We also started asking new questions when referrals were completed to quantify and qualify benefits. These are the outcomes from the 155 referral recipients from March 2017 to November 2018 that have been reported so far:

• 312 hours saved by community pharmacists by not dispensing medicines • 190 occasions when community pharmacists identified unintentional prescribing errors on the first prescriptions issued by GPs following hospital discharge.

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With all these outcome data there is an element of under-reporting; the true figures will be higher, although it is the latter statistic which starkly shows the value Refer-toPharmacy has brought to Pennine Lancashire – it’s a large patient safety intervention. A preliminary analysis of our readmission data suggests at least 100 fewer patients are being readmitted each year. It’s easy to see why this is with the numbers of people receiving medicines adherence consultations, or having harm prevented. Has the idea spread beyond ELHT and if so where has it spread most successfully? With regards to Refer-to-Pharmacy we are still waiting for a willing Trust to become the next site. There is a lot of interest in the system and there are other systems offering a similar solution albeit without the level of IT integration that Refer-to-Pharmacy has. I am hopeful that the system will go elsewhere soon which I think will encourage other health economies to look more seriously at implementing our solution. ELHT are the innovators of Refer-to-Pharmacy – we need some early adopters to convince the majority of Trusts around the country that this is something they should be doing. The principle has been adopted within NHS Wales, using a system that has been developed ‘in house’ by NHS Wales, using their own health records and software to make referrals. Which other health economies look likely to benefit? My belief is that hospital to community pharmacy should be de rigueur everywhere; not just in the UK, but worldwide. I think human nature is such that it takes a certain critical mass to persuade the majority of

leaders in medicines management within health economies to take the necessary steps to introduce a referral system. It takes time, political will and a small amount of investment to set a referral system up, and I suspect that other priorities are confounding potential spread (even though there is a high return on investment and improved safety). What recognition have you received within the healthcare sphere? Refer-to-Pharmacy has received a number of awards: Patient Safety Award for Best Emerging Patient Safety Technology in 2016; Building Better Healthcare’s for Best Communications or IT product in 2016. I personally have been the recipient of two awards as a result of the leading the development of Refer-to-Pharmacy: The Royal Pharmaceutical Society’s Leadership in Pharmacy award in 2016, and the North West Coast’s Academic Health Science Network’s Innovation Champion in 2017. Can you recommend further reading material on Refer-to-Pharmacy in Journals and other publications? We have had several articles published about Refer-to-Pharmacy including one in Spanish! The links below are a selection; the later ones also include information of ELHT’s latest pharmacy initiative Dedicated Ward Pharmacy. That is a whole other story, but if you are interested Google the term: #DedicatedWardPharmacy.

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Date of interview:

Conflict of interest disclosures

20.12.2018

Disclaimers and conflict of interest policies found at: http://www.patientsafetyjournal.com/policies.html

Resources Pharmaceutical Journal (2016). Transfer of care: how electronic referral systems can help to keep patients safe https://bit.ly/2C4GHzk Hospital Pharmacy Europe (2017) Dedicated ward pharmacists make an impact https://bit.ly/2m7aRuu Pharmaceutical Journal (2017) Tearing down walls to deliver a dedicated ward pharmacy service https://bit.ly/2EqZHIO La Farmacia en el mundo (2018) Reino Unido: breve historia de los primeros 21 meses del volante para la farmacia https://bit.ly/2Ts6f3f

Contacts/correspondence Alistair Gray, Clinical Services Lead Pharmacist, East Lancashire Hospitals NHS Trust, Royal Blackburn Hospital, Haslingden Road, Blackburn, Lancashire, BB2 3HH

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Criteria Led Discharge: a systematic review and patient safety Dr Liz Lees-Deutsch PhD MSc BSc Dip HSM RGN1 2 Keywords Patient Discharge (MeSH), Patient Selection (MeSH), Systematic review, Criteria Led Discharge, Patient Safety

Abstract This paper summarises a presentation of a Systematic Literature Review regarding Criteria Led Patient Discharge (Lees-Deutsch and Robinson, 2018) from the Bristol Patient Safety Conference held during May 2018. Four questions guided the review to identify literature and critique safety, quality, length of stay and implementation factors; however the primary question asked ‘is criteria-led discharge safe?’. The review concluded that Criteria Led Discharge is safe, provided that its implementation is supported through the process of clinical governance; education for staff and that it is integrated with the usual patient discharge process. Discussion points raised by delegates focused on how to align criteria led discharge with the usual process; how to manage increased patient turnover and lack of time to pre-plan patient discharge for unplanned admissions and how criteria led discharge is interpreted by some, in practice. Five patient safety points have been summarized as: criteria led discharge should enhance the existing discharge process, not expose inadequacies; any workforce shortfalls should be addressed prior to commencement of work; the knowledge and skills required of staff to lead the discharge process must be addressed; ensure criteria, protocols and the patient selection process is robust and finally that outcomes are measured such as,

1 2

readmissions, length of stay and patient satisfaction.

Introduction Improving patient flow through hospitals and creating timely bed capacity is a global issue. CLD is a process that enables patient discharge to be safely accelerated in accordance with specified clinical criteria and parameters. During June 2017, NHS improvement (NHSi) held a series of events to promulgate the development of CLD in NHS Hospitals throughout England. While the concept of CLD in England is far from new1 it became apparent from delegates that some had tried and failed to implement CLD, while others hadn’t yet commenced work. The backdrop to this was peppered with myths regarding criteria led discharge and a relatively scarce evidence base regarding its safe development. Subsequently, following the first NHSi collaborative event, several pieces of work ensued: a set of principles aimed at guiding the safe implementation of CLD were developed2; myths surrounding CLD were explored3 and a Systematic Review of CLD literature addressing safety and quality factors was undertaken4. Finally, spurred on by the NHSi collaborative, exploratory work relating to patient selection/suitability for CLD in an acute medicine service was also commenced at a West Midlands NHS Hospital Trust.

University Hospitals Birmingham NHS Foundation Trust, Heartlands Hospital University of Birmingham, Institute of Clinical Sciences

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The concept of criteria led discharge I began the presentation by explaining what is already known about criteria led patient discharge, in particular that this term has gradually been introduced into the discharge planning vocabulary in acute hospitals in developed countries throughout the world5. Moreover, the discussion of nurse led discharge has arguably, gradually metamorphosed onto criteria led discharge. While CLD has similarities with nurse led discharge there are differences, which need to be understood by those considering implementing CLD to improve the patient discharge process. Criteria-Led Discharge (CLD) has been recently described as a process where the clinical parameters for patient discharge are clearly defined through: • A care pathway, a condition-specific protocol or a bespoke clinical care plan; • Agreement between the consultant leading the care and the multidisciplinary team; • Standardised procedures for particular clinical conditions to be adapted to provide person centred discharge; • Patients, who should be actively involved in their discharge process. (Lees-Deutsch and Gaillemin, 2018, p33). Criteria and nurse-led patient discharge are often described synonymously, but crucially, when nurses lead patient discharge, it is nurses who will lead and manage the patients discharge process by using the clinical management plan and explicit clinical criteria1 the use of criteria facilitates transparency of the clinical parameters to be reached by the patient, in order for a safe discharge from hospital. In Criteria-Led discharge, the difference is that any competent registered healthcare professional may lead the patient’s

discharge, guided by clinical parameters established with the medical team3. Hence to this end, CLD may be introduced where therapists and other health care professionals, not necessarily nurses or doctors, typically take a leading role with patient care. In addition, many elements other than clinical parameters are likely to form part of the patient’s discharge plans; these will continue to be organised through the usual mechanisms and discharge process. Most importantly, as I conveyed at the Conference, “criteria” do not lead the patient’s discharge; their use should help to make clear the patient’s clinical management plan, the clinical parameters required for discharge and adequately guide practitioners without necessarily the need for the permission or further direction from the medical team.

Methods For the Systematic Review searches were made of CINAHL, MEDLINE, PubMed, Cochrane Library and Joanna Briggs database. Studies were selected using the terms ‘patient discharge’ (MeSH term), ‘discharge planning’, ‘patient selection’ (MeSH term), Criteria Led Discharge, nurse led discharge, nurse facilitated discharge, safety, quality and implementation. They were applied singly or in combination to identify published literature in the English Language from 2007 – 2017. The quality of included papers was appraised using a tool for disparate studies6. Two reviewers extracted relevant data independently in accordance to the following four review questions: 1. To what extent does the literature indicate that criteria led discharge is safe? 2. To what extent do discharges guided by criteria contribute to an improved quality of patient experience?

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3. To what extent do discharges guided by criteria contribute to a reduction in length of patient stay in hospital? 4. What are the facilitators to implementing a safe process for criteria led discharge?

Results Fifteen papers met the inclusion criteria. Studies did not show any increase in patient readmission rates or complication rates; demonstrating that CLD is safe. The quality of the patient discharge and their experience was unremarkable and comparable with the usual discharge process. Three studies provided definite evidence indicating a reduction in length of stay; others described small insignificant reductions in length of stay, however overall data on this was hampered by lack of robust data collection. Nevertheless, none of the studies showed an increase in length of stay and reductions in the length of patient stay, however small, particularly in emergency care, were welcomed to bring the time of patient discharges down ahead of new admissions. Facilitating factors required for the safe implementation of CLD were identified across the papers as: n Executive

level support and policy/ guidance is needed

n To

review of existing discharge procedures (amend local policy/guidance)

n Establishing

a multi-disciplinary steering group (create a shared vision)

n Identification

of the patient populations that would benefit

n Pre-audit

of current process against outcomes measures envisaged e.g., length of stay

n Release

of clinical staff to enable time to participate in changes implied

n Develop

clearly defined criteria & associated process with documentation

Identify staff training needs (across professional groups) n Pilot

the CLD process, allowing time to embed, with feedback loop

n Involve

patients in project, considering patient information/person centred care

n Monitor

patient feedback and amend policy / practice as necessary

n Conduct

an annual review of the criteria led process

Discussion Points Following my presentation, conference delegates asked several questions, firstly how does CLD align with traditional hospital discharge planning? The core principles of discharge planning still apply with CLD,7, 8 most notably that â&#x20AC;&#x2DC;discharge planning should commence on admission to hospitalâ&#x20AC;&#x2122;9. In addition, with the advent of Ambulatory Care and other elective pathways of care, patient discharge often includes a preadmission planning phase to which the evidence suggests CLD, naturally fits10. If CLD were to be adopted as routine in practice settings, this would become one of the principles of discharge planning: patient selection for CLD would be the start of the process. Some delegates expressed their concern regarding the increased prevalence of unplanned patient admissions and rapid patient discharges where planning and time to pre-plan are compromised; thus often resulting in minimal time to instigate the patients discharge process. Further related concerns were expressed regarding the current discharge process, which described this as predominantly reactive which might therefore make the introduction of CLD unsafe, especially in situations where the length of stay is very short (<48 hours). In such situations, this may mean CLD may not be appropriate to initiate from the point

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of the patient’s admission and should instead engaged nearer to, or on the day of the patient’s discharge. This would allow for the medical and discharge plan to evolve. Despite these challenges, CLD should not be an “add on” to the usual patient discharge process, rather, it should be used to aid patient selection, identifying patients where criteria introduced into the discharge process, could expedite the patient discharge and make the availability of their bed for the next patient timelier. One delegate made the point that discharge instructions were frequently left for the clinical team to follow after a ward round and surely this constituted CLD? While such instructions may be explicit and serve to empower the team, they may also exist independently of the usual hospital discharge process and be relatively unsupported in practice. For example, the clinical governance of such independent activities is improbable, may not be audited or have the results shared more widely to understand the difference this makes to safety of the patient discharge process. Hence, as with any new practice, making the process transparent through governance will protect patient safety.11 Finally, it was proposed that perhaps all patient discharges were in fact criteria-led as they are implicitly guided by clinical parameters, at least in leading to the stage where the patient is deemed medically stable and fit for discharge. While this is a reflection of the typical decision-making process, achieving medically stability however, is only one aspect of a patient’s care indicating readiness for discharge from hospital. The point of clinical criteria is to enable the baton of care to be handed to other, perhaps non-medical, members of the health care team. This should enable the clinical focus to be maintained when perhaps more senior decision makers are not planning a patient

review or are elsewhere occupied. A set of principles cognisant of these issues was shared on the NHSi electronic platform.

Summary The systematic literature review revealed that safety, quality and length of stay are inextricably linked factors, which are codependent upon the process designed and used for the implementation of CLD. The experience of patients and caregivers with CLD was underreported and future research is warranted.

Summary points from the conference: n Safe

process: should improve existing discharge process – not exposes inadequacies.

n Safe

staffing: address workforce shortfalls, then roles an responsibilities

n Safe:

address knowledge and skills required to lead the discharge process

n Safe:

ensure criteria, protocols, patient selection process is robust (testing)

n Safe:

comparable with existing outcome measures (readmissions, length of stay and satisfaction)

Conflict of interest disclosures Disclaimers and conflict of interest policies found at: http://www.patientsafetyjournal.com/policies.html

Article submission and acceptance Date of Receipt: 6.9.2018 Date of Acceptance: 14.9.2018

Contacts/correspondence Acute Medicine Unit, Ward 20, Heartlands Hospital, Bordesley Green East, Birmingham, B9 5 SS. Email address: liz.lees-deutsch@nhs.net

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References 1

Lees L. Making nurse led discharge work to improve patient care. Nurs Times. 2004; 100 (37): 30-32 Lees-Deutsch L. A brief guide to developing criteria-led discharge; NHS Improvement 2017 London: publication code IG 27/17. Available at https://improvement.nhs.uk

Lees-Deutsch L, Gaillemin O. Dispelling myths around nurse-led and criteria-led discharge. Nurs Times. 2018; 114 (4): 32-5. www.nursingtimes.net

Lees-Deutsch L, Robinson J. A systematic review of criteria-led patient discharge. 2018; e-print: J Nurs Care Qual. [in press] www.jncqjournal.com

Agency for Clinical Innovation. Criteria led discharge: planning for discharge on admission. A resource developed by the acute care taskforce to support implementing CLD. 2016; www.aci.health.nsw.gov.au [Accessed August 26th, 2018].

Hawker S, Payne S, Kerr C, Hardey M, Powell J. Appraising the evidence: reviewing disparate data systematically. Qual Health Res. 2002;12 (9):1284-1299.

Lees-Deutsch L, Yorke J, Caress, A. Principles for discharging patients from acute care: a scoping review of policy. British J Nurs. 2016; 25 (20): 1135-1143. PMID: 27834522.

Lees L. Exploring the principles of best practice discharge to ensure patient involvement. Nurs Times. 2010; 106 (25): 1-14. www.nursingtimes.net

Atwal A. (Nursesâ&#x20AC;&#x2122; perceptions of discharge planning in acute health care: a case study in one British teaching hospital. J Adv Nurs. 2002; 39 (5) 450-8. https://doi.org/10.1046/j.1365-2648.2002.02310.x Webster J, Connolly A, Paton F, Corry J. The effectiveness of a protocol drive, nurse-initiated discharge in a 23-h post surgical ward: a randomised controlled trial. Int J Nurs Stud. 2011; 48 (10):1173-1179.

Bowen A, Kumar R, Howard J, et al. Nurse led discharge, improving efficiency, safely. Clin Governance. 2014; 19 (2): 110-116.

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Patient consent after Montgomery Practical guidance for doctors James Badenoch QC1 About the author: Mr James Badenoch QC was counsel for the successful plaintiff in Montgomery v Lanarkshire Health Board [2015] UKSC 11. He specialises in clinical negligence, medical law and professional discipline, and has appeared in a succession of major cases in the High Court, Court of Appeal, House of Lords, Supreme Court, and the Privy Council, and also in the GMC and GDC. He is a Fellow of the Royal Society of Medicine, Chairman Emeritus of the Expert Witness Institute, and has been a deputy High Court Judge, a President of the Mental Health Review Tribunal, and a Recorder of the Crown Court. He has now retired from practice at the bar, but continues to write and lecture on medico-legal issues of all kinds. 1. The Montgomery test for the adequacy or otherwise of disclosure for the purpose of valid patient consent ordains that the doctor’s duty is to take reasonable care to ensure that the patient is aware of any material risk of proposed treatment, (whether in respect of outcome or of potentially intervening complication). Breach of or compliance with this duty is a legal test applied by the court, and decided, where disputed, on the basis of the evidence which the judge accepts and prefers. 2. This test replaces the “Bolam test” of “professional sanction” under which the adequacy in law of disclosure was judged solely by whether it was approved by at least a responsible body of the medical profession themselves. If yes, the disclosure had to be accepted as adequate a matter of law, even where that body was a very small minority. The profession was thus judge in its own cause. 3. A material risk is now defined in law as: (a) a risk that a reasonable person in the patient’s position would be likely to attach significance to; OR (b) a risk that the doctor is or should reasonably be

aware that the particular patient would be likely to attach significance to. The consenting process under Montgomery summarised (i) First identify the risks of the proposed treatment about which a reasonable patient in this patient’s position would need and want to know [the objective test], and disclose accordingly, explaining the balance of those risks with the expected benefits of what is proposed and the likely prospects if untreated. (ii) Next consider the particular patient’s individual characteristics and situation in life, e.g. age, intellectual ability, nature and demands of employment, family and other responsibilities, social and other problems etc, and having done that: (iii) P ersonalise the issues so as to identify what this patient with his/her personal characteristics and situation would reasonably need and want to know [the subjective test] and adapt the disclosure accordingly. Patients are not “standard issue”. (iv) Next if there are any reasonably available and potentially effective alternative

1 Crown Office Row, Temple, London EC4 7HH

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treatments/procedures, describe them and their relative risks and benefits (explaining if wished why they are not the doctor’s first choice). (v) Explain the patient’s absolute right to choose between alternatives, and to refuse treatment altogether, detailing the risks of the choices. Guidance on putting the process into effect. 4.

he assessment of materiality of risk T is fact sensitive. Statistics/percentages of risks are relevant, but not necessarily decisive (in particular for the reasons below).

5. A small risk of serious harm may be expected to be of significance to most patients, and particularly significant to a patient undergoing minor, and/or non-urgent, avoidable, or purely cosmetic treatment. 6. By contrast a relatively large risk of very minor harm would not be expected to weigh heavily or at all in the minds of patients, especially when the proposed treatment was vital or strongly indicated. 7. A risk, however remote, may be of particular significance to a patient whose life or livelihood would be especially adversely affected if the risk materialised, e.g. threat to fertility for a childless young woman, or risk of damage to the voice of a singer or the finger of a concert pianist. 8. The purely “mechanical” approach, (getting the patient to read and sign a pro-forma consent form, without explanation) of itself proves only that the patient can write his/her own name. That will not suffice save possibly for the most simple and minor routine procedures. 9. There must be genuine dialogue between doctor and patient in every case save those where:

(a) the patient is a young [non Gillick competent] child or mentally incapacitated (eg because of unconsciousness or intoxication) and therefore judged reasonably to be incapable of understanding; or (b) the patient is so endangered by his condition that urgent need for immediate treatment allows no safe opportunity for discussion (the “emergency proviso”). 10. In the case of a patient who is a young [non Gillick-competent] child or who is unconscious or otherwise judged incapacitated by reason of some impairment or disturbance in the mind or brain, the dialogue must take place where possible and time allows with a parent (for a child) or lasting power of attorney/ deputy for personal welfare (for adults). Alternatively, those close to the adult patient (family/friends) must be consulted in order for the doctor to make a best interests decision (s4 Mental Capacity Act 2005). In any such case, including the emergency situation, the facts and the doctor’s reasoning should be carefully recorded. If a patient is incapacitated, any advance decision to refuse treatment (ss24-26 Mental Capacity Act 2005) must be respected if valid and applicable to the circumstances. 11. Genuine dialogue about risk requires the doctor: (a) to use understandable language, and check that it is understood; (b) to avoid excessively detailed information – keep it simple; (c) so far as possible to avoid technical jargon; (d) t o tailor the discussion to the individual patient. 12. The “therapeutic exception” will in rare cases allow a doctor to avoid disclosure

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if he decides on reasoned and carefully noted grounds that the patient is so psychologically fragile or otherwise vulnerable that disclosure would present a real threat to the patient’s mental health or stability. 13. T he “recusant” patient: If a patient of adult years and with mental capacity adamantly insists on not being told about the benefits and risks, and the prospects or uncertainties of outcome, the doctor: (i) Should first decide whether there is nevertheless a compelling need to disclose a risk (e.g. a recognised complication which would result in very serious harm), the withholding of which could vitiate consent. (ii) May, absent such a compelling need, accept the patient’s wish not to be told, and limit disclosure accordingly, but (iii) Should in either case make a careful note of the matter. 14. T he required extent of disclosure is reasonable not exhaustive. Accordingly the recitation of a catalogue of risks of very minor and/or transient side-effects (such as is found in the small print of drug data sheets) will not be required and should generally be avoided altogether. Reasonableness is the key, and the courts can be expected to apply the test of reasonableness in all cases. Common sense should prevail. 15. Personnel: The person who advises/ prescribes/carries out the treatment should whenever practicable provide the information and obtain the consent. It may sometimes be reasonable to delegate this, but only to one sufficiently informed and trained for the task. 16. Communicating with patients: a doctor who is not good at communication, whether because inexpert or unwilling,

must recognise the fact and take steps to acquire the necessary skills. 17. L ack of time for adequate dialogue with the patient may seem an everpresent or insuperable obstacle. It must be overcome, because what is at issue is the patient’s most basic and fundamental right to make a true and free choice, which requires adequate information, whether to submit or not to proposed treatment, or which of alternatives to choose. 18. T he doctor’s own position: If asked directly by the patient what choice he would make for himself or e.g. for his child, the doctor may answer truthfully, but with words carefully chosen to avoid exerting or appearing to exert undue pressure, such as: “It is entirely a matter for you. You and I are quite different people, but I would choose, and I would want my loved ones to choose, to undergo this (or that) treatment”. 19. S ensitive and frank disclosure in advance of risks and benefits, including acknowledgment of any real uncertainty of a successful outcome, may be expected to engender less anger, bewilderment and recrimination in the patient if and when things do not turn out well. 20. I nformation which displaces ignorance will (as the GMC have asserted and the Supreme Court agreed) make it less likely that the patient will have recourse to lawyers in the belief that a bad outcome must be the result of bad performance, and this should ultimately reduce litigation. JAMES BADENOCH Q.C. 1 Crown Office Row, Temple, London EC4Y 7HH November 2018

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The responsibility for the above is the authorâ&#x20AC;&#x2122;s. It does not of itself have the force of law, though it is derived with intended accuracy from the judgment of the Supreme Court in the case of Montgomery v. Lanarkshire Health Board, from published GMC guidance, and from recent decided cases. It is a development of a document first offered by the author in lectures at Hong Kong University and the Chinese University of Hong Kong.

Conflict of interest disclosures Disclaimers and conflict of interest policies found at: http://www.patientsafetyjournal.com/policies.html

Article submission and acceptance Date of Receipt: 22.11.2018 Date of Acceptance: 22.11.2018

Intellectual property & copyright statement We as the authors of this article retain intellectual property right on the content of this article. We as the authors of this article assert and retain legal responsibility for this article. We fully absolve the editors and company of Patient Safety Journal (PSJ) of any legal responsibility from the publication of our article on their website. ÂŠ 2019 The author retains copyright. For reprints and permissions contact: James Badenoch QC, 1 Crown Office Row, Temple, London, EC4Y 7HH

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Winter is Coming: Improving Antibiotic Prescribing for Sore Throats Dr Rajan S. Pooni1, 2, Dr James McKinnon1, 2

Abstract Significance and background The World Health Organisation (WHO) states “many medical breakthroughs during the last century are at risk of being lost due to spread of antimicrobial resistance”1. In primary care antibiotics are prescribed unnecessarily for sore throat symptoms. Through a targeted prescribing approach, we can reduce the number of patients on antibiotics inappropriately. Improvement aim To ensure all patients presenting with sore throat symptoms at Gresleydale Healthcare Centre receive appropriate antibiotic therapy based on the Modified Centor Criteria. Interventional methods Over eight weeks and four PDSA cycles, interventions included delivering a presentation outlining the Centor Criteria, displaying posters in all clinical areas, implementing a drop-down Centor Criteria computerised template with subsequent prescribing recommendations and refining this template further with prompts upon typing of ‘sore throat symptoms’. Outcomes Results showed an increase in complete Centor Criteria reviews from 40% (without intervention) to 77% (following the fourth intervention), with an increase in antibiotics prescribed appropriately from 25% to 70%. Keywords Antibiotics, Centor Criteria, general practitioner, PDSA cycle, prescribing, primary care, quality improvement, pharyngitis, sore throat, tonsillitis

Background Sore throat is a common presenting complaint in primary care with the majority self-resolving without antibiotics2. In the UK, antibiotics are most commonly prescribed in relation to respiratory tract infections, including sore throats, with the largest proportion prescribed in primary care3,4.Whilst antibiotics reduce rates of potential bacterial complications (otitis media, acute sinusitis, quinsy)5, the aetiology of most sore throats are viral6. Therefore, 1 2

current guidance recommends against routine antibiotic use, and if there is ambiguity about whether antibiotics are required a delayed prescribing approach should be considered7,8. The National Institute of Health and Clinical Excellence (NICE) outline two different scoring tools for sore throat symptoms, ‘FeverPAIN’ criteria and the ‘Modified Centor Criteria’ 9,10. Both tools predict the likelihood the sore throat is Streptococcal in aetiology. The

Derby Teaching Hospitals NHS Foundation Trust Gresleydale Healthcare Centre

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Modified Centor Criteria is based upon five parameters; age (3-14 years =+1, 15-44 years =0, ≥45 years =-1), tonsillar exudate (+1), anterior cervical lymphadenopathy (+1), temperature > 38.0 ºC (+1) and absence of cough (+1)9,11. A total score of 0-1 does not warrant antibiotics, with a 13-18% likelihood of Streptococcal infection. A total score of 2-3 suggests a 34-40% likelihood of Streptococcal infection and thus a delayed prescribing approach may be considered. A score of 4-5 warrants immediate antibiotics, with a 62-65% likelihood of Streptococcal infection9. Whilst the Centor Criteria, first proposed in 1998, is well established, FeverPAIN is relatively new (created in 2013)12. Unlike the Centor Criteria, FeverPAIN does not take into account age, thus treating adolescents/adults the same as pre-adolescents, who are known to have a much higher Streptococcal carrier rate13. The aforementioned antibiotic guidelines are clear, transparent and readily available, and hence prescribing methods should reflect these recommendations, where possible, to ultimately reduce non-evidence-based prescribing.

Problem The combination of growing antibiotic resistance and a curtailing number of new antimicrobial agents is a well-recognised threat to public health1. Indeed, the latest report by the WHO highlights the “serious lack of new antibiotics under development to combat the growing threat of antimicrobial resistance”14. Whilst antibiotic prescribing rates have fallen by 5% since 2012, following significant investment in their research and development, “at least 20%” of all antibiotic prescriptions in primary care are inappropriate15. More worryingly, variations in regional primary care antibiotic prescribing

cannot be explained by a variation in the prevalence of specific conditions16. It is established that patients are more likely to receive antibiotics when general practitioners (GPs) perceive that patients expect them17,18. Therefore, an innovative approach is needed to tackle the existing unwarranted elevated antibiotic prescribing culture, either through a national or international strategy.

Aims To ensure all patients presenting with sore throat symptoms at Gresleydale Healthcare Centre receive appropriate antibiotic therapy based on the Modified Centor Criteria.

Methods Baseline Measures Gathering the data Using the GP surgery’s computer system, ‘SystmOne’19, a search algorithm was formulated encompassing the following coded terms: • Sore throat • Sore throat symptoms • Tonsillitis • Pharyngitis The search algorithm was applied to both the history and diagnosis box. Subsequently, the preceding two-week period returned 20 patients in total.

Figure 1: Search algorithm and analysis leading to baseline measurement

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Analysing the data Each data point (patient consultation) was analysed individually on two counts. Firstly, had all components of the Centor Criteria been documented; i.e. was the Centor Criteria complete or incomplete? Secondly, were antibiotics appropriately prescribed (immediately or via a delayed approach) or not prescribed according to NICE guidance? The antibiotic parameters were then further analysed. Baseline data revealed that only 40% of consultations documented a complete Centor Criteria review and that, according to NICE guidance, antibiotics were prescribed appropriately in only 25% of cases. Further analysis revealed that in 58% of incomplete Centor Criteria reviews one component was missing. In the majority of these cases the missing component was â&#x20AC;&#x2DC;absence of coughâ&#x20AC;&#x2122; (67%). Antibiotic parameters, including antibiotic choice, dose and frequency, were correct in 94% of cases.

Design The baseline results were presented to the GP surgery faculty at the weekly clinical meeting. Members present included GP partners,

Figure 2: Pareto identifying components missing in incomplete Modified Centor Criteria scores

trainee GP registrars, prescribing nurse practitioners and the practice pharmacist. During the meeting reasons for why antibiotic prescribing rates were inappropriately high for patients presenting with sore throats were explored. Commonly recurring themes were the lack of time clinicians had per appointment (10 minutes) to fully explore the patientâ&#x20AC;&#x2122;s presenting complaint(s) and access prescribing guidelines, unfamiliarity with the Centor Criteria by a number of prescribing staff and an automaticity to prescribe immediately rather than use a delayed approach.

Figure 3: Fishbone diagram showing factors contributing to inappropriate presciptions

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Interventions PDSA cycle 1 After obtaining the baseline data, the initial intervention was delivery of this information to the clinical staff at the weekly meeting. The main focus of this intervention was to draw attention to the NICE guidance (Centor Criteria) for sore throat prescribing and to highlight that subsequent prescribing rates would be monitored for eight weeks. An improvement in both documentation of complete Centor Criteria reviews and in the rate of appropriate antibiotic prescribing was anticipated. As no Hawthorne effect was observed (essentially there was no significant change from baseline) data from the first intervention was instead incorporated into the diagnostic data (our baseline measurement above) to increase statistical significance20. PDSA cycle 2

outlined the Centor Criteria, recommended prescribing approach (immediate, delayed or no antibiotics) and specific antibiotic parameters (choice, dose, frequency and length). I envisaged the poster would act as a hard reference tool for staff to use in the clinical arena when confronted with patients presenting with sore throats. Data analysis after two weeks showed only a small increase (4%) in completed Centor Criteria reviews and a similar increase (6%) in appropriate antibiotics prescribing. PDSA cycle 3 With the GP computer system, SystmOne, at the centre of all clinical consultations and documentation, the third intervention involved implementation of a computer-based tool template. Again, at the clinical meeting a â&#x20AC;&#x2DC;Modified Centor Score Calculatorâ&#x20AC;&#x2122; template available on SystmOne was highlighted to all prescribing staff. The template was in many ways similar to the poster, essentially resulting in an antibiotic recommendation. It was designed as a drop-down menu for each Centor component with an auto-calculated score providing the recommendation. Results showed a marginal improvement (6%) in completion of Centor Criteria reviews. However, a 19% increase in appropriate antibiotic therapy was observed. When the template was used the Centor Criteria review was always complete. However, despite a substantial increase in appropriate antibiotic prescribing, interestingly the template was rarely used. PDSA cycle 4

Figure 4: Poster tool outlining the Modified Centor Criteria and score recommendations

The second intervention involved the development and display of a poster tool that was displayed in all clinical areas. The poster

The fourth intervention built upon the previous PDSA cycle, which displayed the first significant improvement in the project. Firstly, feedback was obtained regarding the template from all clinical staff. Many used computer-based templates on a daily basis in

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other clinical areas (e.g. QRISK2 scores, PHQ-9 scores, medication reviews). However, these templates involved a visual prompt upon typing the relevant clinical information. The Centor template differed as it had to be manually searched for. Thus, the fourth intervention involved adding a prompt, so that

upon typing ‘sore throat’, ‘tonsillitis’ or ‘pharyngitis’, the clinician would receive a visual prompt taking them to the template. The results once again were significant. There was a marked increase in both completed Centor Criteria reviews (27%) and in appropriate antibiotics prescriptions (20%).

Figure 5: Screenshot of the computer template designed to provide antibiotic prescribing recommendations

Results Over an eight-week period involving four PDSA cycles, results showed a marked improvement in both complete Centor Criteria reviews, from 40% (without intervention) to 77%, and an increase in appropriate antibiotic prescriptions from 25% to 70%. The total number of patient’s consultations (data points) evaluated in this timeframe was 68. Analysing the data further, the increase in compliance with NICE guidance was primarily due to a reduction in antibiotic prescribing rather than from using a delayed prescribing approach.

Choice of antibiotic was correct in 92% of cases (down from 94%), antibiotic dose correct in 98% of cases (up from 95%) with antibiotic frequency and length remaining at 100% throughout. The most significant improvement came following the third and fourth PDSA cycles (introduction and editing of the computerbased template), with relatively little improvement in the first two cycles (clinical meeting intervention and poster tool).

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KEY:

----- Running three-point average. ----- Correct prescription or not for each patient contact. ----- Introduction of new intervention

Figure 6: Run chart showing antibiotics prescribed correctly according to Modified Centor Criteria

Discussion Lessons and limitations Several limitations were recognised throughout this quality improvement project. The primary issue was in regards to coding. The data collected over the eight-week period was from coded data on SystmOne. Therefore, any ‘free text’ consultations were not able to be analysed. Whilst it is difficult to provide an estimate on the number of ‘free text’ consultations, we do know that junior clinicians, including rotating GP registrar trainees and foundation doctors, have a preference to use free text due to inexperience with new computer software and coding. Furthermore, this affected the project in two ways. Firstly, a smaller sample size than the true baseline value was obtained (the sample size did improve throughout the project as the importance of coding was promoted). Secondly, the true rate of appropriate antibiotic prescribing was unknown; there may have been a profound difference between ‘free text’ consultations and the (coded) consultations we were able to analyse. Clinician/prescriber behaviours would have to be further analysed if this was the case. Extrapolating further, with a reduced sample size and relatively small time period (eight

weeks), results were more greatly influenced by one or two single prescriptions21. This point is further fortified by the fact that there were only 11 prescribers at the practice. Thus, a single prescriber’s practice has a 9% influence on prescribing (if it is assumed that each clinician prescribed equally). Another often-overlooked challenge was that, once established, a clinician’s practice is difficult to change, including GPs’ antibiotic prescribing practice22. Therefore, despite implementing several changes, including a permanent fixture on SystmOne, I concede that over an eight-week timeframe to substantially change a GP’s prescribing approach is unlikely. Thus, an approach which gives more weight to working with prescribers and analysing their behaviours should be considered. With the focus on primary care, a prescriber’s decision is often influenced by diagnostic uncertainty, patient expectation and time pressures, among others. Participant engagement is crucial before introducing change to a well-established system. Early intervention (i.e. prescribing education at the weekly clinical meeting) was key to establishing recognition and concern in high sore throat prescribing rates. However, providing more weight to the initial focus

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group, in highlighting why inappropriate prescribing occurs, may have been beneficial in guiding more successful initial PDSA interventions. A crucial presumption to guard against is generalisation; i.e. considering this general practice as the â&#x20AC;&#x2DC;normâ&#x20AC;&#x2122;. Further data analysis regarding sore throat prescribing is required for both regional and national general practices, with particular emphasis on practices with similar population demographics (age, sex, rates of disease, etc.). Only then can it be concluded that regional and national sore throat prescribing approaches are better or worse than the general practice analysed in this project, and furthermore what lessons can be learnt. Furthermore, increasing the sample size (by increasing the timeframe and with better computer coding capabilities) would allow us to reduce confounding factors and reduce the effects of a single prescriber. This would certainly reduce prescriber bias. However, with the variability in prescribing behaviour, bias can never be excluded entirely.

Conclusions Antibiotic misuse causes unpleasant side-effects for patients, unwarranted costs for general practices and accelerates the process of antibiotic resistance. Ultimately, inappropriate antibiotic prescribing is a patient safety issue. Moreover, vigilant prescribing needs to be via a GP-led approach, so that such practice is fortified by those who are constant in the specific general practice. Conclusions suggest that, due to variability in healthcare staff (high turnover of junior clinicians and use of locum doctors) subjective interventions are not sustainable. Indeed, objective interventions, particularly the computer template, are more definitive and thus showed the most marked improvement.

Over a short time period there did appear to be a shift in prescribing-associated behaviour. I accept that prior to any proposed systemic change or sustained improvement, a realisation of oneâ&#x20AC;&#x2122;s own practice and subsequent results are imperative. Furthermore, perhaps a novel prescribing approach should be considered. I postulate this could involve authorisation of electronic prescribing only after the relevant evidencebased template has been reviewed, in this case the Centor Criteria. Following on from this quality improvement work, I envisage more frequent discussion about prescription rates and targets on at least a quarterly basis, with re-review of evidence-based material as appropriate. Similar improvement studies and subsequent analysis are advised in other regional general practices. Finally, the purpose of this project was to improve sore throat prescribing and, more broadly, to highlight disparities between antibiotic prescribing and NICE guidance. I believe the interventions in this project have displayed significant change in both fields at this general practice. I postulate that a similar approach at this general practice to other infections (community-acquired pneumonia, urinary tract infections, etc.) involving the use of templates and prompts, could also lead to more appropriate antibiotic prescribing and ultimately contribute to reducing antibiotic resistance. However, further education for newly joining prescribing staff is needed, in order to ensure they know of prescribing tools available to them. Additionally, recognition and revision of factors limiting appropriate antibiotic prescribing, coupled with vigorous re-review and re-audit of sore throat prescribing practices, will decide whether further intervention is required.

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Acknowledgements

Contacts/correspondence

Many thanks to all clinical and clerical staff at Gresleydale Healthcare Centre, with a special mention to Nigel Jones (Practice Pharmacist) for his assistance with implementing the computerised template.

Dr Rajan S. Pooni Email: r.pooni@nhs.net

Conflict of interest disclosures Disclaimers and conflict of interest policies found at: http://www.patientsafetyjournal.com/policies.html

Article submission and acceptance Date of Receipt: 16.9.2018 Date of Acceptance: 30.10.2018

References 1

Costelloe C, Metcalfe C, Lovering A, Mant D, Hay A. Effect of antibiotic prescribing in primary care on antimicrobial resistance in individual patients: systematic review and meta-analysis. BMJ 2010;340:c2096.

NICE guideline. Sore throat (acute): antimicrobial prescribing. 2018 Jan 26.

Goossens H, Ferech M, Vander Stichele R, Elseviers M, ESAC Project Group Outpatient antibiotic use in Europe and association with resistance: a cross-national database study. Lancet 2005 Feb. 12-18; 365(9459): 579-587.

Petersen I, Johnson A M, Islam A, Duckworth G, Livermore D M, Hayward A C. Protective effect of antibiotics against serious complications of common respiratory tract infections: retrospective cohort study with the UK General Practice Research Database. BMJ 2007;335:982.

Shallcross L, Davies S. Antibiotic overuse: a key driver of antimicrobial resistance. Br J Gen Pract 2014;64(629):604-605.

NICE. Respiratory tract infections (self limiting): prescribing antibiotics. Clinical guideline [CG69]. 2008 Jul.

Public Health England. Management and treatment of common infections. 2017 Oct. Public Health England. Sore throat (acute): antimicrobial prescribing. 2018 Jan.

McIsaac W, Kellner J, Aufricht P. Empirical Validation of Guidelines for the Management of Pharyngitis in Children and Adults. JAMA. 2004;291(13):1587-1595.

Little P, Moore M, Hobbs FD, Mant D, McNulty C, Williamson I. Cheng E, Stuart B, Kelly J, Barnett J, Mullee M, PRISM investigators. Primary care Streptococcal Management (PRISM) study: identifying clinical variables associated with Lancefield group A β-haemolytic streptococci and Lancefield non-Group A streptococcal throat infections from two cohorts of patients presenting with an acute sore throat. BMJ Open. 2013 Oct 25;3(10):e003943.

Mitchell MS, Sorrentino A, Centor RM. Adolescent Pharyngitis: a review of bacterial causes. Clin Pediatr (Phila). 2011 Dec; 50:1091–1095

NHS Digital. GP Systems of Choice.

McCambridge J, Witton J, Elbourne DR. Systematic review of the Hawthorne effect: New concepts are needed to study research participation effects. J Clin Epidemiol. 2014 Mar; 67(3): 267-277.

World Health Organisation, Antibacterial agents in clinical development. An analysis of the antibacterial clinical development pipeline, including tuberculosis. WHO/EMP/IAU/2017.11.

Kmietowicz Z. One in five GP prescriptions for antibiotics is inappropriate. BMJ 2018;360:k936.

Pouwels K, Dolk F, Smith, D, Smieszek T, Robotham J. Explaining variation in antibiotic prescribing between general practices in the UK. J Antimicrob Chemother. 2018 Feb 1;73(suppl_2):ii27-ii35.

Cockburn J, Pit S, Prescribing behaviour in clinical practice: patients’ expectations and doctors’ perceptions of patients’ expectations – a questionnaire study. BMJ 1997;315:520.

Butler C, Rollnick S, Pill R, Maggs-Rapport F, Stott N. Understanding the culture of prescribing: qualitative study of general practitioners’ and patients’ perceptions of antibiotics for sore throats. BMJ 1998;317:637.

Teixeira RA, Rogue F, Falcao A, Figueras A, Herdeiro MT. Understanding physician antibiotic prescribing behaviour: a systematic review of qualitative studies. Int J Antimicrob Agents. 2013 Mar;41(3):203-212.

Razai M, Hussain K. Improving antimicrobial prescribing practice for sore throat symptoms in a general practice setting. BMJ Open. 2017 Jan. 6(1).

de Lusignan S. The barriers to clinical coding in general practice: A literature review. Med Inform Internet Med. 2005 Jun:30(2):89-97.

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Shock through the heart, and youâ&#x20AC;&#x2122;re to blame: reducing DC cardioversion errors using a checklist and simulation training Dr Nathan Riddell and Dr Nico Swetenham Keywords Patient Safety, Checklist, Cardioversion, Simulation

Abstract Background

Results

Direct Current cardioversion (DCCV) is a procedure used to treat irregular heart rhythms. In our centre, elective DCCV lists are run by trainee doctors who are not specialising in Cardiology. This project aimed to improve patient safety and doctor safety culture through use of a checklist inspired by the WHO surgical safety checklist, and to improve operator confidence through targeted simulation training and provision of an updated training manual.

Prior to our interventions 27 DC cardioversions were observed during which 13 errors and complications were recorded (7 operator-related, 3 medical and 3 logistical). Following our interventions 20 DC Cardioversions were observed during which 3 complications occurred (1 operatorrelated and 2 logistical). Self-rated operator preparedness scores improved from a mean of 3 out of 10 in the pre-intervention group to a mean of 8.6 in the post-intervention group.

Methods

Conclusions

Errors and complications during elective DCCV procedures were recorded for a six week period and a checklist was designed based on identified procedure critical steps. A didactic simulation session was delivered and the trainee induction handbook was updated to include extended DCCV coverage. Trainee confidence was surveyed prior to and following the interventions. The checklist was introduced and a further six weeks of elective DCCV procedures were observed for complications.

Incorporation of a checklist for DC Cardioversion and delivery of a teaching session reduced the number of operator related errors and improved junior doctor confidence in performing DC cardioversion.

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Background Introduction Direct Current Cardioversion (DCCV) is a simple procedure to treat certain irregular heart rhythms1. It is a single electrical shock to the heart, synchronised with the electrical rhythm naturally produced by the sinoatrial node of the patient’s heart. If performed

incorrectly, however, the risk of complications including arrhythmias and stroke is increased. This diagram summarises the patient journey from diagnosis to arrival at our coronary care unit for the procedure (Fig.1& Fig.2):

Figure 1: Patient pathway from diagnosis to booking for DC Cardioversion

Figure 2: Patient pathway once arrived at hospital for DC Cardioversion

In our centre the procedure team includes a Cardiology junior doctor (FY1/FY2 or Internal Medicine Trainee (IMT) equivalent, i.e. not a cardiology specialist), an anaesthetist, an operating department practitioner (ODP) and a coronary care nurse. The junior doctor on call for the day is responsible for completing the procedures listed for that day, with distant supervision by the on-call registrar who is reachable by telephone or bleep. On average, each junior doctor on the team is responsible for between one and four procedure lists during a 4-6 month rotation.

Context Junior doctors are required as part of their training to complete Advanced Life Support (ALS) training2 in their first 2 years of practice, which covers simulated use of a defibrillator in the management of acutely unwell patient with “shockable rhythms”. Recertification is

required after four years, so it is possible that a doctor responsible for completing their first DCCV list may only have used the defibrillator once in their ALS course and never on a patient. Prior to the project, we observed a lack of confidence and a number of errors and inefficiencies surrounding the DCCV list, and we were often asked to teach others the procedure or to give advice to the on-call Cardiology junior doctor during the lists. Based on this anecdotal experience, we designed a formal Quality Improvement project.

Safety culture and study design Safety culture is paramount in healthcare3 . However, it is often usurped by the busy workload and unexpected challenges of unscheduled care. Following on from the success of checklists in the aviation industry4,

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there is increasing evidence for the use of checklists to improve safety in hospitals5. Introducing system change and a safety culture to hospital procedures requires consideration of multiple technical factors and of the complex social dynamics within a multi-disciplinary team6. Using the feedback from discussions with several staff groups, including consultants, nursing staff and junior doctors, the project team decided a dual approach was required to address our core aims: 1. A simulation teaching session delivered to new starters, accompanied by revised written material for induction, covering DCCV and other topics unfamiliar to new trainees 2. A verbal checklist to guide the DCCV procedures around evidence-based protocols

Project aims Primary aim: To reduce the occurrence of complications arising from human error in an elective DC cardioversion list to zero or negligible through the introduction of a checklist and simulation training.

Plan project flow and direction Data collection #1 A total of 27 DCCV cases were observed over a six-week period prior to the intervention and critical procedural steps were identified. Complications and issues were recorded and then categorized into “operator-related”, “medical” (including anaesthetic complications), or “logistical” (delays, insufficient operating space, personnel not present). Creation of the checklist An adapted WHO surgical safety checklist was created for the DCCV procedure composed of 5 steps: basic checks, equipment, anticipate complications, team agreement to proceed, conclude (Appendix 1). The checklist was then revised over multiple iterations through observation of junior doctors and the behaviour of the other team members with the checklist in use, and with feedback from users. Questionnaire

To improve operator confidence in performing DC Cardioversion lists.

Current trainees were surveyed on whether they had received prior teaching in DCCV, had received the induction handbook, how useful they felt it was, whether ALS was completed and how confident, prepared or knowledgeable they felt about DC Cardioversion. A 10-point scale was used, with 10 being highest and 1 being lowest.

Methods and interventions

Teaching session

The project intervention phase was timed to coincide with a trainee rotation, when some new junior doctors responsible for DCCVs were joining the department and others leaving; this was in order to facilitate a culture shift towards our new model for DC Cardioversion in a staff group not exposed to the procedure in the pre-intervention period. The focus from early on was to produce a sustainable culture change in the DCCV list.

Two teaching sessions were delivered, each lasting 2 hours. All existing junior doctors performing DCCVs, and all new starter trainees in Cardiology who would be performing DCCVs attended. Cardiology Advanced Nurse Practitioners were also invited to attend the training, but they did not perform any DCCVs on patients subsequently. Sessions were held in a non-clinical space using a resuscitation model and a defibrillator

Secondary aim:

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in simulation mode, which could be manipulated by the instructors to show different rhythms and to realistically simulate several scenarios encountered when performing the procedure as closely as possible. The teaching session included: 1. Didactic teaching covering the theory and practice of the DC Cardioversion list, including: preparation, pre-procedure checks and consenting of patients for the procedure. ECG rhythm identification was covered to ensure trainees could identify whether DCCV was indicated in the patients they treated. 2. Demonstration of a DC Cardioversion: the instructors acted the roles of a Cardiology junior, an anaesthetist and a Cardiology nurse. This covered the procedure and use of the checklist including accurate documentation of the outcome and any complications that occurred. 3. Simulated scenarios. Each participant took the role of Cardiology junior in a unique scenario observed by the instructors and other participants. Different shockable rhythms were presented to participants. Individual feedback was given after each simulated scenario. 4. Discussion of complex or ambivalent ECGs that had been collected during the observation period of this study, such as multifocal atrial tachycardias, atrial flutter and variant forms of atrial fibrillation. 5. Feedback gathering and distribution of certificates for attendees signed by head of department to evidence their learning in their portfolios.

Inclusion of checklist and improved information on DCCV in the induction handbook The final version of the checklist, approved by senior members of the department with expertise in DC cardioversion, was incorporated into the local departmental guidelines with the support and engagement of nursing and junior doctor team members and became the standard protocol for the procedure in this department. The induction handbook was updated to include the DCCV checklist, instructions of the DCCV dayâ&#x20AC;&#x2122;s requirements, information on the procedure itself and how to document DCCV outcomes. The updated version was sent to senior members of the department and, following approval, was then distributed to new starting trainees. Intervention Summary 1. Introduction of a safety checklist based on the WHO Surgical Safety Checklist 2. Simulation teaching session 3. Updated local departmental guidelines and protocols 4. Engagements of key team members including senior Coronary Care nurses, Consultant Cardiologists and Anaesthetists Data collection #2 Following our intervention, a further 6 weeks of DC Cardioversion lists were observed and complications were recorded and categorised. During this period a total of 20 DC Cardioversions were completed using the new checklist.

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Figure 3: Summary of project flow and direction

Results Complications and events

Operator confidence

Pre-intervention: Six weeks of DCCV lists were audited (27 cases). 13 complications were recorded of which seven were operatorrelated (26% of all cases) â&#x20AC;&#x201C; one classified as a critical incident (patient sedated prior to rhythm check and was found to be in sinus rhythm), three classified as medical and three classified as logistical. Complications included wrong pathway selection (atrial fibrillation vs atrial flutter), absent documentation of the DCCV procedure, organisational delays, incorrect pad position and difficult rhythm check interpretation.

Five trainees who were present both pre- and post-intervention answered the questionnaire reflecting on the situation prior to intervention of which one had received previous formal DCCV training rated 5/10 for quality. Another had received informal training rated 2/10. All had received the induction booklet but the mean rating of its usefulness for DCCV was 3/10. Mean self-knowledge rating for DCCV procedure, indications and processes was 4.2/10. Mean self-rated preparedness to perform the DCCV lists was 3/10.

Post-intervention: Six weeks of DCCV lists were re-audited (20 cases). Three complications were recorded of which two were classified logistical and one (5% of cases) was classified as operatorrelated (pad positions werenâ&#x20AC;&#x2122;t changed to anterior-posterior for the 3rd shock) (Fig. 4). Observation period

Operator-related

Medical

Logistical

Total

Pre-intervention

Post-intervention

In the post intervention group, two had received informal training in previous rotations. Our training session was rated overall as 9.6/10. Despite all having been sent the induction handbook to their registered emails, 2 reported they were yet to receive it and it was subsequently sent to updated email addresses. The mean handbook usefulness following our update was 7/10, mean self-knowledge rating was 8.6/10 and mean self-preparedness rating was 8.6/10 (Fig. 5).

Figure 4: Recorded complications

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Figure 5: Survey results

Structured DC Cardioversion Education session The teaching session was assessed using a questionnaire. Additional comments, areas of excellence and areas for improvement were invited (Fig. 6).

Figure 6: Education session feedback

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Discussion Error, Safety and Checklists Data from England’s Department of Health suggests up to 10% of hospital admissions result in iatrogenic harm7. Human factors are a source of avoidable harm and remain a vital contemporary issue in healthcare8. Junior doctors are often asked to perform tasks they may not be comfortable doing9 and patient safety can become compromised when procedures are performed by operators with insufficient time available, lack of confidence, a long time interval since the procedure was performed previously, or overall insufficient skill level6. The focus of this project was to improve patient safety by identifying and eliminating human factors involved in the process of performing DC Cardioversion lists. Considering the role of human error in patient safety, Atul Gawande promotes Gorovitz and MacIntyre’s original idea of “necessary fallibility” – a limit on humans’ capacity to avoid error10, 11. Doctors, who make numerous critical decisions on a daily basis, are particularly susceptible to serious error. In a busy department Gawande advocates the use of checklists as a risk reduction tool12. Although checklists have been commonplace in aviation since the Second World War, healthcare providers have been slow to adopt checklists as a patient safety tool. WHO adopted the use of the Surgical Safety Checklist in 2009, with a demonstrated reduction in operative mortality associated with its use13. The usefulness of checklists is now being recognised in healthcare as tool to emulate the leadership and safety culture of the aviation industry4. In their role as a standardised protocol, they provide structure for less experienced individuals, and allow repeatable, standardised procedure rather than less predictable, unstructured procedures. The use of checklists for procedures is a contemporary and efficient

way to improve leadership and therefore reduce iatrogenic harm in hospital admissions14. Checklists must strike a balance between thoroughness and practicality to ensure safe practice while keeping the team engaged with the checklist. A checklist’s function is to address “avoidable failures” – an issue in hospitals which remains current and problematic15. Modelling our checklist on the WHO Surgical Safety Checklist, we designed the DCCV checklist to incorporate steps critical to the safety of patients during the DCCV procedure to eliminate “avoidable failures”. We reduced the complex task of performing the DCCV to a series of individual repeatable steps based on personal experience, then used an iterative process to eliminate common operator-related errors. Importantly we were careful to watch the checklist being used, ensure it saved time rather than caused delays and enlisted staff participation; three major pitfalls highlighted in a Nature review of hospital checklist failures16. The process involved discussion with senior members of staff and constant revision throughout the initial observation period to ensure all common errors had provisions in the final checklist. The aim was to produce a sufficiently detailed, but not overly tedious protocol that would encourage confident procedures and prompt appropriate seeking of senior help when complications or uncertainties arise.

Teaching, induction and leadership There is an improvement in leadership amongst junior doctors when they receive adequate teaching and induction information17. Our teaching was designed to maximise experiential learning – learn by doing18, 19. By incorporating the checklist into a simulation session and allowing participants

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to run through the procedure with peer-led feedback, we gave participants experience and a structure to work from. This contributed both to operator confidence and to the sustainability of the project20. Our checklistâ&#x20AC;&#x2122;s usefulness as a tool to to confirm missioncritical steps have been completed was supported by the user feedback: mean preparedness increased from 3/10 before teaching and checklist introduction to 8.6/10 post-intervention. The inclusion of real scenarios experienced by the instructors during their time performing the DCCV list was highlighted in feedback. Our teaching encouraged operators to work within the limits of their knowledge and seek appropriate senior help when the cardiac rhythm was uncertain.

Improvement of system structure and temporal efficiency The structure of DCCV lists in our organisation was recognised as requiring improvement. It depended on a busy on-call doctor to review, cannulate and perform the procedures. There was also a perceived system failure in the insufficient training some trainees felt they had received, senior supervision via telephone, and insufficient written information at induction. Overall this project aimed to improve operator awareness of potential errors, which is vital for safety culture21, and sought to enable junior doctors to take a leadership role in patient safety by improving the efficiency and effectiveness of a defined patient journey, and to train them in adequate documentation of any successes, errors and complications during a patientâ&#x20AC;&#x2122;s DCCV. No patients came to serious harm during this project. However, the intervention reduced overall operator-related error between cohorts from 26% to 5%. Inclusion of the checklist in the departmental protocol will ensure the projectâ&#x20AC;&#x2122;s long-term sustainability and will allow

for ongoing documentation of error to facilitate further study evaluating the effects of this intervention. It is important to now re-audit the process to ensure the checklist is being used throughout all lists.

Conclusion and recommendations Although checklists have recently become commonplace in surgical procedures they are less well utilised in medical specialties. Our checklist and simulation training improved departmental protocol and reduced the number of operator-related errors observed during elective DCCV lists. Improved leadership in performing the list was observed by the project team: juniors who had previously lacked confidence to perform the procedure were able to confidently proceed using the checklist protocol and their learning experience from simulation training. Overall self-reported confidence and knowledge improved, and the intervention encouraged the use of evidence-based pathways for DC cardioversion which may reduce the number of failed procedures, costs of treating complications, and most importantly, may reduce avoidable harm to patients. We encourage all clinicians who perform procedures to assess their current safety protocols and to consider whether use of a checklist could mitigate risk to their patients and improve communication between their team members. Acknowledgements We would like to acknowledge the support of the coronary care and cardiology department staff in supporting and encouraging the project.

Conflicts of interest Disclaimers and conflict of interest policies found at: http://www.patientsafetyjournal.com/policies.html

Article submission and acceptance Date of Receipt: 17.9.2018 Date of Acceptance: 20.11.2018

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Annexes Annex 1 – WHO surgical checklist Annex 2 – Initial checklist adapted from WHO surgical safety checklist Annex 3 – Finalised checklist as included with DCCV Safety booklet and used in current procedures at the test centre. 45

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Annex 1 â&#x20AC;&#x201C; WHO Surgical Safety Checklist

As seen above, the checklist is split into three sections: Prior to anaesthesia, before incision of skin, before patient leaves the operating

theatre. It incorporates mission critical safety steps to ensure as many unavoidable procedural errors as possible are prevented.

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Annex 2 – Initial checklist

Based on the WHO checklist we split the initial list into a more comprehensive pre-anaesthesia section in light of this being the most common place for errors to occur. When the patient is anaesthetised there is only a very brief period of procedural points: once the patient is adequately asleep the monitor is checked to be synchronised with the patient’s own heart rhythm (which has

already been checked in “equipment” based on project team prior experience when monitors are faulty and have to be switched (completing this prior to anaesthesia minimises time under anaesthetic)), the patient receives a shock and rhythm is rechecked. If successful, the procedure is finished and conclusion checks can be performed.

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Annex 3 â&#x20AC;&#x201C; Finalised DCCV safety checklist as included in DCCV Safety bundle

The final version is more comprehensive to include specific aspects critical to patient safety: anticoagulation checks are specified clearly, more specific confirmation on defibrillator pads orientation and display are instructed, and implanted device checks (which can interfere with the procedure) are included. It also includes the procedure under anaesthetic to ensure the pathway is

adequately followed and documented (a pre-shock rhythm strip is to be printed and a rhythm strip at time of shocks). Overall this has been ratified by the consultant body and is now included in all elective DCCV procedures and the DCCV bundle.

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Corresponding author/contact Dr Nathan Riddell nathansriddell@gmail.com

article. We fully absolve the editors and company of Patient Safety Journal (PSJ) of any legal responsibility from the publication of our article on their website. Copyright 2019. This is an open-access article distributed under the terms of the Creative Commons Attribution Licence, which permits unrestricted use, distribution and reproduction in any medium, provided the original work is properly cited.

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Caries Prevention: dietary counselling and fluoride intervention. A multi-centre quality improvement project (QIP) within Primary Care Dental Practices. Dr Jonathan Davies BDS MFDS PGCert Imp PGCert Sed1 Miss Julia Harris BSc(Hons) BDS PGCert Dent2

Abstract Introduction Dental decay is a serious oral health problem estimated to cost the UK economy £37 million per year1. The consequences of decay (pain and tooth loss) impact upon quality of life. By providing preventive intervention of dietary counselling and fluoride intervention to high caries risk adults, the prevalence of caries and associated consequences can be reduced.

Project Outcomes High caries risk patients aged >16 years were assessed for receiving both dietary counselling and fluoride intervention. The “Delivering Better Oral Health” guidelines were highlighted to clinicians and an automated ‘high-risk’ reminder was added to the examination screen and adherence to the current guidelines was continuously assessed using a run chart. The outcome was an improvement in adherence to guidelines and a resultant decrease in risk to patients.

Results and conclusion After intervention an increase in provision of prevention methods has been seen in the primary care settings assessed. Sodium fluoride prescription increased from 32.9%

Primary Care Dental Practice, North Devon Primary Care Dental Practice, East Devon

1 2

to 93.1%, and dietary counselling provision increased from 68% to 99.2%. This indicates that the specific changes implemented are an effective means of improving patient care and adherence to current guidelines.

Relevance to patient safety/quality improvement Reviewing the guidelines and implementing reminders has improved the preventive care provided to patients. The quality improvement cycles can be repeated allowing continuous assessment.

Cost savings (time/efficiency) Prevention of decay reduces the need for treatment intervention (fillings, root canal treatments and extractions). The intervention is of minimal time and cost, whilst providing an effective prompt for the treating clinician to provide dietary counselling and prescribe high fluoride toothpaste.

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Keywords Dental caries, fluoride, dietary counselling

Background Dental decay (caries) is a serious oral health problem affecting most adults and 60-90% of children worldwide1. Dental problems are estimated to cost the UK economy 37 million pounds per year due to sick days and time off work to attend dental appointments1. The consequences of caries (pain and tooth loss) can also impact many aspects of an individual’s quality of life; affecting nutrition, function in speech and mastication as well as self-esteem and confidence due to altered appearance. The Delivering Better Oral Health Toolkit1 provides guidelines for preventing caries development in all age groups. For adults, those aged 16 years and over, who are considered to have a high caries risk, a combination of dietary counselling and high fluoride toothpaste should be provided to reduce the prevalence of caries and associated consequences.

Aims To determine whether prevention guidance is being followed by General Dental Practitioners (GDPs) in two primary care practices in the UK. To review the “Delivering Better Oral Health” toolkit with GDPs in practice as part of continued professional development. To implement a ‘high-risk caries’ reminder system to improve the frequency with which prevention intervention is delivered. To assess whether there is an improvement in the delivery of dietary counselling and prescription of 1.1% sodium fluoride 51g toothpaste to high risk patients after intervention.

aged >16 years were assessed for receiving both dietary counselling and fluoride intervention. Patients were deemed high risk if they had current dental caries, xerostomia, or other special needs. Information on the ‘Delivering Better Oral Health’ guidelines was highlighted to GDPs and an automated ‘highrisk’ reminder was added to the examination screen to prompt the clinician to provide dietary counselling and prescribe sodium fluoride 1.1% 51g toothpaste. Data collection was achieved by inspecting notes for all patients seen by the involved clinicians. The caries risk of the patient was determined and then the occurrence of dietary counselling and high fluoride toothpaste prescription noted.

Results Baseline data collection revealed that mean compliance with prescribing sodium fluoride 1.1% 51g toothpaste was only 32.9%. After intervention, compliance increased to 93.1% over a seven-week period, with the last five weeks at 100% compliance. The results demonstrate a shift, six or more points above the median, towards better compliance with prescribing guidelines for high fluoride toothpaste in high caries risk patients. Baseline data collection revealed that mean compliance with dietary counselling was 68%. After intervention, mean compliance increased to 99.2%. An upward trend and shift are evident from intervention, with compliance increasing until 100%.

Methods A quality improvement project was implemented in two primary care dental settings in the UK. High caries risk patients

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Figure 1: Compliance with Guidelines on 1.1% Sodium Fluoride Prescribing in Patient with High Risk of Dental Caries

Figure 2: Compliance with Guidelines on Dietary Counselling in Patients with High Risk of Dental Caries

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Discussion

Conflict of interest disclosures

This quality improvement project assessed the performance of two General Dental Practitioners but has the potential to be extended further to assess a larger number of clinicians. The guidelines on preventative advice have a strong evidence base for reducing dental caries. It was possible to monitor the preventative interventions provided in the primary care dental setting and implement changes leading to improvements in the quality of care provided. After reviewing the guidelines and implementing the automated â&#x20AC;&#x2DC;highriskâ&#x20AC;&#x2122; reminder into the examination screen, an improvement in the preventative care provided to patients was demonstrated. The run charts could be used to continuously monitor the dentistâ&#x20AC;&#x2122;s performance to ensure improved care is sustained in the future.

Disclaimers and conflict of interest policies found at: http://www.patientsafetyjournal.com/policies.html

The aim of making preventative interventions is to improve oral health and reduce caries rates in patients. Furthermore, dietary counselling and high fluoride toothpaste should reduce the need for treatment interventions (fillings, endodontic treatment and extractions) as well as emergency pain appointments. The intervention can be efficient if delivered succinctly, requiring minimal time and cost. The potential impact this can have on a patient and their family could be lifelong, helping develop healthier, sustainable habits. Moreover, dietary counselling could contribute to the improvement of other serious health issues, such as diabetes and obesity.

Article submission and acceptance Date of Receipt: 6.10.18 Date of Acceptance: 20.12.2018

Contacts/correspondence Dr Jonathan Davies. Pure Dental Centre, Roundswell, EX31 3UD. jonathan.davies@rcsed.net

References 1

Delivering better oral health: an evidence-based toolkit for prevention. Public Health England. 2014