BPSC2021 National Patient Safety and Quality Improvement Poster Competition

National Poster Competition th 16 June 2021 16 category groups 160 Patient Safety and Quality Improvement posters

www.bristolpatientsafety.com

Save the date

BPSC National Poster Competition 2022 Open for poster entries now: https://bit.ly/2ZhcoUw Deadline

th 9

March 2022

Categories include Quality Improvement and Audit Independent, online conference, designed to share learning nationally Shortlisted entrants will be invited to present their th poster at our conference on 18 May 2022 and will receive a certificate – poster presented at a national conference

www.bristolpatientsafety.com

Bristol Patient Safety Conference is an independent national event designed to share learning Thanks to all 216 poster competition entrants and to the presenters of the 160 posters selected to be presented at our eighth annual conference on the th 16 June 2021.

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

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

www.bristolpatientsafety.com

National Poster Competition Winners BPSC2021 Group Group A: maternal, neonatal care

GROUP B: Medicines Management (1)

GROUP C: Medicines Management (2)

Group D: Care of the Older Patient

Prize

Title

Authors

Organisation

Group A 1st Prize

In the Know or in the dark?- Keeping parents updated on their babies’ result

Jeanne Uhiriwe, Akudo Okereofor, Nicola Davey

North Middlesex University Hospital

Group B 2nd Prize

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

Pauline Hewitt, Joanne Colliver

Gloucestershire Royal Hospitals NHS Foundation Trust

Group B 1st Prize

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

Dr Jerome Ling, Dr Damien Drury

Swansea Bay University Health Board

Group B 2nd Prize

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

Dr Jessica Michael, Dr Rachel Scott, Dr Oliver Martin & Christine Sluman

North Bristol NHS Trust

Group C 1st Prize

In The NAC of Time

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

Hampshire Hospital NHS Foundation Trust

Group C 2nd Prize

Improving the co-prescription rate of DOACs and PPIs

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

Taunton Vale Healthcare

Group D 1st Prescribing of PPI cover with NSAIDs use in over Prize 65s

Dr Hazel Chon, Dr Piranavan Kirupananthan

University Hospitals of Leicester NHS Trust

Group D 2nd Prize

Dr Alexandra Uren, Mr. Louis Hainsworth, Miss Alanna Pentlow

University Hospital’s Bristol and Weston

Elizabeth Beasant

GPST1 Cardiff and Vale UHB

Dr Isobel Joy McFadzean & Dr Rebecca Jenkinson

Kingsway Surgery

Abbas A, Brackenborough K

NHS Frimley Health Foundation Trust

Mark Hoey, Pauline McIntyre, Sussamma Raju, Leanne McKeown, Alan MacPherson, Clare Diamond , David Brennan, Gareth Lewis

Northern Health and Social Care Trust

Matilda Fox, Rosie Pettit, Ernest Mutengesa, Marcus Wright, Anu Mitra

Imperial Healthcare NHS Trust

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

Group E: Group E 1st It’s red and lumpy”. Improving the process of Improving Primary Prize reviewing skin complaints virtually in General Care Practice using patient submitted photos Group E 2nd Prize

Antipsychotic monitoring: A Quality Improvement (QI) project

Group F Group F 1st Recognising the deteriorating patient: Optimising Care of the unwell Prize lab to ward communication of abnormal blood patient (1) results

Group F 2nd Prize

FRIDAYS – Make Every Day A Friday

Group G: Group G 1st Introducing Blanket Screening for Human Care of the unwell Prize Immunodeficiency Virus in a Central London patient (2) Emergency Department

GROUP H: Handover

GROUP I: Education and Training (1)

GROUP J: Education and training (2)

Group G 2nd Prize

Streamlining Venepuncture To Improve Efficiency and Patient Safety

Dr. Sachin Wimalagunaratna, Dr. Oliver Small, Royal Devon and Exeter NHS Mrs. Joanna Walsh-Quantick, Dr. Michael Foundation Trust Barrington, Dr. Russell Eason, Dr. Naomi Spencer

Group H 1st Prize

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

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

Royal United Hospital Bath

Group H 2nd Prize

Is anyone coming to handover?

Stephanie Hill and Samuel Protheroe

Hull Royal Infirmary

Group I 1st Prize

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

Dr Anna Halstead, Dr George Williams, Dr Andrew Mcgaughey and Dr Grace Southern

University Hospitals Dorset

Group I 2nd Improving usability of a digital clinical decision Prize support tool through PDSA cycles

Harry Chappell, Dinesh Yoganantham , Joseph Read, Alexander Crawford, Claire Pettinger, Rudrik Thakkar, Emma Grace, Neha Gupta, Thomas Rose, Katrina Glaister , Simon Williams, Sebastian Gray

Salisbury District Hospital

Group J 1st prize

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

Olivia Hartrick, Jessica Duckworth Molly Dineen, Royal Devon & Exeter NHS Aniela Pawar, Miles Edwards, Tabitha Atkinson- Foundation Trust Seed, Victoria Henderson, Lucy Sigley, Amber Pankhurst, Grace Liversedge, Nicola Mathieu, Robert Bethune

Group J 2nd prize

Trainees Improving Patient Safety through Quality Gary Jevons; Sophie Green; Hannah Baird; Improvement (TIPS QI) Cameron Whytock; Kathryn Newell; Rion Healy; Eleanor Abbot; Jack Dover; Jack Dalziel; Deepa Krishnan; Ayoub Behbahani

Manchester University NHS Foundation Trust

Continued overleaf

National Poster Competition Winners BPSC2021 Group

Prize

Title

Authors

Organisation

GROUP K: Improving processes and healthcare outcomes (1)

Group K 1st prize

“Doctor...can you update the family please?...”

Amy Prideaux & Thanuja Thananayagam

University Hospital of Wales, Cardiff

Group K 2nd prize

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

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

Royal Devon and Exeter NHS Foundation Trust

GROUP L: Improving processes and healthcare outcomes (2)

Group L 1st prize

Will I Finish Work on Time today?

Dr Hajera Sheikh, Dr Emma Parish, Nicola Davey North Middlesex Hospital, London

Group L 2nd prize

Transforming the task-board: Improving out-ofhours task identification and prioritisation

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

Group M: Group M Improving patient 1st prize handover and intensive care Group M 2nd prize

Improving the culture of electronic handovers

Gemmell C, Rogers S, Davis J, Davoudi K, Hinds J, Taunton and Somerset NHS Ahmed J, Jenkins G Foundation Trust

Mind the step’-down

Declan Beattie, Ciara Murphy

NIMDTA - Belfast Trust

Group N: Improving admission and discharge care pathways

Group N 1st prize

Improving the Quality of Referrals from the NHS 111 Service

Dr John Flemming, Dr Robert Tan

Epsom and St Helier University Hospitals Trust

Group N 2nd prize

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

Eunkyung Lee, Ridhi Majithia, Rachel Roberts

University Hospitals Plymouth NHS Trust

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

S. Biggs, L. Dixon, B. Clayphan, L. Jordan, S. Dalton & A. Pullyblank on behalf of PreciSSIon Collaborative

Glos Hospitals, Great Western Hospitals, RUH Bath, North Bristol Trust, Univ Hospitals Bristol & Weston on behalf of PreciSSIon and WEAHSN

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

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

Maidstone and Tunbridge Wells NHS Trust

Reducing the number of appointments for fibroepithelial polyps (FEPs)

Dara Murphy, Nicola McCurley, John Hanratty

Oral and Maxillofacial Unit, Ulster Hospital

Standardising Surgical Ward Round Documentation

Leila Ellis, Sophie Howlett and Joe Parvin

Torbay and South Devon NHS Foundation Trust

Group O Group O :Care of the 1st prize surgical patient (1)

Group O: 2nd prize Group P: Group P: Care of the 1st prize surgical patient (2) Group P: 2nd prize

Royal Devon and Exeter NHS Foundation Trust

th 16

June 2021

Poster Competition Group A

Improving maternal, neonatal and paediatric care First prize: In the Know or in the dark?- Keeping parents updated on their babies’ results Presenter: Dr Jeanne Uhiriwe North Middlesex University Hospital Second Prize: Optimal Thermoregulation of the Pre-term Infant on Admission to the Neonatal Intensive Care Unit Presenter: Pauline Hewitt Gloucestershire Royal Hospitals NHS Foundation Trust

In the know or in the dark?

Keeping parents updated of their babies’ results Jeanne Uhiriwe1, Akudo Okereafor 1, Nicola Davey2 1 North Middlesex University Hospital, 2 QIC Learn

Problem

Diagnostics We tell parents we want to partner with them in their babies’ health.

Imagine, then, how frustrating it is for the parent to find out that their baby had an abnormal result weeks prior, and they had not been informed!

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

Ideas to test 1.

Chosen measure Recording of Cranial ultrasound results as communicated to patients Inclusions All neonatal admissions at North Middlesex Hospital who have one or more cranial ultrasounds performed during their stay in the unit.

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

Sampling method & frequency: Patient notes- review fortnightly

PDSA

2.

3.

4. Improve staff awareness of problem

Future PDSAs

PDSA Test #

PLAN

Do

1.1

Trigger to remind clinicians to Add parental communicate results to communication parents trigger box on ward round proforma

1.2

Trigger to remind clinicians to Add parental Improved uptake communicate results to communication box parents to the existing cranial ultrasound form

Continue with form and encourage use by raising awareness

2.1

Team engagement

Progress to presentation to the staff in teaching sessions

WhatsApp reminders to record communication of results

STUDY

ACT

Trigger boxes not used at all and left empty

No change made to existing sheet, but, add a more direct trigger to the cranial ultrasound form

Only 2 members of team have so far used any of the trigger boxes

Result •

Run Chart Were ultrasound results communicated to parent?

Ultrasound result communicated to parent

Yes

Median

•

1.2

•

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

•

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

•

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

2.1 No 3

5

7

9

11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51 53 55 57 59 61 63

Ultrasounds performed

Prior to the PDSAs, there were very few positive data points. Over the first 30 data points, there was only one recorded documentation, but over the next 30 , there were 6 recorded documentations of parental communication A simple trigger on the existing form created the most change

Reflections

1.1

1

Collaborate with team currently changing proforma to add section to prompt checking if parents updated Adding a section to the already existing cranial ultrasound form to trigger communication of results Improve parental presence during ward rounds

Optimal Thermoregulation of the Preterm Infant on Admission to the Neonatal Intensive Care Unit Pauline Hewitt, Lead Midwife for Delivery Suite & PERIPrem Lead Joanne Colliver, Consultant Nurse & Senior Advanced Neonatal Nurse Practitioner

Introduction Mortality rates in the preterm infant are increased by 28% for every 1 degree decrease in the recorded temperature of a baby on admission to the Neonatal Unit. To optimise outcomes, at least 90% of preterm babies under 34 weeks gestation are required to have a normothermic temperature (36.5 - 37.5C) measured within one hour of their admission to NICU. Gloucestershire Royal Hospital is enrolled in PERIPrem (Perinatal Excellence to Reduce Injury in Premature Birth), an 11 element perinatal bundle to reduce mortality & brain injury in preterm infants in the South West. At baseline audit, Normothermia compliance was found to be variable and a perinatal Quality Improvement project launched to optimise normothermia.

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

STUDY: Collect data via optimisation tool Analyse data for trends

PLAN: Identify environmental barriers to optimal thermoregulation: cold towels

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

Results & Lessons Learned:

Run chart or data here !!!!!

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

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

Outcomes: Improved optimal thermoregulation was achieved through: • Improved perinatal team cohesion and functioning • Theatre staff ensuring optimal room temperature in the theatre setting • Pre-heated towels available from a dedicated towel warmer on Delivery Suite • Individual Transwarmer pads placed under the preterm baby to ensure optimal temperature control • Monthly review of cases and continuous improvements made to factors impacting optimisation

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

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

Moving on up!

Establishing a transition service for young people with epilepsy S Barrow 1, N Davey2, A Okereafor 1,2 1 North Middlesex University Hospital, 2 QIClearn Acknowledgements: with special thanks to Emma Devereux 1 and Natasha Price 1

DIAGNOSTICS

BACKGROUND

Fishbone

Process Map Young person to move to adult services

Lack of transition service for young people with epilepsy….....

Seen in paediatric clinic

Refer patient to adult services

Maintain contact with patient until seen by adult team

Patient transferred to adult services

CHANGE IDEAS

AIM

• Design survey to gauge ideas, knowledge and concerns about moving to adult services • Discuss key areas (based RSG programme) that can be impacted on: responsibility with medications, being seen alone, young person/parental concerns about leaving paediatric services • Document evidence of topics discussed using RSG paperwork

By the end of February 2021, all 14-17yr olds with epilepsy will have at least one discussion about moving to adult services with the help of the Ready Steady Go Transition programme.

MEASUREMENT Review most recent clinic letter to identify if transition or moving to adult services has been discussed Inclusions - all young people ≥ 14yrs with epilepsy Exclusions - ≥ 16yrs who have been referred to adult neurology services

• Signpost young people to suitable online resources • Set-up transition clinic for teenagers with epilepsy

PDSA cycles 1.1

Survey results:

RUN CHART Review of outpatient clinic letters to identify if transition has been discussed

1

0 1

3

5

7

1.3

1.2

9

11 13 15 17 19 21 23 25 27 29 31 33 35 Patients (≥14yrs)

• Most young people were unsure about the names/doses/how often they take their medications • All young people wanted to know more about the differences between paediatric and adult services • Some young people were not sure about being seen alone for some or part of their next appointment

1 = Yes 0 = No = median

| qiclearn.com | @qiclearn

| londonpaediatrics.co.uk | @LondonPaeds

2.1

2.2

REFLECTIONS & LEARNING • RSG programme was adapted to help impact key areas associated with transition to adult services.

• Further work is required to improve areas in which young people need help with e.g. responsibility with medicines and transitioning those with more complex needs.

• There is now an established monthly epilepsy transition clinic which enables focussed discussion around transition.

• The focus of this clinic has enabled the paediatric epilepsy team to better achieve the objectives of transition and prepare young people for adult services.

THE FIGHT AGAINST MATERNAL SEPSIS: A QUALITY IMPROVEMENT PROJECT AT A DISTRICT GENERAL HOSPITAL IN UK Dr Stephanie Adeyemi, Miss Rabia Zill-e-Huma and Miss Jasmine Leonce

Aims

Why is this important?

The MBRRACE-UK 2013-15/2014-16 reports have highlighted sepsis as a leading cause of direct maternal deaths (0.56 per 100,000). Early recognition and management of sepsis is crucial to improve maternal outcomes.

The aim of this project is to improve recognition and response to maternal sepsis. This will be achieved by evaluating if all the changes implemented so far have improved the key areas in the recognition and management of sepsis.

Methods Project involves a continuous retrospective review of notes with quarterly to six monthly cycles, starting from June 2018 onwards utilizing 79 randomly selected cases to evaluate if Trust/ National guidelines are met and interventions improved recognition and management of sepsis.

Interventions implemented since the initial cycle include: Introduction of UK Sepsis screening tool, MDT working with Trust sepsis team and regular robust review of sepsis cases. A ‘code sepsis’ alert has been instated so that the delivery of sepsis 6 can be performed in a timely fashion analogous to a maternal hemorrhage call

PDSA PLAN: improve maternal sepsis via interventions such as using UK sepsis tool, MEOWS, sepsis 6, appropriate use of antibiotics and collaboration with Trust Sepsis Team DO: Communication sheets, availability of UK sepsis tool proformas in clinical areas and formation of Sepsis Working Group STUDY: regular review (6 cycles) ACT: UK sepsis tool proformas, PROMPT (Practical Obstetric Multi Professional Training) sessions sepsis champions, newsletters, maternity alerts, code sepsis

Results

Outcomes

Sepsis screening tool use and documentation of clinical assessment have improved, however areas for improvement included taking blood cultures and giving antibiotics within first hour. Monthly PROMPT training sessions and support from sepsis champions should help with sustained improvement in these parameters.

Moving from peripheral project to Devon Partnership integrated governance: Developing System Sustainability in Excellence Reporting NHS Trust

Dr Jessica Scott CT3 Psychiatry; Dr Jennifer Ledger CT2 Psychiatry Thomas Scobie, Business Administrator and Quality Improvement Coordinator; Dr Helen Smith, Consultant Forensic Psychiatrist Secure Services Langdon Hospital, Devon Partnership NHS Trust

INTRODUCTION AND AIMS: Healthy cultures within NHS organisations are key to delivering high quality, safe care. (King’s Fund). A focus towards developing systems which both recognise and learn from excellence has been shown to improve the safety of services and contributes to staff’s morale. (Kelly et al 2016).

Secure services within DPT developed an excellence reporting system. Once successfully piloted, this would be spread to other Trust departments. Perinatal services was our first step for this spread.

The aim was for the system to be embedded so staff could as quickly and instinctively report excellence as they could an error. The aim was nine months in to average thirteen reports a week (by 30/09/19) in Secure Services and six in Perinatal (by 01/01/21).

METHODOLOGY/ PDSA CYCLES: We developed our Theory of Change using Deming’s theory of profound knowledge, and ran a series of PDSAs, and introduced an Excellence reporting system to Secure Services.

We engaged early adopters, sent hand-written cards and publicly thanked reporters. We shared our data widely with regular newsletters, emails and discussions in meetings.

Learning included understanding setting up the system, and appreciating the importance of a team rather than an individual holding the system. We took this forward to introduce the system to Perinatal. We then continued to run a series of PDSAs to attempt to fit the system to the service - including timing the launch, how the cards were delivered and identifying members of the team likely to have influence.

Figure 1: Excellence reporting flowchart

PROJECT RESULTS AND LESSONS LEARNT: Across both sites staff were excited, reports submitted, feedback good, then a plateau and a slump. Despite an initial receptive atmosphere, something was stopping the system perpetuating.

When staff received timely thanks, and others heard about it, staff would go on to promote excellence. Despite enthusiasm the positive feedback loop became interrupted and reporting stopped.

Both sites’ results show with the current level of administrative support the system cannot be sustained; for it to continue staff need the positive feedback which is not possible without sufficient resources.

FUTURE DEVELOPMENT: We recognised the system’s potential long-term impact on safety and staff morale, but ultimately we needed buy-in from the top who allocate resources, for it to become part of a job specification, embedded and mobilised.

REFERENCES:

As such we have presented the data at Senior Directorate Level who recognised the value and agreed to support. Our aim is to fully embed the system into day to day workforce culture. This has not been possible on an individual team level but will hopefully be successful now it’s supported and once its presence is expected at governance level.

Kelly N, Blake S, Plunkett A. Learning from excellence in healthcare: a new approach to incident reporting. Arch Dis Child 2016; 101: 188-791 Kings Fund. NHS Leadership and culture: our position. 2020. www.kingsfund.org.uk/projects/positions/nhs-leadership-culture Jones AS, Isaac RE, Price KL, Plunkett AC. Impact of Positive Feedback on Antimicrobial Stewardship in a Paediatric Intensive Care Unit: A Quality Improvement Project. Pediatr Qual Saf 2019;5:e206.

Paediatric Admission Booklets Increase Documentation of Responsible Consultant Dr Lucy Scales, Mr James Barnes, Dr Alison Kelly Bristol Royal Hospital for Children, University Hospitals Bristol and Weston NHS Foundation Trust

Introduction and Aim

Methodology

In 2019 Paediatric admission booklets were introduced to Bristol Royal Hospital for Children (BRHC) as previously presented1.

A key recommendation of the Francis report2 was that every patient admitted to hospital in England should have a named identifiable clinician assigned to them; known as a Responsible Consultant or Clinician. Admission booklets are recognised to increase the completeness of clerkings for adult patients3.

We audited the use of Paediatric Admission Booklets for 120 emergency admissions to BRHC in September 2020. The electronic patient record was reviewed for each patient admitted to review and record whether an admission booklet had been completed and what information was recorded.

Twenty-three Royal Collage of Physician (RCP) 2009 criteria were measured, including documentation of Responsible Consultant.

Our aim was to study and increase the information included in the initial paediatric admission clerkings by auditing the use of Paediatric Admission Booklets, including the documentation of Responsible Consultant.

This project was a re-audit following two previous audit cycles (January 2019 and January 2020). The second audit cycle resulted in changes such as modification of the booklet in response to user feedback. Other changes had only been partially completed prior to our third audit cycle, however we opted to for an early re-audit due to a new cohort of trainees.

Results

This work with multiple audit cycles supplements the PDSA cycles completed in 2019 leading to the design and implementation of these booklets.

Our results showed Paediatric Admission Booklets were used for 75% of paediatric medical admissions and 57% of surgical admissions.

21 of the 23 RCP criteria increased in documentation with the use of Paediatric Admission Booklets.

The Responsible Consultant was documented in 91% of clerkings using the admission booklet compared to just 9% when no booklet was used.

Other criteria in which documentation was increased when using Paediatric Admission Booklets were: • Vaccination Status (increased to 62% from 34%) • Social Worker (increased to 72% from 14%) • Observations (increased to 62% from 34%) • Allergies (increased to 96% from 64%)

Percentage of Clerkings in which Criteria Documented

120

The Percentage Difference in inclusion of criteria between clerking on admission booklet vs on paper – September 2020

100 80

60 40

20 0

Date

Time

Source of Referral

Location Patient Seen

Name of Clerking Dr

Grade of Clerking Dr

Bleep

Responsible Person Presenting Consultant Accompanying Complaint Child

Past Medical Medications Allergy Status History

RCP Criteria

The results from this audit support the use of admission booklets in paediatrics because clerkings consistently documented more criteria when they are used. There was a large increase in documentation of the Responsible Consultant in clerkings using the admission booklets, 91% compared to just 9% when no booklet was used.

Vaccination Family History Social History SW Safeguarding Examination Investigations Status Involvement Concerns

Proforma

Plan

Observations

Paper

Plan

Conclusions Our results compared favourably with the results of the January 2019 audit cycle but less so with the audit cycle from January 2020. We feel this highlights the importance of ensuring recommended changes from previous cycles are fully implemented prior to re-audit, and the importance of including clerking booklets in the induction programme for new junior staff.

Allergy Reaction

1. Ensure availability of admission booklets across all wards 2. Communication with junior staff to ensure awareness of admission booklet – targeting main induction dates 3. Re-audit after implementation of further changes

References 1.

2.

3.

Use of a paediatric orthopaedic admission booklet to improve clerking documentation. National Patient Safety and Quality Improvement Poster Competition. Bristol Patient Safety Conference 2019.

Francis, R. 2013. Report of The Mid Staffordshire NHS Foundation Trust Public Inquiry. London: The Stationary Office Limited. Available at: www.midstaffspublicinquiry.com/report Smallwood, N., Russell, J., Forbes-Pyman, R. and Coates, A., 2018. Do medical admission pro formas improve the completeness of documentation? A multisite observational study. Future healthcare journal, 5(2), p.121.

Improving the communication through discharge summaries between Paediatric Emergency department and GP in a District General Hospital Dr Zainab Afzal, Ashford and St Peters Hospital NHS Trust foundation.

Background, Aims and Objectives •

It is important that Paediatrics attendance to the Emergency department be bought into the attention of the GP for continuity of care.

•

While reviewing a few discharge letters sent to GPs, we came across some discrepancies and incomplete information being sent to GPs, as lot of information being entered by the doctors was not being displayed on the electronic letter as intended.

•

Results Improvements

•

The results after the re-audit showed improvement in overall discharge summaries having all clinical details present from 10% to 100% after making changes to the IT system.

•

Addition of proper sections of presenting complaint , investigation and treatment tab showed promising results in maximum information being relayed on discharge Summaries to GP.

•

This project demonstrated the significance of having a good discharge summary for Patient Safety. Poor quality discharge summaries were being sent out to GPs without any proper clinical information and risking the continuity of care of the Patient.

•

By improving the overall communication between secondary and primary care, we were able to make a very impactful change to patient Safety and good clinical management

Through this project We aim improve the information sent to GPs via electronic discharge letter from Paediatric Emergency department

Methodology •

Audit was done of 30 discharge letters sent from St Peters Hospital Paediatric Emergency department to GPs between the dates 02-1020 to 06-10-20.

•

The details of these patients were obtained from emergency department daybook records.

•

We noted the mention of correct presenting complaint, diagnosis, investigations and treatment on the letters.

•

The results of the audit showed clear absence of correct information about the clinical details and Management of the patient in ED, with most information not present on the discharge summary.

Antibiotic Exposure in the Neonatal Period: Are we Going Overboard?

Dr Jessica Hawksley, Dr Miles Wagstaff, Dr Alex Brooks-Moizer, Dr Sally Henderson Gloucestershire Hospitals NHS Foundation Trust

Introduction

•

Early onset sepsis (EOS) causes significant neonatal morbidity and mortality within the first 72 hours of life but it is hard to predict those at risk. The incidence is ~0.9/1000: so we predict 5-6 cases of EOS per year in Gloucestershire.

•

Infective risk factors occur prior to delivery (maternal sepsis, chorioamnionitis), during delivery (organisms from birth canal, e.g.: Group B Streptococcus) and after delivery (exposure to new organisms).

•

The unnecessary use of antibiotics increases risk of childhood atopy, allergy and obesity alongside antibiotic toxicity, side effects, drug resistance and risk from drug errors. Time spent separated from baby impacts on maternal bonding and anxiety, especially with reduced partner visiting during COVID.

•

We aimed to introduce a new method of stratifying babies at risk of EOS to try and safely reduce antibiotic exposure in the neonatal period.

1. Plan

Prior practice using NICE Guidance

Aims: 1) Reduce antibiotic use in neonates at risk of EOS in first 72 hours of life.

2) Ensure new policy is safe and does not miss cases of EOS.

Antibiotics given if any red flag risk factors (eg: maternal pyrexia/maternal antibiotics) OR two or more non red flag risk factors OR clinical indicators

Our prospective audit completed in 2018 predicted an 80% reduction in antibiotic use for neonates >34 weeks gestation through the proposed introduction of a new Kaiser Sepsis Risk calculator (SRC). Previously, NICE guidelines for antibiotic use were used. (See text boxes 1 & 2)

Risk factors are binary variables If no red flags and only one risk factor - observation and consider withholding antibiotics. No bloods performed unless decision to screen.

Text box 1

Proposed practice: Kaiser Permanente Sepsis Risk Calculator (SRC) Applicable to term/early preterm neonates > 34/40 Calculation of risk based on known risk factors using statistical algorithm.

Gives a suggested plan of management stratified against risk

Plan

Do

Non binary variables used 4 potential recommendations: No culture, no antibiotics, Routine observations No culture, no antibiotics, 4 hourly observations for 24 hours Blood culture and 4 hourly observations 24 hours.

Empiric antibiotics, bloods and observations as per NICE.

Act

Study

2. Do

1) Trust guideline completed.

2) Education to all teams to introduce sepsis risk calculator in August 2020 for all babies >34 weeks gestation with infective risk factors.

3) Babies using SRC recorded to allow re-audit to take place.

3. Study

Re-audit completed 6 months following introduction of SRC over 5 week period: 8th August 2020-12th September 2020. Total of 50 babies included.

For all neonates using SRC in time period: - Kaiser scores calculated and compared to previous NICE recommendations - Blood results reviewed (if taken) - Length of stay calculated - Evidence of readmission within 72 hours assessed.

In 6 month period since SRC introduced: - All readmissions reviewed for evidence of EOS - All positive neonatal blood cultures reviewed.

Comparisons made between use of NICE and SRC guidelines.

Text box 2

% Gloucestershire babies requiring antibiotics

Chart 1: Bar chart showing clear reduction in babies requiring antibiotics in first 72 hours of life comparing previous NICE guideline and new Kaiser SRC guideline 9

4. Act

SRC demonstrated to be a safe and effective tool in managing babies with infective risk factors at delivery.

8 7

1) We will continue to implement the SRC with increased education to different teams to ensure tool used correctly and SRC recommendations followed.

2) Education and teaching regarding maintaining aseptic technique to blood culture collection.

3) Reaudit planned in 6 months time.

6 5 4 3 2 1 0

NICE

Kaiser SRC

Results

1. Significant reduction in antibiotic use

2. Significant reduction in length of stay

3. Deviations from SRC recommendations

4. One case of ‘missed EOS’

• 1.8% of all babies born in Gloucestershire required antibiotics using SRC (78% reduction from prospective audit) (See chart

• Introduction of SRC resulted in significant reduction in length of stay equating to 2.4 beds released to care per day.

• Deviations noted in 6 babies: 5 undertreated. Nil readmitted with EOS. 1 required partial septic screen for clinical symptoms in first 24 hours.

• One positive GBS blood culture result ‘missed sepsis’: neonatal team not alerted to this baby so not put through SRC or observed as per protocol.

1)

5. Quality of blood culture sampling needs improvement • 10 positive blood cultures in 6 month period: 70% NICU admissions (SRC not applicable).

• 60% of these likely contaminants

References: Morris R., et al. Comparison of the management recommendations of the Kaiser Permanente neonatal early-onset sepsis risk calculator with NICE guidelines CG149 in infants >/= 34 weeks gestation who developed early-onset sepsis. Arch Dis Child Fetal neonatal Ed 2020; 105:F581-F586 https://jamanetwork.com/journals/jamapediatrics/fullarticle/2604260

Relevance of audit to Patient Safety and Quality Improvement

A significant reduction in antibiotic use in the neonatal period should contribute to reducing: • Childhood atopy and allergy • Childhood obesity • Antibiotic toxicity • Drug resistance • Drug errors • Parental anxiety The reduction in length of stay will have significant financial benefits for the trust

Increasing the Rates of Outpatient Induction of Labour Introduction

Accumulative Total of Women Opting for OPIOL

The Outpatient Induction of Labour (OPIOL) service was first launched at the Trust in 2017 to improve women’s birth experiences in line with the Maternity Transformation Programme. Yet an audit highlighted only 17 women opted for OPIOL throughout a two year period.

Service user feedback suggested the reason for the poor uptake centered upon poor staff awareness and adoption of OPIOL. Furthermore, the Trust noted a number of complaints from women who were keen to use the service, however they did not meet the inclusion criteria (as the initial service was appropriately piloted with a low risk group of women). A plan was made to expand the inclusion criteria and re-launch the service.

Induction of Labour Rates are Increasing Nationally with the aim to Reduce Maternal & Neonatal Morbidity & Mortality

The Quality Improvement Process

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0 1 2 3 4 5 6 7 8 9 10 11 12 13 Number of Months Since Service Launch

The team utilised the quality improvement methodology of ‘Plan, Do, Study, Act’ (PDSA). Staff engagement sessions were held with all members of the service. The team also liaised with the local Maternity Voices Partnership to obtain their views on seeking feedback from women. An Induction of Labour (IOL) proforma was implemented. The proforma contained the revised OPIOL inclusion criteria to assist staff with familiarisation of the expanded service. The service re-launch was communicated through posters, social media and the ‘Theme of the Week’. The service was re-launched in February 2020 with a plan for continual audit to monitor OPIOL rates and safety outcomes. Questionnaires were sent to women to ascertain their views on the service.

Results Over a one year time period, a total of 120 women opted for OPIOL Women choosing resulting in a combined hospital reduction admission time of 2032 Outpatient hours. Women provided positive feedback including “the experience Induction of Labour was so much nicer than staying in hospital would have been!” and “I felt more comfortable in my own home with my own bath to relax spend on average in. As I was induced during the pandemic, it meant I was not 17 hours less in separated from my partner which was really important to me”. hospital and report Additionally, staff feel more confident in facilitating OPIOL with the a more positive support of the IOL proforma meaning the inclusion criteria is readily birth experience available. The uptake of the OPIOL service has increased significantly and is currently approximately 10-15 women per month.

The Induction Of Labour Working Party Lauren Graham - Midwifery Team Lead, Rachel Marshall-Roberts - Consultant Obstetrician & Gynaecologist, Claire Hein - Consultant Obstetrician & Gynaecologist and Natalie Adams - Midwifery Team Lead.

With special thanks to all of the women as service users & staff within maternity services for supporting the quality improvement project.

SWAP TO STOP IN PREGNANCY Wellbeing Team (WT) & UHP Maternity Services Co-authors Julie Fortt, Melanie Edwards, Clara Southby, Jaz Nolan

PROBLEM:

UHP Aim

Leicestershire County Council & BANES shared Standard Operating Procedures (SOPs)

To increase the proportion of smoke free pregnancies to 94% or greater by 2022

Developed Measurement strategy and linked with MatNeoSIP Smoke Free Pregnancies Project at UHP/liaised with Commissioner Plymouth City Council securing funding and Flavour Vapour supplier (Trading Standards accredited.

Already previous vape project Plymouth Community Homes tenants 2019 & WT)

Numbers of Plymouth women declining stop smoking support at midwifery booking appointment not decreasing significantly since LifeQi measures introduced

ACT:

Increase advertising of Swap to Stop vape/NRT during STOPTOBER and beyond

AIM:

Determine if free Swap to Stop Vapes increases number of referrals of Plymouth pregnant smokers to Specialist quit smoking Service

Maternity and Neonatal Health Safety Collaborative (now MatNeoSIP) works towards reducing perinatal mortality by aligning it’s work with Saving Babies Lives Care Bundle (SBLCBv2 2019) Element 1. Reducing smoking in STUDY: pregnancy 1.8 Maternity providers encouraged to focus improvement in following From 1.7.20 to 30.6.21, areas: a. Effective identification of women who smoke during their pregnancies. compare numbers monthly of b. Increase the provision of effective training of staff in relation to smoking pregnant smokers accepting during pregnancy. c. Working with local partners to develop effective Swap to Stop Vapes only or Vapes pathways of care for referral for specialist stop smoking advice. and NRT. Compare quarterly Outcomes (Quit, Not Quit, Project aligns to National Maternity Review Better Births 2016 Lost to contact) of women providing personalised safer woman centred care and choice with on this scheme to previous collaborative multi-professional working across boundaries.

Outcome data

WT Developed E-Cigarettes: Protocol for supply to smokers registered with Livewell Southwest Wellbeing Team

Setup LifeQi data July 2020 & PDSA cycle

Spring Launch delayed as a result of COVID, reset for 1.7.20

Facebook Advertising push STOPTOBER 2020 & Jan 2021 with posters/leaflets to midwifery bases/UHP wards

Smoking still accounts for more years of life lost than any other modifiable risk factor. This project aligns to NHS Long Term Plan 2019 working towards a smoke-free society, using a smoke-free pregnancy pathway to reach goals: Joined-up care at the right time in the optimal care setting, to cut smoking in pregnancy reducing health inequalities, improve pregnancy outcomes through extra funding for this important group.

Next PDSA cycle use Audit to compare quarterly Outcomes (Quit, Not Quit, Lost to contact) of women from 1.7.20 to 30.6.21 to previous Outcome data and compare numbers of pregnant smokers accepting Swap to Stop Vapes only or Vapes and NRT

Measures

PLAN:

Monitor how many Plymouth women accept Swap to Stop Vaping in Pregnancy support, maybe alongside Nicotine Replacement provision & routine behavioural support

DO:

Offer NRT/Vapes to all Plymouth women wanting to stop smoking who access Specialist Service

Change ideas

Test & learn

Change ideas PDSA 1: Increase referral to specialist services with an increase in uptake of this (July 2020). On the Uptake of smoking cessation referrals Run Chart increases seen in Oct 2020 & Feb-March 2021, traditional higher referral times in previous years too as higher numbers of pregnant women then. Also UHP facebook advertising push Oct 2020 for STOPTOBER, further leaflets and posters in Jan 2021.

Provision of Swap to Stop Vapes for Plymouth pregnant smokers

Uptake of smoking cessation referrals

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Chart shows women who may not be able to afford a vape are offered this choice. Swap to Stop Vaping in pregnancy became an additional offer in Quarter 2.

Referrals increase Jan-March 2020 & 2021

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% of women recorded as “smokers at booking” Declining referral to Stop Smoking Services

This Run Chart may reflect COVID-19 lockdowns.

Numbers of women declining referral at booking appointment remain constant except March 2021

Conclusions: Swap to Stop Vape offers women confidence, more choice and information to quit plus increased harm reduction.

What women think: Popular incentive

smoke free pregnancy Giving your baby the best start

“I don’t have to go out in the cold”

“save money, vapes too expensive to buy”

“likes compactness, easy to set up, refill and charge”

“Disliked flavour, leaked, too strong – exchanged free”

“It gives you something to do with your hands and mouth”

What did staff think: More choice, recommending vapes in booking appts, cheaper than NRT. Good communication between Plymouth MatNeoSip group, WT & Flavour Vapour supplier. Collaborating with UHP colleagues, we found using LifeQi alerted our joint services to the gaps in support for women and staff. WT learned that advertising a new offer is a challenge. LSW Comms were busy during 2020 due to the COVID-19 pandemic with less time to promote. UHP/WT staff had few face-to-face appts to give out posters/leaflets.

WT had less contact with staff to promote the offer. Overall small number of quitters, but almost doubled each quarter compared to 2019-20. Over half have quit on a vape only so far.

Special thanks to MatNeoSip Team, Melanie Edwards, Jacqui Connell and Lisa Hoskins (WT)

02790 - A1 Help with Health QI Poster FINAL.indd 1

18/05/2021 09:27

th 16

June 2021

Poster Competition Group B

Medicines Management (1)

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

Presenter: Dr Jerome Ling Swansea Bay University Health Board Second Prize: Antimicrobial stewardship: improving antibiotic prescribing practice in COVID-19 patients Presenter: Dr Jessica Michael North Bristol NHS Trust

Gentamicin prescribing at a tertiary surgical centre: are we achieving proper Dr Jerome Ling & Dr Damien Drury usage?

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

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

Methods • Data collected over 5 time periods in early 2021 on all general surgical wards at a tertiary surgical centre • Drug charts where once daily gentamicin had been prescribed and dispensed at least once were included • Assessed to ascertain if; 1)Dispensing time was documented for each dose of gentamicin given 2)Appropriate gentamicin serum level monitoring was performed

Initial Results 317 drug charts initially assessed; 54 suitable for inclusion.

65% (N=35) had the dispensing times documented for all doses of gentamicin, 80% (N=43) had appropriate gentamicin serum-levels..

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

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

With all times noted Without all times noted

Fig. 1

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

Improvement The documentation of dispensing time for gentamicin was improved by 19%. A relationship was found between all dispensing times being noted and a higher proportion of those patients having correct gentamicin serum-level monitoring.

Subsequently, there was also an improvement in the number of patients receiving appropriate serum-level monitoring of 6%. The eye-catching sticker, placed in a very visible and relevant location has shown to be an effective and simple intervention in improving patient safety.

Antimicrobial stewardship: improving antibiotic prescribing practice in COVID-19 patients R. Scott, J. Michael, O. Martin, C. Sluman North Bristol NHS Trust

INTRODUCTION Anti-microbial stewardship is an organisational approach to promoting and monitoring judicious use of antimicrobials, to preserve their future effectiveness.[1] Managing respiratory infections during the COVID-19 pandemic has often involved diagnostic uncertainty with antibiotics frequently commenced whilst awaiting PCR results.

The potential benefits of early introduction of broad spectrum antibiotics must be balanced against the risks associated with their overuse.

Data collection 1

Intervention 1: Junior doctor teaching sessions

Data collection 2 Intervention 2: Educational posters

Data collection 3 Intervention 3: Antibiotic review stickers on drug charts

Data collection 4

RESULTS • Overall reduction in percentage of inappropriately long antibiotic prescriptions from 38% to 33% • There 6 C. difficile cases prior to interventions, all in patients with inappropriately long antibiotic prescriptions. None were recorded post-intervention.

DISCUSSION General Challenges:

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

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

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

Figure 1: Antibiotic review stickers used in Intervention 3 summarising NBT guidelines: 48 hour review of antibiotics prescribed for COVID-19 Antibiotics can be safely stopped in COVID-19 if patients have: • A positive COVID-19 PCR result • Symptoms and blood results (e.g. lymphopenia) consistent with COVID-19 • Chest X-ray or CT scan consistent with COVID-19 • Negative urine antigens, blood cultures or sputum samples/cultures

Prescriptions exceeding 48 hours in the absence of a neutrophilia, radiological changes in keeping with bacterial infection or positive cultures were considered inappropriately long.

METHOD

•The unpredictable nature of the COVID-19 pandemic - ward closures, changes in population size and quarantining all disrupted data collection •Interventions 2 and 3 limited by small sample size due to reduction in COVID-19 patient numbers.

Intervention 1

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

64%

55% 45% 36%

34% 20%

WARD 28A

WARD 28B

35%

24%

WARD 9B

WARD 26B

Before teaching sessions After teaching sessions

Intervention 2 • Reduction in inappropriately long prescriptions from 35% to 25%.

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

28A % of prescriptions Continued over 48hrs Inappropriately (Intervention 2)

• Only showed a positive impact on wards where the entire junior team attended teaching (28A and 28B) • Adverse timing of data collection prior to junior doctor rotation and the Christmas holidays may have contributed to the negative impact seen on Ward 9B and 26B. • Consultants not included in teaching.

Some juniors were hesitant to challenge seniors’ prescribing.

Intervention 3 : • Reduction in inappropriately long prescriptions from 30% to 23% 27B % of Prescriptions Continued over 48hrs Inappropriately (Intervention 3)

30%

35%

23%

25%

BEFORE POSTERS

AFTER POSTERS

BEFORE DRUG CHART STICKERS

AFTER DRUG CHART STICKERS

Future impact: Data presented to microbiology team to guide management in future COVID-19 waves: 1.Drug chart stickers to be rolled out by antimicrobial pharmacist 2.NBT guidance on stopping antibiotics in COVID-19 to be simplified for clarity

• • •

•

Data was collected on 238 COVID-19 patients across 5 wards between November 2020 and March 2021.

Drugs charts were reviewed for antibiotic duration.

Patient investigations available at 48hrs, (including neutrophil count, cultures and chest imaging) were reviewed.

Incidence of C. difficile infections recorded.

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

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

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

Dr Henry Tyzack-Clark & Dr Rhys Andrews; Princess of Wales Hospital, Bridgend

INTRODUCTION: The increased risk of thrombotic events in COVID-19 are associated with adverse clinical outcomes. For patients with COVID-19, current local trust guidelines mandate the routine prescription of low molecular weight Heparin (LMWH) for venous thromboembolism (VTE) prophylaxis. The prescribed dose is calculated using patient body weight, clotting risk factors and renal function. Frequently, body weight is often predicted at the bedside or reported by the patient, rather than obtained accurately with weighing scales.

This quality improvement project aims to increase the accurate measurement of patient body weight, to justify the safe, efficacious dosing of VTE prophylaxis for patients with COVID-19 pneumonitis.

PRE-INTERVENTION AND PDSA CYCLE 1: ‘The poster’: In our pre-intervention cycle, the number of patients prescribed ‘standard’ or ‘enhanced’ regimes according to a documented body weight were recorded.

Our preintervention audit of the ward sample identified only 45% of patients (n=5) with a documented weight against their LMWH prescription.

The first PDSA cycle introduced a poster (Figure 1) to advocate the importance of accurately dosed VTE prophylaxis. This included the trust guidelines for ‘enhanced’ and ‘standard’ doses, to be displayed in the treatment room.

Following the first PDSA cycle, 50% of drug charts displayed a weight (n=7) at 7 days post-intervention.

Over a five-week period, our single ward-based study monitored the number of patients with COVID-19 pneumonitis, prescribed LMWH according to either 'standard' or 'enhanced' dosage protocol, dependent upon infection severity and individual clotting risks. Drug charts and notes were inspected for a documented body weight obtained during the current admission. Patients receiving oral anticoagulation or 'therapeutic' LMWH for suspected or confirmed VTE were excluded.

Figure 1 (right): The poster introduced during the first quality improvement cycle.

PDSA CYCLE 2: ‘The inventory check’: The second PDSA cycle undertook an inventory and maintenance check of the equipment necessary for weighing patients.

During the second PDSA cycle, we identified that all the available ward electronic scales were presently non-functioning. This equipment was replaced during the cycle. Subsequently, at 7 days post-second PDSA cycle initiation, 79% of patients had a documented weight (n=11) against their LMWH prescription (Figure 2).

CONCLUSIONS: It is commonplace for a patient’s accurate bodyweight to be overlooked during the prescription of Heparin for VTE prophylaxis during admission. Not only is this fundamental to the safety of the prescription in accordance with the patient’s creatine clearance, but also the efficacy of the dose in offering adequate prophylaxis during acute COVID-19 illness.

Figure 2: Chronological results of the quality improvement project, as measured by the number of ward patients prescribed VTE prophylaxis with a documented bodyweight during their admission throughout cycles 1 and 2.

Conclusively, this project aimed to safeguard the dosing of anticoagulation for COVID-19 patients. We highlighted simple environmental adjustments that can support accurate prescribing, whilst reaffirming the important clinical utility of body weight.

Introduction

• Pain is a very common presentation in surgical patients.

• Management often varies from one patient to another, and the WHO analgesia ladder is widely used to guide clinicians in decision making.

Improve compliance to the WHO analgesic ladder Reduce the risk of opioid toxicity and side effects of analgesia for patients

Aims and Objectives

Improve use of pain scale on the ward Improve awareness of analgesia prescribing and poly-pharmacy Improve multidisciplinary input in optimisation of analgesia for patients

1

2

Accurate and comprehensive medicine reconciliation of patient’s analgesia during admission

Regular departmental teaching on effective analgesia prescribing practice

Interventions 3

4

5

Encourage clinicians and nursing staff to use pain scales on the ward

Early involvement of the pain team in management of complex case

Review polypharmacy of analgesia with the ward pharmacist

Results

• 164 patients were included in the project over a duration of 4 months.

• Over 80% of patients engaged in the use of pain chart, and 57% said that this has helped with their symptom control.

• We noted significant improvement in analgesia prescribing practice.

100

Dec 2019 Feb 2020 April 2020

90 80

% of patients

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Use of strong opioid

Strong opioid as first line agent

Conclusion

• Compliance to the WHO analgesia ladder can be easily improved.

• Involvement of various members of the multidisciplinary team boosted this effort.

• The pain team is a valuable resource that may sometimes be under-utilised by clinicians, especially in complicated cases where titration of analgesia, including opioids, has proven difficult.

Improving the Management of Hypoglycaemic Episodes in Secondary Care Royal Hampshire County Hospital (RHCH) Authors: Dr S Daniel-Papi, Dr V Smith, Dr E Baldwin, Dr H Sheppard, Dr T Nyoni, Dr M Parsad

Background • • •

Documentation – Template

Hypoglycaemia is a common complication of diabetic treatment, defined as a blood glucose <4.0 mmol/L in diabetic patients.

Can result in a range of symptoms including confusion, coma and seizures; prolonged episodes can result in permanent neurological deficits.

Increases length of hospital stay, morbidity and mortality.

•

A hypoglycaemic event template has been introduced to aid adherence to hospital treatment protocol.

Introduction • •

Clinical management of hypoglycaemia needs to meet hospital protocol criteria to minimise harm to the patient.

Previous audits have highlighted particularly poor management and documentation of hypoglycaemic episodes.

Aims

Interventions

Primary Aim: 100% of hypoglycaemic events being managed in accordance to local guidelines.

Secondary aims:

1) Raising awareness of the hypoglycaemic event template • Posters in treatment rooms and posted online • Email to matrons regarding hypoglycaemic template • Reminder to use hypoglycaemia template on hypoglycaemic boxes 2) Healthcare staff education on the management of hypoglycaemia • Group sessions on wards • Foundation year doctors’ teaching • Departmental meeting presentations • ‘Safe use of insulin’ e-learning

Approved treatment

Use of the hypoglycaemic event template

Type of treatment

Medication review

Recheck of blood glucose 15 minutes after treatment

Results

Methods • • • • • •

Approved Treatment

Both cycles of this closed loop audit were retrospective cohort studies.

First cycle: 6 week period (16/09/19-28/10/19) at RHCH with 88 patients.

Second cycle: 8 week period (16/11/20-12/01/21) at RHCH with 129 patients.

More patients were identified during both cycles but lacked patient ID, therefore were not able to be used for data collection.

Systematic selection of all hypoglycaemic episodes over the selected period (cases initially identified from centralised glucose meter reports).

Further information gathered from: patient notes, inpatient blood glucose charts, ePrescribing (JAC) and clinical noting.

Inclusion Criteria

Exclusion Criteria

CBG <4.0mmol/L in diabetic patients CBG <3.0mmol/L in non-diabetic patients

Maternity unit CBGs

≥18 years of age

Emergency department CBGs

Medical or surgical inpatient at RHCH

Local Guidelines Conclusion

• • •

Overall, in cycle one, 31% of hypoglycaemic episodes were treated as per hospital protocol and 34% in cycle two.

With the use of the hypoglycaemic template, 78% in cycle one and 100% in cycle two of hypoglycaemic episodes were treated according to hospital guidelines; compared to 24% in cycle one and 39% in cycle two if the template was not used.

In cycle two, blood sugars were always rechecked 15 minutes after treatment for a hypoglycaemic event if template used, compared to 30% if it was not used.

Conclusion • • •

The second audit cycle showed a slight improvement in hypoglycaemic management at RHCH (31%à34%).

The use of the hypoglycaemic template has proven to be even more effective in the re-audit (78%à100%).

Results illustrate the poor adherence to local guidelines in regards to treatment of hypoglycaemia, however they also illustrate that the use of a convenient and userfriendly template massively increased correct management of hypoglycaemic events.

Limitations • • •

Based on Joint British Diabetes Society (JBDS) guidelines

Excluded paediatric, maternal and emergency department hypoglycaemic events.

Significant proportion of patients had no patient ID therefore we could not analysis.

Analysis of medication changes was only possible if diabetic medications were changed or stopped, not if they were suspended looking retrospectively through the ePrescribing system.

Tackling Hyperglycaemia in Dexamethasone treated COVID patients: Part of the problem, even bigger part of the solution Murshed M, Abraham S, Memon M, Nixon J Department of Diabetes and Endocrinology, Nottingham City Hospital Nottingham University Hospitals NHS Trust

Introduction

90

• Dexamethasone therapy has demonstrated reduction in mortality of patients suffering from COVID-19 infection with oxygen requirements.

• Combining corticosteroid use with insulin resistance linked to COVID-19, leads to acute hyperglycaemic events, DKA and HHS in both diabetic and non-diabetic populace, respectively.

• Guidelines by the Diabetes UK and National Inpatient Diabetes COVID-19 Response Group explain how hyperglycemia in these situations should be managed.

Results

100

80

Glucose monitoring completed appropriately after commencing Dexamethasone First 48 hours

• A third of the patient cohort had their blood sugars checked significantly less frequently than the recommended 6 hourly checks in the first 2 days of treatment.

• 60% of patients with hyperglycaemia as a result of steroid therapy did not receive appropriate treatment to correct this • A total of 52% were not started on appropriate maintenance therapy following the episode of hyperglycemia

After 48 hours

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Interventions

Aims • To audit the current management of hyperglycaemic events secondary to dexamethasone in the setting of COVID19 in inpatients wards • To devise simple solutions for more widespread implementation of COVID: Diabetes guidelines • To encourage awareness among healthcare professionals of the importance of adherence to it.

• Posters with flowchart simplifying guideline put up in all inpatient wards • Management prompt circulated among juniors via hospital WhatsApp groups and emails • Covid19 ward managers made aware of the prompts for dissemination among nursing staff

Methodology

Lessons Learnt Managing acute hyperglycemia

• Source of Data: Notes and drug charts of inpatients over the age of 18 with COVID 19 infection, receiving dexamethasone • Sample size: 30 patients • Duration of study: 1 month (January 2021) • Data collection: • Frequency and timing of blood sugar monitoring • Immediate action and long term action in response to episodes of hyperglycaemia compiled with excel.

• Data Analysis: Assessed frequency of errors and most common steps where they were encountered

• We recognised that as junior doctors and nurses without a background in respiratory or diabetes specialities looking after COVID19 patients, the significant gap in knowledge of monitoring and management of hyperglycaemia in these patients was due to a lack of awareness of current guidelines and the fact that they were not easily accessible.

• The prompt we created bridged the gap noted in our data analysis and guide appropriate treatment accordingly.

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47 Not checked/given 0

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References 1.Diabetes UK and National Inpatient Diabetes COVID-19 Response Group 2. Dexamethasone therapy in COVID-19 patients: implications and guidance for the management of blood glucose in people with and without diabetes. Diabet Med. 2021 Jan;38(1):e14378. doi: 10.1111/dme.14378. Epub 2020 Sep 21 3. Corticosteroid-related In-Hospital Hyperglycemia: Does It Negate Mortality Benefits in Coronavirus Disease 2019?, Clinical Infectious Diseases, 2020;, ciaa1423

‘Diabetes and Dialysis- Don’t sugar coat it!’

How to improve patient safety by improving diabetes management in dialysis patients Dr Nadia Osman, Dr Jessica Matthews, Dr Jyoti Baharani Department of Renal Medicine, Heartlands Hospital, Birmingham

Introduction and Aims There is a clear link between poor diabetic control and worsening morbidity and mortality in dialysis patients.

• Survival on dialysis in patients with diabetes is about half that of their non-diabetic peers (3.7 vs. 7 years)1.

• JBDS-IP2 suggested that each diabetic dialysis patient should have access to a link dialysis nurse responsible for coordinating monitoring of diabetic complications as well as escalating when appropriate.

To do this, it is clear that dialysis nurses must have a level of diabetic monitoring and management knowledge.

Thus, the aim of this QIP was to: • Improve this knowledge • Improve diabetic care • hopefully make an impact on the significant morbidity and mortality associated with diabetic dialysis patients.

Fig 2: Education poster designed to improve knowledge within the dialysis areas of Heartlands Hospital.

Project Results Pre session questionnaire 19 nurses participated with varying experience in haemodialysis from 5 months to over 20 years.

Confidence pre interventions - Average of 5.6 on a scale of 110, where 10 was the most confident.

Knowledge pre intervention - Average of 45% correct answers.

Post session questionnaire 11 nurses participated over 2 small group sessions.

Overall confidence increased to an average of 9.6 on scale of 1-10, where 10 was the most confident.

Knowledge post intervention - Average of 81.25% correct answers.

Fig 1: JBDS-IP ‘Management of adults with diabetes on the haemodialysis unit’ Knowledge

Post interevention

Project Methodology An online questionnaire was sent to all dialysis nurses to assess knowledge of monitoring requirements and complications as well as their confidence in applying this knowledge. Following this, diabetes teaching sessions were designed, focusing on areas that were less well known about according to questionnaire results.

Education Actions (with adaptations due to COVID-19 pandemic): 1. Small group teaching sessions were conducted to enable social distancing.

2. Posters were placed in dialysis areas.

3. Questionnaires were done online.

4. It was also seen as particularly important from a safety point of view to teach about diabetes management at this time as diabetic CNS's were offering advice over the phone to mitigate COVID risk rather than physically reviewing patients and a lot more responsibility was on dialysis nurses to manage and escalate diabetic complications.

Prior to intervention Confidence

0

Fig 3: Years experience of the nurses participating in the project

20

40 60 Percentage

80

100

Fig 4: Comparison of knowledge and confidence prior to and post intervention.

Learning points • Dialysis nurses felt very under confident regarding diabetes management and this was reflected in the pre-intervention knowledge and confidence scores.

• With very limited intervention, knowledge and confidence significantly increased.

Feedback suggested that dialysis nurses felt they received very little teaching generally and from a safety point of view, felt that more short teaching sessions on a regular basis would benefit them hugely both in confidence and knowledge.

This was fed back to their manager and teaching schedules were being discussed in order to provide a regular programme.

Why so high?

COVID-19, Dexamethasone, and Blood Glucose Management:

A Quality Improvement Project

Ben Ivry1, Emily Harrison1, Nwe-Ni Aung1, MG Masding1.

1

Poole General Hospital, University Hospitals Dorset NHS Foundation Trust Introduction

Evidence from the RECOVERY trial has shown that dexamethasone has a role reducing mortality with COVID-19 in patients requiring ventilation or oxygen therapy.

However, there is growing concern about the link between COVID-19 infection and insulin resistance in both diabetic and non-diabetic patients.

Combined with steroid use, patients are at significant risk of hyperglycaemia and even DKA. There has been an observable associated increased risk of mortality in such patient groups.

This has led to guidance from Diabetes UK and the Association of British Clinical Diabetologists in managing such patients and their blood glucose levels.

This QIP was designed to measure any improvement in blood glucose management for COVID-19 positive patients in Poole General Hospital with the introduction of a local policy based on national guidance.

Diagrams

Discussion We have shown that blood glucose monitoring in COVID-positive patients has improved with the introduction of this QIP chart. Although 50% of the latter monitoring was performed on the pre-existing charts.

There is also a relatively higher level of its use on the ward with the highest number of COVID positive patients.

We considered that wards caring for COVID patients more often become more familiar with the chart. Conversely, if staff encounter fewer COVID patients on their wards, chart awareness and use falls as well

A B

Numbers of inpatients with COVID have fallen considerably with the advent of vaccination. Whilst desirable, it naturally has limited the appropriateness of a reaudit at present.

Frequency of blood glucose monitoring in COVID patients 80%

We will be prepared to roll out further changes and re-educate staff if and when COVID admissions increase again.

70%

Aim

60%

50%

To ensure that all patients on high dose glucocorticoid regimens receive appropriate glucose surveillance and appropriate management of hyperglycaemia.

Recommendations

40%

Our next steps in this QIP are: • Improving awareness with posters and screensavers •Collecting qualitative feedback on the chart layout •Proposing such changes to the trust and publishing an updated version • Offer teaching sessions on chart use to ward teams when a rise in admissions is anticipated.

30%

20%

10%

Method An audit of 20 randomly selected patients in October was performed. Inclusion criteria were being COVID-19 positive and having received dexamethasone. Exclusion criteria were admission to intensive care and death.

We recorded whether this group had their blood glucose levels monitored, and if so, whether it was monitored at the frequency advised from national guidance.

A new chart based on national guidance was published locally on the 30th October 2020 (see image). We repeated the audit for another 20 randomly selected patients who met the criteria above, and compared the two data sets.

0% Oct-20 Comparison: COVID patients and QIP chart use on wards (Nov-20) Nov-20

25

20

References

15

QIP chart

10

Patients

5

0 A4

Lytchett

Stroke Rehab Kimmeridge

C4E

https://abcd.care/resource/concise-adviceinpatient-diabetes-during-covid-19-guidancemanaging-inpatient https://www.recoverytrial.net/files/recovery _dexamethasone_statement_160620_v2final .pdf https://www.nice.org.uk/guidance/ng191

MITS: Making Insulin Treatment Safer at Weston General Hospital - An MDT approach to improving inpatient diabetes care

Dr Rebecca Jordan (FY2) and Sarah Karthauser (Deputy Lead Pharmacist and MSO)

Foundation Doctor Survey Foundation doctors were invited to complete a survey to determine their confidence with insulin prescribing: 1. How confident do you feel prescribing insulin on the wards?

Average : 52% confident

2. Do you feel confident managing diabetic emergencies on the ward?

Average : 59% confident

3. Do you re-check patients' blood

sugars after prescribing insulin during an on-call? (i.e. do you seek out patient's results the next day to learn whether what you prescribed was correct)

4. Would you like to have more teaching on insulin prescribing?

Yes No

MITS at Weston General Background 1. Multiple insulin prescription errors were identified by the pharmacists and diabetic nurses at Weston General.

2. These errors were raised at the Foundation teaching sessions and a number of junior doctors disclosed that they did not feel confident prescribing insulin.

3. We conducted a survey of the foundation doctors which determined that only 52% of juniors felt confident prescribing insulin.

4. Following from the results of the survey, it was identified that more formal insulin prescription training was needed for juniors in Weston General.

5. Following discussion with pharmacists, nurses and doctors, we determined that to improve insulin prescription support for juniors, we needed a strong MDT approach. We decided that the MITS scheme in Belfast would best meet these needs.

What is the MITS scheme?

Insulin prescribing errors are extremely common. 40% of inpatients on insulin have an insulin-related prescription error according to the National Diabetes Inpatient Audit England, 2019.(1) MITS - Making Insulin Treatment Safer, was set up by Queens University Belfast (QUB) to help tackle this issue. (2) The MITS scheme trains up senior members of staff to facilitate case-based discussions (CBDs) regarding insulin prescriptions with junior prescribers. The CBDs enable junior staff to reflect upon their prescribing and sign-post them towards prescription support. The MITS team in Belfast won The Royal College of Physicians 2018 Education Award for Excellence in Patient Care.(3) We worked with the MITS team from QUB to deliver their award-winning training programme in Weston General in March 2020.

Aims

Primary aim: Encourage an MDT approach to increase support for juniors prescribing insulin.

Secondary aim: Decrease rates of insulin prescription errors.

MITS proforma for recording CBD

MITS Training Two members of the MITS team who are former diabetic specialist nurses came to train 23 senior staff members at Weston General on 5th March 2020. There were two half-day sessions for staff members including Pharmacists, Nurses, Physician Associates and Doctors. The training involved lectures, group-work and role-plays.

Why an MDT Approach?

• Many different healthcare professionals have specialist knowledge surrounding management of diabetic patients.

• An MDT approach to teaching enables a more nuanced understanding of insulin prescribing.

• An MDT approach will optimise use of specialist knowledge and better educate and support junior doctors prescribing insulin.

MITS CBDs

After successfully completing their training, staff received a certificate and became trained ‘MITS debriefers’. The MITS debriefers were asked to record CBDs in a MITS proforma as well as in the junior’s eportfolio.

Unfortunately, due to Covid-19 and the closure of Weston General there was a delay in commencing the Case Based Discussions.

However, debriefers were sent example videos and materials from the course. Refresher courses were provided on request. Posters advertising MITS were put in the Juniors’ Mess and reminder emails sent. Some of the MITS debriefers have now moved hospitals however, many are now facilitating remote CBDs.

Summary Insulin prescription errors are common. Junior doctors often feel under-confident and under-supported when prescribing insulin.

Weston General is the first English hospital to be involved in the MITS scheme which aims to tackle high rates of insulin prescription errors and empower junior prescribers using an MDT approach.

References: (1) National Diabetes Inpatient Audit England 2019 page 5 https://files.digital.nhs.uk/F6/49FA05/NaDIA%202019%20-%20Full%20Report%20v1.1.pdf (2) Making Insulin Treatment Safer website http://www.med.qub.ac.uk/mits/ (3) Royal College of Physicians London website https://www.rcplondon.ac.uk/about-rcp/whos-who/people/making-insulin-treatment-safer

Introducing a Standardised Approach for the Treatment of Paracetamol Overdose at Weston General Hospital Ben Stainer, Natasha Howes, Waseem Said, Tariq Memon, Irfan Khan

Introduction

Paracetamol overdose is the commonest form of selfpoisoning in developed countries and is treated with the antidote N-Acetylcysteine (NAC). TOXBASE lists two different regimens for NAC administration; a conventional 3-bag regimen over 21 hours, and a modified 2-bag regimen over 12 hours[1].

Weston General Hospital (WGH) guidelines recommended use of the 3-bag NAC regimen. However, following a merger with Bristol Royal Infirmary who utilised the 2-bag NAC regimen, there was significant confusion amongst junior doctors about which protocol to follow.

3-Bag Regimen

2-Bag Regimen

50mg/kg over 4 hours

150mg/kg over 1 hour

100mg/kg over 2 hours

100mg/kg over 16 hours

200mg/kg over 10 hours

Aim

Results

The initial audit demonstrated that 97% of patients admitted with paracetamol overdose received the 3-bag NAC regimen.

The median length of patient stay was 28 hours, and one patient experienced an adverse reaction resulting in the cessation of NAC treatment.

Following implementation of the 2-bag NAC protocol, a reaudit demonstrated that 74% of patients received the 2-bag NAC regimen. The median length of stay decreased by 2 hours to 26 hours, and no patients experienced an adverse reaction to NAC. Patients Receiving 3-Bag Versus 2-Bag NAC Regimens 100% 80%

40% 20% 0%

3-Bag Regimen Baseline Audit

Repeat Audit

30

Hours

Baseline audit: a retrospective audit of the notes of patients receiving NAC treatment between May 2018 and May 2020 Intervention: a 2-bag NAC protocol designed and implemented by WGH Emergency Department Repeat audit: a retrospective audit of the notes of patients receiving NAC treatment between June 2020 and March 2021

2-Bag Regimen

Median Length of Patient Stay

Method

Repeat Audit

Baseline Audit

Adverse Reaction Complications

No Adverse Reaction No Complications

Conclusion

60%

The aim of this project was to assess the use of 2-bag versus 3-bag NAC regimens, including length of patient stay and side effect profiles, to facilitate the introduction of a standardised approach to treatment of paracetamol overdose at WGH.

Results

Incidence of Adverse Reactions

28

This project demonstrates that: • The 2-bag NAC protocol has been effectively implemented at WGH, with the capacity for further improvement to achieve standardised care • The implementation of a 2-bag NAC protocol can be reliably justified due to the associated reduction in length of patient stay coupled with a reduction in the incidence of adverse reactions Our findings echo those of a number of recent studies comparing 2-bag versus 3-bag NAC regimens[2-3].

Recommendations

26

24

Baseline Audit

References

Repeat Audit

The next steps following on from this project include: • Ongoing efforts to raise awareness of and educate junior doctors about the 2-bag NAC protocol • A repeat audit with a larger sample size to assess for further improvement

1. TOXBASE. Paracetamol. [internet]. 2017 [cited 2020 Oct 1]. Available from: https://www.toxbase.org/poisons-index-a-z/p-products/paracetamol------------/. 2. Pettie JM, Caparrotta TM, Hunter RW, Morrison EE, Wood DM, Dargan PI, et al. Safety and efficacy of the SNAP 12-hour acetylcysteine regimen for the treatment of paracetamol overdose. EClin Med. 2019; 11: 11-17. 3. Wong A, Isbister G, McNulty R, Isoardi K, Harris K, Chiew A, et al. Efficacy of a two bag acetylcysteine regimen to treat paracetamol overdose (2NAC study). EClin Med. 2020; 20.

th 16

June 2021

Poster Competition Group C

Medicines Management (2) First prize: In The NAC of Time, Reducing Length of Stay (LOS), freeing up inpatient beds during COVID, with SNAP 12hr paracetamol overdose regime.

Presenters: Paul Flattery, Beatrice Bertolusso Organisation: Hampshire Hospital NHS Foundation Trust Second Prize: Improving the co-prescription rate of DOACs and PPIs Presenter: Dr Kaveh Davoudi Organisation: Taunton Vale Healthcare

Risk assessment for initiation of anticoagulation

by ED for patients with a new diagnosis of Atrial Fibrillation Thivanka Witharana, Viacheslav Koshonko

Thivanka Witharana Colchester General

Hospital, ESNEFT Email: thivanka_witharana@h otmail.co.uk

Atrial fibrillation (AF) is the most common clinically significant arrhythmia1. Around 1.2 million people in the UK have AF2. It increases the risk of getting a stroke 5 fold2. NICE and local guidelines recommend the use of CHA2DS2VASc and HASBLED scores to risk assess initiation of anticoagulants in patients with AF3,4. A local audit carried out from August-November 2019 showed poor adherence to these guidelines with only 9% of eligible patients having evidence of CHA2DS2VASc and HASBLED scores calculated

Aims

REFERENCES 1.

2.

3.

4.

Morillo, C., Banerjee, A., Perel, P., Wood, D. and Jouven, X., 2017. Atrial fibrillation: the current epidemic. Journal of geriatric cardiology, [online] 14(3). Available at: <https://www.ncbi.nlm. nih.gov/pmc/articles/P MC5460066/> Stroke Association.

2021. Atrial fibrillation (AF) and stroke. [online] Available at: <https://www.stroke.or g.uk/resources/atrialfibrillation-af-and-stroke Nice.org.uk.

2021. Overview | Atrial fibrillation: management | Guidance | NICE. [online] Available at: <https://www.nice.org. uk/guidance/CG180> [Accessed 27 February 2021].

ESNEFT Colchester General Hospital, 2016. Management of Atrial Fibrillation in the Emergency Department.

Colchester.

Methods

INTRODUCTION

Primary: To ensure that at least 50% of eligible patients with a new diagnosis of AF are risk assessed for the initiation of anticoagulants prior to discharge from A+E in the next 3 months Secondary: To ensure that at least 50% of eligible patients with a new diagnosis of AF are referred to the AF clinic on discharge from A+E in the next 3 months

METHODS A+E clerking proforma was updated to include CHA2DS2VASc and HASBLED scores as a prompt from 1st of July 2020. An audit was then carried out 3 months later.

Criteria

Target

Exceptions

Source of evidence

All patients with new onset AF should have CHA2DS2VASc and HASBLED scores calculated during clerking

50%

Already on anticoagulants for other indications

Local policy

All patients with new onset AF should be referred to AF clinic

50%

Exclusion criteria for AF clinic referral

Local policy

Results 50%

Percentage meeting criteria

CONTACT

45%

40%

35%

30%

Prior to intervention

25%

Post intervention

20%

15%

10%

5%

Criteria

0%

Calculation of CHA2DS2VASc and HASBLED scores

AF clinic referrals

Conclusion Results 37 patients identified

15 excluded 14 – known AF 1 – admitted

22 final sample

CHA2DS2VASc and HASBLED scores were calculated in 36% of the participants. In all these cases, anticoagulants were initiated appropriately as indicated by the scores.

AF clinic referrals were appropriately made in 32% of the participants.

Although our target of 50% was not met, there was a 4-fold increase in calculation of CHA2DS2VASc/HASBLED scores for patients with a new diagnosis of AF. There was a decrease however in AF clinic referrals, which can be explained by lack of education. As there is scope for improvement, we proposed a second intervention of education for A+E doctors on AF guidelines with a plan for re audit after 3 months.

Oxygen: To prescribe, or not to prescribe, that is the question Dr Ewen Fraser, FY2

Introduction

Methods

• Hypoxaemia is a common sequela of respiratory conditions.

• Accurate documentation of target saturations is a key element in delivering safe care to patients.

• The COVID-19 pandemic has highlighted the importance of this in patient management.

Initial data collection

Data analysis

guideline(1)

for • The British Thoracic Society (BTS) oxygen used in adults in healthcare and emergency settings states that oxygen should be prescribed, and a signature should be entered on the drug chart on each drug round.

• The BTS national oxygen audit in 2015(2) found that 42% of hospital patients using oxygen were doing so without an oxygen order.

Aims • To assess whether oxygen prescription had been carried out and if target oxygen saturations were documented.

Intervention

Second data collection

• February 2020 – data collected from all patients on the respiratory floor of Queen Elizabeth University Hospital (QEUH), Glasgow (n=112)

• Data audited against BTS guideline • Must meet inclusion criteria

• Teaching session to staff • Posters placed throughout the department

• May 2020 – further data collection (n=79)

• Findings presented to the department Analysis

Inclusion Criteria • Drug chart present at time of data collection.

• Space to document target oxygen saturations on drug chart

Results • Oxygen saturation documentation increased from 80.8% to 88.5% (% change = 9.5%) • Oxygen prescription rose from 7.9% to 27.3% (% change = 245%)

% Completion & % Change

250% 200% 150%

Conclusion

100%

• There was a considerable increase in the number of patients prescribed oxygen, however, not to the standards identified by the BTS

50% 0% Sats filled out Round 1

Oxygen prescribed Round 2 %Change

• The COVID-19 pandemic changed the way in which we practice and will have a lasting effect on oxygen prescription and target saturations

Figure 1. Oxygen data

References: 1. O’Driscoll BR, Howard LS, Earis J, Mak V. British Thoracic Society Guideline for oxygen use in adults in healthcare and emergency settings. BMJ Open Respir Res [Internet]. 2017 May 15;4(1):e000170. Available from: https://bmjopenrespres.bmj.com/lookup/doi/10.1136/bmjresp-2016-000170 2. O’Driscoll R. Emergency Oxygen Audit Report. 2015.

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

Aims

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

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

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

• To establish the co-prescription rate of DOACs and PPIs at the largest surgery within the Somerset CCG. • To get into the top 10% of the CCG surgeries with the target co-prescription rate of 80%.

• To ensure sustainability of any improvement achieved.

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

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

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

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

Oral Presentation EMIS Reminder 1

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

EMIS Reminder 2

Figure 2. illustrates the second EMIS reminder.

Figure 1. illustrates the first EMIS reminder.

Results

Conclusion

DOACs and PPI Co-therapy percentage 100 95 90 85 80

77%

75

65

80%

72%

70

65%

60 55 50

Baseline

Presentation

TVH

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

EMIS warning 1

CCG Target

EMIS warning 2

• Average number of patients in each cycle was 230 • Co-prescription rate increased from 65% to 80% over a 6 month period.

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

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

• We have liaised with the practice pharmacist to ensure continued monitoring of the co-therapy rate.

References

Safe Oxygen Prescribing at a London District General Hospital: A 3-Cycle Quality Improvement Project A. Brown1, K. Man1, F. Bakko1, L. Shabeer1, B. Lipfriend1, V. Parris1, 1London North West University Healthcare NHS Trust

Introduction Correct oxygen prescribing is essential to patient safety, however it is often poorly completed (Barrett, 2020). The British Thoracic Society (BTS) guidelines should be used to help prescribe oxygen and identify target saturations (O'Driscoll, 2017).

Oxygen prescribing has become paramount to patient safety during the COVID-19 pandemic in which we are seeing increased oxygen utilisation and high patient turnover. We therefore conducted a quality improvement project, at a London district general hospital, with the aim of improving oxygen prescribing practices, and in turn patient safety.

Prior to the first intervention, 32% of drug charts had incorrect oxygen prescriptions, with target saturations identified in 61%, and 81% of these identified correctly. The first intervention resulted in a 39% increase in recording of target saturations, of which 98% were correct. After the second intervention correct oxygen prescriptions were identified in 74%, of which correct target saturations were identified in 100% of cases.

Percentage of correct oxygen prescriptions before and after interventions 1 and 2 100%

100%

98% 100% 85%

80%

Aims • Analyse the proportion of patients with correctly prescribed oxygen • Highlight importance of accurate oxygen prescribing • Improve prescribing practices within multidisciplinary teams (MDTs) • Enhance patient safety

Drug charts of patients admitted to two acute medical wards during the COVID-19 pandemic were analysed over two days. The target saturations, initial oxygen, delivery device and flow, date, and signature were collated, then compared against British Thoracic Society (BTS) guidelines (O'Driscoll, et al 2017). Oxygen was considered incorrectly prescribed if: no attempt to prescribe oxygen had been made, target saturations were not given, initial flow or oxygen delivery device were missing, or if the prescription was not signed or dated. Drug charts of current inpatients were re-analysed, following each intervention.

Two interventions were carried out: 1. Importance of oxygen prescribing was highlighted at daily MDT meetings.

2. Junior doctors teaching session outlining BTS target saturation criteria, followed by posters detailing correct oxygen prescription on an example drug chart, and on the weekly hospital newsletter.

Results Correct oxygen Target prescriptions saturations (%) identified (%)

Target saturations identified correctly (%)

Pre-interventions (n=44)

32

61

81

Post Intervention 1 (n=48)

25

100

98

Post intervention 2 (n=54)

74

85

100

O2

61%

32% 25%

20% 0%

Methods

O2

74%

60% 40%

81%

Correct Oxygen Prescriptions (%)

Pre-Intervention

Target Saturations Identified (%)

Post-Intervention 1

Target Saturations Identified Correctly (%)

Post-Intervention 2

Figure 1: Bar chart comparing the percentage of correct oxygen prescriptions and target saturations of inpatient drug charts at: baseline (n=44); after the first intervention (n=48); and after the second intervention (n=54)

Discussion In the peak of the COVID-19 pandemic, accurate oxygen prescriptions and target saturations are essential to ensure early escalation for those who may require further intervention (i.e.

Optiflow and NIV) and avoid unnecessary days in hospital among patients with decreasing oxygen requirements. The low rates of correct oxygen prescriptions before the interventions could be due to several factors, perhaps even lack of awareness that every drug chart requires an oxygen prescription. The sudden deterioration seen in COVID patients may also mean that oxygen was administered prior to checking the drug chart to determine if the right device and flow is prescribed.

Limitations of this study include a small sample size and a singlecentre setting; future work could expand this research to other sites while simultaneously expanding the teaching interventions, to ensure accurate oxygen prescribing and to ultimately improve patient care.

Conclusion Oxygen prescribing improved following simple and cost-effective educational interventions. Further education and training is required across the MDT to ensure safe prescribing of oxygen is attained and maintained.

References • Barrett, R., Catangui, E. and Scott, R., 2020. Acute oxygen therapy: a cross-sectional study of prescribing practices at an English Hospital immediately before COVID-19 pandemic. Expert review of respiratory medicine, pp.1-8.

• O'Driscoll, B.R., Howard, L.S., Earis, J. and Mak, V., 2017. BTS guideline for oxygen use in adults in healthcare and emergency settings.

Thorax, 72(Suppl 1), pp.1-90.

Oxygen Prescribing and Venous Thromboembolism Prophylaxis in Intensive Care Vijayakumar Gopal, Sarah Leathem, Despoina Kitmiridou West Suffolk NHS Foundation Trust INTRODUCTION Oxygen (O2) and venous thromboembolism (VTE) prophylaxis ensure the safety of patients in hospital. Oxygen should be prescribed to achieve a patient-specific target saturation. (1) Over-oxygenation can lead to alveolar damage. (2) Proper prescription of oxygen ensures that what the patient receives is faithfully documented for the prescriber and administrator, minimising risk of harm. (1) The immobility of critically ill patients makes the importance of VTE prophylaxis paramount. (3). In the critical care setting basic factors may be overlooked during an emergency, particularly in view of non critical care experienced staff being deployed to a critical care setting during the pandemic. An electronic prescribing ‘bundle’ was implemented and studied, as well as the incidence of timely VTE prophylaxis prescription.

During August and September, 11.4% (4/35) and 8% (3/37) of patients had a recorded target saturation at 24 hours, with an improvement to 72% (26/36) after implementation of the bundle in October. The patients with an O2 prescription at 24 hours increased gradually over the course of the three months, indicating increased awareness among new staff : August 22.9% (8/35), September 62% - (23/37), October -72% (26/36).

Target Sats (%) 80%

60%

40%

METHODS A retrospective review was performed of patients admitted to the intensive care unit of a district general hospital, before and after the implementation of an electronic prescribing ‘bundle’, which aimed to ensure correct prescription of oxygen and target saturations on admission. The timeline of the study was 3 months with the bundle implemented at the end of month 2. A total of 108 patients records were analysed, the total number of admissions over a 3 month period to a 10 bed unit.

An electronic bundle was designed using Metavision (4) so that during admission of a patient the admitting clinician was reminded to prescribe O2, and in doing so it was a requirement to record a target saturation range for that patient. This intervention was applied on 05/10/20 and affected 30/36 admissions that month.

20%

0% August

O2 Prescription August

Although the study looked at prescription of both VTE prophylaxis and oxygen prescription, only oxygen prescription was included in the prescribing bundle.

There was a large improvement in the first objective, which elucidates how the bundle was moderately successful in achieving its aim. As a target of 100% was not reached in either measure, these outcomes will be re-analysed and any bundle modified accordingly.

Prescription of VTE prophylaxis showed some improvement over the first month with a subsequent small drop in the second: 82.8% (29/35) in August, 94.6% (35/37) in September and 91.7% (33/36) in October.

VTE prophylaxis August

VTE prophylaxis September

VTE prophylaxis October

2

O2 Prescription September

O2 Prescription October

28% 38% 62% 72%

77%

Y

CONCLUSIONS

October

23%

OBJECTIVES Prior to the development of the bundle, ensuring patient safety checks was all done on the ward round by clinicians in conjunction with pharmacists, however during the time of an overstretched unit and the practical and ethical dilemmas posed by the COVID-19 pandemic, it was decided to formally assess these two patient safety outcomes and implement a prescribing tool to minimise human error.

The first objective was to quantify the number of patients who received a formal O2 prescription within the first 24 hours of their admission to the intensive care unit and concomitantly whether they had a recorded target saturation on their electronic record. The aim was for 100% of patients to receive both of these targets. According to the British Thoracic Society guideline, the target saturation of Oxygen for each patient should be written on the drug chart or entered in an electronic prescribing system.(2) This was subsequently tracked over the course of three months to analyse whether the introduction of the e-prescribing bundle was useful in achieving that aim.

The second objective was more simply to quantify the number of patients who received a prescription for VTE prophylaxis within 24 hours of their admission within the same time frame, no intervention was added during this time.

September

N

Y

N

Y

N

These results show the efficacy of the introduction of an electronic feature to avoid human error in prescriptions. Even with the huge improvement in O2 prescription and recording of target saturations, these parameters still do not meet the aim of 100%. VTE prophylaxis prescription improved slightly from August to September, with a drop in October and similarly did not reach 100%. These results show the need for increased awareness among staff, especially new members and a further audit cycle following implementation of a bundle which includes VTE prescription to ensure improvement. They also highlight the importance of utilizing features of newly introduced electronic systems, to improve care and increase patient safety. It is important to note that with the combination of the annual changeover period and the COVID-19 pandemic, which hailed the most difficult time in the lives of intensive care staff all over the world, all the hard work of any kind put into patient safety is greatly appreciated.

REFERENCES 1. O’Driscoll, B., Howard, L., Earis, J. and Mak, V., 2017. BTS guideline for oxygen use in adults in healthcare and emergency settings. Thorax, 72(Suppl 1), pp.ii1ii90.

2. Ohshimo, S., 2021. Oxygen administration for patients with ARDS. Journal of Intensive Care, 9(1), pp.1-14.

3. Hill, J. and Treasure, T., 2010. Reducing the risk of venous thromboembolism (deep vein thrombosis and pulmonary embolism) in patients admitted to hospital: summary of the NICE guideline. Heart, 96(11), pp.879-882.

4. 2017. Metavision. Dusseldorf: iMDsoft.

CONTACT Dr Sarah Leathem FY1 sarah.leathem@wsh.nhs.uk Dr Despoina Kitmiridou FY2 despoina.kitmiridou1@nhs.net

3

6

ACKNOWLEDGEMENTS 29

Y

RESEARCH POSTER PRESENTATION DESIGN © 2019

www.PosterPresentations.com

N

33

35

Y

N

Y

N

Supervisor – Dr V Gopal WSH anaesthetics clinical director Special thanks to Sue Southwood and Hayley Gilbrook WSH ITU Clinical Governance

IN THE NAC OF TIME

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

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

WHY?

• Paracetamol is the UK’s most common overdose drug, approx.

100,000 presentations to ED’s yearly(1).

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

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

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

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

12hr SNAP PROTOCOL

Aim

D P D A S

P

S

PDSA cycles 1

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

2

education plus protocol implementation for the 12hr SNAP regime.

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

• 60% of patients had at least 1 problem with management • Mean LOS in hospital 36.10 hrs

Results

• Our average LOS reduced from 36.10hr to 23.57hr, this saved 194.44 inpatient hours (8 bed days) • Presentations with ≥1 management problem, reduced from 60% to 35% over our 5 month follow up.

LENGHT OF STAY (LOS)

Compliance with Paracetamol levels taken at 4 hours

A

80% 60% 40%

40%

54%

74.19 %

20% 0%

I N P A TI E T H O U R S

baseline

1

2

cycle 1

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

23.57hr 100%

95%

80%

36.1hr

33.09hr

cycle 2

60% 40% 20%

35%

58%

0% baseline

TIME

cycle 1

cycle 2

Discussion and Learning points 1. The LOS saved following cycle 2 is greater than simply completing NAC 9hr 3. The implementation of the 12hr SNAP regime demonstrated a quicker. This supports our theory that initial delays/errors with these presentations significant reduction in patient LOS were increasing patients LOS. This theory is further supported by the small 4. Our review was in-line with previous national audit 2013/2014 reduction in LOS seen following education alone after cycle 1. highlighting MHRA/TOXBASE guidance compliance to be as low as 75% (3).

2. With bloods often taken by junior nursing staff or healthcare assistants on Whilst our overall compliance never reached the same level, we feel the patient arrival we feel particularly proud of the impact our protocol and education improvements made in practice to be a significant improvement in patient drive has had across all the levels of the team in the emergency department. care.

References: (1) Park et al. Paracetamol poisoning. Systematic Review. BMJ Clinical Evidence Review. 2015 October. (2) Pettie et al. Safety and Efficacy of the SNAP 12hr N-acetylcysteine regime for treatment of paracetamol overdose. Lancet: EClinical Medicine. 11(2019)11–17. (3) National Report: College of Emergency Medicine. Paracetamol Overdose Clinical Audit 2013–2014.

Timely Care Pathways for Perioperative Anaphylaxis Dr Beth McElroy and Dr Kay Chidley

1 set of notes not be obtained so 12 0%

We looked at the following processes:

Pre-op risk assessment and consent

Care during the clinical incident

µg/L

75% Angio 12.5% -edema 0%

37.5%

37.5% 50%

87.5% 75%

Inc HR

Wheeze /AP

Rash

Hypotension

BP <50

Follow Up

12.5%

0%

(2019)

(2020)

37.5%

25%

SBP<50

SBP<50

2019

2020

100%

12.5% Local f/u 0%

100% 12.5%

100%

Pt letter

0%

GP letter

20%

25.0%

87.5% 100%

40%

87.5% 100%

80% 60%

100 50 0 1 2 3 4 5 6 7 8 A B C D Patients: 1-8 (2019), A-D (2020)

Given an agent they were known to be allergic to Severity of allergy documented Cases of surgery abandoned

• • •

Referral procedures followed

Allergy clinic follow-up and feedback

Patient satisfaction and understanding

1

0

(Chlorhexidine)

0%

0%

37.5%

25% 0

One night in ICU

37.5%

50%

Seen in allergy clinic

62.5%

25%

45 days

62 days

(16-365)

(covid related)

Average wait for immunology clinic Anaphylaxis confirmed

37.5% Chlorhexidine Teicoplanin Amoxicillin

Agents

Patient Feedback 2019:

Permanent communication channel set up with immunology clinic.

All feedback now returned to Anaesthetic Lead Consultant.

Anaesthetists encouraged to consent for peri-operative ‘allergy’ and document the severity of anaphylaxis.

Teaching regarding setting up an anaesthetic alert.

Tea trolley style teaching on anaphylaxis.

Dissemination of anaphylaxis guidelines and how to access referral information (on shared drive & intranet).

• 1 pt couldn’t be contacted.

• 100% identified their allergen.

• One was dissatisfied with their care (lost to follow-up).

• Of those who had surgery abandoned, all had subsequent uneventful surgeries.

• Only 14% of those contacted would have liked local follow up.

Conclusion and Future Action: 1. Presumed anaphylaxis not always managed according to guidelines.

2. Severity of anaphylaxis never documented and alerts not created. Further education needed.

Immediate in hospital follow up

2020

1

Improving Quality: • • •

2019

(1 cancer)

Cancelled surgery resulted in serious harm.

Notes 25.0% alert 25%

• All cases between April 2019 and March 2020 on the trust anaphylaxis database.

• Inclusion criteria: that the anaesthetist caring for the patient suspected a possible peri-operative anaphylaxis. No exclusion criteria. All age groups were included.

• The anaesthetic chart, notes, ICU database and electronic pathology records were examined.

• Where data was missing the immunology clinic was contacted for details regarding referrals and outcomes. Timely care was set by our audit team as <6 weeks.

• Patients were phoned for a short questionnaire.

• Re-audit April 2020 – March 2021

(2020)

Cons contacted

Methods:

75%

150

CPR

(2019)

Referral received

Ascertain if patient needs were met or if better local services were needed.

62.5%

Referral complete

Determine how many of the suspected cases received a confirmatory diagnosis of anaphylaxis.

87.5% 75%

Percentage of Patients

20%

Adrenaline

Percentage of Patients

•

•

60% 40%

Noncancer 75% Cancer 25%

1st MCT 2nd MCT 3rd MCT

200

0%

Evaluate the care against the anaesthetic National Audit Project (NAP) 6 guidelines.

250

2020

80%

Establish the number of suspected cases of peri-operative anaphylaxis in a large DGH.

Assess whether follow-up pathways for patients were robust and timely.

Cancer 50%

Surgeries 2020

Mast Cell Tryptase Results

2019

100%

Aims:

•

Consented for a risk of allergy both years.

Signs of Anaphylaxis

One recommendation from NAP6 was that ‘Investigation of perioperative anaphylaxis should include follow-up, either in hospital or in primary care’.

As local follow-up in our DGH is not formalised we were keen to investigate whether this was needed.

•

Noncancer 50%

12.5% Incorrectly completed by the ward in 2019.

The incidence of peri-operative anaphylaxis is thought to be approximately 1:10,000, with the main culprits identified as antibiotics, chlorhexidine, methylene blue and neuromuscular blocking agents.

•

cases examined.

100% Allergies completed in two places both years.

37.5% 25%

The anaesthetic National Audit Project (NAP) 6 on peri-operative anaphylaxis was published in 2018 and is the largest prospective study to date. In light of this and the expected new UK Resuscitation Council Guidance on Anaphylaxis (May 2021) we wanted to learn how well we were performing as a Trust.

Surgeries 2019

9 patients in 2019, 4 patients in 2020

87.5% 100%

Context:

Results:

3. Clinical teams very good at caring for patients post-op.

Now that guidance has changed, retraining must occur.

4. Local follow-up, although advocated by NAP, does not seem to be something patients seek in these cases.

5. COVID has resulted in disruption to services. Once re-established it is important to redefine what waits are acceptable.

6. Only 25% of patients have had anaphylaxis confirmed. Other causes include high spinal, type A reaction, oral allergy syndrome, bronchospasm, non IgE allergic reaction and anaesthetic related hypotension.

7. Important to note that anaphylaxis was only diagnosed when mast cell tryptases were raised so three samples are needed.

References: 1) Anaesthesia, Surgery and Life-Threatening Allergic Reactions Report and findings of the Royal College of Anaesthetists’ 6th National Audit Project: Perioperative Anaphylaxis May 2018 2) Emergency treatment of anaphylaxis Guidelines for healthcare providers Working Group of Resuscitation Council UK May 2021

Promoting Smoking Cessation and use of Nicotine Replacement Therapy for inpatients in a Mental Health Hospital Sarah Ahmed, Joyce Lui, Carys Gilbert, Paris Bruno, Faye Norman Wotton Lawn Hospital Background 1 Those with severe mental illnesses are up to three times more likely to smoke compared to the general population . Smoking is one of the 1 most significant modifiable risk factors that contribute to excess deaths among those with serious mental illness . Research has shown that 2 smoking cessation is also beneficial to mental health . The National Health Service (NHS) long-term plan is for all inpatients to be offered 3 NHS-funded tobacco treatment services by 2023 .

Aim To improve the confidence of healthcare professionals in discussing smoking cessation and increase the number of nicotine-replacement therapy (NRT) being offered to Wotton Lawn Hospital inpatients.

Staff confidence in initiating a brief conversation with an inpatient about smoking cessation 60 50

40

PSDA 1: In-person training session on Very Brief Advice for smoking cessation, with an option to complete an online course PDSA 2: Leaflets and posters on prescribing NRT disseminated on the wards PDSA 3: Email reminders about Very Brief Advice and prescribing NRT sent to staff on each ward PSDA 4: Discussion of NRT with each patient was incorporated into the weekly multi-disciplinary team meetings

30 20 10 0

1: Not at all confident

2

3

Baseline

PDSA 1

4 PDSA 2

5: Extremely confident

PDSA 3

Staff confidence in prescribing NRT Outcome measures 1. Five question survey completed by healthcare staff detailing confidence with elements of Very Brief Advice (VBA) and Nicotine Replacement Therapy (NRT) – prior to intervention and after each intervention 2. The number of patients with NRT prescribed on each ward – after each intervention Results In-person training led to an increase in staff who had been trained in Very Brief Advice from 25% of staff surveyed, to 51% of staff.

There was a 24% increase in confidence reported by staff in discussing smoking cessation with inpatients, and an increase in the frequency of these discussions occurring.

There was increased confidence in staff offering NRT, with a 12% increase in staff who reported they would they would feel “extremely confident” prescribing NRT for an inpatient.

There was no change in the amount of NRT prescribed on inpatient drug charts.

Percentage of staff surveyed who had:

Start of QIP

End of QIP

Been Very Brief Advice (VBA) trained

25

51

Prescribed NRT for an inpatient

40

41

50 40 30 20 10 0

1: Not at all confident

2

Baseline

3 PDSA 1

4 PDSA 2

5: Extremely confident PDSA 3

Staff reports of how often they discussed smoking cessation with inpatients 60 50 40 30 20 10 0

Never

Rarely Baseline

Occasionally

PDSA 1

PDSA 2

Often

Always

PDSA 3

Discussion Smoking cessation was discussed more frequently with patients during this project. There was a clear trend of increased confidence reported by staff in having this discussion, and in prescribing NRT. Maintaining the increase in confidence seen in staff is crucial in order for them to continually promote smoking cessation with inpatients. A systemic, consistent approach to staff training, and regular promotion of smoking cessation, will likely improve outcomes ​and work towards changing the culture around it's importance within the department.

Though there was increased confidence in staff offering NRT, there was no significant change in the amount of NRT prescribed on inpatient drug charts. Indeed, patients may refuse NRT after being offered it on the first occasion or may not simply be well enough on admission to consider smoking cessation. Mental health inpatients tend to have longer lengths of stay so discussing smoking cessation at regular intervals during admission may offer a solution to this, and could even be explored more successfully towards discharge.

References 1.

Prochaska JJ, Das S, Young-Wolff KC. Smoking, Mental Illness, and Public Health. Annu Rev Public Health. 2017; 38:165-185 2.

Taylor G et al. Change in mental health after smoking cessation: systematic review and meta-analysis BMJ 2014; 348 :g1151 3.

NHS Long Term Plan. Available at: https://www.longtermplan.nhs.uk/online-version/chapter-2-more-nhs-action-on-prevention-and-health-inequalities/smoking

QIP: Prescribing Secondary Prevention in Patients with PAD Nootigattu M S, Murray I, Osborne C

Background

Aims

• Over a 5-year period, approximately 10-15% of patients presenting with intermittent claudication will die of cardiovascular causes within 5 years.

• A further 20% will have a non-fatal cardiovascular event.

• Aim of treatment with anti-platelet agents is to prevent occlusive vascular events and recurrence of these events.

• Strong evidence also supports the use of statins in PAD to reduce cardiovascular events and mortality.

1. All patients with PAD should be offered/prescribed a statin and a form of antiplatelet therapy.

2. 100% of patients admitted to the vascular surgery department with ischaemic disease should be taking a statin and antiplatelet.

3. Of those who were previously not taking either, 100% should be initiated on these therapies during admission.

4. All patients taking a statin should be optimised on Atorvastatin 80mg.

Guidelines

Method

NICE: • Secondary prevention of cardiovascular disease should be offered in those with PAD. • This includes lipid modification/statin therapy and antiplatelet therapy.

• Clopidogrel is recommended for prevention of occlusive events in those with PAD. • First-line lipid modification therapy recommended is high-dose statin therapy with Atorvastatin 80mg (although any treatment is better than no treatment).

• Data was collected for all vascular patients admitted on the ward during a 2 week period, who had ischaemic disease.

• Patients who had presented with acute limb ischaemia as a result of trauma were excluded.

• Data was collected at a single point during the patient’s admission using their paper notes, Careflow summary and ICE data.

• Following Cycle 1, intervention was made as outlined below, and data was collected again for Cycle 2 after a 3-month period.

Intervention • • • •

Poster in doctor’s office on vascular ward to remind juniors of need for antiplatelet and statin therapy to be optimised if possible, in patients with PAD. Present findings of Cycle 1 to the new incoming juniors at their induction, to highlight to the new team the areas for improvement.

This should then encourage juniors to flag up to seniors when suboptimal secondary prevention is noted, and in turn improve prescription of these medications.

Plan to re-audit in 3 months time.

Results Cycle 1 Sample Size:

Cycle 2

19, one discounted as was for palliative care, leaving 18

Antiplatelet/Anticoagulation:

24

I

Taking prior to admission • Of which, antiplatelet further optimised

89% (n=16) • 0%

N

79% (n=19) • 26% (n=5/19)

Initiated on Clopidogrel during admission

50% (n=1)

T

40% (n=2)

Overall, on antiplatelet/anticoagulation

94% (n=17)

E

83% (n=21)

To conclude…

Only 50% were correctly identified and started on an antiplatelet.

R

Only 40% were correctly identified and started on an antiplatelet.

Statins: Taking prior to admission • Of which, on Atorvastatin 80mg • Of which, optimised to Atorvastatin 80mg

72% (n=13) • 23% (n=3/13) • 0%

V

Initiated on a statin

0%

N

Documented statin allergy/intolerance

6% (n=1)

To conclude…

72% of patients were receiving statin therapy, and 23% of those were receiving high-dose Atorvastatin.

E

T

0% of patients with PAD and not on a statin at admission, were initiated on a statin during this admission.

I O N

79% (n=19) • 32% (n=6/19) • 16% (n=3/19) 0% 9% (n=2) 79% of patients were receiving statin therapy. 16% of patients were optimised on high-dose Atorvastatin, leading to 48% in total on highdose Atorvastatin.

0% of patients with PAD and not on a statin at admission, were initiated on a statin during this admission.

Table 1: Table comparing proportions of patients in Cycle 1 & 2 on statins, antiplatelet/anticoagulation, and whether they were initiated/optimised appropriately for secondary prevention.

Discussion Overall, there was no improvement in initiation of anti-platelet agents in patients with PAD. There was some improvement in statin prescribing.

There was no improvement in initiation of statins in those not already receiving one.

However, more individuals were optimised to high-dose Atorvastatin treatment in the second cycle.

Limitations of this QIP include the small and varied sample sizes for data collection.

Data was also collected at a single time point during admission, but not always the same – which meant patients were at different stages of their management. As a result, medication changes may have been made later on during admission that we did not record.

• There may have been further clinical reasoning for not starting/altering these medications, which we did not routinely record/account for.

• Further intervention, such as a prompt on the clerking/ward round proformas, could be implemented, before repeating the QIP cycle again. A check prior to discharge (e.g. by the junior doctor writing the discharge summary) may also be worth trialling.

• • • • • •

madhura.nootigattu@nbt.nhs.uk

Improving Antibiotic Prescribing on a Vascular Ward C. Osborne, M. S. Nootigattu, I. Murray

Introduction Antibiotics are regularly used in hospital to combat bacterial infections. Antibiotic misuse can have negative consequences. Many vascular surgery patients have bacterial infections in addition to their vascular pathology.

Although most antibiotics have a good safety profile, there are common side effects including dermatological and gastrointestinal upset and rarer effects such as leukopenia, electrolyte disturbance and C.diff infection1, 2.

Prolonged courses of certain antibiotics increase the risk of developing side effects or C.Diff infection3. In addition, antibiotic resistance is rising worldwide secondary antibiotic overuse and misuse4.

Vascular patients often present with multiple co-morbidities, which add an additional layer of complexity for the antibiotic prescriber.

Plan

Do

The aim was to evaluate how well antibiotics are routinely prescribed on a vascular ward. We assessed how far the Southmead drug chart was completed for each prescription. In particular, if the 'indication' and 'duration' sections were completed and adhered to.

Study

We collected data for three separate projects using the same database, which was anonymised and saved securely on a hospital hard drive. Data was collected from 21 patients in Nov 2020 on the vascular surgery ward. Data was collected using a combination of ICE, Careflow Connect and inpatient drug charts. Data Introduction included patient demographics, details of admission and current and completed antibiotic prescriptions.

The process was repeated in February 2021 on another set of 21 patients.

We analysed the data set in December 2020 for the first cycle and March 2021 for the second.

Act After the first cycle we introduced an A1 poster in the vascular office about safe prescribing, of which antibiotics was a part.

Results The graphic below demonstrates the percentage of ‘indication’ and ‘duration’ sections which were completed on the drug chart and also the percentage of completed ‘duration’ sections that were adhered to.

Cycle 1 (n=30) Indication

90%

Cycle 2 (n=24)

96%

77%

79%

70%

84%

Duration

Adherence to duration

Discussion There was a modest improvement in the number of completed ‘indication’ and ‘duration’ sections.

The greatest improvement was that there were fewer patients on a prolonged course of antibiotics in the second cycle without explanation (better adherence to prescription duration).

Future development would be holding a teaching session with the junior prescribing team. It would be interesting to see if there was sustained change with subsequent junior teams.

References: 1. Marchant J. When antibiotics turn toxic. Nature. 2018 Mar 22;555(7697):431-3.

2. Grill MF, Maganti RK. Neurotoxic effects associated with antibiotic use: management considerations. British journal of clinical pharmacology. 2011 Sep;72(3):381-93.

3. Cunha BA. Antibiotic side effects. Medical Clinics of North America. 2001 Jan 1;85(1):149-85.

4. Optimising Antibiotic Usage to Treat Bacterial Infections Paterson IK, Hoyle A, Ochoa G, Baker-Austin C, Taylor NG. Optimising antibiotic usage to treat bacterial infections. Scientific reports. 2016 Nov 28;6(1):1-0.

th 16

June 2021

Poster Competition Group D

Care of the Older Patient First prize: Prescribing of PPI cover with NSAIDs use in over 65s Presenter: Dr Hazel Chon University Hospitals of Leicester NHS Trust

Second Prize: Following the Fix: A proforma to promote post operative reviews of Neck of Femur Fracture (NOF) Patients Presenter: Dr Alexandra Uren University Hospital’s Bristol and Weston NHS Foundation Trust

An Audit of an anti-psychotic monitoring care bundle Introduction Anti-psychotics are a commonly prescribed class of psychotropic medication.

They are used in a variety of diseases including primary psychotic disorders, mania, and psychotic depression. Unfortunately these medications exhibit a large side effect profile. Many of these can have significant effects on morbidity and mortality (1). These medications therefore require significant long term monitoring especially die to the high risk of metabolic syndrome (2). As antipsychotics are usually initiated in secondary care the primary surveillance and handover to the GP are of critical importance. I aim to audit patients started on an anti-psychotics during an inpatient admission over a six month period to determine if their monitoring is compliant with NICE guidelines. I plan on implementing change to improve our compliance and handover to GP’s Methods Due to practical difficulties we decided to introduce a range of measures at the same time as apposed to performing PDSA cycles. This gave the benefit of additional measures but sadly means the effectiveness of each individual measure is not known. We introduced the following changes; 1. Designed a chart for the junior doctors’ to record patients on anti-psychotics and to tick off the guideline requirements.

2. Add checklist to patient notes for nurses and doctors to complete to ensure compliance.

3. Added a drug monitoring section to the weekly ward round checklist so compliance could be reviewed weekly

Discussion Although the sample size was small the results demonstrate that our bundle increase compliance with NICE guidelines leading to greater care for our patients.

The improvements seen were consistent across multiple domains and different areas of monitoring. This project was conducted during a period of high stress on the ward whilst dealing with the COVID 19 pandemic suggesting the changes do not place unmanageable additional burden of nursing or medical staff. These interventions were especially important in measuring the parameters relating to metabolic syndrome.

Results • The percentage of patients with full baseline monitoring rose from 33 to 77% (figure 1) • The interventions led to a rise in the necessary weights recorded from 64.8% to 90.2% (figure 2).

• Before our intervention there was no documented evidence of blood glucose monitoring. This rose to 100% compliance (figure 3) • The percentage of necessary tests at 3 months rose from 33% to 100% (figure 4)

The challenge with this quality improvement project stems from maintaining these benefits after the junior doctor cycle. I hope the creation of a junior doctor handbook and education of the consultants will enable this however re-auditing after changeover would be interesting. Finally, although not audited, I hope our interventions improved hand over of care to GP’s. This is especially important as patients often require long term therapy and the risks of metabolic syndrome develop many years after in patient admission. Additionally patients with mental health difficulties have been showed to attend primary care less (3).

References

1. Newcomer, J. W. (2007). Antipsychotic medications: Metabolic and cardiovascular risk. The Journal of Clinical Psychiatry, 68(Suppl4), 8–13 2. NICE clinical guideline [CG178]. Psychosis and schizophrenia in adults: Prevention and management. Update 01/03/2014 3. Lisa B Dixon, Yael Holoschitz, llana Nossel. Treatment engagement of individuals experianccing mental illness: review and update. World Psychiatry 2016 Feb;15(1):13-20

Future directions include 1. Implementing this bundle on other wards 2. Re-auditing after the junior doctor cycle / implement strategies to ensure progress is maintained 3. Audit patients handover to GP’s for continuity of care

Prescribing of PPI cover with NSAIDs use in over 65s Dr Hazel Chon, Dr Piranavan Kirupananthan INTRODUCTION More than 30 million people consume non-steroidal anti-inflammatory drugs (NSAIDs) worldwide every day.1 Despite their beneficial effects, NSAIDs can cause a wide range of preventable harm to patients. Gastrointestinal complications, including gastric ulcer, bleeding and perforation, are the most common side effects associated with NSAIDs.2 Elderly NSAID users are 4 times more susceptible to gastrointestinal bleed, making them vulnerable targets for hospital admissions because of NSAIDs induced major gastrointestinal adverse events.3 Approximately around 8500 hospitalisations in the UK were related to gastroduodenal ulcers annually.4 The annual cost of initial hospital treatment for acute upper gastrointestinal bleed is estimated to be £155.5 million in the United Kingdom.

AIM This QI project aims to achieve 100% in prescribing PPI cover for NSAID users aged ≥ 65 and improve PPI compliance by 10% in two local GP practices over 8 months.

The aim of this project used the SMART framework to set a concise and achievable target. This project utilised the Model for Improvement to develop, test and implement changes leading to improvement. The NICE guidelines recommend all NSAID users over the age of 65 should have PPI cover prescribed.5 Figure 1 shows the driver diagram used in this project. Table 1 shows the qualitative and quantitative data collected. Table 2 shows the measures used to generate stable growth for the project. 3 PDSA cycles shown in figure 2 were used to test out changes on a smaller scale.

Table 1 shows the data collected for this QI project.

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

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

Fig. 2 shows three PDSA cycles performed.

RESULTS In the first month, practice 1 had 92.6% (75/81) patients with PPI cover and 7.4% (6/81) with no PPI cover; practice 2 had 93.3% (56/60) patients with PPI cover and 6.7% (4/60) with no PPI cover. Among those who had PPI prescribed, 12% (9/75) patients had poor compliance in practice 1 and 12.5% (7/56) in practice 2.

Practice 1 - Proportion of patients with PPI prescribed (%)

Practice 2 - Proportion of patients with PPI prescribed (%)

102

102

100 100 98 98

96 94

96

92 94

Change over of junior doctors

90 88

Change over of junior doctors

92

Covid-19 outbreak in practice

86 84

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

90

No. of hospital admissions related to NSAID induced GI adverse events 3.5

88

82 Aug

Sep

Oct

Nov

Dec

Jan

Feb

Mar

Apr

Aug

Sep

Oct

Nov

Dec

Jan

Feb

Mar

= Median

Apr 3 2.5 2 1.5 1 0.5 0 Aug

Sep

Oct

Nov

Dec

Jan

Feb

Mar

Apr

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

Lessons learnt

• Not all changes lead to improvement • Consider using Six Sigma DMAIC to study medication error in healthcare • Next step is to expand project regionally and maintain sustainability References: 1. Melcarne, L., García-Iglesias, P. & Calvet, X. (2016) Management of NSAID-associated peptic ulcer disease. Expert Review of Gastroenterology & Hepatology. 10 (6), 723-733. 2. Morrison, C., Beauchamp, T., MacDonald, H. & Beattie, M. (2018) Implementing a non-steroidal anti-inflammatory drugs communication bundle in remote and rural pharmacies and dispensing practices. BMJ Open Quality. 7 (3), e000303. 3. Pirmohamed, M., James, S., Meakin, S., Green, C., Scott, A. K., Walley, T. J., Farrar, K., Park, B. K. & Breckenridge, A. M. (2004) Adverse drug reactions as cause of admission to hospital: prospective analysis of 18 820 patients. Bmj. 329 (7456), 15-19. 4. Rockall, T. A., Logan, R. F. A., Devlin, H. B. & Northfield, T. C. (1995) Incidence of and mortality from acute upper gastrointestinal haemorrhage in the United Kingdom. Bmj. 311 (6999), 222-226. 5. Naitonal Institute for Health and Care Excellence (2021) Scenario: NSAIDs prescribing issues | Management | NSAIDs - prescribing issues | CKS | NICE. [Online]. 2021. Cks.nice.org.uk. Available from: https://cks.nice.org.uk/topics/nsaidsprescribing-issues/management/nsaids-prescribing-issues/#gastrointestinal-adverse-effects [Accessed: 25 March 2021]

QUALITY IMPROVEMEN T TRACK PROJECT - TRACKING REST, ACTIVITY, CALORIES & KIP

Question: Can an activity tracker be a useful tool in the assessment and care planning of patients with dementia who continuously pace?

‘Wandering’ or ‘walking with/without purpose’ is a common Behavioural and Psychological Symptom of Dementia [1]. In extreme cases the person can’t sit to eat, drink, use the toilet and only stops due to exhaustion. This can result in falls, weight loss, dehydration, constipation and sleep disorder. All of which have a detrimental effect on quality of life, distress for families and challenge for staff.

"Connected health ‘wearable’ devices present an opportunity to passively and unobtrusively capture high resolution data from people in everyday life" [1].

- Not having clear information for ward rounds about certain patients pacing behavior and sleep patterns

To have clear data to present in ward rounds to help with care planning and medication choices. To improve quality of life.

How? Trial use of an activity tracker.

Belvedere Ward is a Dementia Specialist Unit. There is usually at least one patient who continuously walks with/without purpose.

Trust values: Commitment to quality care; Working together for patients; Improving lives.

TRACK TEAM: Physio, Dietician, RMNs, HCAs, Assistant Practitioner, Doctor, Innovation Team

You can easily see times of activity and sleep patterns

PLAN: Why a Fitbit Inspire 2?

-

Battery life up to 9 days Waterproof Simple to use Clear charts for health data review Low cost Comfortable, unobtrusive Data is easily unidentifiable, requires only age, weight and height Easily transferable between patients Easily cleaned ACT: IT problems Requires non-standard software request to install on trust computer due to risk of data breach

] e

References: [1] James, I. (2001) Understanding Behaviour in Dementia that Challenges. A guide to assessment and treatment. JKP. [2] Hassan et al. (2017) Tea, talk and technology: patient and public involvement to improve connected health ‘wearables’ research in dementia. Research Involvement and Engagement 3:12 Project lead: emma.howard36@nhs.net

A Quality Improvement Project on increasing senior reviews for older patients presenting with abdominal pain prior to discharge from Gloucester Royal Hospital Emergency Department Dr. Joyce Claresta Lui, Dr. Fiona Field, Ms. Jessica Hassell, Ms. Madeleine Browne, Dr. Muhammed Hamza Shaikh

Background •

Abdominal pain in older patients is a common presentation within A&E

•

Non-specific symptoms, falsely reassuring examination findings, unremarkable blood results à premature discharges, and high morbidity and mortality rates

•

RCEM 2016 standard: all older patients presenting with abdominal pain should be reviewed by a senior (Consultant or SpR 4+) prior to discharge

Aims Assess and improve the incidence of senior reviews in patients over the age of 70 presenting into A&E with abdominal pain prior to discharge.

Methods Outcome measures: 1. Use of senior review form.

2. Documentation by consultant or SpR 4+.

3. Junior documentation of a discussion with an appropriate senior.

4. Any documentation of senior involvement.

Intervention 2

Intervention 3

teaching

Email reminders sent to

Incorporating the senior

audit

sessions on the necessity

all A&E staff encouraging

review form into the A&E

the

and rationale of senior

use

clerking proforma.

reviews.

form.

Intervention 1

Baseline audit

Retrospective collection

data to

compliance

with

RCEM standard.

Departmental

of

senior

review

Results Intervention 1: Percentage of patients seen by each grade of clinician

Intervention 1

Consultant or SpR 4+ 20%

Intervention 2 69%

68%

Junior 80%

Intervention 2: Percentage of patients seen by each grade of clinician

20%

23% 14%

Consultant or SpR 4+ 27%

0%

Junior 73%

10%

0%

SENIOR REVIEW FORM USED

SENIOR REVIEW DOCUMENTED IN NOTES

DOCUMENTED DISCUSSION NO SENIOR INVOLVEMENT WITH SENIOR

Data post intervention 3 is incomplete with data analysis expecting to begin from June.

Conclusions •

The 2 interventions achieved an 3% increase in documented senior reviews and 4% increase in clerking with senior involvement.

•

Anticipated that incorporating the senior review form into the clerking proforma will facilitate more senior reviews à safer discharge thus reducing morbidity and mortality for this patient demographic.

• 1.

2.

3.

4.

5.

Could be beneficial to investigate barriers to completing senior reviews and areas for improvement.

Spangler R, Van Pham T, Khoujah D, Martinez JP. Abdominal emergencies in the geriatric patient. Int J Emerg Med [Internet]. 2014 Dec 21;7(1):43. Available from: https://intjem.biomedcentral.com/articles/10.1186/s12245-014-0043-2 BURNS E. Older people in accident and emergency departments. Age Ageing [Internet]. 2001 Aug 1;30(suppl 3):3–6. Available from: https://academic.oup.com/ageing/article-lookup/doi/10.1093/ageing/30.suppl_3.3 Henden Çam P, Baydin A, Yürüker S, Erenler AK, Şengüldür E. Investigation of Geriatric Patients with Abdominal Pain Admitted to Emergency Department. Curr Gerontol Geriatr Res [Internet]. 2018 May 30;2018:1–8. Available from: https://www.hindawi.com/journals/cggr/2018/9109326/ Bugliosi TF, Meloy TD, Vukov LF. Acute abdominal pain in the elderly. Ann Emerg Med [Internet]. 1990 Dec;19(12):1383–6. Available from: https://linkinghub.elsevier.com/retrieve/pii/S0196064405826022 White AL, Armstrong PAR, Thakore S. Impact of senior clinical review on patient disposition from the emergency department. Emerg Med J [Internet]. 2010 Apr 1;27(4):262–5. Available from: https://emj.bmj.com/lookup/doi/10.1136/emj.2009.077842

75

24%

50

25

0

1 2 3 4 5 6 7

24%

92%

96%

72%

100%

69%

44%

< 70

70-79

> 80

FOLLOWING THE FIX A proforma to promote post operative reviews of Neck of Femur Fracture (NOF) Patients Dr Alexandra Uren, Mr. Louis Hainsworth, Miss. Alanna Pentlow University Hospitals Bristol and Weston

Background

Aims

• NOF Fractures are a common serious injury in older people associated with high morbidity and mortality • Current practice at Weston General Hospital requires these patients to be reviewed at 6 and 12 hours post-operatively

To assess whether the introduction of a proforma would promote these reviews Ensure all important information documented – 8 key points to be included in the review •

•

Method March 2020 20 patients notes reviewed who had undergone surgical management for a NOF fracture • Only 50% had received postoperative reviews • 0% had had pain level documented • Post operative review proforma introduced to existing clerking booklet

Act

Plan

PDSA Cycle

•

Study

Do

Comparing the percentage of patients who received post operative reviews pre and post proforma

•

Results

Percentage

70 60 50

67% of patients received 6hour post-operative reviews • 100% of the 6-hour reviews had all 8 necessary points recorded • Of the the remaining patients NOT on the proforma – only 20% patient had all paints recorded •

40 30

10

• 80% increase in the documentation of all 8 points when using the proforma Plan to introduce the proforma to junior doctor induction days to encourage its use

• 30 patients notes reviewed • Recorded time of reviews, level of reviewer, and how many of the 8 points recorded

80

20

Take Home Message

August-September 2020

0

Pre Proforma Post Proforma 6 Hour review

12 Hour review

8 REVIEW POINTS

Observations ü Pain ü Neurovascular Status ü Wound dressing ü Venous Thromboembolism risk ü Nausea and Vomiting ü Level of reviewer ü Time of review ü

Communication: a tool to reduce discharge delays in Medicine for the Elderly Dr K Strathie, Dr K Wilkinson, Dr J Coenen, Dr S Malani Medicine for the Elderly, Charing Cross Hospital

Background

Results

It is well recognised that for older patients, longer stays in hospital are associated with worse health outcomes and an increase in long-term care needs. In addition to this, discharge delays reduce a ward’s capacity to admit and treat acutely unwell patients, consequently slowing patient flow through a hospital.

The Office for National Statistics estimated that in 2015 £820m was spent on hospital beds for older patients who were no longer in need of acute treatment.

Our simple intervention saved 200 bed days during the second cycle. We reduced discharge delays from an average of 4.37 days to 1.75 days (table 2, figure 2).

We also examined qualitative outcomes for members of the MDT with similarly positive results. Following our intervention there was a 157% increase in respondent awareness of a patient’s estimated discharge date, and a 132% increase in respondent satisfaction regarding discharge planning (table 2).

Aims and Objectives Our aim was to improve communication within the multidisciplinary team (MDT) on our Medicine for the Elderly (MfE) ward to reduce avoidable delays to patient discharge.

Cycle One

Cycle Two

Difference

Time until declared MFFD (days)

6.78

5.28

-1.5

Time between MFFD & leaving hospital (days)

4.37

1.75

-2.62

Method Retrospective data was gathered over a period of one month, comparing when patients were declared medically fit for discharge (MFFD) to actual discharge date.

A questionnaire was distributed amongst the MDT members collecting opinions on communication and discharge efficiency. Post intervention, we repeated the data collection and questionnaire three months later. Figure 1 shows our patient selection. Patients were excluded if they moved wards or died during admission.

Cycle 1: 17.07.20 – 17.08.20

Cycle 2: 01.11.20 – 01.12.20

78 patients admitted in the

63 patients admitted the 30

30 day period prior to 17th August

day period prior to 1st December

18 patients

14 patients

excluded

excluded

60 patients included in

49 patients included in

the data set

the data set

Table 2: shows the difference pre and post intervention between time until declared MFFD on the ward, and the time between a patient being declared MFFD and being discharged from hospital.

Questions I think communication within the 8 South MDT regarding plans for each patient once they are medically fit is always excellent

August (/10)

November (/10)

6.38

7.82

It is always clear when the doctors declare a patient is MFFD

7.38

7.73

I am always aware of a patient’s EDD

5.15

8.09

I am always aware of what the cause of a patient’s delayed discharge is

6.23

8.27

I think that the system we have in place currently for planning care once MFFD is excellent

5.46

7.18

Table 3: shows the average answer rating (out of 10, with 10 being post positive and 1 being most negative) for the questions shown, pre and post intervention.

Figure 1: Flow chart demonstrating patient inclusion into the study

Intervention We identified the following issues with the once a day ward meeting; • Often patients were new and had not yet been seen by doctors • Lack of open communication between different members of the MDT after the meeting for the rest of the day • Several delayed discharges

August Feedback

Action taken

“Give more • Shortened morning handover to 5-10 minutes structure to • Limited discussion to unwell patients & potential morning meetings” discharges.

• Created & disseminated a template to follow for morning meetings & board rounds • Introduced paper handovers “There should be a • Trialled a midday board round: 12:30 – 13:00 to discuss board round post EDD, steps needed prior to discharge, potential delays ward round” and action plan to mitigate delays.

“Introduce a white • We were unable to introduce this due to data protection board” and information governance concerns.

Table 1: shows the free-text comments received on the questionnaire and the subsequent actions taken.

Figure 2: Bar chart demonstrating the average discharge delay in days in August, compared to post intervention in November,.

Conclusion By focusing on clear communication within our MDT we were able to produce tangible outcomes with an impact at both a patient and an organisational level.

Delays in the discharge of patients was clearly reduced following the implementation of a midday meeting. The new system also allowed a clear focus on clinical priority at the start of the day, making for safer care.

This data shows how our intervention improved cooperation and communication in the MDT, resulting in a more positive and effective work environment.

EVALUATION OF POLYPHARMACY AND IMPLEMENTATION OF MEDICATION REVIEW IN PATIENTS PRESENTING WITH FALLS Dr Chitnis A. , Dr Pissaridou M. , Dr Borkar V. Department of Medicine for Older People, Stoke Mandeville Hospital, Aylesbury BACKGROUND Falls in the elderly population are common and are associated with significant morbidity and mortality. In the over 65 age group, 1 in 3 people are estimated to have a fall every year. This has a substantial burden on the NHS of £4.6 million per day.

The risk of falls is multifactorial, with polypharmacy being a common risk factor1, associated with a 21% increase in falls rate. In a globally ageing population, with increasing multimorbidity and consequent polypharmacy, falls are a public health issue2.

RESULTS • 21 patients were included in the study with an average age of 89.95.

• 13 (62%) patients were female, 8 (38%) patients were male.

• 100% were multi-morbid with identified polypharmacy in 14 (67%) patients.

• 5 (24%) patients had a complete falls assessment, and 8 (38%) had an incomplete assessment.

• A fall cause was identified in 15 (71%) patients.

• 8 (38%) patients had at least 1 medication stopped with 5 (24%) patients having a note to the GP for medication review.

AIM The aim of the study was to identify incidence of fall-related admissions under the Medicine for Older People (MFOP) team and evaluate implementation of medication review, tackling polypharmacy as part of a falls risk assessment and prevention strategy.

• 4 (19%) patients have passed away.

OBJECTIVES 1. Identify number of falls-related admissions under Medicine for Older People 2. Evaluate and improve implementation of medication review prior to discharge 3. Assess the incidence of readmission

METHODS Data collected retrospectively over a period of 7 weeks.

Subjects included were patients over the age of 65 admitted under MFOP at Stoke Mandeville Hospital. Patients deceased during specified admission and patients discharged on End of Life Care (EOLC) were excluded. The data was tabulated and analysed using Microsoft Excel.

Fig. 2 Proportion of patients undergoing medication review resulting in discontinuation of medication

DISCUSSION A positive correlation between patients admitted with falls and polypharmacy was identified with associated suboptimal inpatient medication review.

CONCLUSION This study highlights the importance of appropriate medication review to tackle polypharmacy as part of a falls prevention approach to patients admitted with falls in a geriatric setting and the need for incorporating this as part of the routine assessment of such patients.

INTERVENTION

Fig. 1 Proportion of patients identified with polypharmacy

1.

2.

Falls in older people: assessing risk and prevention. Clinical guideline [CG161] Published date: 12 June 2013 Dhalwani, N., Fahami, R., Sathanapally, H., Seidu, S., Davies, M. and Khunti, K., 2021. Association between polypharmacy and falls in older adults: a longitudinal study from England. [online] bmjopen.bmj.com.

Available at: <https://bmjopen.bmj.com/content/7/10/e016358>

1. Audit results presentation at Academic Half Day 2. Poster reminders in geriatric clinical areas 3. Medication review tick box incorporated in the newly introduced ward round proforma.

th 16

June 2021

Poster Competition Group E

Improving Primary Care First prize: It’s red and lumpy”. Improving the process of reviewing skin complaints virtually in General Practice using patient submitted photos Presenter: Dr Elizabeth Beasant Organisation: GPST1 Cardiff and Vale UHB Second Prize: Antipsychotic monitoring: A Quality Improvement (QI) project Presenter: Dr Isobel Joy McFadzean Organisation: Kingsway Surgery, Swansea

ANTIPSYCHOTIC MONITORING:A QUALITY IMPROVEMENT (QI) PROJECT I.J.MCFADZEAN & R.JENKINSON ABSTRACT PDSA1

BACKGROUND

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

RESULTS

PDSA1: ADHERENCE TO

PSYCHIATRY RECOMMENDATIONS INCREASED BY 9%.

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

CONCLUSION

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

ANTIPSYCHOTICS

• MISSED DOSES • INCORRECT DOSES • PROMAZINE ISSUED INSTEAD OF PROMETHAZINE • NO MONITORING

WHAT ARE WE TRYING TO ACCOMPLISH? REVIEW OF ANTIPSYCHOTIC MEDICATIONS

1

HOW WILL WE KNOW IT’S AN IMPROVEMENT?

2

MEASURE OF ADHERENCE TO LETTERS/CLINIC ATTENDANCE

WHAT CHANGE RESULTS IN IMPROVEMENT?

3

KEY CHANGES WITHIN PDSA 1&2

80

OF PSYCH LETTERS ADHERED TO

60

96 87 % %

BEFORE AFTER

40 20

ACT LETTERS FROM PSYCHIATRY SENT TO PHARMACIST

STUDY 75% OF PRACTICE ATTENDED & PHARMACIST RECRUITED

ACT NURSE- LED MONITORING CLINICS BEGIN

BEFORE AFTER

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

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

PLAN

EVALUATE PROCESS & PLAN MEETING

DO MEETING WITH INCIDENT ANALYSIS

PDSA 2

PLAN EVALUATE MONITORING & PLAN MEETING

STUDY

DO

70% OF PRACTICE ATTENDED & NURSE TRAINED

MEETING TO DISCUSS CLINICS

2

CLINICAL INCIDENTS

%

KEY

0

SA PD

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

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

FIG 1.MODEL FOR

1 IMPROVEMENT

1

METHODS

PRIMARY AIM: IMPROVE ADHERENCE TO PSYCHIATRY RECOMMENDATIONS BY 5% WITHIN 6 MONTHS. SECONDARY AIM: INITIATE MONITORING CLINICS FOR PATIENTS PRESCRIBED ANTIPSYCHOTIC MEDICATION.

PD SA

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

AIM

FIG.2: BAR CHART SHOWING ADHERENCE TO PSYCHIATRY RECOMMENDATIONS BEFORE & AFTER PDSA1 100

INITIALLY WE HAD NO FORMAL PROCESS TO MONITOR THESE PATIENTS. OUR PILOT FOCUSED ON >65’S & 36/44 (82%) OF THEM WERE REVIEWED IN CLINIC PRIOR TO THE COVID19 PANDEMIC.

DISCUSSION

THE QI PROJECT HELPED TO EDUCATE THE PRACTICE ABOUT ANTIPSYCHOTICS AND TACKLED MISCONCEPTIONS OF RESPONSIBILITY WITHIN CLINICAL MEETINGS. OUR NEXT STEP INVOLVES CLINICS FOR THE REMAINING PATIENTS.

REFERENCES 1. The Plan-Do-Study-Act (PDSA) cycle was published by W. Edwards Deming in The New Economics for Industry, Government, and Education Revised 2nd edition[Cambridge, MA: The MIT Press; 1993].

2. NICE Guidance, Psychosis and schizophrenia in adults: prevention and management. CG178. Feb 2014. Accessed at https://www.nice.org.uk/guidance/cg178

Dr Elizabeth Beasant

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

Project Methodology • Process map created • Baseline data collection to access scope of issue • Brainstormed solutions/interventions at practice meeting

Plan

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

• Baseline data analysed • Practice email account generated • 1st intervention and 2nd intervention

Do

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

Aims Act

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

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

• Data analysed and successful intervention adopted

Secondary outcome measures that would demonstrate improvement included: • • •

Baseline data collected over 2 weeks.

• Emailed clinical staff with the -41 telephone appointments that were related to skin practice email address and st complaints 1 encouraged them to use it - 46% of these appointment were given a second intervention appointment- face to face, or called back at a later stage with the same initial problem • Posters given to reception and - Only 27% of appointments were asked to send in asked staff to ask patients to photos email in photos at the time of - Within the 27% that were asked for photos, many 2nd intervention booking their appointment were not sent immediately. There was a combined delay of 18 hours for the photos to be received after being requested. 3 of the photos were never received.

A reduction in number of steps in the process map Reduction in additional appointments needed for the same issue Improving quality of virtual consults by encouraging more patients to send in pictures to review as additional information for their consult

Below: Process map prior to any intervention - Orange represents sources of delay/wastage

Results • • •

Appointments with photos available at time of appointment increased from 10% to 40% Secondary outcome measures as shown Process map steps reduced from 13 to 11. 8 sources of error reduced to 3.

Percentage of appointments in which photos were asked for

Percentage of appointments with photos available at the time of the appointment

60% 50%

50%

40%

40% 45%

20% 10%

51%

27%

30% 20% 10%

0%

0% Percentage

10%

24% 100%

Percentage

Percentage of patients given a second appointment 50% 40%

90% 80% 70%

Run Chart showing percentage of appointments in which a photo was available at the time of the appointment Intervention 1 % of appointments that had photos available to view at the time of the appointment

Intervention 2

60% 50% 40%

Median from (baseline data)

30%

30% 20%

40%

Percentage

30%

46%

20%

45%

10%

28%

10%

0%

0% Percentage Date

Conclusion • • • •

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

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

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

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

Below: Process map after interventions - Orange represents sources of delay/wastage

Future recommendations - Planned 3rd intervention is to get an automatic reply on the email account to safety net patients who may send in unrequested pictures or other clinical queries that are not appropriate.

- Audit the administrative process of how the photos are uploaded into the medical notes and deleted from the mailbox.

Improving the quality of discharge summaries of patients admitted with ACS, in line with NICE guidance to ensure correct continuation of care upon discharge.

A. Sim, C. Crook Musgrove Park Hospital, Taunton

Background

Aims

Current NICE guidelines1 state that every discharge summary for patients managed of acute coronary syndrome (ACS) should include the diagnosis, the results of investigations as well as information on future management in the community and advice on secondary prevention.

To improve the quality of discharge summaries of patients admitted with ACS, increasing the inclusion of relevant information on diagnosis, investigations and management upon discharge in >80% of discharge summaries.

Results Pre/Post Intervention

Details and timing of incomplete drug titrations and advice on monitoring blood pressure and renal function are examples of what should be communicated to the GP.

STANDARD (from NICE Guidance NG185)

REF:

Confirmation of diagnosis of ACS

1.7.1

As discharge summaries are key documents providing hand-over to primary care, a lack of communication of all relevant information may lead to patient safety being compromised.

Results of relevant investigations i.e. angiogram, ECHO

Prescription of ACE inhibitor, dual antiplatelet, beta blocker and a statin Prescription of GTN

Methods We audited the discharge summaries of all patients admitted to Musgrove Park Hospital coded with STEMI or NSTEMI in the month of July 2020.

We identified 41 eligible patients, with the exclusion criteria being death prior to discharge.

From the discharge summaries we identified whether the following information was included:

Ensure that GPs are notified to: • Further titrate medications • Monitor blood pressure and renal function • Duration of antiplatelet therapy

1.7.1

1.4.1

EXCEPTIONS

Clear explanation as to why these were not undertaken

Contraindication to any of the medications

1.4.13 1.4.26

Clear advice on secondary prevention including dietary advice and smoking cessation

1.7.1

DVLA/driving advice

1.8

1.9

TARGET (%)

COMPLIANCE (%) pre intervention

COMPLIANCE (%) post intervention

80%

>90%

>90%

80%

>90%

>90%

ACE inhibitors 95%

ACE inhibitor 100%

Dual antiplatelet 78%

Dual antiplatelet 95%

Beta blocker 83%

Beta blocker 95%

Statin 99%

Statin 100%

GTN 66%

GTN 68%

Up-titration 38%

Up-titration 45%

BP & renal function monitoring 19.5%

BP & renal function monitoring 45%

Duration of antiplatelet therapy 78%

Duration of antiplatelet therapy 90%

Dietary advice 7%

Dietary advice 31%

Smoking cessation 22%

Smoking cessation 29%

19%

65%

80%

80%

Non-smokers for smoking cessation advice

80% 80%

Indication of the diagnosis and investigations Prescription of ACE inhibitor, beta blocker, GTN spray, statin and antiplatelets Advice on duration of antiplatelet therapy Advice on up-titration of ACE inhibitor and beta blocker Advice on monitoring renal function and blood pressure

Results of Audit A summary of all the results are displayed in the table, however the main areas that needed improvement were: • Notifying GPs on further titration of medications • Advising GPs to monitor BP and renal function • Specifying the duration of antiplatelet therapy

Smoking cessation advice Dietary advice

• Clear advice on secondary prevention including smoking cessation and dietary advice

Results Post Intervention To evaluate our intervention, we re-audited the discharge summaries in January 2021 which included 38 patients. A summary of all the results are displayed in the table above; overall we identified improvement in: Advice on monitoring renal function and blood pressure has doubled A three-fold increase in the documentation of DVLA driving advice

• DVLA/driving advice

DVLA advice

A four-fold increase in the documentation of dietary advice

Action Plan After analysing the data and discussing with the cardiology juniors we implemented two changes: 1) Addition of ‘snippets’ to the discharge summary generator on EPRO EPRO permits the addition of ‘snippets’ to their discharge summary generator, allowing the user to visualise options of sentences to include in the discharge summary and to automatically add them by simply clicking on them. We created relevant snippets on key areas which were frequently omitted on discharge summaries.

Improvement in medication up-titration advice and duration of anti-platelet therapy advice Beta blocker prescription has also improved Our intervention however did not make a difference to the prescription of GTN spray.

2) Education on cardiac rehabilitation and secondary prevention We created a poster explaining how to use this function on EPRO and reminding doctors the essential information that should be included in the discharge summaries, and placed them on appropriate wards. We also displayed the NICE visual summary on ‘Cardiac Rehabilitation and Secondary Prevention’.

Despite the drastic improvement, our target of 80% compliance had not been achieved in most fields which needed improvement.

Conclusions From the initial auditing of patients being discharged following an ACS, it was clear that improvement was needed with regard to ensuring that the correct information is relayed to patients and GPs - this includes advice on up-titration and monitoring of medications in the community, as well as guidance on secondary prevention.

From discussion with junior doctors, it is clear that not all are aware of the information that is required as per guidelines, and that time pressure is a limiting factor to include all of the relevant information on a discharge summary. This leads to pieces of key information being missed.

Our intervention has led to an improvement in the documentation of most relevant information in the discharge summaries, however it did not meet our target. It is important to educate junior doctors on what information should be relayed to the GP to allow continuity of care.

Example of EPRO Snippets

Educational poster

References: 1. National Institute for Health and Care Excellence (2020) Acute Coronary Syndromes [NG185].

Available at: https://www.nice.org.uk/guidance/ng185/chapter/Recommendations#drug-therapy-for-secondary-prevention [Accessed 15 March 2021]

Improving the uptake of cervical screening through the use of communication Dr Julia Gibb and Dr Rebecca Paterson Introduction Cervical cancer is the 14th most common cancer in the UK with 3200 new cases reported every year. The cervical cancer screening programme aims to reduce this by contacting women aged 25-64 by letter to undertake a cervical smear test. Gosport Medical Centre is a general practice in the South East of England with a cervical smear uptake rate of 72.8% in women aged 24-49 and 76.4% in women aged 50-64. Gosport Medical Centre sends additional reminder letters to eligible women.

Aim This project aimed to increase the number of women who accepted their invitation for a smear test by using alternative methods of communication Methods Women eligible for a smear who were due a reminder in February were identified using the Open Exeter database.

Cycle 1 The practice sent women an additional text reminder at the time their third letter was due encouraging them to them to book an appointment.

Women who did not have a mobile number were sent a reminder letter instead.

Cycle 2 Women who did not respond to the text were then contacted by phone without offering any medical advice. The patient was given the opportunity to book an appointment during the phone call

Dear We are aware that you have been invited for cervical cancer screening but have not taken up the opportunity. Cervical cancer can affect anyone, and screening can detect changes early allowing treatment and preventing cancer. Please ring the surgery to arrange an appointment with the nurse.

Please watch this video for more information. https://bit.ly/2Ypy7WP https://www.nhs.uk/conditions/cervical-screening/

Cycle 1 Of 120 women identified, 115 received a text message and 5 were sent letters. Smears were booked for 20 patients after the first round of communication, all of whom had received a text message. A further 2 patients refused, and 6 patients supplied reasons to not have a smear.

Reasons included pregnancy and transferring to a different practice.

Cycle 2 Phone calls were then made to 90 women, of whom 4 were uncontactable and 43 answered the phone. Of these, 25 (58.1%) booked an appointment, 8 (18.6%) said they would ring back, 4 (9.3%) gave a reason for not having a smear, 3 (7.0%) wanted to receive their covid-19 vaccine first and 3 (7.0%) refused.

Conclusion This project demonstrated using a different method of communication can increase the uptake of smears.

Phone calls to the women invited was found to be the most successful method and something Gosport Medical Centre will continue to do.

Establishing a tool to identify COVID-19 pneumonia patients for Respiratory follow up in a Birmingham Teaching Hospital

Aims

Background & Issue

A Pailing*, H Marsland*, D Kavanagh, G Hagan British Thoracic Society guidance (May 2020) states all patients with COVID-19 pneumonia (suspected/confirmed clinically with COVID changes on chest X-ray or CT) require specialist outpatient respiratory follow up.

Methods Limitations

Time frame 1st March – 31st May

Performed in 5 phases: Phase 1: Individual imaging reports in COVID-19 swab positive patients manually checked Phase 2: Additional ‘flags’ added by radiologists during image reporting to reduce burden of manual reviewing Phase 3: Dates adjusted to create on overlap of 1 week, ensuring patients swabbed in previous phase but imaged in current phase (and vice versa) not missed.

Newly established email referral for COVID-19 follow up.

Less initial processing of COVID swab positive list reduced workload for clinical audit department.

Phase 4: Carried out as with phase 3 Phase 5: Highlighted those patients discharged from ITU § The initial phase was labour intensive. This was not a sustainable method to use as the pandemic continued. § Coding of imaging reports could not always be relied upon solely, due to outsourcing and subjectivity. § During such a busy time, we could not expect Junior Doctors to ensure all patients were referred by email. § Images are reported a few hours after being performed, before which time a patient may have already been sent home from ED/AMU and follow up not arranged.

A time and resource efficient tool has been developed to identify patients with COVID-19 pneumonia, whilst patients requiring COVID-19 pneumonia respiratory follow up have been correctly identified. A single point of access email adds another safety-net to ensure no patients are missed, but cannot be relied upon solely for the referral of all patients. As the pandemic continued the tool was used to risk stratify patients, allowing priority follow up for those with most severe disease.

Duplicates & deceased removed (n=843)

Imaging reports in COVID19 swab positive patients manually read to determine follow up requirement

To identify all patients seen at a cross-site teaching Hospital in Birmingham with COVID-19 pneumonia since the start of the COVID-19 pandemic To produce and refine a tool for identifying COVID-19 pneumonia cases which could continue to be used as the pandemic progresses.

Generated list of COVID-19 swab positive patients (n=1203)

Generated list of all CXR & CT requests/reports which contain the word “COVID”

At a cross-site teaching hospital in Birmingham, COVID-19 services were delivered by all medical specialties. There was no established process for identifying discharged patients with COVID-19 pneumonia.

Data from a cross-site teaching Hospital in Birmingham Data collected over 3 month periods: § Imaging requests/reports with COVID in the text § COVID-19 swab positive patients Cross-referenced to identify all COVID-19 pneumonia patients Utilised and developed/refined methods concurrently

Conclusions

Phase 1

Patient list for follow up generated, n=634

Phase 2

Time frame 1st June– 23rd August

Generated list of COVID-19 swab positive patients n=241

Generated list of all CXR & CT requests/reports which contain the word “COVID” Imaging reports with COVID flag B (highly likely), n= 40

Imaging reports with COVID flag C (indeterminate) n= 32

Duplicates* & deceased removed n=78

Imaging reports with no COVID flag

Lists combined to give swab positive patients and their imaging reports n=78

Manually screened imaging reports to include those with confirmed COVID pneumonia Patient list for follow up generated, n=55 *Including those already filtered from COVID flag B and C, and those previously followed up

Phase 3 Time frame 17th August – 20th October

Generated list of COVID-19 swab positive patients n=709

Generated list of all CXR & CT requests/reports which contain the word “COVID” Imaging reports with COVID flag B (highly likely), n= 28

Imaging reports with COVID flag C (indeterminate) n= 4

Single point of access email referral for any clinician treating a patient with COVID-19 pneumonia

Duplicates* & deceased removed n=528

Imaging reports with no COVID flag

Lists combined to give swab positive patients and their imaging reports n=528

Manually screened imaging reports to include those with confirmed COVID pneumonia Duplicates removed Patient list for follow up generated, n=87 *Including those already filtered from COVID flag B and C, and those previously followed up

Phase 4

13th October – 31st December Swab positive* = 978, Total Follow Up = 413

Phase 5

24th December – 1st March Swab positive* = 1616, Total Follow Up = 447

*duplicates and deceased removed

British Thoracic Society Guidance on Respiratory Follow Up of Patients with a Clinico-Radiological Diagnosis of COVID-19 Pneumonia. V1.2 11 May 2020

Show some ReSPECT! Improving the documentation of treatment escalation recommendations during Covid-19 and their communication with primary care Matthew Beresford (IMT2), Amy Gimson (IMT2), Annabel Jones (FY2), Evie Watts (FY2), Caroline Woodman (IMT2)

Background:

Did we meet our aims?

The ReSPECT form records personalised recommendations for a person’s clinical care and treatment in a future emergency in which they are unable to make or express choices.

This standardised form was introduced nationally in 2016 to overcome variations between trusts in the documents previously used to record such decisions. In September 2019, it was officially adopted by UHBW yet significant barriers existed to its use.

Aim 1:

What was the problem?

-Low no. inpatients with a ReSPECT form (50% Nov 2019) -Often not documenting capacity or suitability of specific treatments e.g. NIV -Poor communication of treatment escalation decisions to primary care Surveys of consultant and junior body identified barriers: 1. Training and education needed 2. Lack of time for escalation discussions 3. Cultural expectations of patients/relatives

- ReSPECT form completion rose from 5% in September 2019 to 90% in March 2021, achieving our first aim - Pertinent information on the TEP form re. ICU and NIV fell from >85% to 40% following the peak of the COVID pandemic Aim 2:

What were our aims?

AIM 1: Ensure >90% of medical admissions at the BRI have a valid (signed by a clinician) ReSPECT form which records a decision on whether resuscitation, ITU and NIV would be appropriate in the event of clinical deterioration within the first 48 hours of admission AIM 2: Increase the percentage of medical discharges at the BRI who have treatment escalation recommendations (TERs) recorded on their discharge summary from 59% to >80% by December 2020 - Dramatic change in documentation on discharge but missing our - >80% target

What did we change?

Lessons and Limitations: ● Senior clinical staff engagement necessary to drive behaviour change ● Passive information delivery less effective ● Significant impact of making ReSPECT section of discharge summary mandatory ● Further work on quality as well as completion rates

Ideas for the future

1

Teaching around what GPs would like to know on discharge

2

Patient information leaflets

3

Ward posters explaining ReSPECT process

4

e- ReSPECT form which links to connecting care

5 ReSPECT tag added to board round whiteboards

Changing Methods of Communication: Steroid Alert Card Patient Safety Audit Dr Fiona Kirkham-Wilson & Dr Lauren Medwell, Royal Hampshire County Hospital, HHFT

Introduction All patients taking steroids for more than 3 weeks should have a steroid alert card.

There have been 328 incidents related to steroid replacement therapy and 4 deaths in the past 2 years.

A steroid-alert card is an important safety measure to ensure patients receive correct medication and avoid adrenal crisis.

The Covid-19 pandemic necessitated change in communication between General Practitioners and patients – this offered new opportunities for improving patient safety.

Methodology Plan • Audit all patients taking any dose of prednisolone daily and establish if they have previously carried a steroid alert card, how this was issued to them, and whether they require a new card.

Act

Do

• All patients without a steroid alert card were issued with one.

• Patient records were updated to include current dosage and ownership of the card.

• A yearly alert was added to electronic records for follow-up.

• 64 patients were identified as daily prednisolone users from electronic records.

• 50 were appropriate to contact – those receiving palliative care, or intermittent users were excluded.

Study • All 50 patients were contacted within 2 attempted telephone contacts.

• 10 patients had never had a steroid card.

• 22 patients required a new card due to loss or having filled the space for dose change.

Results 100% of patients were contacted within two attempted contacts.

80% had been issued with a steroid card.

54% of patients had lost or filled their cards.

Most patients received their initial card from their specialist who started the treatment.

No patient had ownership of a steroid alert card included in their electronic patient record.

The intervention stage was completed in under 10 hours – contact time of 12 minutes per patient.

Discussion All patients were available within two attempted telephone calls – possible impact of being in a national lockdown – this may not be reproducible in future years.

Use of telephone-based intervention required two sessions meaning fewer patient contacts available for other service users.

74% of long term steroid users did not have a useable steroid alert card putting them at risk of serious health consequences.

A text based system would be an alternative intervention for future years, although not accessible to all patients.

Documentation of ownership of a steroid alert card, and current dose taken, should be made standard in electronic patient records as a second safety feature for a patient admitted to hospital.

References Team, D.T.B., 2020. Steroid emergency cards: action needed.

Simpson, H., Tomlinson, J., Wass, J., Dean, J. and Arlt, W., 2020. Guidance for the prevention and emergency management of adult patients with adrenal insufficiency. Clinical Medicine, 20(4), p.371.

Dean, J.D., 2020. A coordinated approach to patient safety for people with adrenal insufficiency. Clinical Medicine, 20(4), p.370.

Improving accurate transfer of discharge information between secondary and primary care: an FY1 Discharge Checklist for IDDs Helen Kerr FY2 and Rebecca Reid FY2, Southern Health and Social Care Trust

Background Transfer of information between secondary and primary care is important to ensure a seamless transition of care takes place when a patient leaves hospital.

Clear and complete documentation in a patient’s health record is essential, allowing GPs to access information and ensuring quality and continuity of care – improving patient safety.

Completion of an immediate discharge document (IDD) for patients is a key task performed by FY1 doctors.

The Problem A survey of FY1 doctors based in Craigavon Area Hospital revealed: the number one reason for difficulties obtaining discharge information was lack of documentation in patient notes.

Aims & Objectives 1.

2.

To review and improve documentation of information required for completion of IDDs. Ensure accurate transfer of information from secondary to primary care for ongoing patient care.

Results

PDSA 1 Plan: Defined problem and questions we wanted to answer with this project.

Do: Distributed survey amongst FY1 doctors and reviewed GAIN guidelines.

Audit of patient notes >50% notes had no discharge diagnosis documented.

Study: Analysed data and decided on intervention.

Act: Implemented ward round proforma for discharge information documentation. (Fig.1)

PDSA 2 Plan: Monitor/evaluated intervention, obtained feedback.

Do: Collected data on proforma use – only 5% uptake. Re-audit of patient notes – no improvement.

Study: Analysed data obtained.

Act: Changed intervention after feedback – implemented discharge checklist poster on wards. (Fig.2)

PDSA 3 Plan: Monitor/evaluated intervention.

Do: Covid-19 Pandemic disrupted further data collection on improvement in documentation in notes.

Study: New need identified for FiY1 pandemic induction material – need for discharge resources.

Act: Discharge checklist poster included in FIY1 NIMDTA Induction.

Methods The Standard: 2011 GAIN Guidelines on Regional Immediate Discharge Documentation for patients being discharged from secondary into primary care (1).

• • • • •

Survey performed with FY1s to identify most important items of discharge information, alongside guidelines.

Audit performed of discharge information documented in patient’s notes.

Discharge ward round proforma created – an aid for documenting 5 key items of discharge information on day of discharge (Fig.1) Awareness raised about proforma through teaching.

Further PDSA cycles – feedback and relevant changes made.

Fig. 2

Fig.1

Discussion Poor transfer of information between secondary and primary care directly impacts on quality of care patients receive.

Lack of information documented in notes leads to inaccurate completion of IDDs. Interventions to improve documentation of discharge information in notes, clearly challenging amongst pressures of a busy ward.

PDSA Cycle 3 interrupted by Covid-19 pandemic: new pathway to continue QIP, educating new incoming junior doctors on key requirements for an IDD with teaching during induction and visible reminders on the ward in the form of our poster.

• Poster included in NIMDTA regional induction for FiY1s in 2020 - a new resource created to aid education of new doctors on key discharge information and to highlight importance of accurate transfer of this information between secondary and primary care.

• • • •

References

1. GUIDELINES ON REGIONAL IMMEDIATE DISCHARGE DOCUMENTATION FOR PATIENTS BEING DISCHARGED FROM SECONDARY INTO PRIMARY CARE [Internet]. 1st ed. 2011 [cited 28 March 2021]. Available from: https://www.rqia.org.uk/RQIA/files/73/734a792f-f9d4-47f0-830f-31f9db51c82a.pdf

COVID-19 Respiratory Follow-up at Poole Hospital: A Quality Improvement Project Dr Jae-Ram Song, Dr Francesco Folli, Dr Yin Wai (SHO); Dr Kunal Sharma, Dr Ahmed Mohammed (SpR); Dr Simon Crowther (Cons.)

Background During the COVID-19 pandemic, our hospital struggled to keep track of patients who were discharged following their COVID-19 pneumonia infection. It was vital these patients were offered follow-up as they were at risk of developing respiratory complications post infection. It quickly became clear that hospitals were required to create an adequate system to ensure early diagnosis of such complications and appropriate management.

Aims and Method

Flowchart outlining the follow-up pathway

1. To see how many patients had been followed-up appropriately according to British Thoracic Society guidelines (1).

Repeat CXR to be booked for within 12 weeks. Ensure this is written on discharge summary and patient informed.

We aimed to follow-up patients with a clinical and radiological diagnosis of COVID-19. We initially analysed the COVID-19 admission data between March and June '20 to determine how many of these patients were followed-up appropriately.

Referral to respiratory COVID follow-up pathway through IPR email address respiratory.referrals@uhd.nhs.uk

2. If applicable, create a robust follow-up system applicable to our hospital, managing available resources appropriately.

We created a system based on BTS guidelines outlined below.

3. To ensure optimal capture of as many patients as possible.

We increased awareness of our new pathway via PDSA cycles.

Actions included emails sent to the medical directorate outlining the process and Grand Round presentation in January '21.

Our COVID-19 Follow-up Pathway We created a semi-automated internal electronic referral process which went live in November '20.

Persistent changes on CXR

Telephone consultation between 6-12 weeks.

Patients will be assessed at this appointment for ongoing respiratory symptoms.

At time of discharge, doctors complete an internal online inpatient referral form (IPR) and request a repeat CXR within 12 weeks for all patients meeting our follow-up criteria. We have weekly clinic slots to review these repeat radiographs. Those with normal imaging received a letter containing the COVID-19 hotline number to call if they had ongoing symptoms post discharge. Those with abnormal CXR received a telephone consultation to consider further investigations.

Resolved changes on CXR

A letter will be sent to the patient.

This will include details of who to contact if the patient has ongoing respiratory symptoms.

(Contact number: 03000192972)

The following will be considered at this appointment: Pulmonary function tests Further imaging including CTPA Face to face clinic appointment

oms

sympt g n i o g On

Results We discovered only 7 patients who met the criteria were appropriately followed-up between March-June '20, out of a total of 47, although this is limited due to difficulty in data collection.

Since our system launch in November '20, we have followed up a total 214 patients to date. Of these, 131 patients have had a repeat CXR so far. Figure 1 shows the proportion of patients requiring further investigations or clinic review as a result.

Figure 2 shows how our follow-up capture progressed month-to-month.

We have successfully increased the number of patients captured from 26 to 89 between December '20-January '21 after increasing awareness via PDSA cycles.

We have increased our % capture from 15% (7 of 47 total COVID-19 admissions) between March-June'20 to 58% (78 of 134) in January '21 as illustrated in Figure 3.

We are continuing to capture and follow-up patients from March '21.

Figure 2: Number of patients captured by month

Figure 1: Follow-up Outcomes Further Investigations: 8.4 % n=11

Clinic review: 22.1 % n=29

Discharged: 69.5 % n=91

Challenges and Future Outlook

100 80 60 40 20 0

Mar '20

Nov '20

Dec '20

Jan '21

Feb '21

Often medical patients were under different teams on outlying wards due to bed status. This meant they were missed from follow-up.

We aim to increase capture of these patients by continuing to raise awareness hospital-wide e.g. teaching/intranet page update.

There was difficulty obtaining total COVID-19 admission data for all months to calculate % patients captured for follow-up for comparison.

As a DGH we had to manage limited resources to capture a huge number of new patients.

We aim to continue junior doctor involvement to improve our system and ensure optimal capture of patients.

Figure 3: Comparison data for % patients captured for follow-up March-June '20

15% captured

85% missed

January '21

58% captured

42% missed

References 1. British Thoracic Society (2020) 'British Thoracic Society Guidance on Respiratory Follow Up of Patients with a Clinico-Radiological Diagnosis of COVID-19 Pneumonia'. Available at: https://www.brit-thoracic.org.uk/document-library/qualityimprovement/covid-19/resp-follow-up-guidance-post-covid-pneumonia/

A semi-automated system to ensure safe renal function monitoring Howell Fu1, Bubbu Thava2 1 Royal

Berkshire Hospital, Oxford Foundation School 2 Milman and Kennet Surgery, Reading

Methods

Audit standard Population: l Patients >= 75 yrs l Taking ACE inhibitors/ARBs/Loop diuretics

Single GP surgery 15000 patients

Requirement: l U&E and GFR monitoring every <= 15 months

Manual analysis for underlying reasons

Emis search: - Active drug

- Blood results

in relevant groups - Patient age dates

66/432 patients overdue monitoring

Reasons for non-monitoring No reason, 27%*

66 patients

Palliative; 1%

* In most cases, patient had consultations for other No consultation; problems, and the clinician 35% ran out of time or did not remember to discuss GFR monitoring

Secondary care; 1% Not engaging; 5%

Pt did not book/DNA; 12%

Admin error; 8%

Intervention: • Clinician education session • New system (flow diagram on the right)

Declined (covid); 11%

Annual EMIS search On clinical governance calendar

Identify non-monitoring patients

Mobile number on EMIS

Root cause analysis: - Reliance on clinician encounters - No overarching system to catch non-monitoring Reminders via batch SMS iPlato platform

No mobile on EMIS

Reminders via mail

Conclusion • We identified patients missing monitoring and implemented a semi-automated system to ensure nobody falls through the cracks.

• We will re-audit at one year to assess its effect.

th 16

June 2021

Poster Competition Group F

Care of the unwell patient (1) First prize: Recognising the deteriorating patient: Optimising lab to ward communication of abnormal blood results Presenter: Dr Aya Abbas NHS Frimley Health Foundation Trust

Second Prize: FRIDAYS – Make Every Day A Friday Presenter: Dr Mark Hoey Northern Health and Social Care Trust

A Quality Improvement Project to create an electronic fluid balance chart to improve the documentation of the fluid balance and the prescribing of fluids Jonathan Moriarty 1, Natassja Moriarty 2, Alan Barton 3 Furness General Hospital

Introduction and Aims • This project started out initially as an Audit of the July 2016 NICE Sepsis 6 guidelines of patients (18 years and older and not pregnant) who were admitted through the Emergency department to the AMU. • The Audit showed that there was poor compliance with the prescribing of IV fluids and the implementation of a Fluid Balance chart within 1 hour of diagnosis of Red Flag Sepsis.

Project Results • The implementation of the Electronic fluid balance (EFB) resulted in the target of 80% being achieved.

• In August 2019, 56% of persons had IV fluids prescribed within 1 hour, after the EFB was implemented, this improved to 83%.

• In August 2019, 77% of persons had a fluid balance put in place within 1 hour of diagnosis but after the EFB was implemented, this improved to 88%.

• This then led into a Quality improvement project with the Aim of introducing an Electronic fluid balance (EFB) on the Electronic Ward Round note to improve the compliance of : 1. Implementation a Fluid Balance chart and 2. Prescribing IV fluids to an 80% compliance rate when assessing and treating a patient with Sepsis.

Fig 3: Summary of cycle 1 audit findings

Fig 1: Summary of cycle 0 audit findings

Project Methodology • It is predicted that with the implementation of an (EFB) this will serve as a reminder and as a result improve the Compliance rate to the targets above.

• Questionnaires were given to the doctors asking how they felt about implementing the (EFB) and most them agreed that it would be helpful.

• The IT department was consulted and a preliminary EFB was created and trialled on the Electronic Patient Records.

• Data was collected for the patients admitted to the AMU in May 2020 (at the peak of COVID) with red flag sepsis and they were assessed for a Fluid balance chart and IV fluids given within 1 hour of diagnosis.

• This data was compared for analysis and suggestions taken from other Doctors.

Fig 2: Electronic fluid balance on the electronic patient record

Lessons Learnt The importance of accurate documentation of fluid balance results in: • Early detection of shock in septic patients • Accurate measurement of ongoing losses such as in haemorrhage, gastroenteritis, surgical drains • Accurate measurement of urine output in patients with acute kidney injury • Objective correlation between the patient’s fluid status (euvolaemic/hypovolaemic/hypervolaemic) and the fluid balance

Audit into Acute Kidney Injury (AKI) Management in a Medical Admissions Ward Tribedi, Thomas Methodology

Background

• Trust guidelines for the management of Acute Kidney Injury were used to generate a list of criteria to be assessed. Standards were set, allowing a small margin for cases which deviate from guidelines due to clinical judgement • All patients admitted to Emergency admissions unit (EAU), at Grantham and District hospital, with an AKI of any staging, as proven on blood tests, were included in this audit.

• Medical notes, blood results (WebV) and drug charts were reviewed for evidence of fulfilment of the criteria. For the purpose of this audit, ‘on admission’ is considered to be the duration of time up to and including the ‘post-take’ senior review. Microsoft excel was used to record and analyse the data.

• Cycle 1 was conducted during the period of 14/01/20 to 13/02/20 inclusive. 22 patients were identified, all were found to have a pre-renal cause of their AKI. In terms of distribution of AKI staging: 7 (31.8%) were in stage 3, 2 (9.1%) in stage 2, and 13 (58.1%) in stage 1.

• Cycle 2 was conducted during the period of 22/03/20 to 21/04/20 inclusive. 17 patients were identified, all were found to have a pre-renal cause of their AKI. In terms of distribution of AKI staging: 2 (11.8%) were in stage 3, 3 (17.6%) in stage 2, and 12 (70.6%) in stage 1.

• Acute kidney injury (AKI) occurs in 13–18% of all patients admitted to hospital, with the percentage being higher in acute admissions and older adults.[1,2] • AKI carries both a high rate of morbidity and mortality especially as it is often present alongside additional pathologies [2].

• These patients are managed initially by healthcare professionals of specialties other than nephrology, and therefore it is vital that available guidance is being followed to ensure the optimum care of AKI patients is delivered, to reduce both complications and potential mortality.

• A prospective audit was undertaken with the aim to assess the compliance to AKI management guidelines and ensure all patients are investigated, managed, and escalated appropriately.

Interventions

Discussion

• Following the first cycle a number of interventions were implemented: • Discussion with senior clinicians to highlight areas of below expected standard of fulfilment • Refresher presentation to doctors on ward on the topic of initial AKI management and investigation • Implementation of posters on the ward displaying simplified guidelines for management and investigation of patients with AKI

• Re-audit following interventions showed significant improvement across all criteria, particularly in regards to identifying and investigating cause and contributors to AKI

Results Criteria

Standard set

Cycle 1

Cycle 2

1 - Patients with AKI should have their risk factors identified on admission

100%

81.8% (18/22)

100% (17/17)

2 - Patients with AKI should have their fluid status address (i.e. IVI in hypovolaemia, or diuretics in overload)

100%

100% (22/22)

100% (17/17)

3 - Patients with AKI should have their medications reviewed and nephrotoxics held on admission

100%

77.3% (17/22)

100% (17/17)

4 - Patients with AKI should have a full set of bloods on admission including bicarbonate 5 - Patients with AKI should have a urine dip on admission

100%

63.6% (14/22)

94.1% (16/17)

90%

72.7% (16/22)

94.1% (16/17)

6 - Patients with AKI should have an input/output chart implemented on admission 7 - Patients with AKI should have a AKI Proforma completed on admission

90%

90.9% (20/22)

100% (17/17)

80%

40.9% (9/22)

76.5% (13/17)

8 – Patients with unresolving AKI stage 2 or AKI stage 3, should be discussed with the renal team

100%

100% (7/7)

100% (3/3)

9 – Patients with AKI should have daily bloods until AKI has resolved

90%

90.9% (20/22)

94.1% (16/17)

• However the use of the AKI proforma remained below expected standard, despite some improvement in utilisation • In terms of patient care the audit interventions can be seen as successful as in all areas which directly impact patient care there was improvement to an acceptable standard • The low utilisation of the proforma poses a potentially interesting question into the role of proformas in delivering high quality patient care and patient safety.

• Follow-up from this audit: • Keep guideline posters on displayed in wards • Arrange refresher presentations on initial AKI management and investigation for junior doctors during each new rotation of trainees • Undertake an annual reaudit to ensure sustainable change in the standard of patient care

References 1. National Institute for Health and Care Excellence (NICE). Acute kidney injury – Quality standard. 2014.

2. National Confidential Enquiry into Patient Outcome and Death (NCEPOD). Adding Insult to Injury. 2009

F.R.I.D.A.Y.S. – Make Every Day A Friday Improving the out of hours experience Background Weekend on-call services in acute hospitals are potentially high-risk periods for patients. We learnt a significant proportion of on-call junior doctor time in our Medicine department was spent completing routine administrative tasks that should have been completed during normal working hours. Junior doctor experience at weekends was poor.

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

Intended benefits: To improve out of hours staff experience.

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

Project team Baseline data collection Afternoon checklist introduced Scale and expand ward by ward Staff experience survey

Afternoon Checklist and Process Map

Results Out of hours bleeps for routine tasks 70 Baseline Ward 1

Number of bleeps

60

Baseline Ward 2

50 40 30

Start Ward 1

Start Ward 2

20 10 0 Month 1

Month 2

Month 3 Ward 1

Month 4

Month 5

Staff experience survey results

Ward 2

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

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

Mark Hoey – Lead Author mark.hoey@northerntrust.hscni.net Pauline McIntyre - Service Improvement Manager Leanne McKeown - Hospital At Night Co-ordinator Clare Diamond – Broad Based Training Year 1 Doctor Gareth Lewis – Consultant Acute Physician

Sussamma Raju - Ward Manager/ Nurse Alan MacPherson – Foundation Year 1 Doctor David Brennan – ST5 Registrar Doctor

A Quality Improvement Project

Authors

Introduction of treatment escalation planning in a tertiary centre for cardiothoracic surgery

Dr Shehani Alwis Dr Maximilian Greenfield Mr Shahzad G. Raja

Introduction Treatment Escalation Planning (TEP) forms are an invaluable tool for initiating discussions with patients to better understand their ideas, concerns and expectations regarding ceilings of treatment. It is also a useful opportunity for the admitting medical team to objectively assess patient’s fitness for potentially invasive treatments which may not necessarily be in their best interest. Additionally, TEP forms are a useful way of quickly communicating escalation plans to all members of the multidisciplinary team (MDT) in the event of acute patient deterioration.

Our aims for this project were to ensure that all new cardiothoracic admissions have a TEP discussion documented. We aimed to carry this out by introducing a locally approved form and setting up an educational programme to ensure junior doctors develop confidence in initiating treatment escalation planning discussions and all members of the MDT are aware of the different levels of escalation.

Methodology Following assessment of current literature and guidelines as well as registration with the trust clinical governance office; medical records for cardiothoracic inpatients (n=38) were reviewed for evidence of documented TEP or DNACPR. We analysed the notes of both elective and emergency admissions, for patients who had arrived as an inter-hospital transfer we additionally noted whether they had a documented TEP or DNACPR at their previous hospital. Additional data including age, comorbidities and pre- or post-operative status was collected.

A departmental TEP form was developed following consultation with key stakeholders and presented at both departmental teaching sessions (within the department for cardiothoracic surgery) as well as the trust-wide clinical governance day. Following this, all cardiothoracic admissions were required to have a TEP form completed by the clerking doctor and countersigned by a senior within twenty-four hours. Additionally, we had discussions with senior nursing staff on the introduction of the TEP form and added this as an element in the admission checklist.

Following this we re-audited the use of TEP forms in patient’s notes across two of the main surgical wards. We noted whether any discussion had been documented, the form countersigned by a senior within twenty-four hours as well as additional information on patient demographics as per the first audit cycle.

Quantitative outcomes for the project include successful completion rate of TEP forms whilst qualitative data related to staff feedback was also collected.

P

Results and lessons learnt

P D

A

S

S

n=38

n=30

No TEP discussions documented

Form, education and admission checklist 33% patients had TEP form, 30% had TEP discussion documented

Following introduction of the TEP forms it is clear that there was an improvement in discussing treatment escalation plans with patients on admission. However, we noted that for the patients who did not have a completed TEP form they had often been admitted elsewhere in the hospital - either coming from home directly into the Day of Surgery Admission Unit via the pre-admission team or as an inter-hospital transfer onto a non-surgical ward. This highlighted the need to widen the scope to a hospital-wide initiative to ensure that all patients across the site are having TEP discussions on admission. Following presentation and discussion at the trust-wide clinical governance meeting, a Treatment Escalation Planning Working Group has been set up to ensure consistent delivery of TEP discussions across the different specialities and wards in the hospital.

Overall the feedback from stakeholders has been constructive and positive. From an education point of view, some staff stated that they do not yet feel comfortable initiating TEP discussions but have started to develop a better understanding of TEP than they had previously. Therefore our priority, prior to our third cycle will be a continuing educational programme to empower staff to discuss treatment escalation with patients.

D

A

The first cycle demonstrated no cardiothoracic inpatients had a documented TEP. Of note, 6 patients transferred from an acute hospital had previously documented TEP discussions which were not continued into their current admission.

Following the second cycle of the audit, ten of the thirty surgical inpatients across two of the surgical wards had a completed TEP form at the front of their inpatient notes. Of these ten completed forms, nine had a documented discussion in the notes and only three had a completed senior review within twenty-four hours.

P

D

A S

Further education sessions then re-audit.

Conclusion Overall, treatment escalation planning with patients admitted to our tertiary cardiothoracic centre improved with the introduction of TEP forms and both departmental and cross-site education sessions. Prior to our next cycle, we aim to have more targeted education sessions on TEP discussions to ensure this continues at our hospital and improve patient care.

Recognising the deteriorating patient: Optimising lab to ward communication of abnormal blood results Abbas A*, Brackenborough K, Higton A (Supervisor) Wexham Park Hospital Bristol Patient Safety Conference 2021 *Correspondence to aya.abbas1@nhs.net

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

ü Aims

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

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

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

ü Results

ü Methods CYCLE 1 - October 2020 PLAN: Allocated a team to shadow the biochemistry biomedical scientist as they attempt to contact the wards to relay abnormal blood results.

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

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

Answers and informs Incorrect patient location

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

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

CYCLE 2 – March 2021 PLAN: Four main medical wards with IT systems discrepancies resolved.

Biochemical scientists (haematology now also recruited) invited to use the new NIC contact list to communicate abnormal results.

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

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

Figure 2: The range of overall number of attempts vs time to contact all wards.

CYCLE 1: Of these 54 results, 19% of communication attempts were eventually abandoned and the results subsequently uploaded online only.

CYCLE 2: Of these 52 results, 100% were communicated over the phone, although 4 (8%) were unable to reach the allocated NIC number.

ACT: Promoted further engagement of staff on wards that remained more difficult to contact.

ü Conclusions and scope for further improvement Communicating abnormal results involves a complexed system within the acute hospital setting with areas where human factors play a large roll.

Many areas for improving safety and efficiency were highlighted from our systems map, and our second cycle showed that simply updating ward contact numbers and locations meant that 100% of abnormal results were communicated over the phone in a more timely manner.

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

Figure 3: CYCLE 1 Chart showing the Figure 4: CYCLE 2 Chart showing the relation between actual and request from same data after correction of ward name location of patients and the reasons discrepancies on the pathology behind any discrepancies. 4% were software. delayed to programmed software errors.

ü References and acknowledgments

1. Croal B. (2017) The communication of critical and unexpected pathology results. The Royal College of Pathologists.

Available from: The-communication-of-critical-and-unexpected-pathology-results-pdf. [Accessed 20th December 2020].

We would like to thank A Parmar, N Zaman, S Saravanabavan, F Odunsi, H Kaur, S Abdelkahem, S Pestana, R Seleman and the biochemical scientists at WPH pathology for their contributions to data collection.

Improving access to equipment for neurological assessment of patients with suspected malignant spinal cord compression (MSCC) Dr Terese Grace Nicholas; Supervisor: Dr Gareth Ayre Bristol Cancer Institute, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK

BACKGROUND • • • •

Within the Acute Oncology Unit at Bristol Cancer Institute, patients are frequently assessed with symptoms suspicious for MSCC These patients require thorough neurological examination in order to guide appropriate and timely investigation and management, as delays in assessment and treatment of MSCC risk irreversible neurological damage[1] It was noted within our department that equipment required to perform a neurological examination for suspected MSCC (e.g. tendon hammers, Neurotips) was not always available or easy to find Difficulty in accessing this equipment has the potential to cause unnecessary delays in the assessment of patients with suspected MSCC, or the neurological assessment performed may be compromised by lack of available equipment

INTERVENTIONS

AIMS & OUTCOME MEASURES What are we trying to accomplish?

1. To improve the availability of equipment required to perform a comprehensive neurological assessment for patients presenting with suspected MSCC 2. To reduce the time taken by staff to find equipment for neurological assessment of patients presenting with suspected MSCC A second cycle of the project was conducted based on staff feedback, which (in addition to the above aims), endeavoured to improve the ease of telephone triaging of patients with potential MSCC contacting the Acute Oncology Unit.

How do we know a change is an improvement?

• All clinical staff based regularly on the Acute Oncology Unit at Bristol Cancer Institute were surveyed; this included doctors, nurses and advanced nurse practitioners (n=7) • Staff surveys were used to identify issues, and to guide and measure the impact of change

`

PDSA Cycle 1 interventions: • Creation of a neurological equipment box (the “MSCC Neurobox”) – a clear plastic storage box with a lid, clearly labelled to indicate its purpose, containing tendon hammers, Neurotips and cotton wool (for sensory examination), and lubricating jelly (for testing anal sphincter tone via rectal examination) • The MSCC Neurobox was located in the main workspace of the Acute Oncology Unit • The presence of the MSCC Neurobox was publicised by word-of-mouth PDSA Cycle 2 interventions: • Tuning fork, laminated dermatome/myotome information sheet – added to MSCC Neurobox • Laminated information poster developed (adapted from existing local guidelines) to aid telephone triage for patients with potential symptoms of MSCC or new spinal metastases • Continued efforts to increase awareness of MSCC Neurobox via word-of-mouth

PDSA CYCLE 1 Initial staff survey • Staff rating of ease in finding equipment for MSCC assessment (1= extremely easy, 10= extremely difficult) à mean score 7.1, median 7 • Staff also questioned on current equipment use for MSCC assessment and indicated desired equipment for MSCC assessment (Figure 1)

PDSA CYCLE 2

“MSCC Neurobox” created in response to initial survey

Repeat staff survey approximately 3 weeks postimplementation – assessing awareness of MSCC Neurobox and impact on difficulty rating for finding equipment required for MSCC assessment (Figure 2 and Figure 3)

Issues identified from PDSA Cycle 1 post-implementation surveys: • Not all staff were aware of the MSCC Neurobox • Desire for additional tools to aid MSCC assessment • Desire for guidance to aid telephone triage of patients with suspected MSCC Ø PDSA Cycle 2 interventions (described above; illustrated in Figure 4) Ø Repeat staff survey approximately 4 weeks post-Cycle 2 interventions Figure 4: PDSA Cycle 2 interventions

RESULTS • 71.4% of respondents reported assessing patients with suspected MSCC 1-2x/week on average • 85.7% aware of the MSCC Neurobox, and all who were aware of the MSCC Neurobox felt since its implementation they were able to find equipment for assessment of suspected MSCC more quickly Figure 1: Actual use vs. desired equipment for assessment of suspected MSCC from initial staff surveys 100

100

80

100 85.7

100 85.7 71.4

60 57.1

40 20 0

14.2 Neurotip

Cotton wool Current use (%)

Tendon hammer Lubricating jelly Desired (%)

Preintervention

Postintervention

Median

7

1

Mean

7.1

2.3

Figure 2: Average difficulty rating (1-10) for finding required equipment for MSCC assessment, pre- and post-implementation of MSCC Neurobox

Figure 3: Difficulty rating scale for finding equipment; arrow indicating change in median rating pre- and post-MSCC Neurobox

LESSONS LEARNED Implementation of the MSCC Neurobox: • Improved availability of equipment deemed important for comprehensive neurological assessment of patients with suspected MSCC • Is a simple but effective intervention that has improved the ease and rapidity in finding neurological equipment for MSCC assessment on the Acute Oncology Unit Feedback from regular staff working on the Acute Oncology Unit helped identify areas for improvement, as well as assessing response to interventions, highlighting the importance of the multi-disciplinary team in driving the ongoing process of improvement.

RESULTS – following Cycle 2 interventions: • 100% now aware of MSCC Neurobox • 100% aware of dermatome/myotome information sheet with 100% reporting that they had found this helpful in MSCC assessment • 100% aware of laminated information poster to aid telephone triage for suspected MSCC – 85.7% had found this helpful in telephone triage for suspected MSCC (N/A for 14.3% - not yet used)

SUSTAINABILITY & NEXT STEPS Local stakeholders involved in the procurement of consumables contained within the MSCC Neurobox have been identified – plan to work with these colleagues to ensure that items within the MSCC Neurobox are maintained and replaced as needed.

Feedback from Cycle 2 post-implementation surveys indicated a desire for teaching on MSCC assessment and management, as well as further guidance on which patients with confirmed MSCC are most likely to benefit from neurosurgical intervention – further interventions will therefore likely focus on addressing these needs.

REFERENCES: 1. National Collaborating Centre for Cancer (UK). Metastatic Spinal Cord Compression: Diagnosis and Management of Patients at Risk of or with Metastatic Spinal Cord Compression. Nov 2008. NICE Clinical Guidelines, No. 75. 4, Early detection. [Online]. Available: https://www.ncbi.nlm.nih.gov/books/NBK55008/ [Accessed 09/05/2021]

Implementation of a Deteriorating Patient Clinical Pathway and Documentation Proforma Dorset County Hospital C White, S Orr, R Thomas, S Mooney

INTRODUCTION : Early warning scores (EWS) help to identify deteriorating patients, allowing timely review and escalation of care.

Significant variation in practice had been noted in our Trust and care.

• •

AIMS: • • •

To quantify the variation in practice.

To develop tools to standardise care throughout the Trust.

To improve patient outcomes and care.

METHODOLOGY: • Retrospective snapshot audit was carried out in November 2019.

• All adult inpatients (excluding obstetric patients) with EWS >4 were included.

• Results were presented to the Trust’s Sepsis and Deteriorating Patient Committee.

• An ‘All Cause Deterioration Pathway’ and a ‘Deteriorating patient Proforma’ were developed following stakeholder consultation to standardise care and improve assessment.

• These were piloted and feedback was sought from medical and outreach teams.

AUDIT RESULTS: • • • • •

N=41 patients (5 excluded as EOL care/ refusing observations).

23/36 (64%) had an appropriate increase in the frequency of their observations.

12/36 (33%) had a documented escalation for clinical review.

11/36 (31%) were reviewed by a clinician within 8 hours of EWS trigger and 5/36 (14%) within 2 hours.

The grade of clinician reviewing the patient was variable.

Fig 1: Proportion of escalated NEWS scores

Fig 2: Grade of reviewing clinician

CONCLUSIONS: Our initial audit indicated much room for improvement, on both review of patients and documentation by clinicians. This has prompted development of the pathway and proforma, which are currently being finalised before implementation across the Trust. A re-audit is subsequently planned for June 2021.

Abdominal XRs only when the radiologist says it is ok

A quality improvement project on the appropriateness of abdominal XRs in the Emergency department Dr Aldo Bignamini, ACCS CT2, University Hospital Southampton THE PROBELM • High volume of abdominal XRs performed by the Emergency Department • Radiology team highlighted most request as inappropriate

Inappropriate abdominal XRs requests can lead to unnecessary exposure to radiation and/or delayed definitive treatment

METHODS Patient presenting to ED

ED clinician review

RN triage

Decision to perform abdominal xray

AIM Investigation adequate

YES

Decision on patient care

NO

• Fishbone analysis Further imaging • Process Map required • Data Review: data searched for «request reason» of abdominal XRs

Primary aim was then set to improve compliance with the Royal College of Radiologist (RCR) indications on abdominal XRs requesting.

CHANGE IDEAS

• Education: peer teaching • Posters for all clinical areas with RCR guidelines for abdominal plain films • Inclusion of RCR indications to the screensaver slideshow on all departmental computers.

RESULTS PRE IMPLEMENTATION

10 patients had an abnormal report

35 compliant (34.6%)

18 (17.8%) underwent CT despite XR

72 compliant (65.4%)

101 110 AXRs AXRs

POST IMPLEMENTATION 28 patients had an abnormal report

10 (9%) underwent CT following XR

DISCUSSION An area of concern has been identified and after the interventions the compliance with the RCR guideline has doubled, the number of abnormal reports has increased and the percentage of patient who underwent CT following AXR has decreased. The results could be interpreted as better selection of investigations, which actually meant a higher number of abnormal reports. Furthermore, there has been a decreased number of patient exposed to the radiation from both AXR and CT. This project shows as relatively simple interventions could significantly improve patient safety. This project has the potential to reduce patients’ time in the Emergency Department and there is the objective to create an investigation pathway working together with the Surgical Department.

Reducing the Rays Reducing Unnecessary Abdominal X-rays in Older Patients Presenting with Acute Abdominal Pain Fiona Mendes1, Raleigh Jenner-Hillard1, Sehajdev Bhatia1, Heather Shearer2, Nicola Davey2 & Jim Crawfurd 1 1James Paget University Hospital NHS Foundation Trust, 2QIClearn BACKGROUND: DEFINING THE PROBLEM

6/10 older patients with abdominal pain have BOTH an abdominal x-ray AND a CT abdomen in our Emergency Department.

This exposes them to more radiation & delays their diagnosis & treatment.

Serious pathology can be missed on an abdominal x-ray.

AIM & MEASUREMENT DEFINITION

HIGH LEVEL PROCESS MAP

By February 2021 we aimed to reduce the number of unnecessary abdominal x-rays performed in older patients presenting with abdominal pain by 50%.

We measured the number of older patients undergoing an abdominal xray (AXR) and subsequent CT abdomen scan within 24 hours of presenting to the Emergency Department (ED) using continuous daily retrospective data from 1 September 2020 to 30 April 2021.

DIAGNOSTICS: BASELINE DATA HISTOGRAM

Typical pathway of older patients presenting to the ED with acute abdominal pain prior to this QIP. Percentages displayed are from the baseline audit (see histogram). Patients not undergoing imaging were not measured.

• Inclusions: Patients aged ≥65 years old with acute abdominal pain undergoing radiological imaging.

• Exclusions: Patients who had a CT abdomen within the preceding 24 hours of presenting to the ED.

RESULTS: RUN CHARTS & PDSA CYCLES PDSA (Plan-Do-Study-Act) CYCLES 1

3-minute Elevator Pitch raised awareness

2

Discussed change ideas with ED clinicians, radiographers, surgical & medical leads

3

ED Morning Bitesize teaching presentations on abdominal pathology, featuring evidence based medicine Gained insight into clinicians’ decision making & tailored sessions to our target audience

4

Learning Board reminders

5

Royal College of Emergency Medicine Safety Alert poster displayed at ED workstations

6

Designed & launched an online ED educational platform featuring accessible abdominal pathology teaching slides (also available as a phone app)

7

8

generated change ideas

Launched an interactive teaching survey across specialities: a) ED clinicians b) Surgeons c) Medics Qualitative data analysed from 65 clinicians across 3 main specialities Multi-speciality Grand Round presentation with expert consultant panel discussion

Overall reductions were seen in AXRs preceding a CT abdomen & AXRs as a solo event.

From 16 March - 30 April 2021, no older patients underwent both AXR & CT abdomen.

This significant reduction exceeded our aim & is not due to chance alone!

In comparison, from 1 March - 30 April 2019, 52 patients ≥65 years-old underwent both AXR & CT abdomen. 37 older patients had both AXR & CT abdomen during 1 March-30 April 2020.

CT abdomen is increasingly used to investigate the differential diagnoses in older patients with acute abdominal pain. Certain stakeholders were concerned CT imaging would significantly increase; however, this did not happen, due to multifactorial reasons.

REFLECTIONS & LEARNING •

Our Trust’s 2019 Radiology GIRFT report identified the trust as an outlier in requesting abdominal x-rays (AXR).

The national average is 34.7 AXRs per 1000 x-rays. Our Trust performed 60.8 AXRs per 1000 x-rays.

• In 2020, there were 3 serious incidents where misinterpreted and normal AXRs in older patients contributed to the diagnostic delay of fatal acute bowel obstruction and perforation.

| qiclearn.com | @qiclearn qiclearn.com|@qiclearn |@fiona_mendes

• This QIP increased awareness that AXRs have a limited role in investigating acute abdominal pain and significantly reduced unnecessary AXRs being performed in older patients.

• 8 PDSA cycles successfully reduced the reliance on AXRs as a diagnostic investigation, across different clinical specialities.

• Introducing frequent, continuous change ideas through PDSA cycles helped us hone our most successful interventions & abandon or quickly develop the less successful ‘change’ ideas. This has motivated our multidisciplinary team to continue to engage our stakeholders to ensure these changes are sustainable in the future.

Background image: Gorleston-on-Sea, Great Yarmouth

Acknowledgements: Thank you to D. Wheatman, M. West, R. Smith & the JPUH Radiology team.

APPROPRIATE USE OF TELEMETRY MONITORING

METHODOLOGY Alexandra Hospital is one of the busy acute hospitals in Worcestershire serving 200,000 population with bed capacity of 300. Yet, there are 16 cardiac monitoring service including 4 full monitored bed in CCU and medical HDU and 8 telemetry boxes. Therefore, we have witnessed delays in providing cardiac monitoring service when we request during on-calls. Additionally, the trust doesn't have a local protocol or guidance in use for telemetry monitoring although there was a proforma introduced in year 2017/2018.

AIMS AND OBJECTIVES After the first audit cycle, we introduced the use of telemetry request forms (with indications and duration) and reminder stickers (to be put on the patients’ notes).

The aim of this re-audit is to look for whether the above intervention has s / Research brought any improvement to the service or not.

A Retrospective study was conducted of patients admitted in Nov/Dec 2018 for data regarding appropriate initial indications, daily reviews & duration of telemetry Sample size (n=90) for both groups Data was collected from Ez notes and CCU

RESULTS There is still a significant fall in inappropriate initial request for telemetry by almost two-third only 10 % in second cycle and 12 % in the 3rd cycle.

There was an improvement in daily review by 20% in 2nd cycle i.e. 86.67 %, However this has dropped to 74 % in 3rd cycles. Will be an area of further emphasis.

There is a rise witnessed in unnecessary monitoring by almost 20 % in 3rd cycle (20 days in total ) in comparison to 2nd cycle ( 12 days in total) .

However this still remains as a low number in comparison to 1st cycle ( 108 days in total ) Therefore, the current intervention brings benefits to the service delivery and lessen the delays of service provision while maintaining costeffectiveness and patients’ safety . However emphasis should be made on areas of improvement

COMPLIANCE AGAINST STANDARDS Standard

Target

1st Cycle 2nd Cycle 3rd Cycle

Appropriate Initial Indication Daily Review Presence of Unnecessary Monitoring

100%

66%

90%

88%

100% 0%

66 % 54% %

88.6 8.89%

74 % 28 %

CONCLUSION

As a conclusion, we found out that using the telemetry request forms and the stickers has brought significant improvement to the service provision while maintaining cost-effectiveness and safety of the patients. However presence of unnecessary monitoring still remains as an area of development

th 16

June 2021

Poster Competition Group G

Care of the unwell patient (2) First prize: Introducing Blanket Screening for Human Immunodeficiency Virus in a Central London Emergency Department Presenter(s): Matilda Fox and Rosie Pettit Imperial Healthcare NHS Trust Second Prize: Streamlining Venepuncture To Improve Efficiency and Patient Safety Presenter(s): Dr. Sachin Wimalagunaratna Royal Devon and Exeter NHS Foundation Trust

Venous thrombo-embolism Risk Assessments in Inpatient Psychiatry A Dual Centre Quality Improvement Project N. Rassa, K. Arjan, F. Robinson, R. Hutchinson, K Hilferink, R. Runciman Background

Methods

The incidence of VTE is higher in psychiatric patients compared to the general population.

Outcomes measures

Specific psychiatric risk factors: • Dehydration and neglect • Decreased mobility: →Physical restraint →Sedation • Anti-psychotic medication

Interventions

1) 2) 3)

VTE forms completed VTE assessment within 24 hours of admission Patients at risk of VTE

1) Posters 2) Trust wide teaching session and induction 3) – Incorporation of VTE assessment into drug charts

NICE recommend VTE risk assessments for all new psychiatric admissions.

Absent assessments may lead to increased morbidity.

Setting - Working Age Adults 18-65 9 (WAA) - Older Age Adults 65+ (OAA)

Aims Limitations

Achieve 50% increase in the complete VTE assessment within 24 hours in accordance with Trust VTE Policy by 1st December 2020.

Delays in incorporating the VTE proforma into drug charts.

FORMS COMPLETED (%) 40

ASSESSMENT WITHIN 24 HOURS (%)

44

Results

33

100 90 80 70

BASELINE

POSTER

TEACHING

60 50 40

Baseline

Poster WAA

OAA

Teaching

VTE DRUG CHART

Baseline

Poster

Teaching

44

33

40

Assessment in 24 hours 69 (%)

69

88

At risk of VTE (%)

11

6

VTE forms completed (%)

20

Conclusions 1) VTE risk assessment within 24 hours in older age adults did not improve.

2) Posters and virtual teaching were effective measures to increase timely VTE assessments this psychiatric setting.

3) VTE risk assessment documentation should be ergonomic to increase usage.

4) Incorporation of VTE assessment documentation within drug charts will likely further improve compliance.

RE-IMPLEMENTING A NEW PATHWAY FOR INTERMITTENT PNEUMATIC COMPRESSION DURING COVID-19 Introduction Venous thromboembolism (VTE) is a common, potentially avoidable cause of death in patients who are immobile.

Those admitted with hemiplegic strokes are more susceptible to developing a VTE, up to 50% of patients develop a thrombus in either the calf or thigh of the paretic limb. Intermittent Pneumatic Compression (IPC) is recommended as VTE prophylaxis as per the Royal College of Physicians (RCP) national guidance for these stroke patients.

(Image A) However, during COVID-19 it has becoming increasingly more difficult to implement these guidelines Project Methodology I used SWOT analysis and also created a Project Initiation Document to ensure that I achieved specific goals in terms of creating and implementing a change. This justified why my project was needed and provided an action plan along with the involvement of other roles. I undertook an audit prior to implementing the IPC pathway, using existing data over a 5 month period during 2020. This was during a period where COVID-19 did not pose a challenge in terms of allocating patients to the stroke ward. The National Institute of Health Stroke Scale (NIHSS) was used to quantify the severity of their stroke and determine their immobility. This score was then uploaded to the Sentinel Stroke National Audit Programme (SSNAP).

Aims To improve our health board’s compliance with national guidance on VTE prophylaxis in stroke patients, I will attempt to re-implement a proforma that every stroke patient will undergo to establish if they are suitable for IPC.

Image A1

Image B2

VTE Result

3%

97%

VTE -ve

VTE +ve

Graph 1

Project Results and Lessons learnt Seventy seven patients were eligible for IPC, but only 1.3% received IPC. I established that 3% of the 77 patients were positive for a VTE. These results are not in keeping with national guidelines.

The initial proforma was distributed, however the major limitation in implementing this was that it was a Consultant-led decision. There was a disparity in prescribing IPC between Consultants. To overcome this, it was decided that Junior Doctors should have a more active role in the process of initiating IPC and become more involved as leaders. "Sticky labels" were created that contained less information than the original proforma and Junior Doctors were responsible for prompting the Consultants to implement the pathway. I intend to re-audit this data.

Results and Findings I undertook an audit prior to reimplementing the IPC pathway, using existing data over a 5 month period during 2020 this was prior to COVID-19 which created a challenge as not all stroke patients were on the stroke ward. The National Institute of Health Stroke Scale was used to quantify the severity of their stroke and determine their immobility.2 (Image B) Using this score I was able to determine the patient’s level of immobility during admission and whether they should have received IPC. Out of the 77 patients that were eligible for IPC, only 1.3% received IPC during the first 72 hours of hospital admission. This is not in keeping with the current NICE and RCP guidelines, therefore a change is needed in this system.8,9 I established that during this 5 month period, 3% of the 77 patients were positive for a VTE, this could have been prevented.

(Graph 1)

References 1. The Lancet, IPC 2013 2. Lyden P. Using the National Institutes of Health Stroke Scale. Stroke. 2017 Feb;48(2):513–9.

A Top Dr aw er ENT QIP SK YLI N E H I GH

N EW SLET T ER

Dr J. West, Dr A. McGaughey, Dr L. Pheasant, Dr R. Watkins

In t r odu ct ion The ENT SHO position bears significant responsibility, especially overnight.

New juniors are frequently rotated on, and general surgical staff cross cover.

These factors together can make procedures daunting, and difficulty accessing new equipment exacerbates this.

This QIP project aims to streamline equipment collection, and support new staff with procedures, thereby reducing strain on the service, and potentially dangerous errors.

Cycle 2 - Ph ot o Gu ides t o ENT Pr ocedu r es

M et h od

- The concept arose following feedback on the first cycle.

- Survey results graphed below revealed variable confidence in identifying ENT equipment items, some of which are used less commonly.

- Confidence locating given items in the treatment room was noticeably lower, indicating an opportunity for improving the system.

- These guides aim to maximize accessibility, especially for cross-cover staff - Consolidate knowledge of equipment requirements

Cycle 3 - Assim ilat ion in t o In du ct ion Dr aw er Test Does assigning specific labelled drawers to procedures save time in equipment selection?

Recording the time taken with a variety of staff members to collect epistaxis management equipment from the traditional setup (mixture of drawers and cupboards), followed by from a specific procedure drawer.

Results showed significant time savings across the board, up to a factor of over 6x faster for the least experienced staff members.

- All of these aid systems will be more effective if specifically introduced to new personnel.

- Cycle 3 will involve an equipment induction for the subsequent group of ENT trainees.

- Embedding this session in departmental tradition will give the project its future.

Con clu sion s Junior doctors and ANPs pick up the clinical and procedural aspects of the ENT job quickly.

However, initially almost every team member is daunted by the new skills and equipment, and by the independence overnight.

Cross covering general surgeons have the least direct teaching and can benefit most from this support.

Small changes in the ergonomics of the Treatment Room can save large amounts of time and stress, in particular for less experienced team members.

Photographic aids can support procedural familiarity when they are readily visible, and remove issues of unfamiliarity.

Improving the Utilisation of Ultrasound for Peripheral Intravenous Cannulation in the Emergency Department Laura Tan, Homero Alves Do Canto Brum, Lara Jesani, Thomas Loka, Emmanuel Bewaji, Tim Ayres EMERGENCY DEPARTMENT, UNIVERSITY HOSPITAL WALES, CARDIFF & VALE UHB METHODS

BACKGROUND Ultrasound- (US) guided peripheral IV cannulation is able to reduce the number of unsuccessful blind cannulation attempts and improve patient experience in the Emergency Department (ED), particularly for patients with difficult access, however we observed the skill tended to be restricted to the more senior members of the team.

We aimed to upskill junior ED staff in US-guided peripheral IV cannulation via a structured and easily-replicable teaching programme.

Our structured teaching programme consisted of three steps:

1

A specifically developed online e-module and quiz covering the core concepts

2

An in-person clinical skills session with further teaching, demonstration and the opportunity to practice on models to gain familiarity with the technique

3

Supervised practice in the ED, with a sign off once the skill is demonstrated competently and independently.

We measured US use and trainee confidence levels in the skill pre and post introduction of our teaching programme.

R E S U LT S 19 ED junior doctors and nurse practitioners undertook our structured teaching programme. 68% had no previous experience using US for cannulation and 47% had no previous experience using US in any setting.

Feedback was highly positive with the e-learning module rated 4.6/5 on average and the practical session rated 4.9/5.

Following the e-learning, mean reported confidence levels increased from 3.3/10 baseline to 6.4/10, increasing further to 8.2/10 following the practical session. (Fig 1) Following the practical session all participants reported they felt ready to perform the procedure either under supervision or independently.

We also observed an increase in the number of junior staff members utilising US in the ED. Prior to the introduction of the programme, US was used to guide cannulation only twice in a 2-week period (with one by a consultant). Following the programme, across 3 days US–guided cannulation was performed 6 times, all by junior members of the team.

Figure 1: Bar graph showing the mean self-reported confidence level of trainees over the programme. Error bars show 95% confidence interval. A significant increase in confidence level was observed as each stage was completed.

CONCLUSIONS We successfully demonstrated the implementation of a three-step structured teaching programme in upskilling junior members of the ED team to increase the use of US in peripheral IV cannulation. We plan to continue to develop the programme and to encourage further utilisation of US-guided peripheral IV cannulation in the ED. Contact: laura.tan@wales.nhs.uk

Streamlining Venepuncture To Improve Efficiency and Patient Safety Dr. Sachin Wimalagunaratna, Dr. Oliver Small, Mrs. Joanna Walsh-Quantick, Dr. Michael Barrington, Dr. Russell Eason, Dr. Naomi Spencer

Background:

Aims: By July 2021:

• Obtaining blood samples is a common task for clinical staff in hospital.

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

• Furthermore, with our new electronic patient record, MyCare, the patient’s wristband and blood samples should be scanned onto the system before being sent to the lab.

• Adherence to this scanning workflow improves patient safety, yields faster results and ensures trust goals are met.

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

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

Plan Aim 1: Inadequate stocking of venepuncture equipment in wards

Differing layout of stores between wards Inconsistent stocking responsibility

Do

Standardise layout of stock between wards

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

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

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

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

Have all equipment needed for venepuncture in one place Appoint dedicated staff member to manage stock Keep list of equipment that should be stocked

Aim 2: Inadequate scanning of patient’s wristband and sample

Staff unaware of scanning workflow, impact on lab staff and speed of results Additional effort needed to scan patient

Educate staff about scanning workflow Use a wireless handheld scanner Modify current workstation on wheels (WoW)

Act

PDSA Cycle 1

• Reflect upon results.

• Ride the wave of enthusiasm by ward staff for the WoW as a one-stop blood-taking shop.

• Run reports on MyCare to analyse the adherence to scanning workflow for our second aim.

• Recognise the need to raise awareness of the WoW and the benefits of adhering to the scanning workflow.

• Present results at the RD&E Quality Improvement Academy monthly meetings to gather feedback and ideas for progression of the project.

Study

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

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

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

Quantitative results

Conclusions: • Gathering equipment for venepuncture is often a time consuming process in the wards.

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

Future Work:

PDSA Cycle 2

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

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

Pre-intervention • Average time: 4 min 27 secs (n=19) • 50% reduction target: 2 min 13 secs Post intervention • Average time: 2 min 22 secs (n=20) • Of those using bloods WoW: 1 min 36 secs (n=9)

Enteral Tube Insertion Record and Care Plan Audit Danielle Milne & Frances Greer

Introduction: 1

Enteral feeding occurs in 6% of hospitalized patients . NPSA alerts have found that inadequate care 2 and poor documentation of NGT placement can result in NEVER events . To ensure compliance with 3 NPSA guidance, Trust policy dictates that regular audits into enteral tube insertion and care are carried out.

Aim:

Discussion:

To determine if enteral tube insertion and care is adequately documented as per Trust Policy. Expected compliance is 100% for each category.

Confirmation of tube position post insertion and certification of tube as being safe to use were poorly documented. Left unaddressed this could lead to tubes being used before placement confirmation and risk a NEVER event. The date of tube insertion was frequently not transcribed onto new Care Plans. With this information missing it is not possible to use daily checks such as external tube position to confidently confirm the current tube has not migrated or become dislodged. The result of this could lead to unnecessary X-rays to confirm tube position or risk a NEVER event.

The low rate of documentation of bridle insertion may be due to use of bridles being recently rolled out more widely across acute wards, highlighting the need for increased training in this area. Daily care and position checks of NGT and NJTs were inadequate and no clear cause for this could be identified.

Method: This was a prospective audit comparing the completion of the Enteral Tube Insertion Record and Enteral Tube 3 Care Plan against Trust Enteral Nutrition Policy . All nasogastric tubes (NGT) and nasojejunal tubes (NJT) on acute wards and ICU during a 10 day period were included.

Results: In total 47 tubes were included; 44 NGTs and 3 NJTs. The majority of tubes were on ICU (62%) followed by acute stroke (15%). For the Enteral Tube Insertion Record the documentation of pH check, signature post insertion and certification of the NGT as safe for use were areas which had poorest compliance (Fig 1).

Daily completion of the Care Plan was inadequate with 38% of tubes not having the date of insertion recorded.

Documentation of daily care including checking for pressure damage, and tube position checks were poor.

There was minimal documentation for date of bridle insertion (fig 2).

Fig 2: Compliance for Care Plan (Target 100%) 100 80 60 40 20 0

100

98

96

77

62

86

91

80

27

Fig 1: Compliance for Insertion Record (Target 100%) 100 80 60 40 20 0

98

95

95

89

84

77

90

Conclusion: Additional training is needed for all ward staff to ensure safe practices for NGT and NJT insertion and daily care.

Increased training forums have been identified and existing training modules updated. In addition, ward managers and matrons have been updated and specific training needs of wards identified. This audit will be repeated every six months.

References: 1.

Elia M. The cost of malnutrition in England and potential cost savings from nutritional interventions. 2015. Available from: https://www.bapen.org.uk/pdfs/economicreport-short.pdf [Accessed 25/03/21].

2.

NPSA. Patient Safety Alert NPSA/2011/PSA002: Reducing the harm caused by misplaced nasogastric feeding tubes in adults, children and infants. Supporting Information. March 2011 3.

North Bristol NHS Trust. Document No: CG-133. Enteral Nutrition Policy. Bristol: NBT; 2020

The use of bedside pictorial charts to improve oral fluid intake records Dr Songo J Lolomari, Dr Minal D Patel, Dr Lucy Beishon, Dr Sarah Stoneley Leicester Royal Infirmary, University Hospitals of Leicester Introduction and Aims Poor documentation of fluid intake is a pervasive problem in clinical areas. This could affect clinical outcomes in elderly patients, acutely unwell patients and patients with liver, heart or kidney failure (El- Sharkawy et al, 2015).

On the wards, fluid intake/output is usually recorded on a software called Nervecentre by mainly nursing staff. Patients, relatives and some staff (e.g. Catering staff) don’t have access to this software so if nursing staff are not informed when patients drink fluids, this could be unaccounted for.

Clinical staff on our geriatric ward were concerned about accuracy of fluid intake records of the patients and highlighted the need for improvement in this area. In a survey of 13 ward staff, all respondents said it would be helpful to have a means for non-nursing staff, relatives and patients to record oral fluid intake.

We then designed a pictorial oral fluid intake chart (Figure 1) to be kept at the bedside that can be filled in by staff, patients and their carers/relatives.

Comparison of oral fluid intake records between patients given a pictorial chart and patients without a pictorial chart The inclusion criterion was patients had to have Nervecentre (NC) oral fluid intake records. 8 data entries had to be excluded due to lack of Nervecentre oral fluid intake records, so only 90 data entries were analysed.

The average oral fluid intake recorded over 8 hours on Nervecentre (NC) for those without pictorial charts (PC) was 360ml while for those with pictorial charts was 250ml (Figures 2 and 3). Comparison of both NC oral fluid intake averages using Mann-Whitney U test gave a P-value of 0.052 which was borderline significant (Figure 3).

Comparison of oral fluid intake records between different cognitive groups The inclusion criterion was patients had to have oral fluid intake recorded on both charts. For this comparison we decided to use medians rather than means because the data was skewed.

We compared oral fluid intake recorded in pictorial and Nerve centre charts for the 3 cognitive groups (Figure 5).

We then compared the medians of the difference between NC and PC records between the cognitive groups (Figures 5 and 6). The diagnosed dementia group was the only group that showed no difference between NC and PC records. We used the Kruskal-Wallis test to generate P values. The only significant difference observed was between the diagnosed dementia and delirium groups (Figure 6).

Figure 1: Bedside pictorial oral fluid intake chart

We trialled these charts on half of the ward and had 2 main aims: 1. To see if using bedside pictorial charts can help improve documentation of oral fluid intake.

2. To check if there was a difference in accuracy of oral fluid intake recordings between patients with no cognitive impairment and those with cognitive impairment ( delirium and dementia).

Method Data entries of oral fluid intake and cognitive status of patients on a 28-bed geriatric ward were collected over the course of 5 days in a single working week during working hours (between 9am to 5pm). This was done during the pandemic so relatives were not present on the ward.

The ward was split into two halves. There were 14 beds designated to have patients with oral fluid intake recorded on only Nervecentre (NC) and the other 14 beds had patients with oral fluid intake recorded on both Nervecentre and the pictorial bedside charts (PC). The 14 beds consisted of 2 bays (6 beds per bay) and 2 side rooms for each group. Information about the cognitive status was obtained from their medical notes.

A total of 140 data entries were collected. 98 entries were analysed and 42 entries were excluded from the analysis (23 were empty beds, 18 arrived on the ward after 9am on the day and 1 had missing medical notes).

Patients had 3 groups based on their cognitive status: 1. The non-cognitive impairment group 2. The diagnosed dementia group (all patients with formally diagnosed dementia including delirium on background of dementia) 3. Delirium group (patients with delirium that have no diagnosis of dementia).

Discussion and conclusion For the group with both pictorial and Nervecentre charts, the average oral fluid intake recorded on the pictorial chart was 387ml compared to 250ml on Nervecentre (Figures 2 and 4). A Wilcoxon signed-rank test was done to compare both values and this yielded a P-value of 0.001 which is a clinically significant difference (p ≤ 0.05).

Lack of a significant difference between oral fluid intake records on Nervecentre (NC) between the group with the pictorial chart (PC) and the group without the PC was reassuring that presence of a PC did not negatively impact on NC documentation (Figure 3).

In patients with both charts, there was a significant greater volume recorded on PC (Figure 4) which is likely due to accessibility of the pictorial chart by patients and nonnursing staff . It is therefore worth using the pictorial charts alongside Nervecentre.

The delirium and non-cognitive impairment groups had more volume recorded on PC than NC (Figure 5) . However, the diagnosed dementia group had no difference between oral intake records on NC and PC. This is likely due to the relatively decreased level of involvement in documentation on PC by dementia patients.

There was a significant difference between the median of the differences between PC and NC in the dementia versus the delirium group (Figure 6). The difference in patterns between the 2 cognitively impaired groups came as a surprise. The delirium group had more volume recorded on PC. This may be due to delirium gradually resolving in the patients with delirium and perhaps this meant they could be more involved in recording fluid intake on the pictorial chart compared to the dementia group.

Next step The next step is to implement the use of the pictorial chart on the ward consistently as well as promote the use of the charts on other geriatric wards. We have designed posters to promote it on the ward and plan to champion its use during a departmental meeting.

Reference 1. El- Sharkawy, A., Watson, P., Neal, K., Ljungqvist, O., Maughan, R., Sahota, O. and Lobo, D., 2015. Hydration and outcome in older patients admitted to hospital (The HOOP prospective cohort study). Age and Ageing, 44(6), pp.943-947.

Introducing Blanket Screening for Human Immunodeficiency Virus in a Central London Emergency Department Matilda Fox1, Rosie Pettit1, Ernest Mutengesa1, Marcus Wright1, Anu Mitra1 1. Charing Cross Emergency Department, Imperial College Healthcare NHS Trust, London, United Kingdom

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

BACKGROUND • • •

•

HIV has a high morbidity and mortality when left untreated.1 Additionally early diagnosis is cost effective2 and reduces risk of further transmission of the virus.3 NICE and BHIVA guidelines recommend EDs in high prevalence areas ( >2 cases per 1000 population) should screen all attendees age 1659.4, 5 Charing Cross sits in an ‘extremely high prevalence area’, with 7.3 cases per 1000 population6 , making the implementation of blanket testing paramount.

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

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

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

1: Staff survey (September 2020)

PDSA

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

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

CYCLES

PHASE 1 RESULTS:

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

PHASE 2 RESULTS:

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

28%

Concerns about consent

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

% of patients who were tested for HIV

26%

Lack of understanding of indications for testing Concerns about stigmatising patients Cost to trust HIV test not included in standard careset Patients lacking capacity Supply of correct blood bottles Uncertainty on who follows up positive results

24% Actual % of HIV test performed

22% 20%

Aim of 25% of attendees

18%

Baseline % prior to any interventions

16% 14% 12%

Patients' understanding of testing protocol 0

2

4

6

8

10

12

14

16

18

10% Jun-20

Aug-20

Number of clinicians

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

We met our target for testing rates in December.

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

Important lessons we learnt: 1) Involvement of the MDT to see sustained change 2) Use of the behaviour insight “EAST” framework 8 3) The importance of calculating cost effectiveness early in order to fascilitate interventions 4) Rotation of healthcare staff is an important consideration in sustaining change • • •

5. “Gamified” teaching for nursing staff (April 2021)

3. HIV advocate nurse appointed (December 2020)

Sep-20

Nov-20 Jan-21 Time

Feb-21

Apr-21

Jun-21

REFERENCES

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

(2) NICE, December 2016. " Putting NICE guidance into practice. Resource impact report: HIV testing: increasing uptake amound people who may have undiagnosed HIV (NG60):“ https://www.nice.org.uk/guidance/ng60/resources/resource-impact-report-pdf-2727796141 (3) World Health Organisation, 2020 “HIV/AIDS”. Accessed on 15/5/21: https://www.who.int/news-room/factsheets/detail/hiv-aids (4) British HIV Association, 2020. Accessed on 15/5/21 on: https://www.bhiva.org/file/5f68c0dd7aefb/HIV-testingguidelines-2020.pdf (5) NICE, 2016. Accessed on 15/5/21 on: https://www.nice.org.uk/guidance/ng60/chapter/Recommendations (6) Public Health England, 2019. “Sexual and Reproductive health profiles – Hammersmith and Fulham ”https://fingertips.phe.org.uk/profile/sexualhealth/data#page/1/gid/8000057/pat/6/par/E12000007/ati/202/are/E0 9000013/cid/4/tbm/1/page-options/ovw-do-0 (7) Institute for Healthcare Improvement, 2021. How to Improve. [Webpage]. [Accessed 6th May 2021]. Available at: http://www.ihi.org/resources/Pages/HowtoImprove/default.aspx (8) The Behavioural insights team, 2015 “EAST four simple ways apply behavioural insight” , Accessed on 15/5/21https://www.behaviouralinsights.co.uk/wp-content/uploads/2015/07/BIT-Publication-EAST_FA_WEB.pdf

The accuracy of weight measurements of patients admitted to an acute cardiorespiratory admission unit during the COVID-19 pandemic Dr William H. Hunt, Dr Ghayyur Khalil, Dr Jawad Malik, Dr Daniela Cristea-Nicoara Clinical Decisions Unit, Department of Respiratory Medicine, Glenfield Hospital, Leicester, UK

.

Background

The initial Audit – June 2020

Intervention

• Accurate weight measurements are integral to safe and effective patient management • The doses of drugs to treat critical conditions such as pulmonary emboli and acute coronary syndrome are weight dependent • The COVID-19 pandemic has put significant strains and additional time pressures on clinical staff • Despite this, quality improvement is vital to ensure the maintenance of safe and effective practice

• 94% of patients had weights recorded on admission • The mean discrepancy in weight measurements was low (1.2kg) • 9% of patients had a discrepancy >5kg • 8% of patients would have received the wrong treatment dose of dalteparin • 1 patient had a major discrepancy >20kg between the recorded weight and the admission documentation

• The innacuracies identified in the first audit represented a significant patient safety risk • We introduced a standardised procedure to weigh every patient during initial admission triage to increase accuracy • We produced a bulletin to be communicated to all admitting medical staff at handovers • We planned to Re-Audit in 6 months time

The Bulletin

The Re-audit – January 2021

The National Nurse Nutrition Group Guideline 2017 • All patients should be weighed on admission • We decided that the weight measured should not deviate >5kg from the weight recorded at triage • Small changes in body weight are likely to reflect changes in hydration rather than actual body weight

Aims and Objectives • To assess the accuracy of weight measurements on patients being admitted to the acute cardiorespiratory admissions unit (CDU) at the Glenfield hospital in Leicester

Methodology • Data collection took place during June 2020 (n=99), and then again in January 2021 (n=81) • We randomly identified patients sitting in the CDU waiting area after initial nursing triage • Patients were weighed using validated chair scales • This weight was compared with the weight recorded on the admission documentation for each patient • Patients who were not able to sit on the chair scales due to mobility issues or otherwise were excluded Correspondence to: whh5@doctors.org.uk

• 100% of patients had weights recorded on admission • The mean discrepancy in weight measurements remained low (1.5 vs 1.2kg) • There was a reduction in patients with a discrepancy >5kg (6% vs 9%) in weight measurements • There was a reduction in patients who would have received the wrong treatment dose of dalteparin (3% vs 9%) • There were no major discrepancies >10kg between the two weights

Conclusions • There was a significant improvement in the standards set after the intervention • All patients were weighed on admission and there was a reduction in dangerous inaccuracies • Despite the burdens of the COVID-19 pandemic it was possible to implement a simple, but effective change to improve the quality and safety of patient care • We will continue to re-audit annually to ensure a long-lasting effect of quality improvement

th 16

June 2021

Poster Competition Group H

Handover First prize: Something for the Weekend: Improving Weekend Working Through Appropriate and High Quality Weekend Handover Presenter(s): Dr Emma Kirby and Dr Naomi Wardrop Royal United Hospitals Bath NHS Foundation Trust Second Prize: Is anyone coming to handover?

Presenter(s): Stephanie Hill and Samuel Protheroe Organisation: Hull Royal Infirmary

Improving Surgical Handover: An Audit of Handovers during the Emergency Surgical Take Simson RM, Erskine J, Buckle L, Hossaini S, Walker T Gloucestershire Hospitals NHS Foundation Trust, Cheltenham, GL53 7AN

INTRODUCTION - Effective handovers are essential in creating safe working environments and continuity of patient care. Patient safety is indisputably a priority and effective handovers are the duty of every doctor.

AIM – Assessment of handovers of emergency surgical patients at Gloucestershire Royal Hospital in comparison to the national guidelines outlining key principles of safe handovers published by The Royal College of Surgeons of England.

METHOD - Data was collected during surgical handovers using a specifically designed questionnaire. A handover checklist and signs to indicate protected time were introduced along with educational sessions given to relevant departments. Further data collection was performed 4 weeks after changes were implemented.

RESULTS Nursing staff presence increased from 13% to 42%

Improved multidisciplinary input – improved successful flow of information and continuity of care.

Active teaching given increased from 10% to 50%

Known contact info increased from 37% to 75%

Education and Clear contact training - an increase information in specifically noted improved teaching points communication during each pathways promoting handover. effective team work.

Interruptions reduced from 33% to 12.5%

Handover increased on average by 2.5 minutes

Increased length of Reduction in handover may interruptions contribute to maintained structure limited compliance and focus and but overall will lead minimised risk of to improved patient information being safety. missed.

CONCLUSION A checklist along with other subtle modifications to the handover structure is an effective way of improving patient safety, increasing learning opportunities and encouraging MDT approach.

There is however, still a drive for full engagement from all teams to continue to improve the process.

Is anyone coming for handover?

Stephanie Hill and Samuel Protheroe Hull Royal Infirmary PROBLEM: Without a formal medical handover on weekday mornings, sick patients can get missed, doctors go home late and dissatisfied, and crash bleeps can be left unattended.

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

PROCESS MAP:

MEASUREMENTS:

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

Night doctor goes to base ward of Long Day doctor

Night doctor identifies Long Day doctor on the ward

If no volunteer found, night doctor leaves bleep unattended

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

Night doctor hands over bleep and goes home

• • •

Perceived stress of night doctors regarding the handover process Perceived satisfaction of night doctors regarding the handover process Whether the night doctors left late, early or on time

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

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

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

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

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

PDSA 3

PDSA 2

5

4

3

PDSA CYCLES:

2

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

1

A P Intervention was withdrawn and attendance no longer monitored.

Attendance forms put in place and juniors made aware

0

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

2. Introduce a formal handover.

Standard Operating Procedure (SOP) written and agreed with consultants then shared with junior doctors.

Improvement but not 100% compliance so could be improved by introducing formal handover

Significant reduction in stress and increase in satisfaction from baseline.

S

A

P

Intervention effective.

Comments mentioned needing improvement of attendance.

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

A

No chnage in data, unsuccessful change.

S

Completion of forms was variable and added in more work supplying and analysing the forms.

D

Introduce a formal handover

5

4

3 Reduction in stress and increase in satisfaction seen.

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

S

Ensured in 100% the long day doctor was avaliable.

Feedback was that attendance needed improving

2

D 1

0 In 68% the long day doctor found the night doctor (15% in baseline).

Leaving times reported for night doctors

D

100 80

• • • • •

Average stress score on weekdays reduced from 2.7 to 1.7.

Average satisfaction score on weekdays increased from 2.5 to 3.2.

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

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

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

RESEARCH POSTER PRESENTATION DESIGN © 2019

www.PosterPresentations.com

% of Doctors

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

PDSA 2

60

PDSA 1

40 20 0 On time

Late

Early

PDSA 3

Passing the Baton: Improving weekend handover under COVID pressures Dr Timothy Swinn1*, Dr Charlotte Hayden1, Dr Nick Bell1 1- Bristol Royal Infirmary, *timothy.swinn@nhs.net

Background During the January 2021 peak of the COVID pandemic our tertiary centre experienced strain due to high numbers of medical inpatients. This highlighted inflexibility in the existing written weekend handover system and this posed 2 key risks to patient safety: 1. Inaccurate patient demographic and location data risked patient identification errors.

2. Inefficient use of junior doctor time checking list accuracy risked delays in patient care.

Aims: 1. To improve accuracy of patient details and location to 100% within 1 week.

2. To improve proportion of handovers with all key elements by 20% and to maintain this over 3 months.

Methods We identified Careflow Workspace2 as an efficient system for weekend handover as this could automatically populate patient details and dynamically track patient location.

Primary analysis involved assessing accuracy of 8 key handover elements1. Secondary analysis included user feedback via electronic survey and timed analysis of user data input under controlled conditions.

Subsequent PDSA cycles were implemented following analysis of the preceding cycle.

Prevalence of handover elements per PDSA cycle 100% 95%

Baseline (n=137)

90%

Cycle 1 (n=315)

85% 80%

Cycle 2 (n=333)

75%

Cycle 3 (n=513)

70% 65% 60%

Demographics Background & Grade & Day & Location Task

User perception of handover systems 5.00

5-point Likert Scale (5=best, 1=worst), n=28

4.50 4.00 3.50 3.00 2.50 2.00 1.50 1.00 0.50 0.00 Ease of Ease to add Detail of Clarity of finding lists handovers background task Old system

Careflow Workspace

Safety of system

Perfect handover

Cycle

8 elements of a perfect handover1: 1.

2.

3.

4.

5.

6.

7.

8.

Name Date-of-birth Hospital number Location Grade of doctor review Day for review Clinical background Clear task

Intervention

Specific target

Baseline Retrospective analysis 1 2 3

Implementation of Careflow Amended StandardOperating-Procedure User education

Primary outcome Grade of review Day for review

Results: • Accuracy of patient details and location improved to 100% within 1 week.

• Proportion of complete handovers improved from 66% to 87%. This has been sustained over 12 weeks.

• Data input time has reduced by mean 38.5 seconds per patient, giving an overall saving of 1 hour 9 minutes of junior doctor time per week.

• Doctors working the weekend spend less time checking list accuracy (mean 3.0 vs. 16.4 minutes).

• Users rate Careflow as a safer handover system (3.9/5 vs. 3.2/5), easier to use (4.4/5 vs. 3.0/5), and with more detailed patient background information (3.9/5 vs. 3.1/5).

Future directions The process can be made slicker and safer still. It currently involves 2 manual steps however we plan IT upgrades that would consolidate this into a single step. We expect this to reduce human error and result in 100% accuracy for “grade of review”.We will re-audit to assess.

Lessons learned: • Momentum can be harnessed in adversity to expedite systems improvement.

• Ongoing audit cycles are vital to assess both intended and unintended effects of interventions.

References 1. Royal College of Physicians. Acute Care Toolkit 1: Handover. Online, 2015.

Available at: https://www.rcplondon.ac.uk.guidelinespolicy/acute-care-toolkit-1-handover 2. System C. Solutions. 2021 Available at: https://www.systemc.com/solutions/epr/ clinical-workspace/.

Improving Handover in Gynaecology Dr Shona Bhome-Dhaliwal (F2), Dr Safina Ali (GPST1) and Dr Michal Waronski (ST4) Supervisor: Ms Manjambigai

Introduction:

This project aimed to establish: ● the effectiveness of the gynaecology doctor to doctor handover ● Whether the introduction of a handover sheet can improve handover.

Methods:

1.Handover sheet implemented (September 2020) 2. 1st survey handed out 3. Feedback 4. Changes made: 1. Separate handover rooms for gynaecology and obstetrics 5. re-survey (Dec 2020) 6. Conclusions

Nurses’ Responses

Doctors’ responses

Do you feel the doctor's handover sheet improved patient care and doctor's knowledge of ward/EGAU patients in the last few months?

YES- 100% NO-0% Conclusion: -

Improved understanding of patients (46% → 92%) Fewer jobs missed (61% → 23%) More unwell patients highlighted (61% → 92%) Better Verbal handover (15% → 100%) More jobs documented (15% → 100%) Nurses confidence in doctors improved

Recommendations: -

-

Shared drive for easy access and contemporaneous updates.

General awareness and support to update the list before handover.

Aim to highlight ALL patient and miss NO jobs → Further survey and feedback for continuous improvement.

TACKLING THE WICKED PROBLEM OF MEDICAL HANDOVER

IS A PERFECT HANDOVER ACHIEVABLE AT THE BRISTOL ROYAL INFIRMARY? Dr Charlotte Hayden (charlotte.hayden@uhbw.nhs.uk) Co-Authors: Dr Matthew Rendell, Dr Helen King, Dr Gethin Lewis, Dr Natalie Smith, Dr Tim Swinn, Dr Annie Archer. With thanks to: Dr Elizabeth Arthurs, Dr Emily Bowen

BACKGROUND

METHODS

Effective handover is key to avoiding preventable patient harm1,2.

Challenges of COVID-19 caused handover meetings to become inefficient and chaotic, highlighted as a risk to patient safety.

S M AI

1.

2.

3.

Implement a safe, standardised approach to handover Improve leadership, organisation, safety and efficiency Minimise duration of meeting

PDSA 1: Electronic system for routine task handover CYCLES 2: Standardised agenda based on RCP guidance1 3: Weekend whiteboard register 4: Updated agenda and modified attendance structure 5: SBAR education 6: Consolidation through ‘perfect handover’ campaign

EFFECT OF INTERVENTIONS CONTEXT

Highly variable patient acuity and staffing issues with peak during interventions 1-4.

efficiency

(3.4 to 4.8/5.0)

organisation

(4.1 to 4.8/5.0)

leadership

(4.3 to 5.0/5.0)

safety

(4.8 to 4.8/5.0)

quality

(3.7 to 4.0/5.0)

Before (mean)

Morning

46 respondents from FY1 to consultant

minimise time spent in the room by using electronic systems and modifying attendance

incorporate brief operational and staffing updates and ensure everyone is introduced

HUMAN FACTORS

DURATION OF HANDOVER

Evening

KEY SUGGESTIONS FROM STAFF SURVEY

clarify team roles in advance of the meeting, ensure all participants have clear contact details

HANDOVER RATINGS

+42% +18% +16% + 1% +18%

Initial staff survey to guide interventions followed by six PDSA cycles (4-21 days) between Dec 2020 and Apr 2021. Change measured through: 1.

Regular monitoring: start/end times, ratings of leadership, efficiency, safety and organisation (Likert 1-5) 2.

Human factor observations, context and overall quality measured using validated Handover Performance Tool3

greatest improvement

modest improvement

remained stable

After (mean)

28m 51s " 25m 00s 12m 40s " 14m 45s

modest reduction

LESSONS LEARNED ‒ Successful implementation of a robust, sustainable model to cope with changing demands

Unfamiliar team members introduced (1.0 to 5.0/5.0) Role and grade of all participants stated (1.0 to 5.0/5.0) Participants invited to speak up Written informationincluded Ensuring handover is complete

(2.3 to 4.5/5.0) (3.0 to 4.0/5.0) (3.0 to 4.0/5.0)

Deteriorating patients identified Risk mitigation strategies discussed

(4.3 to 4.5/5.0) (3.3 to 4.0/5.0)

Concerns about risk to patient identified(4.3 to 4.0/5.0) Tensions during handover noted (1.3 to 1.0/5.0)

à Sustain and embed change in practice à Ongoing engagement of junior doctors to improve handover culture

NEXT STEPS

‒ Significant improvements in efficiency despite slight increase in duration REFERENCES

‒ High perceptions of safety maintained and human factors improved suggests mitigation of impending risk to patient safety ‒ Widespread improvements in handover practice, with participants taking responsibility for improving handover culture

1. Royal College of Physicians. Acute Care Toolkit 1: Handover. 2015 [Available at: https://www.rcplondon.ac.uk/guidelines-policy/acute-care-toolkit-1-handover] 2. Pezzolesi C, Manser T, Schifano F, et al. Human factors in clinical handover: development and testing of a ‘handover performance tool’ for doctors' shift handovers. International journal for quality in health care. 2013 Feb 1;25(1):58-65.

3. British Medical Association Junior Doctors Committee. Safe handover: safe patients, guidance on clinical handover for clinicians and managers. London: BMA, 2004

Quality of Medical Documentation: Quality Improvement Project

Poster 67

Nadia Youssef 1, Håkon B. Johnsen 1, Jieyun Lee 1 1. Aneurin Bevan University health Board

Introduction •

Lack of awareness, among other reasons, result in poor quality of medical documentation which compromises patients’ care as well as threatens clinicians’ careers 1

•

“If it is not recorded it did not happen”

•

The Royal College of Physicians’ (RCP) documentation standards 2 : 1. Each page in the medical notes must display 3 patient’s identifiers 2. All entries should be dated and timed 3. All entries should be concluded with a signature, printed name, grade of scriber and a contact number 4. All entries must be legible and all deletions countersigned

Objectives Identifying errors in medical record keeping, highlighting them to the team via presentation, and then repeating the cycle to assess the effectiveness of increasing awareness in improving the quality of medical documentation

Methods • Two audits were performed, approximately three months apart.

Prior to the second cycle, medical staff received a teaching on the importance of medical record keeping based on RCP 2007 requirements • Data was collected via studying the handwritten entries in medical notes from the patients’ current admission • Number of errors in documented medical entries were recorded using a data collection template based on the RCP standards • The audit recorded the number of deletions and alterations found in medical entries, and whether they were countersigned • All entries recorded by doctors of all grades were considered for this audit

References 1. Ridyard E, Street E. Evaluating the Quality of Medical Documentation at a University Teaching Hospital. BMJ Quality Improvement Reports. 2015 April 2; 4:u208052.w3253 2. Generic medical record keeping standards [Internet]. RCP London. 2007 [cited 3 December 2020].

Available from: https://www.rcplondon.ac.uk/projects/outputs/generic-medical-record-keepingstandards

Results Number and percentages of continuation sheets with missing patient demographic label Total number of continuation sheets Number of continuation sheets with a missing label • Missing 3+ patient demographic

Before intervention 449

After intervention 126

110 (24.5%)

26 (20.6%)

• 73 (66.4%)

• 21 (80.8%)

Number and percentages of deletions in medical documentations Total number of deletions Number of deletions not countersigned

Before intervention 67

After intervention 14

59 (88.0%)

13 (98.3%)

Number and percentages of errors in medical documentations Total number of medical entries Total number of errors in entries • Missing date • Missing time • Missing name • Missing grade • Missing signature • Missing contact/bleep

Before intervention 889

After intervention 268

1434

283

• • • • • •

• • • • • •

66 (4.6%) 143 (10.0%) 319 (22.2%) 244 (17.0%) 180 (12.6%) 482 (33.6%)

51 (18.0%) 21 (7.4%) 44 (15.5%) 36 (12.7%) 34 (12.0%) 97 (34.3%)

Discussion • This audit found that teaching alone does not produce fruitful outcomes when it comes to medical documentation • A possible reason for poor documentation is understaffing secondary to the COVID pandemic. Consequently correct documentation was not a priority • As missing contact details and time were the most common errors, we suggest individualised medical stamps for staff and working clocks in hospital bays • Rigorous and repeated teaching on the importance of accurate medical recording is required

A quality improvement project to improve standards of handover in the Paediatric Assessment Unit at Great Western Hospital Dr Samuel Jay Great Western Hospitals, Swindon

Introduction

Handover between medical professionals has long been identified as a key source of error leading to potential patient safety incidents. It has been established that structured interventions to handovers can reduce the overall number of medical errors within a healthcare setting [1-4].

The Paediatric Assessment Unit (PAU) at Great Western Hospital (GWH), Swindon, previously operated a handover system whereby outstanding tasks relating to discharged patients were written in a paper diary for clinicians to complete on future shifts.

Due to the way in which the unit is staffed, there is little continuity of medical staff on a day to day basis.

Anecdotally, and in response to several incidents, it was felt that the system allowed for errors mainly through its ‘blank page’ nature which did not force users to insert mandatory data.

An audit of the existing system was planned using criteria derived from RCP guidance [5-6]. A new system was then designed and implemented in response, with further reaudit to complete the quality improvement cycle.

Initial audit

The criteria for safe handover, derived from RCP guidance [5-6] with a standard for each set at 100%, can be seen in the results table below.

All entries to the handover book across two distinct fortnights (29/06/2012/07/20 and 28/09/2011/10/20) were manually analysed by a single reviewer. There were 78 entries. Results are shown below.

This audit confirmed the anecdotal suspicion that the handover book provided very little clinical context to tasks and was inadequate from a governance perspective, with no accountability for entries.

New system and re-audit

Conclusion

In response to the results of the initial audit, a new digital system was developed using Microsoft Excel that intuitively nudged users to input all the required information to meet safety standards. The system also automatically highlights outstanding jobs so they cannot be forgotten.

The re-audit results demonstrate a significant improvement across all domains, with four of seven domains meeting the 100% standard. Of particular note is the massive change in clinician identity data that is so important for medicolegal accountability and retrospective audit/investigation. There is also substantial improvement in the clinical context and plan of action fields, thus greatly reducing the chance of potentially dangerous medical error through lack of information.

Implementation of the new system was timed to coincide with the rotation of junior medical staff, and instruction on its use was included in their induction.

The system was re-audited against the same criteria by the same reviewer a month following implementation.

All entries between 10/02/21 and 24/02/21 were included. There were 34 entries during the timeframe. Results of the re-audit are displayed graphically below, contrasted against the original system.

The initial audit clearly demonstrated that the old handover book was not fit for purpose in governance terms. However there are technical drawbacks to the new system, and it was intended primarily as an interim measure that could be rapidly deployed.

Future PDSA cycles and work within the trust on an overarching electronic handover system should seek to integrate the purpose of the PAU handover spreadsheet.

References 1. Bukoh, MX, Siah, C‐JR. A systematic review on the structured handover interventions between nurses in improving patient safety outcomes. J Nurs Manag. 2020; 28: 744– 755. https://doi.org/ 10.1111/jonm.12936 2. Starmer A J, Sectish TC, Simon DW, et al. Rates of Medical Errors and Preventable Adverse Events Among Hospitalized Children Following Implementation of a Resident Handoff Bundle. JAMA. 2013;310(21):2262–2270. doi:10.1001/jama.2013.281961 3. Li, P., Ali, S., Tang, C., Ghali, W.A. and Stelfox, H.T. (2013), Review of computerized physician handoff tools for improving the quality of patient care. J. Hosp. Med, 8: 456-463. https://doi.org/ 10.1002/jhm.1988 4. CATCHPOLE, K.R., DE LEVAL, M.R., MCEWAN, A., PIGOTT, N., ELLIOTT, M.J., MCQUILLAN, A., MACDONALD, C. and GOLDMAN, A.J. (2007), Patient handover from surgery to intensive care: using Formula 1 pit‐stop and aviation models to improve safety and quality. Pediatric Anesthesia, 17: 470-478. https://doi.org/10.1111/j.14609592.2006.02239.x 5. Royal College of Physicians, Standards for the clinical structure and content of patient records, 2013. 6.

Royal College of Physicians, Acute Care Toolkit, 2015. URL: https://www.rcplondon.ac.uk/ guidelines-policy/acute-caretoolkit-1-handover.

Background •

Medical patients admitted between 09:00 – 21:00 are clerked by a medical take junior doctor or advanced nurse practioner and then reviewed by a consultant who formulates the management plan.

•

Patients are usually clerked and reviewed in A&E or in the Emergency Assessment Unit (EAU) before moving to the Acute Assessment Unit (AAU) which functions as a short stay unit.

•

Prior to the post-take review, patients remain the responsibility of the medical take team. Following their review and move to AAU, responsibility is assumed by the AAU team.

The problem

Results

• Fewer than 20% of patients moving from A&E/EAU to AAU during the daytime

Baseline

• This is dangerous and can lead to delays in care.

• AAU doctors spend clinical time searching through notes and online systems to

90%

90% 80%

66%

70%

ascertain plan and any outstanding tasks.

60%

Intervention

50%

•

40%

An electronic handover system (ehandover) is already used in the Trust for referrals, weekend handover and managing the medical take.

40%

30%

17.6%

20%

We asked the medical take teams to update ehandover immediately after the post-take review using a simplified format consisting of:

1.

2.

3.

Cycle 2

100%

are handed over to the AAU team.

•

Cycle 1

11.8%

16.6%

10% 0%

A single line clinical summary

Patients handed over

Jobs already done by the medical take doctor/ANP

Cycle 2: Of the new patients moved to your bay, for how many do you know (%):

Any jobs to be done by the AAU doctors

Predictions

70

1.

Ehandover use will increase AAU doctors’ knowledge of the new patients

2.

Use of ehandover will not lead to an increase in the percentage of patients with ‘clerking’ jobs* handed over to the AAU doctors

Cycle 1: Proof of principle and trial of prompting by medical take coordinator P - Gathered baseline data and opinions about what information would be useful in a written handover.

D - Posters and emails distributed to publicise the project.

Medical take coordinator asked to prompt clinicians to complete handover.

S - Analysis of ehandover and survey of AAU doctors to assess impact.

A - Changes implemented permanently following positive results.

Cycle 2: Trial of consultant prompting at point of post-take review

70

70

Post-take plan?

Main problem?

50

*defined as jobs included on the trust post-take review checklist as well as tasks more easily done by the clerking clinician such as requesting scans

Method - Plan, Do, Study, Act

Patients with 'clerking' jobs handed over

What to handover to the evening team?

What jobs you need to do?

Discussion • Cycle 1 improved total handover rate (verbal + ehandover) to 66% from a baseline of 17.6%. Rate of clerking jobs handed over remained largely unchanged at 16.6% of patients compared to a baseline of 11.8%.

• In Cycle 2, despite consultant involvement, handover rate fell to 40% and patients with clerking jobs not completed by medical take team rose to 90%. This may be partially explained by the fact that data collection happened on an unusually busy day and on which locum doctors were working who did not have the requisite IT accounts to request scans.

• AAU doctors’ knowledge was surveyed in Cycle 2 only (although will also be part of Cycle 3). Doctors knew what tasks were expected of them for only 50% of new patients, demonstrating an ongoing problem. This might be argued to loosely correlate with the 40% handover rate in that cycle.

P - Refined data points to collect. Prediction that consultant involvement will improve handover rate.

• Feedback received from both medical take and AAU teams was overwhelmingly positive for the simplified handover format. It was felt however that wherever possible, verbal handover is preferable to written ehandover.

D - Consultants asked to prompt juniors to complete handover following posttake review.

.

Lessons learnt

S - Analysis of ehandover and survey of AAU doctors to assess ongoing impact.

• Efficient handovers consist of a brief clinical summary and a plan detailing tasks done and those to be done by the receiving team.

A - Results fed-back to clerking team to reinforce practice and promote further discussion.

• Busy clerking shifts adversely affect quality of handover.

Cycle 3 (in progress at time of writing): Direct involvement of junior doctors

• Improved handover may increase the percentage of clerking jobs inappropriately handed over, an effect which may need mitigation in the future.

• Prompting by an external person is an effective method of promoting compliance with handover.

Dworkin, A. (FY2), Varathan, R. (FY1), Devendra, D. (Consultant in Acute Medicine and Endocrinology)

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

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

Methodology & PDSA cycles:

Cycle 4: Electronic reminder message added to weekend handover system

Current F1 doctor’s were surveyed to ascertain perceptions of the current weekend workload. Data was collected prospectively from the electronic tool and tasks rated as appropriate or inappropriate by reviewers based on task suitability and information clarity.

Several PDSA cycles were undertaken focusing on education and proactive weekend preparation as shown in Fig 1.

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

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

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

Cycle 3: FRIDAY poster emailed to all junior doctors including detailed information (Fig 3.)

Cycle 2: FRIDAY mnemonic reminders put on computer workstations P

D

A

S

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

Fig 1. PDSA cycles

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

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

In a survey of F1 doctors in August 2020, only 18.2% of doctors felt weekend workload to be ‘manageable’.

This increased to 44.4% when the survey was repeated in April 2021.

In addition, the April 2021 survey showed that 55.6% of F1 doctors felt the appropriateness of jobs handed over had improved since August 2020.

Fig 2. Run chart showing percentage of jobs handed over that were deemed to inappropriate (Fig 3.)

Fig 3. FRIDAY infographic

Key Learning Points and Next Steps: The impact of the revised weekend handover template is yet to be evaluated. The modest improvements demonstrated relied heavily on frequent reiterations through our PDSA cycles. This demonstrates the difficulties in changing handover practice which is heavily influenced by differing individual & team thresholds for weekend tasks. This will also vary from organisation to organisation and be heavily influenced by the structure and capacity of the weekend staffing team. The direct effect on patient safety is also difficult to measure.

Moving forwards we need to look at processes which streamline our weekend care, better integrating senior ward rounds with F1 “on-call cover"; minimising duplication of work and out of hours task demand and thus improving communication, efficiency and patient safety.

It is important to note that for several months (November to February) there were significant increased pressures across medical wards due to the surge in the COIVD-19 pandemic.

However, apart from a spike over the Christmas holiday period, a surge in the number of inappropriate handovers was not seen over this 4 month period and this could be interpreted as a success for the educational initiatives in focusing on effective weekend handover.

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

Assessing the Effectiveness of an Electronic Ward Round Checklist to Improve Patient Care in a Surgical Emergency Unit.

Oxford University Hospitals NHS Foundation Trust Rabeet Khan[1], Mahmoud Sallam

•

An effective surgical ward round is central to a patient’s daily surgical assessment. In a surgical emergency department where surgeons are required to attend theatre promptly, ward rounds are often quick and key components of a surgical patient’s care are often not reviewed or documented.

•

Both the Royal College of Physicians (1) and the BMJ Quality Improvement Programme (2) recommend the use of safety checklists to minimise oversights of key components of a structured bedside review.

•

A safety checklist also improves documentation of specified patient care parameters and therefore improves patient continuity of care (3).

•

We conducted a quality improvement project to assess the impact of the implementation of an electronic ward round checklist for the assessment of specified surgical patient care parameters.

•

Key care parameters defined in this project – (Figure 1)

Results & Findings

% review rate

Introduction & Objectives

Figure 3 – Column chart showing the number of times patient care parameters (VTE prophylaxis, antibiotic type, analgesia, oxygen, nutritional status) were reviewed during ward round before and after the implementation of a ward round safety checklist. This data corresponds to a safety checklist completion rate of 28%. We recorded a 19% improvement in VTE prophylaxis reviews, 17% improvement in oxygen therapy reviews, 23% improvement in analgesia review, 49% improvement in nutritional status review and a 19% improvement in recording estimated discharge dates. There was no change in antibiotic review performance as this already had a 100% review rate prior to intervention.

VTE Prophylaxis Nutrition

Analgesia

Estimated Discharge Date

Antibiotic Type

Aims – • To evaluate the current practice of documentation and review of the patient care components specified above.

•

•

To assess whether the implementation of an electronic ward round checklist improves the review rate of the specified care parameters.

•

At the Oxford University Hospitals (OUH) Surgical Emergency Unit (SEU), we conducted a retrospective analysis of previous ward round notes for 113 patients. We recorded the number of times the following six parameters were reviewed on ward round for each patient before and after the implementation of an electronic ward round checklist: • • • • • •

•

•

Results show that the use of a safety checklist is correlated with an increase in the frequency of reviews of key surgical care parameters.

•

The significance of the impact is evident even at a checklist completion rate of 23%. A higher checklist completion rate is therefore expected to improve review rates further.

To identify methods of improving the compliance of WR checklist completion.

Methods

Venous Thromboembolism (VTE) Prophylaxis Antibiotic Type Analgesia Oxygen Therapy Nutrition Estimated discharge date

Limitations and Next Steps

Discussion

Oxygen Therapy

•

•

•

Positive feedback from the nursing team was received as the peri-operative nutritional status (e.g. NBM, clear fluids etc.) was more frequently updated hence improving adherence to ERAS (enhancing recovery after surgery) pathways.

Perioperative plans to withhold/restart anticoagulation were more frequently reviewed. This is expected to minimize risk of VTE and post-operative bleeding.

Through improved documentation and continuity of care, the use of a checklist is expected to reduce surgical morbidity and mortality as demonstrated in literature (4).

•

A key limiting factor in this project was the poor compliance rate for checklist completion. A compliance of 28% limits the level of improvement seen in care parameter reviews.

•

During data collection it was noted that the checklist was not completed correctly in some cases e.g. missing dose of anticoagulant or antibiotic. This limits the benefit derived from the checklist in improving handover.

Next Steps – •

We aim to conduct a teaching session for all new SEU staff explaining the benefit and correct use of the safety checklist.

•

We plan to incorporate drop down options in the checklist to minimise errors and reduce the time taken to complete the checklist.

•

A repeat audit will then be conducted to assess for improvement in compliance.

References

The OUH NHS Trust utilises electronic patient records. We therefore created an updated ward round note template that included the safety checklist on the Cerner patient record system (see below).

Conclusions

• Completed safety checklist example (Figure 2)

The surgical ward round checklist is a corner-stone for optimising the handover process and maintaining smooth transition of care amongst the surgical team.

1. Royal College of Physicians, Royal College of Nursing. Ward rounds in medicine: principles for best practice. London: RCP, 2012.

2. Hale G, McNab D. Developing a ward round checklist to improve patient safety.

BMJ Open Quality 2015;4:u204775.w2440. doi:10.1136/bmjquality.u204775.w24 40

•

Safety checklist use minimises the risk of overlooking key aspects of patient care during a surgical ward round.

3. Krishnamohan N, Maitra I, Shetty VD. The surgical ward round checklist: improving patient safety and clinical documentation. J Multidiscip Healthc. 2019;12:789-794 https://doi.org/10.2147/JMDH.S178896

•

Education of new staff joining the SEU for each rotation is essential in maintaining a high checklist completion rate.

4. Weiser TG, Haynes AB, Lashoher A, Dziekan G, Boorman DJ, Berry WR, Gawande AA. Perspectives in quality: designing the WHO Surgical Safety Checklist. Int J Qual Health Care 2010;22(5):365-70.

th 16

June 2021

Poster Competition Group I

Education and Training (1) First prize: Teaching clinical skills to medical students during the COVID-19 pandemic: A Quality Improvement Project Presenter(s): Dr Anna Halstead, Dr George Williams, Dr Andrew Mcgaughey and Dr Grace Southern University Hospitals Dorset Second Prize: Improving usability of a digital clinical decision support tool through PDSA cycles Presenter(s): Harry Chappell, Dinesh Yoganantham, Joseph Read, Alexander Crawford Salisbury District Hospital

Raising the bar - creation of a sustainable in-situ teaching program, aiming to improve knowledge, team-working, morale and reduce clinical error Dr’s Talia Barry and Vicki Cowling: Royal Free Hospital Emergency Department, London Introduction The remit was to provide a refreshed, cost effective teaching program in a busy emergency department. We needed it to be accessible to all types of clinicians and to focus on team working and morale, providing a safe space for learning from error at minimal cost.

Doctors and nurses were previously taught separately, and silo working was common. It was difficult to disseminate learning from error and serious incidents (SI) across the team. The previous CQC1 report highlighted the need for embedding learning from mistakes across the trust. We wanted to flatten hierarchy and its invisible barriers to communication, and create a space for all clinicians to be able to speak up and learn.

Aims ● ● ●

Use Simulation (Sim) to share knowledge and reduce clinical error.

Improve clinician confidence and team working ability.

Use QI methodology as a vehicle to introduce change based on the learning from Sim.

Discussion Over 15 months we ran 50 SIM sessions with PDSA cycles. From feedback we tweaked and introduced new measures to enhance departmental learning. The SIMs evolved from being didactic and consultant-led, to having a shared lead with ED registrars and clinicians from wider specialties. Cross-specialty involvement improved relationships between the department and the wider trust.

Technical and non-technical learning from each Sim was varied and introduced departmental discussions around human factors for the first time. We gained in so many ways but most importantly we became a team that worked together in the resus area.

Six latent errors recorded had the potential to lead to an SI and of these mostly were regarding infrequently used equipment. We discovered that kits for big events (thoracotomy for example) needed updating and our staff needed reminding where they were and how to use them.

Technical and non-technical outcomes from the 50 PDSA cycles are illustrated below.

NON TECHNICAL OUTCOMES Attendance Increased Erratic due to staffing and shop floor pressures but a trend upwards!

Nursing Staff Confidence Increased Has Sim made you feel more confident in speaking up in clinical situations?

85.7% felt more confident.

People enjoyed it

It improved the learning environment

Have you enjoyed being involved in Sim in the RFH ED?

Do you think Sim has improved the culture of learning in the ED?

71.4% replied ‘Yes, loved it!!’

71.4% felt it definitely had.

Still more work to do on team communication Do you think in situ Sim has improved communication and team working between staff in the ED? Only 28.6% said ‘yes, definitely’ with 57.1% replying ‘yes, a little’.

TECHNICAL OUTCOMES PROMPT Cards3 developed to aid memory in emergencies

Sim Templates A set of Sim templates with equipment list, scenario and guidelines.

Updated Guidance Staff highlighted available guidance that on discussion was out of date - we removed it or updated it on the intranet.

Cross Specialty Involvement Local experts invited to facilitate SIM/teach skills, including cardiology, medics, surgery, vascular, blood bank, renal and resuscitation teams.

Kit Dumps KIt opened to allow staff to familiarise themselves with location and contents.

Education WhatsApp Grp Email fatigue was a problem so we created a whatsApp group to disseminate information and allow more interactive discussions.

Skills Sessions

Supermarket Sweep

Shopfloor teaching in 15 mins on anything from LP’s, plaster application to ring removal taught by doctors, nurses, ENP’s and ACP’s.

A timed treasure hunt to find kit in an emergency.

TILS Courses

Sim Champions

Nursing staff identified trauma as their major area of concern so we ran additional Trauma Intermediate Life Support Courses.

We trained 6 ED staff who could facilitate in-situ Sim and had additional debrief training to ensure psychological safety.

Business Cases We made applications for additional equipment including tuff cuts at the end of every bay, diphoterine for acid splash and penthrox for analgesia.

Resus Nurse Lead A senior nurse was given the role of resus champion in order to keep the motivation going across the nursing team.

References: 1.www.cqc.org.uk/sites/default/files/new_reports/AAAF1114.pdf 2. www.ncbi.nlm.nih.gov/pmc/aryicles 3. https://www.rcem.ac.uk//docs/Local%20Guidance/Prompt_031220%20LO1.pdf Additional Thanks: So many people embraced Sim and QIP but special thanks to Shye Wong, Chandani Sharma, Ashley Baruah, Suzanne Scaffardi, Michaela Wiltshire and all those who wrote and facilitated Sim over the year!

From Frontline Medic to Virtual Teacher – A Remote Teaching Programme for Shielding Trainees During COVID-19 Dr Hannah Courtney ST3, Musgrove Park Hospital & Dr Kathryn Williams ST2, Hull Teaching Hospital

1. Background During the COVID-19 pandemic many doctors have endured significant disruption to work and training.

However, a small cohort of doctors deemed at highest risk, due to specific clinical vulnerabilities, have faced a unique set of challenges. As two Emergency Medicine Trainees advised to ‘shield’, we went from preparing for a global pandemic on the frontline to being in receipt of stark instructions to ‘stay at home’.

We both experienced a feeling of helplessness with not being able to contribute clinically during the first imposed shielding period from March-August 2020.

When shielding was reimplemented for the second time later in the year, we utilised our time to create a bespoke virtual teaching programme for shielding foundation doctors in a similar position.

The objective was to develop our own non-clinical skills and reconnect with clinical medicine through the delivery of regular remote teaching in addition to providing a supportive mentoring forum.

3. Results Shielding during the COVID-19 pandemic has been an unsettling period for many. The weekly teaching programme, however, provided a welcomed routine and has been met with gratitude from those displaced trainees accessing the regular teaching sessions. Weekly feedback was collated and certificates provided as evidence of attendance. Supervised learning events were also completed for trainees who delivered a teaching session and fulfilled the criteria for foundation competencies.

The programme proved a huge success and demonstrated an improvement in knowledge and confidence. The foundation trainees reported the sessions were well-structured, interesting and appropriate for their learning and enjoyed the interactive discussions. They also found the peer mentoring invaluable, especially as shielding can be isolating being away from colleagues and the clinical environment.

Prior to this session I felt confident in assessing the acutely unwell patient

After the session I feel confident in assessing the acutely unwell patient

Strongly agree 0% Disagree 17%

Neutral Disagree 0% 0% Agree 33% Agree 50%

Strongly agree 50%

Strongly agree 100%

Neutral 50%

2. Methods An already made nationwide audience in the form of a WhatsApp group for shielding foundation trainees was used to communicate the teaching sessions.

The first session on the ‘unconscious patient’ and ‘seizures’ was delivered over the online meeting application ‘Webex’ in January 2021. A ten week programme of virtual teaching was then delivered on emergency medicine topics including ECGs, the deteriorating patient, pearls and pitfalls of imaging, endocrinology emergencies, ABGs/NIV, abdominal pain and toxicology.

Foundation trainees from around the country logged in and participated in weekly interactive case base discussions, followed by peer mentoring within the group.

In the second phase of the teaching programme, we supervised the foundation doctors delivering peer-led teaching sessions, helping achieve foundation competencies such as ‘Developing the Clinical Teacher’.

Hannah.courtney@somersetft.nhs.uk Kathryn.williams@hey.nhs.uk

Prior to the session I felt confident in assessing and managing a GI bleed Strongly agree 0%

The sessions were useful and interesting

After the session I feel confident assessing and managing a GI bleed Neutral 0%

Agree 0% Neutral 17%

After this session I feel more confident interpreting ABGs and when to use NIV

Disagree 0%

Agree 33%

Strongly agree 67%

Disagree 83%

Strongly agree 100%

4. Conclusion The virtual teaching programme has provided both a learning and mentoring platform for foundation trainees who are currently unable to work in a face-to-face capacity.

Despite the challenges of shielding, we have proven that being proactive and innovative, time spent away from the clinical frontline can be both rewarding and fulfilling.

‘I have loved being part of these sessions – they’ve been so useful during this uncertain period in my training.

Thank you both so much’.

‘I feel much more confident in returning to clinical work as a result of these sessions. I’ve not done any teaching as a doctor before so having the opportunity to deliver a session in a safe and supportive environment was great for my development’.

‘The sessions were really well structured, interactive and targeted at foundation level.

It’s been great to engage with others in a similar position and learn lots at the same time’.

The introduction of a national structured emergency medicine teaching program for Physician Associate students during the Covid-19 pandemic Dr April Wilson & Dr Max Lyon Southmead Hospital, North Bristol Trust, Bristol, United Kingdom

Background & Aims ➢ Physician Associate (PA) students have spent over 50% of their course under restrictions with reduced face to face teaching due to the Covid-19 pandemic ➢ Despite emergency departments (EDs) ardently continuing to host PA students, many restrictions in the clinical environment have further reduced learning opportunities. ➢ Our ED did not have permanent graduate PAs which means students potentially miss out on valuable mentorship, PA directed teaching and support that their medical student counterparts would expect to receive from ED physicians. ➢ This gap in learning is expected to have an impact on students understanding of the role of human factors in the ED and could have implications for patient safety as knowledge continues to be updated but not disseminated. ➢ This interactive, case based teaching series was introduced to work through real life examples of common ED presentations looking at pearls and pitfalls, undifferentiated presentations, challenges in communication, human factors and patient safety which takes learning a step further. We aimed to incorporate up to date clinical guidelines via National Institute of Clinical Excellence (NICE), Public Health England (PHE) and The Royal College of Emergency Medicine (RCEM) to share knowledge and prepare students for their future practice. By using a virtual platform we ensured no student would be disadvantaged by geography or service pressures.

Methods ➢ This PA teaching programme was developed by two locum SHO doctors at a large, Major Trauma Centre starting March 2021. Informal student interviews revealed many felt they lacked the skills and knowledge needed to manage patients in the ED environment and that they would benefit from teaching . ➢ The planning stage involved liaising with both the ED PA clinical supervisor, PA student clinical lead and the local university senior lecturer to ensure content would align to the PA Matrix. ➢ The ED permitted use of their departmental Zoom account and a structured, once weekly teaching schedule was finalised between key stakeholders ➢ The interactive, case based teaching format was decided based on initial student feedback. It was designed to simulate the process students would naturally go through when seeing a patient in the ED. Cases were designed to evolve throughout the session to include imaging, laboratory findings, patient deterioration, clinical uncertainty, challenges in communication and human factors. Students were presented with single best answer questions at relevant points to check understanding and knowledge.

➢ We engaged with PAUK and PA Buddy Support Network Group to increase student membership and reached out to individual university educational leads with the Whatsapp QR code shared by email and on official Facebook Groups. ➢ Weekly feedback was collected and reviewed with a view to adapting and improving teaching material.

Outcomes Feedback

Results ➢78 members have joined across 10 UK universities in 3 months

‘These cases are great, learned lots of new things’

➢93% of students rated the teaching 5/5 overall

‘I thought it was brilliant, engaging, interactive, and I learnt lots. It was also very clinical and I loved the cases used.’

➢100% of students would attend similar teaching ➢93% of students rated the teaching 5/5 in regards to usefulness

‘I liked how some slides included NICE guidelines stuff, makes it very useful’

➢97% of students felt teaching increased their confidence in the subject

‘Enjoyed seeing different CT imaging, very important to spot abnormalities in those’ SF 2

‘It’s amazing and is helping me with revision. Love the exam style questions’ Figure 1: Map of England showing 8 out of 10 participating universities. University of Worcester and Edge Hill University have not been individually identified but have students taking part.

‘I lacked knowledge in this area so it was a great recap’

Conclusion ➢ Overall, students are finding benefit and utility in our teaching. Student confidence has improved in the emergency medicine topics taught and we feel this has helped to address gaps in learning that may have been lost due to the pandemic. ➢ Our membership is now at 78 PA students across England and growing each week, which ensures up to date knowledge via NICE/PHE and RCEM is being disseminated beyond our locality. ➢ Our virtual platforms are providing supportive and safe places for PA students to share knowledge, interact with their peers and ask questions which can be more challenging in the clinical environment.

Ultimately, we believe that this will improve patient care and safety. ➢ We have empowered locum doctors to lead and take part in teaching initiatives in the departments in which they work, thus tapping into a vast resource of experience and knowledge.

Acknowledgements I would like to thank Southmead Emergency department for their support with this project.

Improving usability of a digital clinical decision support tool through PDSA cycles H.Chappell, D.Yoganantham, J.Read, A.Crawford, C.Pettinger, R .Thakkar, E.Grace, N.Gupta, T.Rose, K. Glaister, S.Williams, S.Gray Intro & Aims Medical errors are a leading causes of morbidity and mortality globally.1 The majority of medical errors have been shown to be due errors of commission and errors of ommission.2,3 CQC and NHS England require that hospitals provide appropriate governance, training and resources for hospital staff. 4,5 Clinical guidelines are beneficial for patient safety, ensuring quality and consistency of care but may also cause harm.6,7 Microguide™ is a customisable platform which hosts selected trust guidelines and is used by over 50% of NHS acute hospitals.8 Our group aimed to improve the usability and functionality of this platform for foundation doctors at Salisbury District Hospital through “plan, do study act” (PDSA) cycles.

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

Initial Survey & Time Trial 1

PDSA 1

PDSA 2

Search

Editing & Keywords

Engine

Time Trial 2

Number of Responses

There were 15, 14 and 16 responses to the initial survey, PDSA 1 survey and PDSA 2 survey respectively.

Microguide was used by 98% at least a few times a week.

The initial survey showed 93% found resources useful but only 20% found it easy to find to a desired resource.

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

10 8 6 4 2 0

PDSA 1

Initial

V. difficult

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

Sustainability

Formatting, App, Audits

How easy is it to find what you want on Microguide? Survey Responses

Results and Discussion

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

PDSA 3,4,5 (ongoing)

PDSA 2

Neither

Difficult

Easy

V. easy

Sustainability Score Microguide Improvement Project Benefits beyond helping patients 16

Infrastructure for sustainability

14 12

Credibility of the evidence

10 8 6

Fit with goals and culture

Adaptability of improved processes

4 2

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

0

Clinical Leadership and engagement

Effectiveness of system to monitor progress

Senior leadership and engagement Staff behaviours

Staff involvement and training

Score Now Ideal state score

Time trial data after both PDSAs

Time trial data before PDSAs 180

Time (seconds)

Time (seconds)

180

135

90

135

90

45

45

0

0

Question 1

Question 2

Question 3

Question 4

Question 5

Question 1

Question 2

Question 3

Question 4

Question 5

Time Trials An initial time trial found it took F1 doctors on average 47 seconds to find the appropriate guideline for a clinical scenario A repeat time trial after PDSA 2 found it now took F1 doctors on average 22 seconds to find the appropriate guideline for a clinical scenario Conclusion and future directions This shows Microguide is a frequently used and valuable resource. It demonstrates a model to effectively improve usability and the methodology could be applied to similar platforms.

A third PDSA is ongoing with the microbiology department looking at implementing “systems based” antimicrobial guidance. All respondents preferred the proposed “systems based” format.

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

References 1. WHO Patient Safety Sep 2019; https://www.who.int/news-room/fact-sheets/detail/patient-safety 2. Clapper, TC, Ching, K. Debunking the myth that the majority of medical errors are attributed to communication. Med Educ. 2020; 54: 74– 81. https://doi.org/10.1111/medu.13821 3. Rodziewicz TL, Houseman B, Hipskind JE. Medical Error Reduction and Prevention. [Updated 2021 Jan 4]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-.

Available from: https://www.ncbi.nlm.nih.gov/books/NBK499956/ 4. CQC Fundamental Standards May 2017; https://www.cqc.org.uk/what-we-do/how-we-do-ourjob/fundamental-standards 5. NHS England policies and procedures https://www.england.nhs.uk/contact-us/pub-scheme/polproc/ 6. Woolf, S H et al. “Clinical guidelines: potential benefits, limitations, and harms of clinical guidelines.” BMJ (Clinical research ed.) vol. 318,7182 (1999): 527-30. doi:10.1136/ bmj.318.7182.527 7. Griffiths, Jill & Brophy, Peter. (2005). Student Searching Behavior and the Web: Use of Academic Resources and Google.” Library Trends 53 (4. Library Trends. 53. https://www.ideals.illinois.edu/ bitstream/handle/2142/1749/Griffiths539554.pdf?sequence=2&isAllowed=y 8. http://www.test.microguide.eu/about-hsp/

The Signs Safari – a novel clinical teaching programme Muhammad Adil Seelarbokus, Tasnime Yearoo, Jafar Shakir, Megan Karczewski

Background and aims

Methods

Mentoring at South Tees (M@ST) is a near-peer mentoring scheme for medical students led by a group of junior doctors.

The Signs Safari is a novel clinical teaching programme aimed at third year medical students introduced in 2019 with a primary goal of complementing the traditional OSCE-style teaching offered by the medical school through focused bedside teaching.

A literature review from 2014 revealed that the use of bedside teaching has been on the decline for several reasons, including high patient turnover rates and increasing reliance on diagnostic tools other than physical examination.1 With Covid-19, clinical placements for students have all been heavily affected with concerns thus arising.2 The programme was originally designed to tackle the deficit in bedside teaching but has now also been adapted to run in a post-Covid-19 era.

The effectiveness and quality of the sessions were analysed through serial feedback collected using Google Forms, with a final post-programme feedback form sent out at the end of the six weeks to evaluate the overall impact of the sessions. 8 sets of feedback were collected for the 2019 programme and 7 for the 2020 programme.

Design

Following the pilot 2019 programme, the 2020 programme was modified to reflect changes suggested by the students in 2019.

In addition, we used weekly feedback to bring continuous changes to each subsequent session. As such we have so far run two complete cycles of the Signs Safari with plans to run a further cycle later this year.

Station A (10 minute examination + 5 minute discussion)

Tutor D Feedback

Tutor A Feedback

(3 mins)

The programme was designed to provide short, focused clinical teaching around specific clinical signs that were either rarely encountered by medical students or “textbook” presentations.

Each week, four pairs of students would rotate around preselected in-patients and perform a focused clinical examination followed by a discussion with a facilitator, as shown in Figure 1.

(3 mins)

Station D

Station B

Group Debrief + Weekly Feedback

(10 minute examination + 5 minute discussion)

Tutor C Feedback

(10 minute examination + 5 minute discussion)

Tutor B Feedback

Station C

(3 mins)

(3 mins)

(10 minute examination + 5 minute discussion)

Figure 1

Combined post-programme feedback (n=15) Exposure to new signs

Strongly agree

Agree

Improved confidence in presenting findings

Neutral

Strongly agree

Agree

Neutral

Improved ability to form differentials

Strongly agree

Agree

Neutral

Improved confidence with OSCEs

Strongly agree

Agree

Neutral

Student comments “Being introduced to and taught how to elicit the signs that I hadn't seen before”

“Small group teaching”

“Fast moving stations” “Having the chance to talk through findings in detail with the doctors”

“The time moving between the wards could have been reduced”

Most useful/valuable aspects from 2019

“The explanations from tutors afterwards was very insightful and helped me to consolidate the signs I’ve seen into my medical knowledge”

“A timer for each doctor because sometimes we overran a lot”

“Interesting signs not seen before. Clinical examination skills reviewed by doctors”

“The 10 minute slots were insufficient to get a good clinical picture”

Improvement suggestions from 2019

“Each week focusing on one specialty rather than doing all the specialties every week”

Implemented changes for 2020 Timings increased to 15 minutes per station (from 10 minutes) Specialty-themed weeks introduced with patients identified on adjacent wards to cut down on time moving between stations Interesting ECGs, scans, and videos displaying signs such as RAPD were collected with consent for backup in case of unforeseen circumstances or ward restrictions due to Covid Additional committee member present to ensure timely rotation References 1. Peters M, ten Cate O. Bedside teaching in medical education: a literature review. Perspectives on Medical Education. 2013;3(2):76-88.

2. Woywodt A, Breed H, Lumsden C. COVID-19 – the ultimate disruptor?. MedEdPublish. 2020;9(1).

“Increase the number of sessions per day”

“Contingency plans if patient unavailable, sometimes if this was the case a weak or very common sign was presented”

Online Near-peer teaching for International Medical Graduates in the United Kingdom By: Jean Marc Pierre, Vikesh Bahadoor, Katherine Lee-a-Ping, Nadya Brodie-Stedman

Introduction International Medical Graduates (IMGs) account for a significant portion of the workforce in the UK and there is currently no formal near peer teaching (NPT) about clinical practice in the NHS.

Methods

Foundation Year 2 doctors who were IMGs of St. George’s University, Grenada designed and implemented a teaching programme with the assistance of clinical faculty.

Learners were students and graduates of the same university intending to practice in the UK. The programme covered aspects of clinical practice unique to the NHS through case-based scenarios that emphasised ethics, communication and management. Weekly teaching was Conclusion delivered via Zoom over 12 weeks Therefore, a teaching programme with clinical faculty also in was designed to facilitate NPT The NPT demonstrated a attendance and Feedback between IMGs working in the successful strategy for guiding students was gathered after each NHS and those seeking through the required exams and the process session to do so. of moving to the UK and NHS system. It was sustainable These doctors are likely to face similar hurdles in adjusting and it was hypothesized that NPT would be a useful teaching tool during the COVID-19 pandemic in preparing for the exams required by IMGs for UK clinical practice.

through the COVID-19 pandemic via the utilisation of videoconferencing software.

Results

Discussion

According to the GMC, There were 39 The transition of medical education to a more online format 39.6% of all doctors feedback responses ensures not only the continuation of learning but practicing in the UK are (response rate of 72%) increased accessibility. Additionally, as the NHS has an graduates from a non-UK In which 100% of learners increasing dependence on IMGs. It is important to medical school. indicated an increase in prepare prospective UK doctors for working in the As the NHS continues to confidence regarding UK NHS and UK medical system in order to maintain expand, the UK’s NHS clinical practice after a high quality of care. cannot keep up with the teaching, with 77% of demand for new doctors and individuals rated the teaching has a large dependence on as “Extremely useful”.

IMGs. Guidance and mentorship about the structure of the NHS, it’s ethos and character are therefore of great importance to smooth the transition How would you rate this teaching overall? into UK clinical practice.

35 31 30 25 20 15 10 5 0

4

0

Exceeded Met expectations expectations

30 25 20 15 10 5 0

Figure 1: The bar chart demonstrates the number of responses on how the learners rated the teaching

Below expectations

How useful was the teaching in preparing you for UK clinical practice and exams?

27

8

Extremely

Very

0

0

0

Somewhat

Not so useful

Not at all useful

Figure 2: The bar chart demonstrates the number of responses on how the learners felt teaching prepared them for UK clinical practice

The COVID-19 pandemic has opportunistically led to the normalization of online medical education and was therefore useful for providing NPT to learners and assisting in the transition to UK practice as evidenced by the largely positive feedback.

When NPT is used in niche groups such as IMGs from the same undergraduate course, there is an added benefit on role modelling and mentorship to learners whilst teaching. Moreover, peers working in the NHS can also share their non-clinical aspects of practice such as referral pathways, overview of the hospital system and wards.

t eaching cl inical skil l s t o mEdical st udent s dur ing t he cov id- 19 pandemic Dr . Anna Hal st ead , Dr . GEORGEWILLIAMS, DR. ANDREW MCGAUGHEY & DR.GRACESOUTHERN

1Int r oduct ion

The GMC sets standards and requirements for all UK medical trainees to ensure they have a minimum level of competence to practice safely. This includes basic clinical skills. During the COVID-19 pandemic, education was heavily disrupted for medical students, with many placements and clinical skills sessions being cancelled or converted to e-learning only.

Practising clinical skills throughout medical school in a controlled environment is crucial for the students' development and to build their confidence. W ithout any formal clinical skills teaching, the students did not feel confident practising clinical skills on the ward.

Resul t s and analysis

3

"It madeusmore confident topracticeon thewards"

"Great explanations; useful topractice"

Image4: examplesof commentsfrom studentstaken fromweekly feedback forms

28 students attended the clinical skills teaching course that was run a total of three times over the academic year. We received excellent feedback throughout (Image 4), and ther e w as an over al l impr ovement in confidence of 72%having attended the cour se. Examples of the confidence difference for some of the individual skills are outlined in Image 5.

2 Met hod

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

Image5: Confidencein eachnamed skill on a scale of 1-5 (1=least confident, 5=most confident). Beforeclinical skillscourse (blue) and after (orange)

By correlating hours of clinical skills teaching to confidence level (see Image 6), we can see that generally the mor e hour s spent doing cl inical sk il l s teaching the mor e confident the students become.

Image1. (right): Driver diagram Image2 (below) : aims, interventionsand measurable outcomes

AIMS: 1. Improve the medical student clinical skills teaching 2. Increase medical student confidence in clinical skills

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

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

MEASURED OUTCOMES: 1. Student confidence - using a pre and post course questionnaire 2. Hours of teaching delivered 3. Weekly student feedback on each session, both written and verbal Image6: Graph comparing thenumber of hourstaught (blue) and the overall confidenceof thestudents(red), out of 10 (10 being themost confident and1 beingthe least)

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

We also sent follow up questionnaires which showed that students had maintained confidence acr oss al l taught sk il l s at thr ee and six months and students unanimousl y r epor ted the cour se gave them l asting confidence.

4 CONCLUSIONS&going f or war d This project has clearly highlighted the importance of spending time doing clinical skills training in a controlled environment and the positive effect that it has on medical students' confidence.

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

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

Image3 depicting each of the3 PDSA cycles. first (top), second (middle), and third (bottom)

Virtual Ward Rounds:

A safe solution for undergraduate teaching during the COVID-19 pandemic F Mouy, S Williams, N Turner

South Bristol Academy, 2nd Floor, Dolphin House, Bristol Royal Infirmary Corresponding author: samuel.williams6@nhs.net

Background and purpose

Methodology

Ward rounds are an essential part of a junior doctor’s work. It is important that undergraduate medical students gain experience of ward rounds to develop medical knowledge, clinical skills and professional attitudes.

A virtual ward round was conducted via video conferencing software on a portable computer in the ward environment. Trust approval was granted for filming in a clinical area and all patients provided written consent prior to the interaction.

The COVID-19 pandemic has prevented larger groups of students from attending ward rounds in order to reduce the risk of virus transmission. As a result, students have been withheld vital learning opportunities for their future careers.

A senior doctor led the ward round in the usual way, with students dialled-in remotely on the portable computer. Students were given dedicated time to take a focussed history relevant to the presentation, before a debrief was held to discuss the patient’s management plan, as would happen on a usual ward round.

Virtual ward rounds represent a viable safe solution for larger groups of students to maintain patient contact and involvement with the clinical decision-making process whilst also maintaining patient safety. The aim was to determine if this was safe and acceptable for patients and an effective learning process for the students.

There was a second debrief, away from the bedside, to consolidate learning objectives from the case. Feedback via an online survey from the session was gathered from both students and patients.

Results Benefits

Drawbacks

More time with the patient

Cannot examine the patient

Don’t feel rushed

Technical glitches

More discussion on management

Fewer patients seen than on usual ward round Less focus on holistic care i.e. options for discharge

A total of 28 third year medical students attended 4 scheduled sessions over 12 weeks of teaching and 6 patients were seen in total. We received 16 responses giving a 57% response rate.

Easily accessible

This patient consented to use of his photograph for this poster

Which ward round provides more educational value?

6%

Virtual Equal value Face to face Don't know

31% 63%

“A few of these sessions would be really helpful for more in-depth learning, but in person ward rounds are better for breadth”

“Quality of teaching very much higher than normal ward round. It was useful to get the whole teaching group ‘in the room’ without having issues of space etc.”

“Things were explained really well, “Although software did not impact which aren't necessarily done on face-to-face ward rounds due to time the value of the education delivered, it was harder to see and hear the constraints” patients compared to other video call “It is rare that doctors take the time services” to [teach] during normal ward rounds “[I] wouldn’t say one is better than and involve students as much” the other, I would like…the option to “Both [face-to-face and virtual ward go to both” round] useful in different ways”

Discussion and conclusion Overall, we have demonstrated that virtual ward rounds via video conferencing software for undergraduate medical students are a safe, effective solution to protect patients and teach larger groups of students during the COVID-19 pandemic. The feedback from students and patients was highly positive, with the majority of students stating that the educational value was higher and that they would prefer to attend these types of ward rounds, even after the pandemic ends.

Virtual ward rounds have been defined in various ways in the educational literature. Doctors at Imperial College London have use augmented reality by using a Hololens headset worn by the consultant physician both as a means of preventing risk of infection to staff members and providing medical education, with virtual images being streamed to students’ home computers1,2. Some have used specific tablets or smartphones to engage with their audience3, whilst others interpreted the concept of a virtual ward round by using simulation4.

Whilst certainly innovative, the Microsoft Hololens 2, even the most basic model, has a retail price of $3,500, money that many education departments do not have available routinely5. Whereas portable computers are commonplace in the NHS and represent a more accessible means of delivering education with the same benefits provided as the Hololens.

We believe our solution has several significant benefits. It is a safe and effective solution and crucially allows easy scalability to other departments and hospitals nationwide.

We promote the concept of virtual ward round as a solution to last beyond the COVID-19 pandemic as evidenced by our cohort’s wholly positive feedback.

References 1. Hagana A, Behranwala R, Aojula N, et al. Digitalising medical education: virtual ward rounds during COVID-19 and beyond. BMJ Simulation and Technology Enhanced Learning Published Online First: 30 September 2020. doi: 10.1136/bmjstel-2020-000742 2. Levy JB, Kong E, Johnson N et al. The mixed reality medical ward round with the MS Hololens2: Innovation in reducing COVID-19 transmission and PPE usage. Future Healthc J. 2021; 8(1): 127-130 3. Raza A, Mukherjee S, Patel V, Kamal N, Lichtarowicz-Krynska E. The smartphone: an evolution or revolution in virtual patient healthcare during and beyond the COVID-19 pandemic? An evaluation and comparison of the smartphone against other currently available wearable technologies in a secondary care setting during the COVID-19 pandemic. medRxiv. 2020 Jan 1.

4. Mayven Tien Li Siow, Alexander Myles Robertson, Austin Begbey et al. Virtual Ward Round Teaching Pilot - A new education method., 01 September 2020, PREPRINT (Version 1) available at Research Square [https://doi.org/10.21203/rs.3.rs-61588/v1] 5. Microsoft. Hololens2. [online] Last viewed 27th April 2021. URL: https://www.microsoft.com/en-us/p/holoLens-2/91pnzzznzwcp/?activetab=pivot%3aoverviewtab

Giving Clinical Governance a Makeover A quality improvement project

Hannah Marshall, Hajera Sheikh, Emma Devereux, Belinda Ng, Anna Gerrard Hughes, Katherine Taylor

The Problem

North Middlesex Hospital NHS, London

• Clinical Governance underpins the daily practice of doctors, nurses and AHPs, affecting patient care, ongoing education and aspiration to excellence. It’s frequently viewed as the remit of consultants and senior managers and can feel far removed from staff on the ground.

• The trust’s most recent CQC report highlighted that staff weren’t always aware of recent incidents (Datixes, Serious Incidents).

• New consultants and senior nurses are expected to take on clinical governance roles and would benefit from more experience during training.

Aim Raise profile of Clinical Governance – increase awareness, understanding and participation of staff by August 2021.

Model for Improvement

Objectives • Gauge levels of knowledge, awareness and involvement in Clinical Governance (CG).

• Improve dissemination of information from CG activity including meetings, rapid reviews, serious incident reports.

• Launch a monthly newsletter.

• Run other CG-based teaching and activities aimed at increasing awareness and participation.

Measure Monthly survey sent to staff members provided a self-reported score on levels of knowledge, involvement and awareness each scored out of 4, with a maximum of 12.

Planning changes Colleagues wanted to know about: • Outcomes of datixes and Serious Incidents (SIs) (97%) • Compliments and complaints (89%) • Clinical guidelines needing updates (81%) PDSAs • Introduced project to wider team • Competition to choose name of newsletter • Developed newsletter: The Chaterpillar • Teaching on QI, following a rapid review, “journey of a datix” • CAMHS sim training development following serious incident • Developed online database of ongoing and past QI projects • CG on teaching timetable regularly

Colleagues wanted to get involved in: • Quality Improvement project (85%) • Writing a guideline (65%) • Investigating a Datix/SI/Rapid review (58%) • Audit (47%)

Results

Results •Multiple changes were adopted in to the fabric of the department •The median score increased from 8 to 9.5 •Participation of junior doctors, nurses and AHPs increased over the course of the project, and scores trended upwards in these groups, too.

Conclusions •Quality improvement methodology brought about change in the profile of Clinical Governance within the department.

•The Chaterpillar newsletter and Clinical Governance teaching sessions provide regular opportunities to hear about ongoing projects and prompts us to learn about and from incidents and good practice.

•There has been lasting impact and enrichment of the paediatric department: oNew involvement, fresh ideas and energy harnessed outside the traditional group of senior managers oLong-term improvement in clinical practice for our department and beyond as more individuals are empowered with knowledge and skills required to be tomorrow’s leaders.

th 16

June 2021

Poster Competition Group J

Education and training (2) First prize: Increasing the rate of Learning from Excellence nominations at the RD&E Hospital during the COVID-19 pandemic by forming an alliance with the Quality Improvement Academy Presenter: Dr Olivia Hartrick Royal Devon and Exeter NHS Foundation Trust Second Prize: Trainees Improving Patient Safety through Quality Improvement (TIPS QI) Presenter(s): Gary Jevons, Sophie Green Organisation: Trainees Improving Patient Safety through Quality Improvement (TIPS QI) (supported by HEE North West)

RCP COVID-19 Study: Preliminary Findings from the Bristol Royal Infirmary Dr Alina Dietrich, Dr Mark Callaway, Dr Emma Redfern. University Hospital Bristol and Weston Foundation Trust.

8th Bristol Patient Safety Conference 16th of June 2021

SJR - Structured Judgement review

Background

The SJR uses a trained reviewer to look at the medical record in a structured manner and to comment on specific phases of clinical care, making qualitative and quantitative judgments.

COVID-19 has forced unprecedented changes in how healthcare is delivered and how many healthcare decisions are being made. The purpose of the work is to provide assurance of the safety and quality of care for patients with COVID-19 during the first wave of the COVID-19 pandemic in 2020.

The RCP COVID-19 study is using modified SJR methodology to include the care of patients who survived COVID-19.

Likert scale for rating care

Aim

1 = Very poor 2 = Poor 3 = Adequate 4 = Good 5 = Excellent

Assess quality of clinical decision making during the first wave of the COVID-19 pandemic.

6 Phases of care reviewed

Objectives

Admission and initial management

Perioperative care

1. Undertake structured judgement reviews on a cohort of COVID-19 patients from the initial pandemic period.

2. Undertake quantitative and qualitative analysis of the completed reviews.

3. Collate findings and generate clear learning and improvement objectives.

Ongoing care

End-of-life care / Discharge from care

Care during a procedure

Overall assessment

Results Care Scores Overall 100% of the 57 patients reviewed received adequate, good or excellent care.

Methodology Medical records for 57 patients that were inpatients at the BRI during the study period (1st of March – 30th Nov 2020) were reviewed using the Royal College of Physicians COVID-19 SJR Tool.

Around 2450 usual expected deaths per year at the BRI BRI Emergency Department Attendance 500 400 300 200 100 0

Survivors Ward Overall 100% Admission 87% Ongoing 87% EOL/DC 94%

Daily BRI COVID-19 ED Attendances and Admissions

Survivors ITU Overall 100% Admission 85% Ongoing 85% EOL/DC 93%

Non survivors ITU Overall 100% Admission 91% Ongoing 100% EOL/DC 93%

Non survivors Ward Overall 100% Admission 87% Ongoing 94% EOL/DC 94%

Distribution of Care Score Across All Admissions

50 30 10

Overall Care Score

-10

COVID_ED_Atts

1,122 COVID Survivors incl. hospital acquired and transfers

COVID_Admissions_via_ED

Initial 24 hours

15 Survivors ward care 57 Patients Selected from 4 categories: Median age: 69 Male: 38 Female: 19

134 COVID Deaths

On going Care

Discharge/EOL care

13 Survivors Intensive care 16 Non survivors ward care 13 Non survivors Intensive care

Case Study 1 - Communicating with the Family

Case Study 2 – Visiting during COVID-19

A 47-year-old patient was admitted with worsening shortness of breath and tested positive for COVID-19. ED clerking noted patient stays at homeless shelter but otherwise lacked NOK or contact details.

Initially patient was stable but then deteriorated rapidly and was admitted to ITU and was intubated and ventilated. ITU staff went through great effort to track down patient’s caseworker and a friend who managed to provide contact details for family living overseas.

Staff were now able to update family.

An 87 year-old was admitted via ED with fever, shortness of breath and cough. The patient has lung Ca and limited exercise tolerance. A diagnosis of COVID19 with likely super-added bacterial infection, was made.

Imaging revealed progression of malignancy. Following discussions with the patient and their family, it was agreed that the patient was likely in the last days of life. Due to COVID-19 restrictions family members were unable to visit. The F1 doctor agreed to sit with the patient and read messages that their family had sent.

0

5-Excellent

4-Good

10

20

3-Adequate

30

2-Poor

40

50

1-Very Poor

60

0-N/A

Thematic Analysis Thematic analysis was undertaken on the free-text comments written by reviewers for each phase of care. Comments from reviewers add explanation and insight into the ratings they attributed. In total 440 comments were collected, 64 comments that were purely descriptive in nature were not included in the thematic analysis. Leaving 376 comments to analyse. A total of 263 positive and 113 negative comments were extracted from the reviews and assigned a theme.

The five most prevalent themes across positive and negative statements were:

Good practice • • • • •

Prompt senior reviews and escalation decisions made in ED. Most Respect Forms completed within 24 hours.

Excellent family communication, senior led updates, during ITU admission.

Intensive physiotherapy input on wards.

Most families offered one family visit for palliative patients.

Learning Points and recommendations • Complete Respect Form on admission.

• Document escalation/ceiling of care discussion in notes.

• Regular family updates on ward and access to senior doctors.

• Justification for changes in decision making not noted.

• Involve palliative care earlier for symptom control.

Acknowledgements I would like to thank Dr Callaway and Dr Redfern for their support and uidance with this project, Alek Berksi from the Business Management Department for providing mortality data.

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

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

N Mathieu, R Bethune

Introduction & Aim

Results

• In the NHS, developments in patient safety have focused on learning from errors. This approach neglects the opportunity to learn from the abundant examples of excellent practice. ‘Learning from Excellence’ (LfE) is a contemporary initiative which advocates a system to report excellence. This is a popular initiative, recommended in the 2019 patient safety strategy1.

However, nationally there has been variable rates of implementation success.

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

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

• In 6 months, we found an average 298% increase in the monthly LfE nominations was observed across the trust from November 2020-April 2021.

• The significant increase in nominations in April 2021 (146) is a result of the latter two PDSA cycles which included the following interventions; the LfE promotion week, CEO twitter takeover and publication of the LfE screensaver.

160 140 120 100 80 60 40 20 0

146

3

8

17

12

14

15

16

12

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

Progress was analysed using nomination run charts.

Focus: emergency department, a medical ward and a surgical ward. Intervention: series of formal and informal discussions which introduced LfE. Result: In 3 months, the number of nominations increased by 300% within ED and 160% in surgery.

Figure 3. Runchart of LfE monthly nominations across the trust.

Limitations This QI project was conducted during the COVID-19 pandemic. It was therefore essential to follow the trust’s COVID-19 guidance. This limited our ability to draw from previous face-to-face QI intervention experience and so we were required to adapt and focus on innovative virtual interventions.

Furthermore, a large number of staff were re-deployed to different departments and many wards were often moved or closed. This likely reduced the impact of our first ward based PDSA cycle and so following PDSA cycles focused on trust wide virtual interventions which proved to be a lot more successful.

Focus: Trust Wide. Intervention: The development of a trust approved animated video and screensaver including a QR code as a direct link to the submission form. Initial results identifies a drastic increase in rate of nominations.

Focus: trust wide. Intervention: Trust approved promotional week, restaurant stand and CEO twitter takeover. Initial results identifies a drastic increase in rate of nominations.

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

Figure 2. Learning from Excellence poster screensaver.

Cycles2

.

Figure 4. Promotional week photos.

Lessons learnt, future direction • We found that an organised and systematic approach to the quality improvement project, involvement of appropriate stakeholders and regular virtual task-focused meetings sustained the momentum and maintained the rate of success of this project.

• Using a multi-faceted cumulative approach improved project outcomes and sustained change.

• Another important outcome of this project was the creation of a group of motivated LfE ‘champions’ who are committed to continue LfE implementation and sustained change within this trust and across the Southwest.

References 1. NHS. 2019. The NHS Patient Safety Strategy:Safer culture, safer systems, safer patients. [Online] Available at: https://www.england.nhs.uk/wp-content/uploads/2020/08/190708_Patient_Safety_Strategy_for_website_v4.pdf > [Accessed 9 May 2021].

2. NHS England. 2021. Plan, Do, Study, Act (PDSA) cycles and the model for improvement. [online] Available at: <https://www.england.nhs.uk/wp-content/uploads/2021/03/qsir-plan-do-study-act.pdf> [Accessed 9 May 2021].

Using Quality Improvement Methodology to enhance the Serious Incident Review process: Introducing the Team Approach

BACKGROUND

A3 THINKING

In December 2019 feedback from a Just and Learning culture workshop highlighted the negative views staff hold about the Serious Incident and Inquest process. This had also been flagged as an area of concern and focus in Operational Leadership Groups and we are aware from colleagues in other Trusts that the issues are widespread.

The Patient Safety and Quality Team (PST) undertook a process mapping exercise which was refined further by completion of fishbone analysis. Identified countermeasures were tested and through a Plan, Do, Study, Act (PDSA) approach were updated. The PST planned to undertake process confirmation and also develop standard work for each step of the Serious Incident process.

In March 2020 a review event took place in response to the significant feedback and dissatisfaction with the current process, an A3 approach was utilised to understand the problem, this was an opportunity to collect data and complete a fishbone analysis.

A further rapid Improvement event was scheduled but due to the Covid pandemic there was a need to adapt the approach. Two smaller meetings with the Head of Quality Improvement were held and further discussions with stakeholders took place to analyse data and prioritise countermeasures.

The patient safety team undertook a process mapping exercise, each step of the existing process has been refined based on the fish bone analysis (Figure 1)

Figure. 1

PRIORITY COUNTERMEASURES Use of a decision grid to ensure a consistent threshold and reduced variation for identifying reportable Serious Incidents Use of Terms of Reference set by senior staff with operational and clinical expertise Using a structured judgement and fishbone analysis approach for a care review Utilising Patient Safety Manager skills to lead a collaborative team approach to investigations

STAFF FEEDBACK

“Prior to the new process of investigating serious incidents I had been an IO for two serious incidents. Since the new process has been introduced I have been part of two Serious Incident review teams.

Working as an IO for two serious incidents was very onerous and challenging to manage alongside my ongoing role and responsibilities. The new process is much more collaborative and supportive and I have found it very helpful to meet with senior colleagues in patient safety and clinical governance to address issues raised through serious incidents and how we can learn from these and disseminate and apply this learning to clinical teams.”

Poster Design by Cori Gumbs, Berkshire Healthcare NHS Foundation Trust

“Much more robust process. Much less subjective. More team ownership. Fits with a nonblaming approach to management of SI’s “

“staff in my team are reporting it feels more compassionate, some staff have had a really bad experience and were dreading the meeting but afterwards felt valued as there was an understanding of the work they had done and they got a chance to explain”

“it is taking up more of my time at the beginning, but I feel it is far more valuable and accurate identification of the areas we need to focus on- we have already seen some real attention to areas required”

“Having been involved in the investigation of serious incidents within the trust for a number of years, I welcomed the introduction of the team approach to undertaking these care and treatment reviews. This methodology allows the review to focus on the areas that will make a difference and where improvements can be made. It is a collaborative approach, where the opinions and input of a variety of care team members is welcomed. Care is reviewed by peers which allows this to be done by those experienced in the complexities of mental health care where needed.

The services I look after report that the new process is focussed on learning and not blame. They feel included and that they have ownership of the learning that they need to embed in their teams to improve care. Families are encouraged to contribute, and the teams discuss any areas they would like to be reviewed.

The Patient Safety Team at Berkshire Healthcare are supportive and extremely knowledgeable. They lead and guide the process, which can be challenging at times, with the utmost competence. Their knowledge results in care and treatment reviews that address the areas required, and deliver professional reports of a high standard. “

Lockdown Learning: Bringing the Urology Theatre to the classroom 1,

1,

Dr Alexandra Uren* Ms Lydia Lilis* Ms Bee Martin 1 University Hospitals Bristol and Weston

1

Background • Covid-19 has had a significant impact on medical education • Fewer learning opportunities for medical students creates a future patient safety risk • Of 20 University of Bristol Medical students, 17 confirmed Covid-19 has affected their surgical teaching opportunities • To bridge this educational gap, we created a Urology half-day teaching session.

• We employed videos and simulation

Image 2: Screenshot of slides: methodology - teaching physiology

Image 3: Screenshot of slides: methodology for teaching the ‘in-theatres’ component Image 1: Screenshot of lesson outline

Teaching methodology • Pre and post-session questionnaires • Basic Urology anatomy and pathophysiology teaching • Practical skills – sterile gloving, male and female catheterisation • Case scenarios, e.g.: a patient ‘s journey from the Emergency Department to the operating theatre • Videos of key Urological procedures and operations (sourced from YouTube) and talked through. o Students were encouraged to participate as though standing in theatre, watching the procedure

Results • Post session questionnaire: 100% of students felt the teaching improved their Urology knowledge • 100% agreed this teaching style helped bridge gaps in their Urology experience Conclusion • We identified accessible and replicable methods of addressing gaps in students' surgical experiences • 100% of students agreed that similar sessions for other surgical specialities would be helpful to their future learning

How not to reinvent the wheel: Building an Evidence Repository to share QI Louise George, Jo Bangoura, Anne Pullyblank (West of England AHSN), John Loy (North Bristol NHS Trust), Elly Bernard (BNSSG CCG) & Prof Nicola Walsh (UWE)

Introduction and Aim The Evidence Repository is a portal for safely sharing non-peer reviewed documents that are not published elsewhere, to promote a culture of shared learning and collaboration. The repository was set up in May 2020 by the West of England Academic Health Science Network (AHSN), in partnership with local STPs/ICSs and hospital libraries, to support rapid evidence sharing. Membership is restricted to NHS, universities, and public health organisations, who upload relevant, locally-written documents to share with others.

Method The repository is hosted on the Future NHS Collaboration platform and launched in May 2020 for NHS, university and public health organisations. Topics were categorised to allow searches in collaboration with library services, and a front sheet was designed to describe how each document had been developed, allowing users to understand how comprehensive the evidence search was.

Results

The Evidence Repository provides a space to share:

Evaluations Evidence Summaries Population Health Management Insight Reports Quality Improvement Projects “Healthcare organisations are constantly seeking evidence to assist with decision making.

Challenges encountered, and therefore questions asked, are frequently quite similar across different organisations. The repository allows sharing of information and has the potential to make better use of resources, as people can see what is already available before they duplicate efforts”

Professor Nicola Walsh, Professor of Knowledge Mobilisation & Musculoskeletal Health, The University of the West of England.

Join the Repository

Conclusions and Next Steps The repository is proving to be a valuable resource, and has received interest from many organisations outside the original pilot area in the West of England. Priorities going forward include working with organisations to make uploading to the repository part of their ‘business as usual’, building repository content (especially QI projects), and working with the British Library and HEE, who are piloting the use of repositories in the NHS. To join the repository contact Louise.George3@nhs.net.

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“Surviving” inductions in COVID-19 – a peer made “Survival Guide” for Elective Orthopaedics at a Tertiary Teaching Hospital Jvalant N. Parekh 1 1 University Hospitals of Leicester Introduction and Aims: The COVID-19 pandemic has had a significant impact on junior doctors inductions to rotations with many going online prior to commencing their job. This has resulted in minimal face-to-face time for junior doctors to receive an appropriate and effective induction.

This survival guide was created as FY2 doctors rotating onto elective orthopaedics did not have a formalised induction whilst expectations of what was expected remaining at that of the pre-pandemic era. Jobs expected of FY2s from day 1 include pre-assessment clinics to declare patients fit for their surgery, knowing appropriate theatre etiquette to assist in operations and independent post-operative assessment of patients on the wards. The survival guide aimed to ensure all new FY2s starting on this rotation were aware of expectations and able to perform them from their first day.

Plan: Near the conclusion of an elective orthopaedic placement, the current FY2s were consulted on elements they felt they could benefit from knowing beforehand. Key topics included pre-assessment clinics, post-operative patient management and navigating on-calls. The significant difficulty many FY2s faced early on in the rotation was managing uncertainty as most of these aspects of the job were done independently, including ward rounds.

Therefore, it was imperative that new juniors starting on elective orthopaedics had a clear understanding of how to perform these tasks to a high standard.

Act: The feedback received on this has been positive. FY2s have appreciated having a greater understanding of the placement they are about to undertake.

Areas of improvement included updating the guide on a 4 monthly basis with a table of supervisors included for each doctor to allow the guide to be the one stop shop.

Otherwise there were no areas for improvement.

Study: The survival guide has been in use for two rotations now.

Feedback continues to be gathered but overall feedback remains positive. This is demonstrated in the graph below.

Do: Following this a “survival guide” was created and after consultation with the departmental administrative team and head of department, was made available to new FY2s coming into the department. This was disseminated to all new FY2s to the department.

Results So n=10 junior doctors were asked for their feedback. N=6 responses were received across two sets of placements. 6 questions were asked on a 5 point Likert scale gaging preparedness, confidence before and after reading the survival guide. Qualitative feedback was used to find areas of improvement which were implemented in subsequent editions of the survival guide.

Confidence Levels

Confidence and Preparedness Before and After Using the Survival Guide 5 4.5 4 3.5 3 2.5 2 1.5 1 0.5 0

Conclusion: Survival guides are an informative and effective manner to ensure that in a time when we have many inductions to new jobs virtually, new doctors can be adequately prepared ahead of time by a peer-created resource which serves.

How well How much did prepared did you you know about feel for your job what you in elective needed to do in orthopaedics pre-assessment before coming in clinic? on your first day?

How comfortable were you with reviewing patients postoperatively and their discharge planning at the start of your rotation?

How would you How much has How much has rate the survival the survival the survival guide given to guide helped you guide helped in you at the start in your pre- your assessment of your rotation? assessment of post-op clinics? patients and discharging patients?

By ensuring that the quality is at the standard expected by the department through review of the content by senior clinicians and the head of the department, it ensures information provided to new junior doctors is at the appropriate level of expectation and ability.

Survival guides should continue to be created for all departments to ensure smooth transition for FY2s and other junior doctors in the future.

Vevox - Free Live Polling Platform to Increase Engagement to 50% in Virtual MRCS Exam Revision Teaching I. Jakaityte, Dr O. Hartrick RILD Building, RD&E Hospital Wonford, Barrack Road, Exeter, EX2 5DW

BACKGROUND • •

• • •

COVID-19 pandemic has limited teaching to virtual-only.

In January 2021, we utilised Zoom video conferencing to deliver our international Membership of the Royal College of Surgeons (MRCS) anatomy and perioperative medicine teaching series.

The question-based revision sessions depended on attendees answering questions using the Zoom chat.

Engagement was low and session feedback revealed the limitations of this approach: lack of anonymity and the ability to be influenced by others’ answers.

Live polling was shown to improve attendees’ engagement in the past.1,2

AIM

Our aim was to improve attendees engagement with the questions to 50% in the virtual teaching sessions using Vevox, a live polling platform.

20.69

26-01-2021

METHODS • •

• • • • •

We acquired attendance data and chat transcripts from the Zoom meetings’ reports.

Baseline engagement was quantified using the number of people who suggested at least one answer in the chat and its proportion to the number of attendees who were at the session for at least 15 minutes.

Questions were uploaded to Vevox ahead of the following sessions.

We shared the joining instructions, session IDs and QR codes with attendees at the beginning of the teaching and on each question slide (demonstrated below).

They were able to join the polling on their phones or laptops and Vevox provided data on active participants.

Feedback on using Vevox was collected.

We compared engagement before and after introduction of Vevox using a t-test, with significance of p<0.01.

Proportion of Attendees Engaged in Answering Questions, % 58.22 52.05 50.00 52.63 46.81 39.13 23.42 22.97 21.10 18.45 With Implementation of Vevox Polling 02-09-2021

RESULTS

23-02-2021

02-03-2021

09-03-2021

30-03-2021

• We achieved our aim with an average engagement (±SD) of 49.81 ± 6.43% in 6 sessions with Vevox polling and an average of 83 attendees per session.

• Engagement in teaching increased by 29.48%, p <0.001.

• More participants felt able to and appreciated the opportunity to participate in answering questions.

REFERENCES

06-04-2021

04-13-2021

04-20-2021

04-27-2021

05-04-2021

LEARNING POINTS • • •

Live polling can increase engagement in online teaching to 50%.

Vevox is the only free live-polling platform that allows an unlimited number of participants and polls per session.

Vevox is a convenient platform to use for providers and attendees.

1. Voelkel S, Bennett D. New uses for a familiar technology: introducing mobile phone polling in large classes. Innovations in Education and Teaching International. 2014 Jan 2;51(1):46-58.

2. Price TJ. Real-time polling to help corral university-learners' wandering minds. Journal of Research in Innovative Teaching & Learning. 2021 Feb 23.

European Medical Graduate Association (EMGA) Bridging the gap between Medical school and the Hospital environment Dr Rute Castelhano, Dr Domna Efthymiou, Dr Helen Kowitz Arroyo Introduction EMGA was created to help the transition period from being an European Medical Student to become a Junior Doctor For the European Medical students there is a shortfall in the preparation to enter the healthcare system of their destination country.

Our aim is to support and guide the future generations of IMG Junior Doctors.

Methodology

Results

We identified a gap in the preparation of Europen Medical Students to enter the NHS

EMGA pre-series survey showed:

We created EMGA teaching series UK programme, built with an unique curriculum, tailored to the student’s suggestions and schedules.

-80% of the students felt unprepared to work as Junior Doctors

It consists of 2 weekly webinars in which we discuss clinical and academic/portfolio topics in order to prepare them for the Foundation Training programme or equivalent.

The sessions are delivered via MS Teams with quizzes, online simulations and clinical cases.

-100% agreed that this teaching programme would help them to prepare to work in the NHS -100% agreed that this programme wold benefit their portfolio development

Online pre- and post- sessions surveys were distributed amonst the attendees The post-webinars surveys showed:

Conclusion This study demonstrated that confidence levels clearly improved and student’s objectives were met With new and creative teaching methods, a high standard quality teaching was delivered in all seminars Future plans include International expansion, EMGA workshops and conferences to offer unique educational opportunities.

Find out more about EMGA search for @emga.comms Contact: Rute Caselhano rute.castelhano@nhs.net

Trainees Improving Patient Safety through Quality Improvement (TIPSQI) No. 117

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

Background: • There is significant variation in exposure to, and training within QI concepts • The Francis and Keogh reports1,2 highlighted junior doctors as “agents for change” • Without formal QI training their potential to undertake improvement is limited

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

Aim: • TIPSQI is a trainee-led organisation set up in 2013 with the aim of teaching QI methodology to all foundation year (FY) trainees within the North-West (NW) deanery, empowering them to undertake effective QI projects Methods: • Peer-led mentor system and “train-the-trainer” model • Workshops delivered within the FY teaching programme reaching all 21 trusts within the NW • Website developed (tipsqi.co.uk), including a TIPSQI project guide • Teaching sessions developed for consultants supervising QI projects • QI conferences arranged to showcase work of FY trainees • In response to COVID-19 we converted to a virtual teaching model; all sessions provided virtually as well as organising a regional virtual QI conference to recognise the excellent QI work during the pandemic 2019/20 – all 21 trusts in NW - 121 sessions - 3500 foundation trainees,, 200 consultants 2020-21 - Conversion to virtual teaching model - More virtual resources - Two virtual conferences

Results: • • •

•

To date, we have reached over 3500 foundation trainees and 200 consultants across 121 sessions, and have delivered 3 regional QI conferences We are supported by Health Education England North West with TIPSQI training being a mandatory deanery wide component of the FY curriculum Through the use of pre and post self-assessment scores for the understanding of individual components of QI methodology, we demonstrated significant improvements in attendee understanding of key QI concepts (Figure 3); as well as achieving overall good feedback in the teaching quality (8.51/10) and relevance to training (8.24/10) Our virtual teaching programme received consistently positive feedback, equivalent to that of our “face-to-face” teaching “Brilliant, finally understand QI”

Figure 1. PDSA cycle to display development of TIPSQI

References 1. Francis R. (2013). Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry. London: The Stationary Office.

2. Keogh B. (2013) Review into the quality of care and treatment provided by 14 hospital trusts in England: an overview report. London: NHS.

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

“Really helpful session – interactive which was great”

Future plans: • Building an online project bank • Expanding our sessions to higher trainees and to different regions within the UK • Developing our online resources

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

Clinical leadership Finalist 2020

th 16

June 2021

Poster Competition Group K

Improving processes and healthcare outcomes (1) First prize: “Doctor...can you update the family please?...” A Quality Improvement Project on Family Updates Presenter(s): Amy Prideaux & Thanuja Thananayagam University Hospital of Wales, Cardiff

Second Prize: A Quality Improvement Project to Improve Access to Clinical Guidelines for Junior Doctors at the Royal Devon and Exeter Hospital Presenter(s): Alice Mcloughlin, Fah (Rungphloy) Jaroenchasri Royal Devon and Exeter NHS Foundation Trust

Novel mobile guidelines application at a District General Hospital Introduction: Guidelines on best practice are challenging to remember, difficult to interpret or simply cannot be found, leading to differences in patient care and impacting safety. Local guidelines at Kingston NHS Trust were found on the intranet as a PDF and were difficult to access and frustrating to navigate. As two new FY1s to the Trust we looked to improve accessibility and useability to enhance the value of these commonly used guidelines.

Cycle one

DO

Plan Scoping: Stakeholders identified and small focus groups run identifying key issues.

• • • •

1.

2.

Data: 79% use guidelines almost daily 35% found guidelines easy to access 16% found guidelines easy to navigate 84% thought a mobile application would be useful Aims: Improve access to local clinical guidelines Improve navigation of local clinical guidelines

Initial steps: 1. Discussions with IT + guideline team approval gained 2. Agreed to develop prototype for focus group review 3. We learnt to code!

Outcome: 1. Mobile application designed using Flutter 2. Guidelines split by specialty 3. Available on all Android/ Apple devices

3 cycles completed so far

Act Conclusions from cycle one • Staff found having guidelines on a mobile device useful • The lack of search function hampered the usability of the application • Application not ready for release Plans for next cycle: • Develop a search function to highlight relevant guidelines • Reconsider layout

Study Data Gathering: • Small groups given chance to test over a week and give feed back in focus groups

Results: • 84% found guidelines easy to access • 10% found guidelines easy to navigate • Main criticism was lack of search function

Summary of cycle 3: Summary of cycle 2: • Colour/ formatting integrated into • Search function developed text • User navigation improved to 82% • Main feedback is text could be improved by • User navigation improved to 94% • Usage measured at 25-30 unique colour/ highlighting key information users per weekday • Application released across the Trust • Application currently offline and Work completed by: under review pending governance Dr Aaron Morjaria Foundation Year 2 issues surrounding update Dr Eleanor Cartwright Foundation Year 2 Dr Ram Kumar ICU Consultant responsibility

ENHANCING PATIENT CARE BY IMPROVING THE REFERRAL SYSTEM Poole Hospital is a district general hospital that boasts a range of specialties. Each specialty has its own unique referral structure, which requires the referrer (usually junior doctors) to know the exact process and which system to use when referring. Examples include bleeping, online forms and printing documents. Incorrect referrals are a patient safety risk, cause undue delay in patient assessment by other specialties and can also delay discharges. The goal of this project was to improve the referral system by creating a dedicated information system on the trust intranet detailing the referral process to each specialty and contingency plans if the referrer is unsuccessful. This would enhance patient care by reducing incorrect or missed referrals to other specialties.

Objectives: Improve the referral system by creating a dedicated information system on the intranet.

Questions: What are the difficulties junior doctors have with referring to specialties?

How can the current system be improved?

Who/How: Junior doctors to carry out project Over 4 months, to compile evidence into a referral system that is relevant and accurate

What was already in place? An outdated document on the intranet that had inaccurate details causing confusion. No details were available on how to update document or contact owner.

Keeping the information current.

What did we do?

We decided to create a dedicated and current referrals information system for the main medical and surgical specialties on the hospital site.

Anonymous data was collected usign an online questionnaire sent to the same group of junior doctors who answered survey 1. Questions ranged from multiple choice to short-answer Who/ How: Junior doctors to carry responses. out second cycle over 2 months.

What changed in this cycle?

Highlighting that system is for nonemergency referrals, only.

We used feedback received from specialties to further update our original intervention.

We updated the contact details so users can inform us of any updates on the referral pathways.

Objectives: Assess the effectiveness of our intervention and highlight further areas for improvement

Our intervention is a dedicated information system on the trust intranet detailing the referral process to different specialties located at Poole Hospital. The initial questionnaire (28 respondents) found that many referral processes were poorly understood. The Respiratory Medicine referral pathway was the most widely understood and Endocrine Medicine referral pathway the least understood. 88% of respondents agreed that referral errors have caused delays in review, management, and assessment from a specialty. A post-intervention survey showed 100% (18/18) of respondents found the dedicated information system benefitted patient care.

Our intervention has clarified the differing referral pathways at Poole Hospital. Users are encouraged to highlight pathway changes to ensure the page remains relevant and to continue to cycle improvement. We would advocate similar referral guides for other trusts and to incorporate this into induction teaching for new members of staff to improve patient care.

We collected both quantitative and qualitative data through questionnaires Quantitative data was analysed using pie charts and bar graphs.

Qualitative data was collected in the form of short answer responses and analysed by coding key themes.

Quantitative data was analysed using pie charts and bar graphs.

Qualitative data in the form of short answer responses was analysed using a coding system.

100% of respondents (20/20) of the second survey believe that the dedicated referral system benefits patient care.

One respondent wrote 'Simple and concise... hopefully no more errors in referrals' Another wrote 'Much needed, especially when new to a hospital or when the pathway frequently changes'

Our data collection highlighted a clear problem experienced by multiple junior doctors. A streamlined refeferrals system was created to aid with patient care and uploaded on the trust-wide intranet. This was circulated to medical staff of all grades including junior doctors via email.

Despite positive feedback on the updates on the system, there are still ways to continually improve : 1. Update document with new information as soon as it becomes available.

2. Email doctors trust-wide with the new updates to the system every time it is updated 3. Plan for cycle three- expand specialty base e.g. neurophysiology, acute pain team and consider including referral pathways to specialties at other trusts.

“Doctor...can you update the family please?...”

A Quality Improvement Project on Family Updates Dr Amy Prideaux and Dr Thanuja Thananayagam, FY1s at The University Hospital of Wales, Cardiff

Problem & Background

Aim

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

Team

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

Driver Diagram

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

Measurement

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

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

PDSA Cycles Plan - Identify problem - Predict that the afternoon board round will increase the frequency of family updates - Design whiteboard table - Collect baseline data

Study

Do

- Analyse data - Brainstorm ideas about the logistics of our intervention

- Implement family update whiteboard - Notify staff on ward - Collect data

‘Relatives and Family Communication Board Round’

Intervention

3pm daily Quick run through of who has been spoken to and who still needs to be updated.

Lessons learnt - Family updates and documentation requires continuous effort from the whole MDT - Effective and efficient feedback between staff members is required to ensure continuity between shifts - Regular updates given to relatives will help ease their concern

- Apply intervention of 3pm board round - Update staff on the ward - Collect further data

Results

Intervention

Re-visited ward 3 months later Ward manager noticed there had been fewer complaints during the intervention.

Patient folders now have an update sheet at the front, for staff to sign when and who they updated. Therefore a proven sustainable change and improved outcomes for staff and patients.

Act

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

Next Steps - Perform QI project on new update sheet and compare results - Allocate patient update advocate at start of shift Next - Integration of family updates into SBAR handover tool - Collect data on family concern and number of Steps complaints made

Acknowledgements Dr Owen Seddon, Infectious Diseases Consultant A7 ward team at UHW

Transfers of Covid-positive patients from Torbay Hospital: A Quality Improvement Project Dr Zara Dyar Trust Doctor

Dr Andrew Griffiths Deputy Medical Director

Jane Dewar Quality Improvement Coach

Cathy Gardner Head of Operations

Project Drivers and Aims With growing numbers of Covid-positive patients in Torbay Hospital, it was identified that transfers to external sites would need to occur in order to maintain cancer and essential surgical care. No standard operating procedure (SOP) existed to enable safe transfers of these patients. This project aimed to develop a SOP for transfer of Covid-positive patients to these external sites from Torbay Hospital.

PDSA Cycle 1 A SOP was constructed initially for transfer of Covid positive patients from Torbay Hospital to the Royal Devon and Exeter Hospital. We discussed and walked through the route of transfer for patients with key stakeholders. Adjustments were made to the SOP following this, and it was implemented.

Admissions of Covid positive patients to Torbay Hospital Sept 2020 - Feb 2021 60

50

40

NHE Exeter opens to Covid positive patients

30

20

10

PDSA Cycle 2 We monitored case numbers and suitability for transfer according to criteria set by the RD&E. With rising case numbers in our hospital and regionally, the Nightingale Hospital, Exeter opened to Covid positive patients. We adapted the SOP to include transfer criteria from the Nightingale and began transferring patients to the Nightingale.

0

PDSA Cycle 3 A board round was implemented as part of the SOP, in order to streamline communication between team members and identify suitable patients for transfer. Roles were allocated to team members responsible for key aspects of transfer.

Team member

Role

Consultant

Identify patients for transfer and discuss with RD&E/Nightingale Consultant

Junior Doctor

Inform patient/Next of Kin of transfer Prepare transfer paperwork including discharge summary, medication TTAs, ensure treatment escalation plan completed

Nursing staff

Ensure patients stable and prepared for transfer, hand over to nursing staff at RD&E/Nightingale

Ward clerk

Book transport, print paperwork to accompany patient, call NHE Control to inform of patient transfer

Clinical site managers Enact transfer SOP using pre-arranged route with cleaning team following

• • “Balancing priorities was hard- it did work as a whole to use the Board Round to regroup & understand who could go the NHE” Torbay Acute Medical Consultant

•

Results and lessons learnt A total of 49 patients were transferred to the Nightingale between November 2020 and February 2021, with 12 patients transferred to the Royal Devon and Exeter Hospital Good communication within the medical team, and with our counterparts at the RD&E/Nightingale proved crucial to allow for efficient transfers of patients to these sites, which was facilitated by the daily Board Round discussion Frailty was a key criterion which prevented patients being transferred in the initial stages of the SOP. This was discussed with the Nightingale and this criterion was removed, and instead a discussion was had between the referring and receiving team around suitability for transfer

IMPROVING SUMMARY CARE RECORD ACCESS AT GWH Ellen James, Rupert Larkin, Matthew Carr, Hennie Helliwelll

The Summary Care Record (SCR) is an electronic record created from a patient’s GP record which allows hospital staff to record accurate drug histories.

Have you experienced difficulty obtaining accurate histories for medications of high importance whilst at GWH?

Yes

SCR has been shown to reduce prescribing errors and improve efficacy within the healthcare system(1) and is set out as a clinical standard in the NHS Universal Capabilities Information guideline(2) The majority of junior doctors were not using SCR at Great Western Hospital (GWH) which represented a patient safety issue.

Yes 18.8%

Unaware of the system

Aims: 12.5% - Establish the prevalence of SCR access across GWH No access - Establish what the barriers are to SCR usage 68.7% - Improve uptake of SCR Have you used the Summary Care Record to access accurate drug histories whilst - Reduce the number of prescribing errors by clerking doctors working at GWH?

Oct '20

Dec '20

Jan '21

Mar '21

Barriers to SCR use by junior doctors - Awareness of the system - Availability of SmartCard readers + relevant software - Knowing how to get an NHS SmartCard, neccesary for SCR access 30

100

20

75

10

50 25 Ap ril

0

December January

February

March

N

ov

em be

r

0

SCR FAQ poster

Despite an increase in applications and use, the majority of foundation doctors still do not have access to the summary care record

Auditing hardware availability Embedding SmartCards in junior doctor induction Analyse pharmacy audit data

References 1. L Cotton. A benefits study of Summary Care Records use in hospital medicines reconciliation and their impact. JOMO December 2015 (pharman.co.uk) 2. https://www.england.nhs.uk/publication/univrsl-capabl-info-resources/

Identifying high-risk inpatients during the COVID-19 pandemic F Stourton, H Neißner, G Lodge, K Wordsell, O Meadows

Background & Aim

During the first wave of the COVID-19 pandemic, an event occurred where a hospital inpatient who was immunosuppressed was exposed to COVID-19. Analysis of this event showed that there was no easy way for nonclinical bed managers to easily identify patients who were "clinically extremely vulnerable" to COVID-19 per the government guidance.

The aim of this project was to create a simple way for these patients to be identified by clinicians in order to minimise exposure to COVID-19 for these patients.

Fig 1. A screenshot showing the tag in-situ on the EPR

Method

An initial audit of the ward where the event occurred was performed. On reviewing the notes, 18% of inpatients (3/16) were identified as being clinically extremely vulnerable according to contemporaneous guidance.

Using the trust's Electronic Patient Record, an alert icon was created that was visible on a patient's summary record. The icon was publicised to clinicians across the hospital, and they were encouraged to add the alert to any patient who met the criteria at point of admission. The site team were also educated about the icon in order to help with isolation and stratification of patients NHS Guidance on “Clinically Extremely Vulnerable” patients1

Prior solid organ transplant Current radical radiotherapy for lung cancer are having targeted cancer treatments that can affect the immune system (such as protein kinase inhibitors or PARP inhibitors) Current leukaemia, lymphoma or myeloma Bone marrow or stem cell transplant in the past 6 months, or ongoing post-transplant immunosuppression Severe lung condition (such as cystic fibrosis, severe asthma or severe COPD) Immune deficiency or conditions predisposing to severe infections (SCID, Sickle Cell) Current immunosuppressant medication Cardiac condition and pregnant Current chemotherapy or immunotherapy N.B. Clinical discretion was also employed in designating these patients as “high risk” Table 1 – NHS guidance at the time of the initial project regarding classification of “Clinically Extremely Vulnerable” patients

Results

I

A repeat audit was performed of a medical and surgical ward. Of the ward inpatients, 60% of those identified as clinically extremely vulnerable had an associated vulnerability icon. All of those with an icon were being cared for in side rooms or were cohorted in bays with patients who had tested negative for COVID. None of the patients had tested positive for COVID following admission.

The aim of this project was to successfully bridge the gap between a patient's vulnerability status (often written in the notes) and their allocated bed within the hospital, in order to reduce their risk of nosocomial COVID19 transmission. Further work is ongoing to ensure all patients who meet the criteria are identified in this way. .

Ref 1: https://www.nhs.uk/conditions/coronavirus-covid-19/people-at-higher-risk-from-coronavirus/whos-at-higher-riskfrom-coronavirus/ [Accessed 21 May 2020]

A Quality Improvement Project to Improve Access to Clinical Guidelines for Junior Doctors at the Royal Devon and Exeter Hospital A. Mcloughlin, R. Jaroenchasri, B. Lane, S. Holloway, P. Gleed, H. Pringle, I. Kwek, A. Routsis, L. Taylor, Y. Mehta, S. Hasan, S. Smith, E. Richards, A. Kennedy, B. Abradu Berchie, P. Ramos Barbosa, A. Richards

Introduction •

•

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

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

Aims • •

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

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

PDSA Cycle 1 •

•

•

PDSA Cycle 2

PLAN/DO – a qualitative survey was circulated to JDs to evaluate the pattern of use and perceived ease of finding clinical guidelines.

JDs and medical students (MS) were invited to find five common guidelines on the RD&E Hub whilst being timed STUDY: ○ 75% of JDs access guidelines multiple times per week ○ Average ease of finding guidelines was rated 2.5/10 ○ Mean average time taken to find guidelines was 109s ACT – a clinical guidelines page was designed and launched onto the RD&E Hub, including commonly used guidelines.

•

•

•

PLAN/DO – to re-survey JDs after implementing the new clinical guidelines page on the RD&E Hub and test the ease of finding five common clinical guidelines STUDY ○ Average ease of finding guidelines increased to 8.7/10 ○ There was an 81% reduction in time taken to find guidelines to a mean average of 21s ACT – a new clinical guidelines app called Microguide was commissioned to further improve access to guidelines.

PDSA Cycle 3 • •

•

PLAN/DO – to populate the new Microguide app with clinical guidelines and test JD’s on finding common clinical guidelines within the app STUDY: Average ease of finding guidelines on the Microguide app was rated 8.75/10 There was a further 57% reduction in time taken to find guidelines to a mean average of 9s ACT – to advertise to wider staff population including physician associates and further JD’s

Ease of Finding Clinical Guidelines

Time taken to find clinical guidelines 109

100

Rating out of 10

Time in seconds

120

80 60 40 21

20

9

0

Cycle 1

Cycle 2

10 9 8 7 6 5 4 3 2 1 0

Cycle 3

8.7

8.75

Cycle 2

Cycle 3

2.5

Cycle 1

Conclusion • •

•

This project identified an area of clinical practice lacking efficiency and negatively impacting junior doctors and the delivery of optimal care.

A simple yet effective intervention of collating guidelines onto a single page on the trust intranet was created leading to significantly improved access to clinical guidelines.

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

1. Grimshaw J, Russell I. Effect of clinical guidelines on medical practice: a systematic review of rigorous evaluations. The Lancet. 1993;342(8883):1317-1322.

P STANIER, S LOCHAB, A KISZELY, J GRICE GREAT WESTERN HOSPITAL, SWINDON – corresponding author: p.b.stanier@doctors.org.uk

BACKGROUND • Interventions such as the use of face masks and improved hand hygiene at an individual level play an essential role in reducing the spread of common droplet virus’ such as COVID-19 • There are extensive guidelines on the need to use face coverings and masks in public places – including hospitals, as well as advice relating to how these should be worn correctly • Simple, low cost measures such as the use of alcohol-based gels are an integral part of reducing viral transmission; combining immediate antimicrobial efficacy with ease of use.

• In-hospital transmission is one of the main routes of COVID-19 spreading between health care workers specifically and there have been long standing multimodal campaigns focused on the use of alcohol-based gel and adherence within trusts • Compliance with these measures is variable and where performed improperly reduce efficacy Image One: Infection control measures observed in methodology

MASKS WORN: • Visitors were observed to be wearing masks on average more than staff.

• In total, 446 people entering the hospital wore masks – 80% of staff members and 98% of visitors.

• The availability of masks at entrances increased their use by 41% (P= <0.001) MASKS WORN CORRECTLY: • 97% of members of staff wearing masks did so correctly, compared to 100% of visitors.

• The presence of a volunteer impacted how masks were worn amongst staff.

HANDS CLEANSED: • Hand cleansing was poor amongst staff → only 36% of staff used the alcohol gel provided at the entrances • The availability of masks correlated with whether the alcohol gel was used.

60% of people cleansed their hands on the 3 days masks were present at entrances compared to only 9% on the days no masks were available (P= <0.001).

EFFECT OF VOLUNTEERS: • People entering the hospital were more likely to wear a mask if a volunteer was present.

• The presence of a volunteer particularly increased the proportion of staff wearing a mask by 29% and increased the proportion of masks being worn correctly from 95% to 100% (P=0.004) • Hand hygiene was improved from 9% to 84% with the presence of volunteers Chart One: Effect of volunteers on the percentage of masks worn and hands cleansed

OBJECTIVE Determine whether provision of masks at hospital entrances and the use of volunteers to ensure correct mask wearing and hand hygiene can improve compliance with infection prevention measures for COVID-19

71% MASKS WORN 98%

95%

METHODS

MASKS WORN CORRECTLY 100%

The study was undertaken at a single NHS District General Hospital (DGH) in the period of five weekdays in the period between (August 12th – August 26th 2020).

Subjects were observed entering the hospital through 3 separate entrances.

To reduce bias, observers avoided wearing a uniform or identification whilst collecting data in an attempt to avoid drawing attention

It was recorded whether subjects were; - A member of the public or staff - Wearing a mask - If so, wearing the mask correctly - Whether they cleansed their hands with the alcohol gel provided.

It was also noted whether there were masks available at the entrance

9% HANDS WASHED 79%

0%

10%

20%

30%

40%

50%

NO VOLUNTEER

VOLUNTEER

60%

70%

80%

90%

RECOMMENDATIONS Ensure presence of volunteers at entrances used commonly by both staff and visitors

Signposting techniques could lead to increased uptake of hand hygiene measures

If there was a volunteer was present

RESULTS

To prevent masks running out → calculate the predicted number of subjects entering the hospital through each entrance and ensure surplus available

Table One: The effect of having; a volunteer present & mask availability on the number of staff and visitors wearing a mask & cleansing their hands on entering the hospital over a 5 day period

CONCLUSION A statistically significant improvement in hand hygiene and correct mask wearing was seen with both the presence of volunteers at hospital entrances and with the provision of masks

100%

The Impact of COVID-19 on cardiac referrals in Morriston Hospital Dr Shuaib Meghji , Dr Parin Shah, Dr Michael Whittington, Dr James Barry Morriston Hospital, Swansea, Wales.

Introduction Coronavirus disease 2019 (COVID-19) due to severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) is causing a dramatic pandemic, spreading rapidly from Wuhan city, with 155 million individuals infected and 3.24 million reported deaths worldwide1.

Health services focused services on the huge flux of patients with COVID-19 which affected the treatment of patients with other medical conditions.

During the pandemic, we restructured the cardiology department and referral system to review patients with cardiac issues directly in the emergency department without initial review by the A&E team.

Objectives

Objective 1: time from admission to formal cardiology review

1. Time from admission to formal cardiology review 2. Duration of inpatient stay 3. Time from admission to angiogram if clinically indicated

Methods Retrospective clinical audit comparing the patients referred to the cardiology team before and during the COVID-19 pandemic. Data was collected from the hospital electronic health record system.

Changes to the Cardiology Department During COVID-19 Increased cardiology presence: • 2 on call cardiology registrars, covering wards and A&E respectively • 4 cardiology consultant covering PCI, electrophysiology, A&E referrals and ward patients • Both the registrars and consultants had stand by cover Direct referrals to cardiology: • Patients with chest pain, palpitations and syncopal episodes were referred directly by the A&E triage nurses and reviewed by the cardiology registrar • Patients referred with preliminary investigations and assessments Triage of shortness of breath: • Patients presenting with shortness of breath were triaged and managed by the medical team in the newly formed respiratory assessment unit • Cardiology assessment and referral was provided if required

The average duration to a formal cardiology review following implementation of changes was reduced from 58 hours to 3 hours

Objective 2: duration of inpatient stay

Non traumatic Chest pain Initial Triage + tests Observations ECG (reviewed by A&E staff) Bloods: U&E, FBC, troponin CXR

STEMI: Urgent STEMI alert call: Cardiology SPR will assess urgently and organize cath lab team/ CCU

Ongoing chest pain /ECG changes / Hemodynamic instability Urgent review by both A&E and cardiology (whichever free first)

Transfer to CCU after review

PRE WARN: cardiology team Suspected COVID however primary/ unstable problem is Cardiac

Stable chest pain high probability of CAD +/- ACS Review by cardiology +/transfer to CSSU

Repeat troponin Inpatient ETT

:

The average duration of inpatient stay was reduced by 9 days, from 11 days pre-lockdown to 2 days post lockdown

Objective 3: time from admission to angiogram Chest pain low probability of CAD Review by A&E &Cardiology

OPD investigations for CAD +/- OPD when available / indicated

Figure 1 Indicates the new referral process and new care pathway for chest pain. Prior to COVID-19 low risk and stable chest pain was admitted under the medical team for initial investigations with cardiology input later.

The average duration to angiogram had improved from 259 hours prelockdown to 74 hours during lockdown

Conclusion The changes made to the cardiac referral system and increased cardiology presence improved the cardiac care and reduced hospital stay.

Results Our audit population consisted of 41 patients forming our ‘Lockdown’ group and 31 patients forming our ‘Pre Lockdown’ group.

Limitations However it is important to recognise the limitations which include small References John Hopkins Coronavirus Resource Centre (2020) John Hopkins COVID-19 World Map Dashboard, Available at: sample size, a small percentage of patients requiring angiogram (16.7%) https://coronavirus.jhu.edu/map.html (Accessed: 01/06/2020). and incurred delays for medical optimisation.

Prof Chaolin Huang, MD * Yeming Wang, MD * Prof Xingwang Li, Prof Lili Ren,Prof Jianping Zhao, Yi Hu (2020) 'Clinical features of 1.

2.

patients infected with 2019 novel coronavirus in Wuhan, China', The Lancet, 395(10223), pp. 497-506

@jameskeitley

INTRO • Blood transfusion sample mislabeling is a potential error with severe consequences(1).

• Elsewhere, electronic labelling has reduced sample rejection and saved time(2-4).

• Tests were previously requested from a small list, labels handwritten and retranscribed onto a computer in the laboratory. Process mapping revealed non-critical steps.

• The aim was to improve time to obtain results and reduce likelihood of transcription errors.

METHODS • iSoft Clinical Manager(5) allowed printed labels to be applied directly to samples and scanned in the laboratory.

• Scanning of patient wristbands to ensure the correct label is applied. Groups of tests could be requested according to patient presentation.

• Time taken to receive results was recorded throughout as well as the proportion of samples using the new system.

• Red sample bags were introduced to distinguish ED samples.

• Staff were surveyed for opinions on the change.

Digitising the ED bloods pathway

The system was rapidly adopted, however result reporting time showed little change.

Satisfaction of staff with the new system, n=17 8

7 7

6 Number of responses

James Keitley Suzy Connor

6 5 4

3 3 2

1 1

Pod system malfunctions may be hiding potential variation.

0 0

Very unsatisfied

-

-

-

Very satisfied

“Quicker”, “Safer”, “Good to request groups of tests” “Much easier to distinguish [which] samples are urgent”

DISCUSSION Pod system malfunctions may be hiding potential variation.

Non-Cognitive Predictors of Student Success: A Predictive Validity Comparison Between Domestic and International Students

Non-Cognitive Predictors of Student Success: A Predictive Validity Comparison Between Domestic and International Students

One lesson was the considerable time taken to change procurement (four months). This is crucial, as motivation for change can dissipate over time.

NEXT STEPS • “Zooming in” to follow individual blood samples through the process and uncover delays.

• Working with IT to increase technological reliability, perhaps with handheld devices

RESULTS • The system was rapidly adopted.

• Run-charts of ‘time-to-report’ showed little change.

• 76% of staff were satisfied, common themes being ‘quicker’, ‘safer’ and ‘combining groups of tests’.

• Laboratory staff felt the system was quicker, and fewer samples were being rejected anecdotally (formal data pending).

• Negative aspects were reliance on temperamental technology, and the possibility of overriding the safety requirement of wristband scanning.

Access more information like my contact details, references, and take part in Q+A

bitly.com/EDBloods

Minimising the impact of pandemic related prolonged grief

Dr Sumreen Butt, Supervisor Dr Hagan Sandwell and West Birmingham NHS Trust

INTRODUCTION Multiple Trauma

Prolonged grief is the persistent, emotional pain, continuing for an abnormal period of time, affecting up to 20% of those bereaved (1).

Higher incidences of prolonged grief following natural disasters are well recognised (2).

The Covid-19 pandemic, caused by severe acute respiratory syndrome coronavirus 2 was declared a public health emergency by the World Health Organisation in January 2020 (3).

Since then, there have been over 4.4 million confirmed cases in the UK with 127,000 deaths and over 3 million deaths worldwide (4). The pandemic has created an atmosphere predisposing to prolonged grief, by mimicking the risk factors seen in a natural disaster, but also the independent risk factors associated with prolonged grief (5), as seen in figure 1.

METHODS The QIP focused on number of family discussions compared to length of stay, and the content of these discussions.

Inclusion Criteria • Length of stay >72hrs on Respiratory HDU • Known next of kin details • Electronic notes titled “Family/NOK discussion/update” A questionnaire for family members to explore their communication preferences.

Discussion

The questionnaire aimed at family members had a total of 10 participants. Cycle 1 collected data during a peak in cases with a total of 48 participants, whereas cycle 2 was collected as the peak was declining, with 13 participants.

The questionnaire aimed at family members placed the expected frequency of updates at three per week. Prior to the intervention the established frequency of updates was 1.67 per week, which increased to 2.07.

A

Desired Frequency of Updates

Sudden Death

B

Person Providing Update

Once a week

0%

20% 0%

Twice a week Three times a week

100%

Limited resources

Inability to follow culture

AIM The aim of the quality improvement project (QIP) was to establish the current frequency of telephone updates and the quality and content of the information relayed.

RESULTS

Doctor Nurse No Preferance

80%

Figure 2. Outcomes of questionnaire given to family members A) How many times per week family members wanted updates B) Any preference on the person providing the update

A

Cycle 1 – Frequency of Updates

>Four

5

Three

5

B

Once

8

Three

2

Once Twice

Twice

ITU admission

Twice Once

Four +

5

10

5 0

15

5

10

Figure 3. A) Frequency of updates during cycle 1, on average 1.65/week B) Frequency of updates during cycle 2, on average 2.07/week

A

Cycle 1 – Content of Update

34%

B

Name and grade mentioned

10% 18%

NOK name NOK number

The damaging psychological aspects of the pandemic are beginning to emerge and are anticipated to continue. Isolation and lack of social interaction has led to individuals experiencing anxiety, diminished well-being, and loneliness (8). Studies have found an increase in maladaptive behaviours during the pandemic, such as the increase in smoking (9).

Cycle 2 – Content of Update

33%

Name and Grade mentioned

Conclusion

NOK name

While the prospect of reducing the psychological impact of a global pandemic is an intense challenge, establishing regular communications for families of critically unwell patients, irrespective of Covid-19, is likely to reduce prolonged grief in all healthcare settings.

NOK number 39%

42% Mention of next update

Figure 1. Risk factors predisposing to prolonged grief

Three

2

Once

11

6% 18%

Low social support

Twice

>Four

0

Ability to understand

Three

12

Working as a multidisciplinary team with palliative care allowed families to prepare for the incoming bereavement, thereby reducing some of the risk factors of prolonged grief.

Cycle 2 – Frequency of Updates

Four +

As the pandemic peak approached its end during the second cycle, the sample size reduced, yet the frequency of updates did not increase accordingly, highlighting that the limiting factor may not be workload as initially anticipated. It was also clear that families of patients identified as dying or deteriorating had increased communication from the medical team, emphasising the importance of early recognition of the dying patient.

Figure 4. Contents of the update provided during cycle 1 and 2.

Mention of next update

References: 1) Killikelly et al, Prolonged grief disorder for ICD-11: the primacy of clinical utility and international applicability (2017), Eur J Psychotraumatol, 8;(6) 2) Esma et al, Prolonged grief disorder following the Coronavirus (COVID-19) pandemic (2020), Psychiatry Res, 288 3) Novel Coronavirus – China (2020) The World Health Organisation. https://www.who.int/csr/don/12-january-2020-novel-coronavirus-china/en/ 4) Coronavirus (Covid-19) – The Office for National Statistics 2021 https://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/conditionsanddiseases 5) Gesi et al, Complicated Grief: What to Expect After the Coronavirus Pandemic (2020), 11, 489 6) Azoulay E & Kentish-Barnes N, A 5-point strategy for improved connection with relatives of critically ill patients with Covid-19 (2020), The Lancet Respiratory Medicine, 8 (6) e52 7) Phua et al, Intensive care management of coronavirus disease 2019 (COVID-19): challenges and recommendations (2020), The Lancet Respiratory Medicine, 8 (5) 506-517 8) Dawson & Golijani-Moghaddam, COVID-19: Psychological flexibility, coping, mental health, and wellbeing in the UK during the pandemic (2020), Journal of contextual behavioural science, 17:126-134 9) Pandemic fans the flames of smoking and health inequality (2020), The Lancet Respiratory Medicine, 9 (5) P435

th 16

June 2021

Poster Competition Group L

Improving processes and healthcare outcomes (2) First prize: Will I Finish Work on Time today?

Presenter: Dr Hajera Sheikh North Middlesex Hospital, London

Second Prize: Transforming the task-board: Improving outof-hours task identification and prioritisation Presenter(s): Daniel Butler, Elizabeth Alexander Royal Devon and Exeter NHS Foundation Trust

Quality Improvement in an Emergency Department: The Decision To Admit Trial Dr Roshan Gunasekera1, Dr Ben Cooper1 1Sheffield Teaching Hospitals, UK Results

Background

Number of discussions

Single Assessment (SA) is a hospital initiative to • Out of 175 discussions recorded 83 were related to DTA/discharge. remove duplication of information collected during an acute admission by eliminating the second clerking • 23% of all DTA/discharge related discussions led to an improvement in a patient’s management plan by a clinician. The aim is to improve the patient (Figure 3). experience by minimising the number of times that a patient retells their story and shorten the time taken • It is feasible to discuss the DTA for patients between senior and junior clinicians when they are for the patient to be reviewed by a senior clinician. seen in ED. Additionally, there will be less repetitive administrative work for the medical team during an Figure 3. Outcomes of the discussions between seniors and junior acute admission. A key driver for this complex clinicians 60 transformational change is the development of a 50 50 medical clerking process where every acutely admitted patient would be discussed with a senior 40 clinician in the Emergency Department (ED).

Purpose The first PDSA cycle (Figure 1) will test the feasibility and practicality of every patient being discussed before the Decision to Admit (DTA) has been made.

The trial will help understand how this new model (Figure 2) will impact the ED system where currently a third of medical assessments are performed solely by senior doctors and advanced clinical practitioners.

PLAN 7 –day trial logistics Communication plan with relevant teams

ACT Findings presented at departmental meeting

DO Change implementation 16.09.19 Data collection 16.09.20 -23.09.19 Anonymised data collection in Excel

STUDY 175 observed discussions Qualitative feedback

Figure 1. PDSA 1 : The DTA trial

Figure 2. Process map: A patient’s journey during the DTA trial

30 20

15

10

7

7

Admit different speciality

Discharge

5

0 Admit - same speciality

DTA - admit

Discharge

Admit

DTA - discharge

Key Lessons • Important to collaborate with service users which in turn helps keep focus on the project’s purpose.

• Multiple communication strategies informing relative departments were key in the success of the trial.

Next Steps The DTA trial featured one element of SA. The next steps are to integrate the medical and ED workforce in the clerking process using quality improvement methodology.

Cardiac Arrests: Don’t miss a BLEEP! Improving Communication in a Clinical Setting Vanisha Amin, Rohit Chandegra, Ram Patel & Jasmine Zacharias

Introduction & Aims Doctors highlighted problems with regards to lack of bleeps at handovers resulting in delays in patient care, especially at cardiac arrests. COVID-19 emphasised the need for sufficient cardiac arrest team members to be present. Our project aimed to find a rapid and cost-effective method to reduce delays in patient care, improve attendance at cardiac arrests and facilitate team introduction before the start of a shift.

Well allocated bleeps according to ward as opposed to speciality.

A survey was conducted amongst medical junior doctors FY1 – IMT grades, to assess the ease of locating the on-call bleeps and attendance at cardiac/peri-arrests preintervention. All medical bleeps in circulation were then recalled and re-allocated to reflect the emergency COVID-19 rota.

This system works far better than the old system. It meant that with every oncall, a bleep was always available.

55% decrease in doctors having difficulties with bleeps. (Pre-intervention 70% to postintervention 15%). 30% of doctors reported at least one missed cardiac/ peri-arrest preintervention. Post-intervention only 12% reported a miss cardiac arrest/peri-arrest.

When you are on call, have you ever missed an arrest?

Yes, because I did not have a bleep

25% 35%

Yes, because my bleep did not work 5%

No

When you have been on-call, have you ever missed an arrest during the COVID-rota?

6%

Yes, because I did not have a bleep

35%

6%

Yes, because my bleep did not work Unsure

unsure

21%

All medical bleeps in circulation were then recalled and re-allocated to reflect the emergency COVID-19 rota.

67%

No

Six weeks after this intervention we repeated our survey.

We introduced a daily 09:00 and 21:00 face-to-face handover meeting. The updated on-call bleep lists were distributed amongst all clinical staff, via email and posters.

Conclusion Through a simple, cost effective, restructuring of existing bleeps we proved that patient safety can be significantly improved.

We believe that whilst bleeps systems are in circulation, they should be annually recalled and allocations reviewed to ensure that they are working and are effective in maintaining patient safety. A fail- safe method of tracking bleeps should be introduced. We found that face to face handovers are useful in ensuring bleeps do not go missing. We have also recommended that the trust removes the pager system by the end of 2021 in line with government guidance to ensure effective communication.

Bibliography: 1Resuscitation Council UK, 2021. Adult advanced life support Guidelines. Resuscitation Council UK. 2Department of Health and Social Care, 2019. NHS Efficiency. Department of Health and Social Care. 3We thank the medical team and staff of Watford General Hospital for their help during the COVID-19 pandemic.

RESEARCH POSTER PRESENTATION DESIGN © 2019

www.PosterPresentations.com

Reducing Staff COVID-19 Exposure Incidents: A Thematic Analysis from the First Wave Dr Arun O’Sullivan, Dr Daniel Pethers Introduction and Aims

Frequency of theme in 148 Datix-reported incidents

Since the early weeks of the coronavirus disease 2019 (COVID-19) pandemic, frontline healthcare workers have been more likely to return a positive COVID-19 test in comparison to the general population(1,2). Many frontline healthcare workers who have tested positive have had severe disease, and some cases have proven to be fatal(2). In addition, time spent in selfisolation by staff who have contracted COVID-19 has added a huge strain to healthcare systems and staff already burdened with the pressures of a global pandemic(3).

We aimed to reduce the exposure of frontline healthcare workers to COVID19 by identifying areas for improvement in Datix-reported COVID-19 exposure incidents.

Methods We obtained all Datix incidents reported from 31/12/19 to 09/06/20 that took place on an Imperial College Healthcare Trust (ICHT) site and applied a

Outcomes and Discussion

filter to highlight the incidents that had been marked as staff COVID-19 exposure incidents. We then read through the descriptions of a subset of the incidents and identified four broad areas (or themes) of potential improvement. The themes were: 1) Personal protective equipment (PPE) 2) Communication 3) Policy and training (P&T) 4) Testing Following this, we reviewed all of the incidents, identifying if one or more of the areas above could have been improved for each incident. We also noted the location/speciality of each incident and whether an aerosol-generating procedure (AGP) was involved.

Whilst all themes were identified in many incidents, policy and training arose most frequently as an area for improvement. In most cases, this was at least in part due to staff being aware or uninformed of the latest trust policies, especially at times when policy regarding the treatment of COVID-19-positive or suspected COVID-19-positive patients. This was often when staff had not been kept informed of the most recent change in policy at a time where guidelines were changing frequently. We passed our results onto the audit team at ICHT who have aimed to improve both the clarity and staff awareness of policy surrounding the treatment of COVID-positive patients. Moreover, there have been improvements in the quantity and quality of PPE available to staff. Testing and screening of both patients and staff has also increased.

One limitation of our data is that it is highly unlikely that all incidents would

Results We analysed 148 Datix incidents of which 60 (41%) were related to PPE, 63 (43%) were related to communications, 87 (59%) were related to P&T, and 64 (43%) were related to testing. Moreover, 32 incidents (22%) involved an AGP. The specialities with the most reported incidents were maternity (22), critical care (18), and acute medicine (15).

have been reported on Datix. We therefore cannot draw any accurate conclusions about the relative frequency of our themes. Equally, it would be presumptuous to draw any conclusions regarding location of exposure incidents, as the proportion of incidents that were actually reported may have varied between specialties.

Despite these limitations, we believe that our data show there is scope to reduce the number of staff COVID-19 exposure incidents in a frontline healthcare

Frequency of incidents by speciality

setting.

References 1. Risk of COVID-19 among front-line health-care workers and the general community: a prospective cohort study Nguyen, Long H; Albert, Christine M. et al.

The Lancet Public Health, Volume 5, Issue 9, e475 - e483 2. Office for National Statistics 3. Gilleen J, Santaolalla A, Valdearenas L, Salice C, Fusté M. Impact of the COVID-19 pandemic on the mental health and well-being of UK healthcare workers. BJPsych Open. 2021 Apr 29;7(3):e88. doi: 10.1192/bjo.2021.42. PMID: 33910674; PMCID: PMC8082128.

DOCTOR WHO?:

IMPROVING COMMUNICATION IN A SEA OF GREEN Dr Eleanor Badhams (FY1), & Dr James Cultan (FY1)

RESULTS With comparison to pre-intervention data, AB and simplified NB improved patient identification of doctors by 18% (n=13) and 52% (n=9), respectively. Coloured NB reduced recognition of ward doctors by 7% (n=14).

During the SARS-CoV2 pandemic, hospital sites across the United Kingdom (UK) introduced new uniform policy to reduce nosocomial transmission of the virus.

METHODS

Novel pre and post intervention questionnaires, were designed for patients and staff members.

Pre-intervention data was collected from RGH staff (n=25) and patients (n=22).

After meeting with hospital infection control representatives and reviewing the All-Wales Uniform policy1, Armbands (AB) and Name Badges (NB) were chosen for testing.

Tests of change were carried out in the Ambulatory Emergency Care unit (AECU) and on Ward 19 at RGH over 4 separate weekdays, between 09:00 and 17:00.

Following each iterative cycle, data was collected through separate staff and patient questionnaires.

Type of Change

The blanket use of green scrubs at the Royal Glamorgan Hospital (RGH) made identifying the roles of members of the MultiDisciplinary team (MDT) more challenging for ward staff and patients, alike.

Patient Identification of Doctors After Iterative Changes Compared to Pre-Intervention Data

AB

INTRODUCTION

Patient Identification of Doctors

Coloured NB

Improve identification of doctors in a hospital environment for both patients and allied healthcare professionals

Simplified NB

OBJECTIVE

-10%

0%

10%

20%

30%

40%

50%

60%

Proportion of Patients able to Identify Doctors

Staff identification of Doctors All interventions reduced time spent looking for a doctor by staff.

AB and coloured NB decreased time spent looking for a doctor for 82% of staff respondents (n=11), and simplified NB for 40% (n=4) of staff respondents, when compared to pre-intervention data.

Staff Tolerance All staff (100%, n=12) felt Simplified NB, and 91% (n=11) felt coloured NB, were user friendly and effective.

Only 63% (n=9) of staff respondents felt AB were effective.

Feedback on AB included ‘…look silly’, ‘…. Uncomfortable’.

Data was analysed using Microsoft excel.

Cycle 1: Coloured AB worn by all doctors.

Colour represented training grade

PDSA CYCLE 1

PDSA CYCLE 2

PDSA CYCLE 3

• Improvement in patient identification of doctors • Poorly tolerated by staff

Cycle 2: Coloured NB worn by all doctors Colour represented training grade • Staff felt NB were user-friendly • Patients found NB difficult to read

DISCUSSION

• Although all interventions improved identification of Doctors for staff, patients or both, the most effective and best tolerated intervention was the simplified name badge.

• Inconsistency in results represented variation in sample populations. A larger sample size from variety of healthcare sites would provide a more accurate dataset.

• For the best outcomes, the challenges face with staff engagement and patient understanding of the roles of healthcare staff would need to be addressed simultaneously.

Cycle 3: Simplified NB worn by all doctors • Improved patient understanding • Supported fully by staff

References and Acknowledgements: Thank you to the Quality Improvement, Acute Medicine and Respiratory medicine teams at RGH, as well as all of the patients who have taken part in this project.

1. All Wales Uniform and Dress Code, 2020. Welsh Assembly Government. Available at: http://www.wales.nhs.uk/sitesplus/documents/862/attachment%20-%20nhs%20dress%20code.pdf [Accessed on 05/05/2021].

Transforming the task-board Improving out-of-hours task identification and prioritisation Daniel Butler, Elizabeth Alexander, Stefan Hudson, Amy Ward, Zoe Evans, Jacob Bruten, George Sylvester, Hussain Al-Jabir, Thomas Christie, Charlea Williams, Chris Ward.

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

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

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

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

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

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

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

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

PDSA Cycle 2: Educational Intervention P: Offline simulated taskboard was created and 15 patient tasks added.

A: 1. Improve the appearance of the task board 2. Educate doctors to optimise their use.

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

S: Qualitative data suggests: 1. Tasks to appear next to patient’s names 2. To be able to remove and reassign tasks.

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

D: Increase in levels of confidence and subjective competence.

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

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

FIGURE 1 - CUSTOMISATION OF THE ELECTRONIC OOH TASK-BOARD

PDSA Cycle 3: Proof of Concept Task-board

160

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

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

See figure 1.

140

TIME (SECONDS)

PDSA Cycle 1: The Current Taskboard

120 100 80 60 40 20

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

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

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

0

Current task-board

Proof of concept task-board

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

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

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

Does a change in communication strategy pose a risk to patient safety Paul Turner

Paediatric Pharmacist, Bristol Royal Hospital for Children

INTRODUCTION

BACKGROUND

The use of radio-pagers (bleeps) has historically been the chosen method of communication within the NHS. They have provided staff with an efficient and reliable means of contacting colleagues and alerting them to emergencies and tasks. However, in recent years their maintenance has become unreliable, resulting in multiple bleeps being diverted to a single device. This can result in the holder of such a single device becoming overwhelmed with tasks, leading to inefficiency and a breakdown of team working models such as the one employed by the children's pharmacy department at the Bristol Royal Hospital for Children (BRHC) i.e. three separate teams serving different clinical areas of medicine, surgery and cancer. In February 2019, the Department of Health recognised this issue with the Health and Social Care Secretary ordering the removal of pagers for non-emergency communications by the end of 2021. A recent quality improvement project that considered, implemented and reviewed alternative communications strategies to the pharmacy department at BRHC delivered results that raised concerns regarding possible risk to patient safety.

Following consideration of several alternative communication methods CareFlow Connect, a program already integrated with Medway (the clinical informatics system used at BRHC) was selected. CareFlow is set apart from other communications platforms as it crucially provides a secure setting for sharing confidential patient information. CareFlow can also facilitate the use of instant messaging and task raising. During the 20 weeks between 14th September 2020 (week 1) and 31st January 2021 (week 20), CareFlow and bleep data were collected and analysed. CareFlow was implemented throughout BRHC pharmacy services on the 23rd of November 2020 (week 11). Data showed a statistically significant increase (P = 0.004) in the weekly average number of CareFlow tasks post CareFlow implementation (71) compared to the weekly average number of bleeps in the 10 weeks prior (42), an increase of 69.5% in communication traffic to the pharmacy teams. Additionally, a statistically significant decrease (P = 0.0002) in the number of bleeps in the 10 weeks post-change implementation, with the average number of bleeps reducing by 45% to 23 per week.

120

Run Chart of Bleep and CareFlow task data Total (bleeps)

Intervention

60 40

18

week 20

week 19

week 18

week 17

week 16

week 15

week 14

week 13

week 12

week 11

week 10

week 9

Response time to CareFlow tasks 17.2

16 14

week 8

week 7

week 6

week 5

week 2

week 1 20

week 4

20 0

Time to response (minutes)

Total (CF tasks)

80

week 3

Number of bleeps/CareFlow tasks

100

Mean Response

13.5

12

10.94

10.32

10

7.5

8

Median Response

5.5

6 4 2

The response time to bleeps has historically been prompt and consistently within the accepted 15-minute limit (estimated at less than 2 minutes). Therefore, response time to tasks raised through CareFlow was deemed an important secondary outcome measure. The median average response times of all three pharmacy teams were shown to be within the 15-minute this time limit. However, mean average response times were higher. Pharmacy teams 2 and 3 remained below the 15minute limit however pharmacy team one exceeded this with 17.5minute mean average response times. Both mean and median response times indicate longer response times to CareFlow tasks, with a significant number of 15minute breaches.

0 Team 1

Team 2 Pharmacy Team

Team 3

DISCUSSION

FUTURE PLAN

CareFlow and similar communication systems possess great potential in their ability to take over from the historic and outdated radio pager system. Their ability to store confidential patient information securely and effectively sets CareFlow apart from other systems. The ability to instantly send a required action/message to a relative team or person is also attractive, with continuity of care increasing between teams and different shifts. Pharmacy is now more accessible and effective in their completion of tasks assigned by other members of staff, including receiving tasks out of hours for completion first thing in the morning. However, mean response times are unacceptably high often breaching the accepted 15-minute limit. This poses a risk to patient safety in the emergency setting such as crash calls and emergency medication needs e.g. anti-seizure where every minute of delay can have a detrimental effect on the patient. This inability to urgently reach the relevant member of pharmacy staff in emergency/urgent situations is likely a factor in the continued low-level use of radio-pager post-change implementation.

For new communications systems to be truly fit for purpose they must first fulfil everything the radio pager currently offers. This is the quick and effective alerting of a member of staff to required action. Push notifications for mobile, and email notifications for PC/laptop do not currently hold the alerting power of a bleep.

Until they do bleeps will remain in use, alongside CareFlow, at BRHC due to the safety concerns related to response delay. Possible improvements to the current system would be the integration of a ”push-alert” which must be acknowledged before the alert can be dismissed, much like an alarm. Conversations will be taking place with the communications and CareFlow teams to optimise the service providing the basis for the quality improvement projects next PDSA cycle.

For any further information contact Paul Turner by e-mail: Paul.Turner@uhbw.nhs.uk

Will I leave work on time today?

Dr Hajera Sheikh1, Nicola Davey2, Dr Emma Parish3 Homerton University Hospital1, Quality Improvement Clinic2, Royal London Hospital3

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

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

DIAGNOSTICS

“Yes it’s a problem.”

“I don’t want to hand over crap” “Everyone else is staying back” “You find that the same people stay back each time” “The whole point of a shift system is that you hand things over.”

Some areas are a particular problem, eg postnates and special care.”

“What time is handover supposed to take place?”

“I feel lucky to have this job - on my terms – I don’t mind staying back” “I’ve never finished on time.”

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

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

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

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

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

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

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

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

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

LEARNING AND REFLECTION • • • • • •

website | qiclearn.com Twitter | @qiclearn

•

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

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

Doctors frequently staying beyond rostered hours, safeguards such as Exception Reporting are rarely used. Likely to be universal Seniors are not a barrier to leaving work on time, or to Exception Reporting. Active and exemplary engagement of consultants to explore solutions.

Through the project, I was able to make a difference as follows: Management of postnatal wards Joint MDT handover Reduction of interruptions Begin afternoon handover early Ongoing endeavour can be divided in 3 areas as follows: Reviewing clinical workload (What we do) Operational efficiency (How we do it) Doctors views/attitudes (Psychology behind overstaying)

Dr Rosanna Fox CNS Abby Foley

IMPROVING PATIENT HUMA MEDOPAD LTD APP USE TO FACILITATE REMOTE MONITORING ON THE COVID-19 VIRTUAL WARD INTRODUCTION

INCLUSION CRITERIA

During the UK’s winter 2020/2021 peak of the Covid-19 pandemic, a ‘Covid virtual ward’ (CVW) was set up at West Middlesex University Hospital to remotely monitor and manage patients with Covid-19.

Patients >18 years with confirmed or suspected Covid19 plus:

Patients requiring ongoing monitoring, but with no immediate need for supplementary oxygen support, were referred from the ward and Emergency Department (ED) for remote monitoring via a smart phone app – HUMA MEDOPAD LTD - and regular telephone consultation. From late December 2020 to early April 2021, the CVW managed 299 patients in total.

AIM “Maintain app registration and regular use (defined as uploading twice per day) at a minimum of 80% for the patients being managed on the CVW at any given time.”

We noted significant variability in patient uptake of the app. Many patients did not register for Medopad Ltd use despite prompting, or else were not uploaded regularly – making remote monitoring very difficult and ultimately effecting the quality of patient care.

90%

PERCENTAGE OF CVW PATIENTS USING THE HUMA MEDOPAD APP OVER A 4 WEEK PERIOD 84.3%

66.9% 62.9%

Maintained SpO2 >=92% on room air <3% drop in SpO2 on ambulation (ED-discharges) Afebrile for 48 hours (ward-discharges) Down-trending CRP (ward-discharges); CRP <60 mg/L for ED-discharges • Platelet count > 100 x 109/L • English speaking (or patients with an English speaker at home with them) • Access to and ability to use a smart phone & Huma Medopad Ltd app

METHODS Step 1: Collect preliminary data for number of patients registered with and regularly using Huma Medopad Ltd app over a period of 7 days (18th-24th January).

Step 2: Intervention Cycle 1: staff teaching using Grand Round forum (26th January)

80% 70%

• • • •

63.3%

60%

Cycle 2: poster referral guidelines with inclusion criteria placed in doctors’ offices and small-group based ward and ED teaching for referring clinicians (1st February)

50% 40% 30%

Cycle 3: text reminders sent to all enrolled patients (8th February)

20% 10% 0% 18th-24th Jan

25th - 31st Jan

1st-7th Feb

8th-14th Feb

Step 3: Assess impact on Huma Medopad Ltd use over the following 7 day period after each intervention cycle

RESULTS Cycle 3 (text reminders) was the most effective intervention and increased app uptake the following week to 84.3% which exceeded our target of 80%.

Mean app use from 15th February onwards was 91.2% demonstrating the positive impact of cycle 3 intervention.

DISCUSSION & FURTHER STUDY 1. Patient engagement is critical to pathway success and patient safety when monitoring an outpatient group.

2. Text message reminders were found to be the most effective means of increasing app use among the CVW population, and this is likely to be reflected in other patient groups where remote monitoring is appropriate.

3. Further study to elicit the barriers to digital app use are key to providing safe and effective remote monitoring services.

Improving communication & consistency in patient care during a global pandemic in a small, paper-note based DGH ITU Cycle 1 - The Hillingdon Hospital (THH) is a small DGH based in outer West London. The ITU normally has a capacity of 9 patients but expanded to 15 during the second wave of the COVID pandemic.

Cycle 2

Survey Feedback I always complete the Checklist

- Following the making of the initial checklist, 22 randomly selected patients ‘checklists’ were analysed to assess how well the checklist was being completed. Overall completion was around 55.67%, with certain sections being completed more than others.

Therefore, some adjustments were made as can be seen in figure ?.

These adjustments saw an overall increase in completion to 77%, with specific sections being completed significantly better than before (Fig 3).

The Checklist improves consistency in patient care

The Checklist is time consuming

Checklist take a long time to complete

- In a bid to improve communication and consistency in patient care, a simple ‘COVID Checklist’ was developed and added to the handover sheets to include specific details about COVID management, including ventilation and medication & patient’s course of illness. After 2 months of the checklist being used, a survey was completed amongst the ITU Junior Doctors to assess the impact of the initial checklist (Fig 1).

It is obvious how to fil out the Checklist

Checklist is Helpful for discussion with other specialities

Checklist is Helpful in Handover

Checklist is Useful 0

10

Strongly Agree

COVID Checklist (Please complete on ITU admission) Symptom onset (date + date of +ve swab) – CPAP (Y/N + date) – ITU Admission – Intubated (Y/N + date) – Antibiotic (Y/N) – Steroids (Y/N + start date) – Remdesivir (Y/N + start date) – VTE Rx (drug + units) – Resp MDT (Y/N + date) – Toci (Y/N + date) – Recovery Trial (Y/N) -

20

30

Agree

40

Neither Agree nor Disagree

50

Disagree

60

70

80

90

100

Fig 1

Strongly Disagree

Improvement in Checklist Completion 100

90

80

70

Percentage Completion (%)

- Due to a paper-note based system and need to have contained ‘COVID’ areas, some difficulties arose. With the number of COVID patients steeply on the rise, it became increasingly difficult to accurately communicate exactly which patients had received what treatment and their course of illness. Difficulties were noticed in: accurately handing over between teams; discussing the patients with other specialties; consistency in patient care as new medicines became available.

60

50

40

30

Fig 2

P&D : Problem à Difficulty handing over accurate information & maintaining consistency in patient care.

Target à to improve communication at handover and with other specialties à COVID Checklist developed on handover sheet S : Survey à to assess impact amongst staff Data collection à 22 randomly selected patients, percentage completion of checklist assessed – overall 55.67% completion A & P : Data analysed and therefore amendment to checklist required, after analysis, specific amendments required D : Checklist amended to make it easier and more likely to be completed in more detail S : Data collection à 19 randomly selected patients, percentage completion of checklist assessed – overall 77% completion A : Improvement seen in checklist completion. Checklist Adopted

Fig 3

20

10

0

Initial Checklist

Improved Checklist

Fig 3

Presented by: Dr Maja Kovac (FY1)

It became necessary to develop strategies to contain coronavirus as effectively as possible to reduce the risk of disease transmission but also reorganise its resources including clinical personnel to support the coronavirus frontline specialities [1].

Reconfiguration of Acute Medical Unit Services to support COVID-19 response- a District General Hospital (Warrington) Dr Manjusha Soni, Dr Alison Cox, Dr Naeem Ashraf, Warrington Hospital response Introduction

Increased Resource Availability

Departments providing enhanced in hours services to AMU

Specialities providing enhanced on call services

High care unit opening

Cardiology consultant remote reviews providing expedited decision making

Respiratory consultant on call 24 hours

COVID Rotas

AMU team internal cardiac arrest bleeps active 9-5.

COVID-19 consultant available on call 24 hours

Cardiorespiratory team performing bedside TTE

Palliative care consultant on call 24 hours

Bedside Ultrasound for vulnerable patients

Resident urology and ENT on call 24 hours

Infrastructure

The severe acute respiratory syndrome Coronavirus 2, SARS-CoV-2 has had a significant effect on all areas of the National Health Service (NHS) in the United Kingdom, and it has necessitated development of strategies to contain coronavirus as effectively as possible.

The AMU traditionally acts as an integral part of acute care areas of a hospital, with particular close ties to emergency department and ambulatory care units. It became necessary to develop strategies to contain coronavirus as effectively as possible to reduce the risk of disease transmission, but also to reorganise its resources including clinical personnel to support the coronavirus frontline specialities {1}.

In the AMU one of the major challenges during the COVID-19 pandemic was to how to modify our practice to deal with protecting and caring safely for patients whilst awaiting initial COVID 19 infection test results.

Unwell patient GP referral

AED referral

Human Resources

Clinical Assessment

Investigations

Rapid assessment and escalation of deteriorating patients

Figure 3.Demonatrating the overall approach to ensuring solutions for the challenges faced.

Infrastructure change Decision Safe Discharge

Inpatient Admission

Figure 1 Patient flow through the Acute Medical Unit (AMU).

Overview of Challenges and Reconfiguration .

Challenges

Enhanced speciality services Morale Boosters

AMU

We describe the challenges and strategies adopted by our AMU to facilitate urgent patient care and support the Accident and Emergency Department (AED). These strategies have allowed the AMU to meet new guidelines and maintain movement through the hospital in the safest manner possible

Staffing pressures and difficulty facilitating training

Improvement strategies

Reducing cross infection on AMU prior to COVID swab results

Minimising unnecessary movement through the hospital

Facilitating safe early discharge

Figure 2. Demonstrating a summary of challenges faced in the AMU in the initial wave of COVID -19 Pandemic.

PROBLEM: High burden of rapidly deteriorating patients requiring frequent assessment of lactate/PO2 levels Only available ABG machine in A&E risking delays and increased movement through hospital.

Solution Procurement of new Arterial blood gas analyser for AMU.

PROBLEM: Solution New Resuscitation Council Grab packs of PPE put together guidance on PPE during arrest and installed on Arrest trolleys for scenarios. {2} Difficult to source easy, quick access appropriate PPE in an emergency.

PROBLEM: Mixed caseload of patients awaiting COVID test results, putting clinically vulnerable patients at increased risk

Solution Expedited creation of 3 additional side rooms in an awaited High care unit on AMU increasing isolation capabilities

Table 1. Demonstrating how departments provided enhanced services in hours and as on call services during the Initial phase of the COVID pandemic.

Maintaining Morale Patients: Hospital cvan be a lonely and frightening place for patients at any time. The COVID-19 led to extremely restricted visiting arrangements, exacerbating this feelign for many. Visiting was allowed only in end of life patients, AMU facilitated this through provision of PPE to visitors and making regular updates to NOK. In order to improve the patient experience, AMU also provided 24/7 telephone access to patients and sourced wifi enabled tablets for face calls.

Staff: There has been an increased strain on staff members through the Pandemic.

Due to staff sickness and increased workload this has the ability to reduce staff morale and make training opportunities difficult. AMU made available a social distanced environment for teaching and encouraged daily short teaching sessions amongst juniors and nursing staff to maintain educational opportunities

Summary The COVID-19 pandemic outbreak has severely affected the UK. In times of such difficulty, innovation is needed to meet the challenges faced. The AMU must not be ignored in these times. Acute medicine is a field which must be flexible to provide care for patients newly admitted to hospitals, when diagnostic uncertainty remains

Many of the challenges faced required a change to the structure of the department. In order to make these changes ,ideas were escalated to management and estates departments to help turn them into reality. In particular the building of a high care unit in AMU was expedited to provide three additional side room spaces. This provided enhanced care and capacity for vulnerable patients requiring isolation and those where COVID status was uncertain. These spaces were invaluable in the time prior to point of care lateral flow testing to try and reduce chances of cross infection.

and patients are often unstable, factors often increased by COVID. It is a gateway

Adaptations to Staff Resources

of AMU has diversified and inefficiencies have been highlighted and targeted for

Through the COVID pandemic many changes were made to the availability of staff throughout the hospital and in AMU in particular. Additional on call “COVID rotas” were made for speciality consultants and for junior medical staff to allow increased staff availability in times of high staff sickness and in scenarios where senior led escalation decisions were necessary.

There was also a necessity to increase resources on AMU to help facilitate early discharges. The provision of enhanced imaging and specialist advice available on the unit avoided unnecessary travel of patient into and through the hospital and helped facilitate timely discharges.

benefit patients and staff for years to come in the AMU.

for many into the hospital and as such it is crucial area to focus on when considering the challenges of the pandemic. Changes of all levels, from ward based innovations, to hospital policies have shaped the AMU to provide a safe starting point to many admissions. Opportunity has been provided for doctors to work more closely with other specialisms, creating a unified medical fraternity. In turn the role change. COVID has been the catalyst for these changes, but they will continue to

References 1) Public Health England. COVID-19: infection prevention and control (IPC). 2020. https://www.gov.uk/government/publications/wuhan-novel-coronavirus-infection-prevention-and-control [accessed 06June 2020 2) Resuscitation Council (UK), RCUK Statement on PHE PPE Guidance, 2020, Available from https://www.resus.org.uk/media/statements/resuscitation-council-uk-statements-on-covid-19-coronaviruscpr-and-resuscitation/statement-on-phe-ppe-guidance/ [Accessed on 09 June 2020]

th 16

June 2021

Poster Competition Group M

Improving patient handover and intensive care First prize: Improving the culture of electronic handovers Presenter: Cameron Gemmell Taunton and Somerset NHS Foundation Trust

Second Prize: ‘Mind the step’-down Presenter: Declan Beattie Northern Ireland Medical and Dental Training Agency (NIMDTA) - Belfast Trust

Facilitating clinical reasoning & unified communication through an ITU proforma

Uniformity through proforma Kohler,

1 G.

Sabu,

2 S. ,

Roberts,

3 G.

1. Foundation Year One Trainee, Cwm Taf Morgannwg University Health Bord 2. Foundation Year One Trainee, Cwm Taf Morgannwg University Health Board 3. Intensive Care Consultant, Cwm Taf Morgannwg University Health Board

Introduction The COVID19 pandemic has changed the shape of healthcare across the NHS. Intensive care has seen a significant increase in admissions, caring for the critically unwell. Now more than ever efficient communication is a priority. Studies in a multitude of specialties including emergency, surgery and medicine have repeatedly proven that introducing proformas can significantly improve the detail, standard and safety of communication between practitioners (1,2,3). All of which are essential in the field of Intensive Care medicine, with its complexities and current pressures.

Admission documentation prior to proforma, on continuation sheets PC HPC PMHx DHx SHx CFS Functional Status

14 (100%) 14 (100%) 13 (93%) 11 (79%) 8 (57%) 0 (0%) 6 (43%)

Examination 14 (100%) Impression/Issues 11 (79%) Plan Escalation

14 (100%) 2 (14%)

Admission documentation using proforma, audit cycle 1.

PC

6 (100%)

HPC

6 (100%)

PMHx

6 (100%)

DHx

6 (100%)

SHx

6 (100%)

CFS

6 (100%)

Functional Status

3 (50%)

Examination

6 (100%)

Impression/Issues 6 (100%) Plan

6 (100%)

Escalation

6 (100%)

Admission documentation using proforma, audit cycle 2.

PC

6 (100%)

Aims

HPC

6 (100%)

PMHx

6 (100%)

1. We aimed to introduce an ITU Admission Proforma to aid the clerking and decisionmaking process 2. We aimed to improve the ease of communication and care continuation between reviewing doctors

DHx

6 (100%)

SHx

6 (100%)

CFS

6 (100%)

Functional Status

6 (100%)

Examination

6 (100%)

Methods A survey was sent to ITU staff seeking opinions regarding the fundamental documentation required on admission to ITU. Admission documentation to the unit, over a two-week period, was then critiqued based on the survey (Figure 1). Proformas from other specialties were analysed for ways that promoted clinical reasoning while providing a clear structure. An ITU proforma was created (Figure 2) and trialled for a two-week period. All staff were informed of its availability by email and reminded at the next departmental meeting.

Admission clerkings during this period were reviewed to assess use/effectiveness of the proforma. After making improvements to location and structure of the proforma, based on feedback, another audit period was undertaken to re-assess.

Impression/Issues 5 (83%) Plan

6 (100%)

Escalation

6 (100%)

Results continued All elements of the proforma were completed apart from functional status. This was filled in 50% (n=3) of cases. During second audit, the proforma was used in 6 out of 13 admissions (46%). Following improvements, functional status reporting was always documented and proforma was fully applied in all but one case.

Discussions The structured approach of the proforma has led to significant increases in completeness of the ITU clerking process, aligned with what has been surveyed to be of clinical importance. All aspects improved significantly, compared to pre-proforma baseline, with substantial improvements in CFS, escalation status and social history.

They were completed in 100% of cases when the proforma was used. These are of particular importance in the ITU setting, during the pandemic, where escalation and prognostication have been such critical considerations.

Uptake remains an issue, through our Figure 1- Pre and post proforma clerking adherence to auditing we note post-op “bed and surveyed key elements breakfast” admissions secondary to high-risk stratification scores tend to not have proformas completed, likely due to paperwork burden. Patients admitted via Resus also tend not to have the proforma filled. This is likely an access to proforma and time constraint issue. As we have demonstrated the proformas worth, we intend to the continue its use in the department and hope to distribute it to wards for ‘escalation to ITU’ purposes.

Conclusions This proforma provides a clear structured approach to the clerking process whilst aiding clinical reasoning. Its benefits have been displayed through auditing processes and has received great praise from staff.

Acknowledgements

Results

We would like to thank the staff at the Princess of Wales Hospital Intensive Care Unit for their ongoing support with the project.

75% (n=9) of staff agreed a proforma would be useful. 14 initial clerkings, all documented on continuation sheets, were identified during the initial two-week period. Of these, 0% documented clinical frailty score (CFS), 42% (n=6) the functional status and 14% (n=2) the escalation plan.

The proforma was utilised in 6 out of the 12 admissions during the two-week trial period.

References

Figure 2- Example pages of ITU proforma

(1) Mathers, M., Shrimankar, J., Scott, D., Charlton, F., Griffith, C. and Angus, B., 2020. The Use Of A Standard Proforma In Breast Cancer Reporting. [online] Journal of Clinical Pathology. Available at: <https://jcp.bmj.com/content/54/10/809> [Accessed 13 December 2020].

(2) Ferran, N., Metcalfe, A. and O'Doherty, D., 2008. Standardised proformas improve patient handover: Audit of trauma handover practice. Patient Safety in Surgery, 2(1).

(3) Al Hussainy, H., Ali, F., Jones, S., McGregor-Riley, J. and Sukumar, S., 2004.

Improving the standard of operation notes in orthopaedic and trauma surgery: the value of a proforma. Injury, 35(11), pp.1102-1106.

Improving the culture of electronic handovers Gemmell C, Rogers S, Davis J, Davoudi K, Hinds J, Ahmed J, Jenkins G

Introduction

Results

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

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

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

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

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

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

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

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

Objectives 1.

2.

3.

Develop a standardised handover template Generate >80% use of uptake within the medical department Template to be adopted by future annual cohorts Uptake of standardised handover template

Methods

Discussions

1. Pre-intervention email questionnaire and draft handover template model circulated via email to gather feedback & views on current system 2. Finalised template made available via ‘auto-fill’ function on electronic patient record system 3. Interventions to improve template uptake: email reminders, laminated notes attached to computer screens, posters and general face-toface reminders on Fridays 4. 25 weekends audited to over an 8-month period 5. Post-intervention survey to gather feedback

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

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

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

Handover template

Limitations / areas for future work • Accessibility: doctors need to be manually given access to the template.

• Patients are not automatically added to the list.

• Template can still be poorly/partially filled out.

• Priority/ escalation status options could be added.

1. Royal College of Physicians. Acute care toolkit 1: handover. London: RCP, 2015

Burnout in the Intensive Care Unit during the pandemic Arnold K, Berrera-Groba C, Tozer L, Ranji T Introduction

Method

• Burnout is a state of emotional, physical, and mental exhaustion caused by excessive and prolonged stress.

• It occurs when you feel overwhelmed, emotionally drained, and unable to meet constant demands.

• Burnout in ITU is well documented in literature and there are multiple models used to assess burnout.

The aim of this study was to assess burnout in the intensive care unit in the multi disciplinary team.

• Over a 12 week period, using a survey tool, we asked staff working in the intensive care unit during the Covid-19 pandemic questions that would assess level of burnout.

• Staff of all disciplines working in the intensive care unit were included in the survey • We used 3 popular burnout screening tools and combined the most relevant questions.

• The most significant questions and answers have been included in this poster.

Results

Would you describe yourself as being 'burnt out'?

Answer Choices Responses

A total of 52 responses were received for the questionnaire Detailed below are the results of the findings from our study

25 27

Answered

52

“How often do you dread going “Do you ever leave work feeling

25 20 15 10 5 0

sad or upset?”

into work?”

y Rarel

Ne ve r Ra re ly So m et Us i… ua lly Al w ay s

Always

Usually

Rarely

Never

48.08% 51.92%

lly ua Us

25 20 15 10 5 0

Somet…

“How often do you feel that demand outweighs the resources?”

Yes No

The most predominant answers regarding whether or not Covid-19 had informed their decisions included: • Uncertainty regarding the future.

• PPE use and how hot it is.

• Redeployment to unfamiliar territory.

• Increased anxiety working in a pandemic with unwell Covid-19 patients.

• Feelings of low morale during the pandemic.

The survey asked how morale could be improved, the most predominant answers are as follows: • Mindfulness sessions either before during or after work.

• Proper breaks, including time outside in the fresh air.

• Having simple refreshments stocked such as milk and coffee.

• Better staffing levels meaning there is more time for learning.

• More organisation of social events outside of work.

es m i et m So

Never Rarely Sometimes Usually Always

“Do you feel that the Covid-19 pandemic influenced any of your answers?”

40 20

Responses

0 Yes

No

When asked what staff felt the top cause of burnout in ITU is, the most predominant answers were as follows: 1. Dealing with emotional situations.

2. Staffing levels.

3. Exhaustion/excessive workload.

4. Lack of support following exposure to intense/emotional situations.

Conclusion: • Despite 51.92% of people saying they did not feel burnout, questions showed that there was some element of burnout, for example feeling unable to wind down after work.

• Encouragingly, 90% of respondents knew where to go for advice if they were feeling burnt out/low, it may be useful in a re-audit to ask what percentage of these have actually sought help when feeling burnt out/low.

• Following this, we are in the process of re-auditing after having implemented simple measures such as offering tea and coffee in the break room and introducing breaks that involve leaving the department for fresh air. It would be also useful to re-audit once the covid pandemic’s impact has lessened.

Limitations from this survey were: • Data that looked at which MDT professional answered the questions were corrupted and hence the breakdown of health care professions who answered was not available.

• Due to the anonymity we could not calculate a score of “burnout” as we would need to know how each person answered each question in order to calculate a score attached to each question.

‘Mind the step’-down Ensuring the safe step-down and handover of surgical ICU patients to ward level Dr Declan Beattie Dr Ciara Murphy

OUTCOME MEASURES

BACKGROUND

AIM

• It is the job of the surgical F2/CT to review patients when they are discharged to the ward from ICU. • These are complex colorectal and upper GI patients with high ICU admission rates post-operatively.

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

• We wanted to implement a proforma to facilitate simple, timely and safe transfer of information to ward level and improve continuity of care between units.

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

80% of patients discharged from ICU had a proforma completed

PROCESS MEASURES Percentage of proforma completed (acceptable standard 75%)

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

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

We then retrospectively audited 20 ICU discharges against these points to see what information was not recorded. Some of which included medication history, fluid balance and surgical complications – all highlighted as essential information by consultant colleagues.

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

Percentage of proformas completed for patients stepped down from ICU % of ICU proforma completed

100

90 Median 80 Goal 70

60

PDSA 3 new proforma

PDSA 2 Education for senior colleagues

PDSA 1 Education for peers

50

Runs of 5 or more

40

30

20

10

RESULTS

0

Proforma 1

Proforma 2

%

28

Pre audit

27

0

26

10

25

20

24

30

23

40

MOVING FORWARD

22

50

21

60

20

70

19

80

18

90

17

100

16

We examined how the proforma was being completed and accepted 75% completion as our standard. The graph shows how each section was completed.

15

•

14

8 more cases were examined which had 88% of patients having a proforma completed to an acceptable standard and a much-improved completion rate in areas of concern.

13

•

12

Following implementation of the proforma 20 cases were examined with 90% having a proforma completed to an acceptable standard. Some areas were still not being completed and hence a further PDSA cycle implemented.

11

10

9

8

7

6

5

4

3

2

1

•

Improving weekend handover using electronic health records

Aim

To increase the proportion of weekend geriatric ward cover doctors receiving a written handover of jobs on Nervecenter (NC) to 100% by 07/04/21.

Why

16% of Serious Incidents at Royal Cornwall Hospitals Trust (RCHT) last year were the result of a communication failure.

RCHT GMC feedback reported that out of hours handover requires improvement.

The weekday team cannot handover directly to a diminished weekend team.

Plan

Junior doctors who had provided weekend ward cover in the past 6 months were surveyed about their weekend handover – 23 replied

W Hughes, K Binmore, G Buckner How did you find your weekend handover of jobs/reviews?

1. Bad. 2. It was completely dependent on who gave the handover - sometimes non existent but sometimes great.

3. Very busy and chaotic and contains a lot of jobs that are not urgent and could be managed by the day team including writing discharge summaries.

4. I like the written handovers but sometimes I got confused about the purpose of junior reviews. I sometimes found that I didn’t know why I was reviewing a patient if it was not related to bloods.

5. I got my jobs from the weekend consultant ward round.

6. Not satisfactory.

7. Unless I had asked, I would not have known that there was a handover on NC. Also, on wards like Roskear, in November, there was a large discharge load.

8. On a piece of paper, handed over by the nurses. But, sometimes, the nursing team didn’t know about the jobs and the protocol. It was stressful because I was constantly worried about things I might miss.

9. Although there is a written handover this is of variable quality. They are often not presented in an SBAR format and may include unhelpful handovers such as “chase bloods” or “senior review”. Not all wards adhere to a strict weekend handover format via NC. 10. Ok, the nurses very helpfully wrote a list of jobs, otherwise I would’ve had no idea.

11. Handover - usually poor/non-existent.

12. Busy and hectic.

13. a) NC "weekend jobs" column. b) Written jobs lists by the ward nurses.

14. Adequate.

15. Sometimes there are plans in NC but this doesn't seem to be ubiquitous. It is instead the nursing staff who are aware of the patient's needs at the weekend. Doctor-todoctor handover, however, seems to be lacking.

16. Written on NC, in the notes or handed over to the weekend consultant by the weekday consultant.

17. It was very hit or miss, sometimes it would be on NC, but sometimes there would be nothing.

18. Sometimes I got a list from the nurses on the ward with stuff to do, other times I found it very confusing to manage patients in other wards.

RCHT has NC, an electronic patient record (EPR) with a weekend plan section for each patient available in SBAR format which can be accessed on PCs or ward iPhones anywhere in the hospital. From the 26/02/21, The Friday day team were reminded via posters in the doctors’ offices to populate NC, including the weekend plan. The weekend team were sent a second poster before their shift, informing them to find handover on NC and what to do during their shift.

How did you find your weekend handover of

Do

Study

Act

On 07/04/21, the 9 junior doctors who had covered geriatric wards at the weekend were r e - s u r v e y e d , a l l responded.

The intervention has improved the weekend handover on the geriatrics wards at RCHT.

The second cycle has begun, we have included the posters into the geriatrics induction booklet and the geriatrics induction lectures. The posters have been put up in all the medical wards. For sustainability, the posters will form part of the FY1 trust induction in August for all specialities.

Some limitations of the project were that although NC was populated with patients who needed jobs doing over the weekend, those patients not needing reviews or jobs occasionally didn’t have their NC populated.

Also, old jobs in the weekend handover section were not, from time to time, marked off as done, which could lead to confusion the next weekend.

Future cycles will focus on resolving these issues.

1.

2.

3.

4.

5.

6.

7.

8.

9.

jobs/reviews?

Written handover on NC. NC weekend plan and written list on ward.

Mostly handover on NC is effective with jobs clear. Sometimes it was not up to date and there was risk of repeating old jobs as you are unaware of the context of the job.

On the weekend plan.

Very good review lists which I found on NC for weekend plans. However other patients I was asked to review later, had no information on Nervecenter.

Good.

Weekend plan section on NC. All info was on NC which was useful, one expected discharge wasn’t prepped but the others were, old notes on Nervecenter need to be deleted once complete in the weekend plan section.

Weekend plan section on NC although for patients with no weekend jobs handed over, their NC information was sometimes not completed.

100%

First Survey

80%

Second Survey

60% 40% 20% 0% Written handover found

Know exactly what is expected

QIP: Creating a COVID aide-memoire to improve the efficiency of information retrieval in ITU Dr Craig George-McDowall (AFP1)

Cycle 2

ITU saw a significant increase in the number of patients during the COVID-19 pandemic.

ITU patients by their nature are extremely complex, undergoing multiple investigations, some of which are repeated frequently, and many treatments requiring active monitoring.

Handover of these patients can be complex and learning about many similar patients in a row can be confusing.

Results

75%

100 90

Percentage of Staff

Problem

80 70 60 50 40

80%

75%

30

93%

20 10 0

Aim Improve the efficiency of handover of COVID pneumonitis ITU patients by producing an aide-memoire to be kept in the notes, which can quickly summarise the patient’s journey.

75%

Aware of aidememoire

Use the aidememoire

Find aidememoire useful

On 2 occasions at 2 week intervals, 75% of red zone patients had an up-to-date aide-memoire

Word document with list of items to include on aide-memoire.

Generated by F1 and 2 ITU consultants.

Qualitative feedback examples: ‘Valuable. Useful record.’

‘Would be even better electronically’ ‘can you get it down to 1 page’ ‘Not useful to repeat information already on bloods charts’ ‘Helpful for writing discharge summaries and when starting work on the red zone’ ‘Chart style forms would be easier to digest’

Do - 1

Act - 2

Pilot trial document with 3 patients to identify pitfalls.

Further adjustments based on feedback, next iteration of form prepared (right).

Ready for use if needed.

Cycle 1 Plan 1

Study – 1 Qualitative feedback was examined between involved parties.

Act - 1 Adjustments were made. Form moved to Excel for easier editing/boxes. Next iteration produced.

Future direction Aide-memoire ready for deployment if there is another wave of COVID19, with another PDSA cycle could be further improved Otherwise is useful tool for use in patients with ARDS

Cycle 2 Plan – 2 Staff informed about new form in meetings/messaging groups.

Do - 2 New form introduced across ITU red-zone. All staff informed daily at morning handovers. Forms put into notes of all COVID patients.

New forms ready for new admissions.

Study – 2 Staff Survey and biweekly walkthroughs of the unit. Qualitative and quantitative elements.

Take home points Aide-memoire can be valuable to speed up handover and make patient monitoring easier.

A pilot trial can be easier and improve engagement as a second iteration will likely be better, and staff are more likely to see benefit.

Qualitative feedback from all levels can be more useful than quantitative Electronic records are preferred due to accessibility (especially due to donning/doffing with COVID and being unable to bring forms out of unit).

Improving uptake of na)onally approved atypical pneumonia inves)ga)ons in a ter)ary centre intensive care unit (ICU) Dr. Faris Hussaina, Dr. Jessie Shawa, and Dr. Matt Morganb aAcademic Foundation Year 1 Doctors, University Hospital of Wales bConsultant in Critical Care Medicine, University Hospital of Wales

-From 08/2018 to 08/2019 -Mean average comple7on rate for atypical pneumonia . inves7ga7ons of 39.1%

Aim

To improve the comple7on of atypical pneumonia inves7ga7ons by a mean average of 10% per inves7ga7on over a 6-month period following the implementa7on of the interven7on changes.

Background From a 12-month data collec7on, atypical pneumonia inves7ga7ons had a mean average comple7on rate of 39.1% per inves7ga7on for pa7ents treated for pneumonia within our intensive care unit (ICU), located in a ter7ary centre hospital.

We implemented design changes to our daily inves7ga7ons form, used in pa7ents’ notes and on ward rounds, to encourage ICU doctors to consider or remember to perform relevant inves7ga7ons for atypical causes of pneumonia.

Methods Interven)on: Addi7onal sec7ons were added to the inves7ga7on form outlining relevant atypical pneumonia inves7ga7ons to remind ICU doctors of these.

August 2020: The ICU team were made aware of our changes and when copies of the new form would be introduced into the ICU.

ACT More design improvements and promo)on -Further design modifica7ons, and promo7on of changes -Further data collec7on over longer 7me period

STUDY Repeat data collec)on -From 08/2020 to 01/2021 -Mean average comple7on rate for atypical pneumonia inves7ga7ons of 41.8%

Bar Chart showing % comple)on of atypical pneumonia inves)ga)ons Immunoglobulin Serum levels

% inves)ga)on comple)on postinterven)on for 35 pa)ents

Urine pneumococcal

Inves)ga)on type

PLAN Ini)al data collec)on

DO inves)ga)on form design changes and department awareness -Pneumonia inves7ga7ons box on inves7ga7on form -Department briefings and announcements

Urine legionella

Viral throat swab

% inves)ga)on comple)on preinterven)on for 112 pa)ents

Blood borne viruses serum inves7ga7on

HIV serum inves7ga7on 0

August 2020 to January 2021: We measured, over a 6-month period that began in August 2020, the frequency, at which the atypical pneumonia inves7ga7ons were done for all pa7ents treated in our ICU for pneumonia.

Future: We plan to repeat data collec7on to cover a 12month period and ensure consistent use of these updated blood forms through regular team briefings.

20

40

60

80

% inves)ga)on comple)on rate in pa)ents treated with pneumonia on ICU

Outcome and Next steps We analysed inves7ga7ons that had been completed for 35 pa7ents over 6 months, comparing our results to informa7on gathered from 112 pa7ents during the previous 12 month analysis.

We saw improvements in comple7on of all inves7ga7ons apart from the inves7ga7on for urinary legionella, which saw a decrease in use by 20.9%.

Excluding this result, the average percentage improvement in inves7ga7on comple7on was 15.3%.

Our results suggest that the form changes improved the comple7on of most atypical pneumonia inves7ga7ons. Alterna7ve explana7ons for this change include the COVID-19 pandemic’s impact and other quality improvement projects, including the introduc7on of electronic test requests.

Data collec7on and analysis over a longer 7me period could further determine how effec7ve our form changes have been.

Improving orientation and location of emergency equipment in an unfamiliar clinical environment Dr Sophie Masterson¹, Dr Beki Baytug¹ ¹Barts Health NHS Trust, Royal London Hospital, Whitechapel Rd, London

Background • During the COVID-19 pandemic an additional clinical area was rapidly developed to expand the critical care capacity at our busy London teaching hospital.

• Patient group all had confirmed SARS-CoV-2 infection, requiring level 2 or 3 care.

Act • Further schematic made when clinical area expanded

• During acute situations we identified uncertainty and delays locating emergency equipment; with the potential to adversely impact patient safety.

• Survey of staff confirmed lack of recall and concern of safety equipment location (see results).

Aim

Plan • Uncertainty

in equipment location identified • Proposal discussed with senior medical and nursing staff

Study

Do

• Pre and post

• Equipment

intervention questionnaires • Qualitative feedback from team

agreed • Schematic produced and displayed • Wall signs made to reinforce locations

locations

To improve knowledge and ease of access to emergency equipment – the difficult airway trolley, defibrillator and intubation drug trays.

Methods • Schematic produced (fig.1) clearly indicating the locations of the equipment, using familiar imagesi to aid recognition.

• Schematic displayed at visible points on units and on the doors from donning area – a point at which all staff were required to stop.

• Signage corresponding with the pictures on the left of the schematic were displayed above the equipment to aid both recognition of equipment and return of equipment to designated spaces.

• A further schematic was produced when a second clinical area was opened.

Figure 1.

PrePostintervention intervention

Results Pre-intervention, 92% thought that a schematic would be a useful aid.

– July 2020 (n=36)

Have attended emergency?

Could identify location of

Conclusion The schematic provided a visual aid which improved knowledge of the location of essential equipment amongst staff working on our critical care unit.

– May 2021 (n=5)

Yes – 44%

Yes – 100%

No – 56%

No – 0%

Difficult airway trolley (x2)

None – 44%

None – 0%

1 – 42%

1 – 40%

2 – 14%

2 – 60%

Resus trolley

None – 66%

None – 0%

1 – 33%

1 – 40%

(x1 pre, x3 post)

Advanced airway equipment

2 – 20% 3 – 40% No – 69%

No – 0%

Yes – 31%

Yes – 100%

Acknowledgements Dr Andrew Leitch Cons1, Dr James Pennington Cons1, Catherine Smith Matron1, Susana Lucena-Amaro1.

References i https://das.uk.com/content/dat_labels, Dr Chris Thomson ii Reason, J. Understanding adverse events: human factors. Quality in Health Care. 1995. 4(2): 80-89

Discussion The impact of human factors on task performance, particularly in high stress environments is well understoodii. We identified challenges imposed by: • Rapid roll out of brand new clinical areas.

• Physical restriction imposed by PPE. • Changing workforce: relocation of usual critical care staff to new area, redeployment of staff from other specialties of varying grades and roles for varying time periods.

This project was particularly useful in orientating redeployed staff as photographs helped staff to identify unfamiliar equipment.

The schematic was also incorporated into junior doctor induction.

Post intervention survey response has been poor which we attribute to change in staffing (rotational junior doctors and end of redeployment) and fatigue of permanent staff resulting in poor engagement.

Limitations were delays in printing and size – further production will be larger.

Further work Regular audit to ensure that accuracy of the schematic is maintained and expansion to further clinical areas.

Clinical Portal Quality Improvement Project Sep 2020 – Feb 2021

Ekemini Ekpo1, Mr Thomas Ball1, Helen Price1, Leigh Burns1, 1. Torbay and South Devon NHS Foundation Trust

Introduction

Methodology

Last year, our department switched clinical systems from Nerve Centre to Clinical Portal .... with some success. It’s become our main tool for inpatient list keeping It has some advantages and disadvantages and we would like to see if we can make it work for us as a department The aim is improve the usability, efficiency and effectiveness of Clinical Portal within our department

Thus improving patient care

Aim

Discussion Clinical Portal has improved the management of our patients - It is more reliable than NC - Improves efficiency overall.

Areas for improvement include: ü Develop a system where bloods observations could be added to the list and prepopulated on a daily basis ü Xray images to be opened through CP ü CP system includes MDT notes

Results

Glycaemic Control in Critical Care DrJessica Moncrieff, Dr David Yates, Dr Vijay Jayagopal Intensive Care Unit, York Teaching Hospital NHS Foundation Trust, Hull York Medical School AIM A quality improvement project to evaluate the impact of introducing the Freestyle Libre blood glucose monitor on the frequency of blood glucose recordings in patients on IV insulin in the Intensive Care Unit (ICU) at York Hospital.

BACKGROUND Critically ill patients suffer from hyperglycaemia; this is thought to predispose patients to complications such as infection, polyneuropathy, multiple organ failure and death (1). Guidelines for York Hospital ICU currently recommend that patients on intravenous insulin should have their blood glucose monitored hourly (2). New technologies for monitoring blood glucose levels in patients, such as the Abbott Freestyle Libre, could improve the frequency of monitoring of blood glucose levels in patients on intravenous insulin on ICU. The appropriate strategy with respect to glycaemic control in critically ill patients has been an area of change over the last seventeen years. In 2001 Leuven demonstrated better patient outcomes in patients with tight glycaemic control (80110mg/decilitre) (1). However, in 2009 the NICE-SUGAR trial (3) reported increased mortality and hypoglycaemia in patients where blood glucose was tightly controlled.

Cohort Patient admitted to ICU

Patient identified as requiring intravenous insulin infusion

Standard monitoring Standard 133 monitoring + Freestyle Libre

Consented for Freestyle Libre Nursing staff record blood glucose using standard practice and Freestyle Libre ICU daily charts assessed for frequency of blood glucose monitoring

Standard deviation (mins)

42 26

On average patients with standard monitoring (23 patients, 746 hours of monitoring) waited 30 minutes longer to have their blood glucose recorded than those with the addition of the Freestyle Libre (10 patients, 1553 hours of monitoring): weighted means 2hrs 43mins (weighted SD=42 minutes) v 2hrs 13mins (weighted SD=26 minutes).

Where we had nurse recorded data of the method of blood glucose measurement (40 data points for capillary blood glucose and 33 for arterial blood glucose) we looked at the difference between these measurements and the Freestyle Libre recording.

On average capillary blood glucose measurements were 2.02mmol/L greater than Freestyle Libre measurements (SD=2.35 mmol/L), whilst arterial blood glucose measurements were 4.25mmol/L greater than Freestyle Libre measurements (SD=3.31mmol/L).

RESULTS

METHODS

• Retrospective analysis of the frequency of blood glucose measurements in two cohorts of patients, requiring IV insulin, who were admitted to York Hospital ICU between July 2018 and December 2018.

• Cohort one was standard monitoring with capillary blood glucose or arterial blood glucose.

• Cohort two was standard monitoring with the addition of the Freestyle Libre.

• Nursing staff were unaware that frequency of measurement was being monitored.

Average time between blood glucose measurements (mins) 163

Total population

DISCUSSION

33 patients

Patients per cohort

Standard monitoring 23

Standard monitoring + Freestyle Libre 10

Total hours monitoring

746

1553

REFERENCES 1. Van den Berghe G et al. Intensive insulin therapy in critically ill patients. N Engl J Med. 2001;345:1359-1367.

2. York Teaching Hospital NHS Foundation Trust. 2017. Variable Rate Intravenous Insulin Infusion (VRIII/Sliding Scale) Adult Prescription Chart. York: York Teaching Hospital NHS Foundation Trust.

3. The NICE-SUGAR Study Investigators. Intensive versus conventional glucose control in critically ill patients. N Engl J Med. 2009;360:1283-1297.

• Introducing the Freestyle Libre device lead to an increase in the frequency of monitoring.

• Variability between blood glucose measurements using standard capillary or arterial glucose monitoring and the Freestyle Libre may have led to reluctance from nursing staff to adopt the new technology.

• Further work is needed to establish if the Freestyle Libre alone would be a safe alternative to standard practice.

• New technologies, which better monitor and control blood glucose levels, could see improved glycaemic control, a reduction in hyperglycacemia and less risk of hypoglycaemia

th 16

June 2021

Poster Competition Group N

Improving admission and discharge care pathways First prize: Improving the Quality of Referrals from the NHS 111 Service Presenter(s): Dr John Flemming Epsom and St Helier University Hospitals Trust

Second Prize: Improving the pathway for patients’ follow-up on swab results in Gynaecology Department Presenter(s): Eunkyung Lee, Ridhi Majithia University Hospitals Plymouth NHS Trust

Surgical Admission Clerking in a Time of Corona: A QI Project to Streamline Admission Clerking Dr Clio Kennedy, Dr Stanley Tang, Dr George Geropoulos, Dr Sabareen Huq, Dr Ahmed Elhamshary, Dr Calum Grant, Dr Sara Moghadam-Rakhashani

Introduction and Aims: There is key information required for any new surgical admission.

A clerking should ideally be conducted in one sitting but without compromising the clerking itself. This is particularly important now, in view of the covid-19 pandemic.

Further an efficient and streamlined admission clerking optimises patient care.

Methodology A short anonymous questionnaire assessing the urology admission clerking process was distributed to doctors and allied health professionals in a specialist urology setting.

An admission clerking proforma was developed in response to questionnaire feedback.

A follow-up questionnaire was distributed to the same staff 1 month after introduction of the proforma. Further changes were then made.

This process was repeated 1 month later to allow for further assessment of and to the clerking proforma.

Results The quality of admission clerking was variable prior to this QI project. Key information was often neglected.

The introduction of a clerking proforma aided clarity around the reason for admission, management plans and information about home medications (including plans for holding some medication peri-operatively).

A second cycle allowed for further edits to the proforma, including adding prompts to ask about activities of daily living and existing packages of care. This aided therapy teams in getting patients home safely.

A good clerking is correlated with more effective handover between health care providers, less medical errors, less treatment delays and improved patient outcomes.

References: Kentley et al The use of a pro forma to improve quality in clerking vascular surgery patients BMJ Open Quality;5:u210642.w4280.

Gupta S, Ratnasingham K, Tamura C, Karthigan R, Bhargava V, West N. Improvement in clinical recording keeping following the introduction of an admission clerking proforma for acute general surgical patients.Clinical Audit. 2013;5:61-66 Park JS, El-Sayed IH, Young VN, Pletcher SD. Development of clinical care guidelines for faculty and residents in the era of COVID-19.Head Neck. 2020;42(7):1403-1408.

Ethan Vargo,Marwan Ali,Fabrice Henry,Daniel Kmetz,David Drevna,Jayram Krishnan,Raymond Bologna Cleveland Clinic Akron General Urology Residency Program's COVID-19 Experience Urology 2020 VOLUME 140: P1-3

Driving with hand trauma: developing a unique clinical guideline Driving advice for patients with hand trauma

E.Jenkins, O.Hartrick and A.Watts Introduction

As per DVLA guidelines, patients with hand trauma should be alerted that their injuries may impact driving. Subsequently they should be advised to discontinue driving.

Aims

97% of patients

did not

receive driving advice

DEC 2020-Jan 2021

1. Driving advice is issued to 100% of

Audit of driving advice given to patients with significant hand trauma patients that are unable hand trauma to control their vehicles 2. Develop a unique guideline for Methods issuing advice ot hand trauma All PDSA cycles were audited by reviewing medical notes. patients A record was made of whether driving advice was given to patients with injuries impairing their fitness to drive.

Interventions Education

Implemented 1/2/21. Formal teaching sessions conducted to educate staff on the laws and guidelines of both DVLA and the GMC.

317 patient notes screened Clinician guideline

Clinical guideline

Implemented on 14/2/21. A formal guideline was developed to to aid clinicians with the process of issuing driving advice. This was developed to specifically advise patients with hand trauma.

‘Smart tool’

Implemented on 1/3/21. A smart phrase was developed

to aid clinicians with documentation of driving advice in digital notes

Conclusions

Significant improvement in rates of driving advice given to patients with hand trauma.

Electronic ‘smart texts’ makes documentation easier. Clinical guideline useful to give concise summary of legal obligations

Next steps

CONTINUAL REAUDIT TO CHECK SUSTAINABILITY

PUBISH GUIDELINE AS A PLATFORM FOR OTHER HAND TRAUMA UNITS

Improving Discharge Documentation at a Major Trauma Centre Background:

Nada Khalil , Meabh Peacock, Samay Mellor ,Simone Giusti, Sumir Chawla, Louis Koizia

Albert Ward is a busy surgical rehabilitation unit attached to a London tertiary trauma centre. It has a high turnover, with many of the discharged patients being elderly, with long hospital stays, complex social needs and extensive follow up plans. As a major trauma centre, the hospital receives a high volume of patient transfers from a wide geographical area, who require repatriation post operatively. Thus accurate and up-to-date documentation is imperative to ensuring optimal patient handover to community services and receiving hospitals.

Significant results:

The problem: • •

Reviewing completed discharge summaries highlighted an unmet need to improve and standardise discharge summaries.

We recognised that poor quality discharge documentation was linked with medication errors and missed follow up appointments post discharge.

Social history

This QI project set out to: • Create a structure to aid completion of discharge summaries in accordance with RCP guidance • Improve the quality of discharge summaries through teaching and feedback sessions

Discharge details Methodology: RCP guidance for discharge summaries consulted

Preintervention Discharge summaries compared against RCP criteria (n=29)

Continued teaching

Postimplementation cycle 2 - 29 summaries reviewed

Plans and requested actions

Interventions 1+2 implemented

Intervention 3 implemented

Post implementation cycle 1 - 29 summaries reviewed

Appointments

Interventions: Teaching sessions for current and rotating junior doctors

Weekly senior lead feedback meetings

Creating a discharge summary template - shortcut on our electronic discharge system to standardise format

Discussion and take home messages • Our interventions demonstrated a consistent significant improvement in the quality of discharge documentation across RCP highlighted categories, including - documentation of follow up appointments, amendments to admission medications and social care arrangements • It is crucial that healthcare staff are aware of the impact that summaries have on the continuing care of patients.

• Poor discharge summaries can lead to missed follow-up appointments, missed opportunities to refer to community services (i.e. memory clinic) or decreased understanding of the indications for new medications. The responsibility for resolving these issues often falls on primary care providers.

• Our project has shown there is room for significant improvement and our next cycle involves providing teaching sessions to the junior doctors of the entire Geriatric Medicine department

Adapting an Emergency General Surgery Service in Response to the COVID-19 Pandemic Patrick Hickland, Joshua M Clements, Liam J Convie, Damian McKay, Kevin McElvanna Craigavon Area Hospital, Southern Health and Social Care Trust, Northern Ireland Introduction In response to the COVID-19 pandemic, the UK governments issued statements declaring the need for changes to healthcare to reduce the rate of spread and prepare for COVID-19 patients needing hospitalisation. In line with specific guidance from the Royal Surgical Colleges and ASGBI, our emergency general surgery (EGS) service underwent significant reconfiguration, including establishing an enhanced ambulatory service, and undertaking non-operative management of selected conditions. This study compares the activity of our service before and after these changes.

Results PreCOVID COVID Patients Referred, no.

Duration of Admission, days Operative/Endoscopic Interventions, no.

281 6.9 78

283 4.8 40

Ambulatory Investigations, no.

Telephone Review, no.

Early CT Pre-Discharge, % 30 Day (Re)Admission, % 30 Day Mortality, %

11 0 5.0 6.5 3.0

39 39 34.7 5.8 2.7

Outcome of Referrals

Methods Patients referred to our EGS service by the emergency department were prospectively identified over a four week period beginning from the date of reconfiguration, (COVID; 29th March – 25th April 2020) and compared to patients retrospectively identified from the equivalent period the previous year (Pre-COVID; 31st March – 27th April 2019), and followed up for 30 days. Data was extracted from handover documents and electronic care records.

Conclusions Adaptations made to our EGS service in response to COVID-19 led to increased use of ambulatory services, including imaging and telephone review. In this time there was a 62.7% decrease in use of inpatient bed days (1519 to 567), whilst maintaining patient safety. We have established safe standards that we advocate can be carried forward into the Post-COVID era.

Improving the Quality of Referrals from the NHS 111 Service Dr John Flemming, Dr Robert Tan - Epsom & St Helier University Hospitals NHS Trust

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

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

Quality Control Patient rings 111, undergoes initial telephone triage

Directed to external service

General Practitioner

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

Pharmacy

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

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

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

Given an appointment in the St Helier Emergency Department

•

Is an ED attendance necessary at all?

•

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

•

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

•

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

•

How can we track our service improvements as they evolve over time?

Appointment with ED GP

Appointment with Emergency Nurse Practitioner

Optician

Appointment with ED SDEC doctor

Other Service

Attend ED within 1 Hour, 2 Hours, 4 Hours, 6 Hours

Successes

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

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

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

The number of referrals judged to be “inappropriate” by the auditing clinician fell markedly over the audit period: Inappropriate Referral Pathway 30

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

25 20 15

Yes

10

No

5 0 18/09/2020

18/10/2020

18/11/2020

18/12/2020

The proportion of patients to be seen within 1 hour rose over the audit period, and lessurgent appointments fell, showing that more urgent complaints were referred over time: Appointment Urgency 30 25 20

6 Hours

15

1 Hour

10

2 Hours 4 Hours

5 0 18/09/2020

18/10/2020

18/11/2020

18/12/2020

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

Introduction

Rapid Referrals: improving efficient communication between hospital specialties

“Rapid Referrals” aims to improve doctors' familiarity with the complex and constantly changing referral process at a small district general hospital.

Referrals are made using a variety of methods including fax, email and direct discussion with a clinician. Out of hours, direct contact with many specialties and services is not available and missed referrals can lead to delays in patient care.

Dr Rhiannon Hoggins, Dr Sarah Mills, Dr Jack West, Dr Anna Harrington, Dr Lewis Pheasant

This is an ongoing project, with the eventual aim of having an easily available, open access guide, continuously updated and improved by Junior Doctors.

rhiannon.hoggins@uhd.nhs.uk

Methods

Aims 1. To assess doctors’ perceptions of the inpatient referrals system in order to establish aspects of the system which work well, as well as key areas of concern to improve in the future

•

Part 1: Questionnaire 1 sent out (via Survey Monkey) to Foundation doctors working in Poole Hospital (n=30) to assess their perceptions of the referrals system à results analysed and key themes identified à guideline document created

•

Part 2: 5 time-trials of F1 doctors equipped with or without the referral guideline

•

Part 3: Questionnaire 2 sent out to Foundation doctors (n=30) to assess their perceptions of the referral guideline document and to identify potential areas of improvement

2. To develop a quick reference referral document in order to summarise how to refer to common specialties within the hospital in order to save time and improve efficiency 3. To quantitively assess the impact of the referral guideline document by performing time trials assessing the referral process with and without the document 4. To assess doctors’ perceptions of the guideline document in order to identify areas for improvement and highlight future work

Part 1

Results 20 participants responded to the initial survey assessing their perceptions of the referral system

How do you currently find out how to refer to other specialties?

Do you have any suggestions of how the referral system can be improved?

Part 3

Part 2 Time-trials Without document (minutes)

With document (minutes)

Dermatology

6:30

6:20

Cardiology

5:00

4:50

Respiratory

2:00

1:58

Haematology

10:30

10:05

Rheumatology

21:00

11:20

17 participants responded to the second survey assessing their perceptions of the referral guideline document

• 100% of Foundation doctors reported that the referral document would be a useful resource when referring to different specialties in the future • They felt that it would improve the efficiency of their referrals

Discussion and Conclusions •

Common themes included: - Concerns regarding fax machines being outdated and referrals not being received - Respiratory referral system working well with an integrated, online system - Participants keen for a uniform & standardised referral system, based online - Many participants suggested that a summary guideline document would be useful

Present at departmental meetings

• The time-trials demonstrated an associated time-saving when referring to less-common specialties, and a small benefit with more common referral processes •

Respiratory department email process led to fastest overall referrals

•

The referral guideline was well received amongst Foundation doctors who felt that it would be a useful tool whilst referring to other specialties

•

A key lesson to be carried to future cycles will be to direct focus onto newly arriving doctors, as the benefits are greatest with clinicians less familiar with the local processes

•

Present at F1 induction

Continual updates to document

Future work Faxing vs online referrals

Opportunity to improve patient safety- referral forms will not be lost, less delays in patient’s care

“A simple solution to a complex system"

Post intervention survey

Include MDT referrals

Introduction Of Clerking Proforma For Primary Percutaneous Coronary Intervention In Cardiology Dr Julia Fullerton, Dr Nicole Tan, Dr Benjamin Slader – Department of Cardiology, Queen Alexandra Hospital

BACKGROUND Patients are admitted straight to the coronary care unit after primary percutaneous coronary intervention (PCI). Initial admission assessments are performed post-procedure and are the responsibility of the ward junior doctors.

Variation of clerkings was noted on the posttake ward round and further amplified during the COVID-19 pandemic as junior doctors were reallocated to work in Cardiology.

AIM ✓ Improve and standardise admission clerkings of post-PCI patients

OBJECTIVES ➢ Ensure ACS risk factors were addressed ➢ Prompt timely requests of appropriate Figure 1: Final clerking proforma

cardiac investigations

RESULTS

METHOD Identify requirements for a good cardiac history

Baseline Measurements: Highlighted inconsistencies with missing investigations

Baseline data: Review current clerkings Are we asking the right questions?

Are the correct investigations being requested?

Development of the proforma

Review of proforma by Interventional Cardiologists Further refinement of proforma

Proforma introduced for use on the ward

DM HTN High Cholesterol Family history Drug history Allergies Smoke Alcohol Occupation HGV Exercise tolerance

1st data collection: after 4 weeks

Examination: Plan: ECG Echo

2nd data collection: after 4 months

Results presented to Cardiology Department

Proforma ratified by Clinical Governance

After 4 Weeks: Clerkings became more consistent and cardiac focused

Baseline 4 weeks 4 months N=20 N=20 N=15 Past Medical History 60% 100% 87% 80% 100% 87% 80% 100% 87% 65% 100% 87% 90% 100% 93% 80% 100% 93% Social History 95% 100% 100% 95% 100% 100% 40% 90% 73% 10% 100% 33% 55%

Feedback from Cardiology Junior Doctors

Data Collection

CONCLUSION

Trop CK LDL Chol HbA1C HDL Triglycerides Table 1: Results

100%

80%

Examination and Management 95% 100% 93% 100% 100% 93% 100% 100% 66% 40% 100% 53% Blood tests requested/available 95% 100% 60% 20% 100% 20% 50% 95% 60% 95% 100% 60% 15% 50% 60% 100% 60% 100% 60%

After 4 Months: More variability but many areas remained well covered

➢ Clerking variability remains ➢ The proforma has helped improve consistency and focus on relevant cardiac history and investigations ➢ During the COVID-19 pandemic the proforma helped reallocated junior doctors carry out high quality clerkings despite having less Cardiology experience

FUTURE PLAN

✓ The proforma is currently highlighted during the cardiology Junior Doctor induction every 4 months ✓ The proforma has been ratified by Governance and will be available in the Trust Document library Acknowledgements Dr H Griffiths and Dr A Dana for their advice and support, Mr Martin Drew for his help establishing the cardiology proforma further as well as the cardiology junior doctors for their valued feedback.

Improving the pathway for patients’ follow-up on swab results in Gynaecology Department Dr Eunkyung Lee1, Dr Ridhi Majithia1, Dr Rachel Roberts1 1Derriford

Hospital, University of Plymouth NHS Trust, Devon, United Kingdom

Background

ERRORS FOUND IN SWAB RESULTS Incorect

6%

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

Patient ID Type of swab Pregnancy status Results

Correct

89%

Sample of form :

23%

However, we noticed a number of errors on the results system, as demonstrated in Figure 1.

Evidently, junior doctors were taking or labeling samples in an incorrect way. As a consequence, patients were called to be re-swabbed and this led to delayed outcome and in some cases, no outcome at all if they were unwilling to re-attend the hospital.

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

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

56% 17% Figure 2. Graphs illustrating the percentage of errors in swab results

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

Error 1 Error 3

Error 2 Figure 1. Types of errors on the swab results.

11%

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

We created and distributed the survey after implementing the new swab form.

The responses were gathered in regards to confidence in the new system

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

Error 4

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

DO

PLAN

1 ACT

2

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

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

ACT

STUDY

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

DO

PLAN

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

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

We revised the swab form including additional clinical information such as pregnancy status.

Recommended swab teaching for the new cohort of junior doctors

STUDY

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

Figure 3. Graphs illustrating 2 Plan-Do-Study-Act (PDSA) cycles

Patient ID:

Swab type

Clinical background Pregnant

Swab taker: (Initials) HVV / VVS Date taken:

Results

Yes No

Actioned This is the final version of the form used in the swab book.

By : Date:

Outcomes

Figure 4. Table illustrating different columns for additional clinical information

Swab results reported since new form implemented 50 45

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

40 35 30 25 20

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

15 10 5 0

1 week

2 week

3 weeks

Acute Gynae Swabs

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

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

4 weeks

5 Weeks

6 weeks

Clinic swabs

Figure 5. Graph illustrating swab results in both acute and outpatient settings with reduced reporting time of average 2-3 weeks (in contrast to 6 weeks pre-implementation of the new swab form)

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

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

DVLA advice in the Cardiology Department Dr Grace Huffer, Dr Holly Andrews, Dr Chris McAloon Gloucestershire Hospitals NHS Foundation Trust RESULTS: PROBLEM IDENTIFIED DVLA based driving advice was poorly given and documented on an inpatient cardiology ward. In data collected over a 1 week period 0% patients had appropriate driving advice documented in their medical notes or discharge summary.

BACKGROUND Cardiovascular diagnoses and interventions frequently result in temporary/permanent driving restrictions for patients. It is the responsibility of the medical team to inform patients of these restrictions. Failure to do this has potentially serious consequences.

The DVLA sets out clear guidance for assessing fitness to drive in patients with cardiovascular disorders.¹ As junior doctors working in a busy DGH Cardiology department, we noted that the frequency and quality of driving advice given to patients, and formally documented, was variable.

Data collection week 1: 0% patients had driving advice appropriately documented on discharge, 0% junior doctors have confidence in giving advice and 60% junior doctors did not know how to access DVLA guidance.

% doctors confident giving DVLA advice % notes/discharge summaries with driving advice documented 0

PDSA Cycle 1 interventions; - Cardiology specific succinct advice and guidance sheet easily accessible on ward and emailed to colleagues - Education session for colleagues

Repeat data collection after cycle 1: 75% patients have driving advice documented appropriately, 80% junior doctors have confidence in giving advice

METHOD Data was collected in 2 ways; 1.Quantitative data was collected using the notes and discharge summaries of all cardiology patients discharged in a 1 week period.

2.Qualitative data was collected via a questionnaire sent to ward based junior doctors to better understand why the quality/frequency of driving advice documented was poor 2 PDSA cycles were then completed with introduction of a sustainable intervention at each cycle and the same data collection was repeated to establish the efficacy of the interventions.

PDSA Cycle 2 interventions; introduction of prompt on doctors handover sheet

Repeat data collection after cycle 2: 83% patients have advice appropriately documented, 100% juniors confident in giving driving advice

50

75

100

+Advice sheet PDSA Cycle 1

+Educational session

% doctors confident giving DVLA advice % notes/discharge summaries with driving advice documented 0

AIM Investigate why driving advice is poorly given/documented and implement sustainable change to improve this, aiming for 100% of patients to have appropriate advice given and documented.

25

CONCLUSIONS We believe the primary reason for our findings is lack of awareness and knowledge amongst ward based junior doctors. This is evidenced by our initial results, and the significant improvement in standards following interventions surrounding education and raising awareness. Our interventions were simple, cheap and reproducible. Re-audit should be performed in the future to ensure the interventions have been sustainable.

25

50

75

100

2.SUSTAINABLE INTERVENTIONS While our interventions were effective, continued junior doctor education will be required at each junior doctor changeover.

Suggestions to ensure sustainable interventions include education of the wider MDT (e.g. nursing staff who are likely to work in the department longer term) and inclusion of the guidance and teaching material in the junior doctor induction session and induction booklet.

PDSA Cycle 2

+Handover sheet prompt

% doctors confident in giving DVLA advice % notes/discharge summaries with driving advice documented 0

25

50

75

FUTURE THOUGHTS: 1.100% DOCUMENTATION With a target of 100% documentation not yet achieved, ideas for further PDSA cycles have been suggested. These include; dedicated, compulsory, sections for documenting driving advice on inpatient discharge summaries, patient information leaflets that can be distributed by all members of the MDT and a sticker in patients drug charts to act as a prompt when completing discharge summaries.

100

QUESTIONNAIRE QUOTES: Below are some responses from the questionnaire sent to junior doctors to establish why driving advice is poorly given. ‘lack of knowledge of guidelines’ ‘unaware of need to document DVLA advice’ ‘lack of time to document advice’

3.CROSS-SITE PROJECT The project has since been expanded to cover a larger sample size and include the Cardiology ward at the other hospital in the trust. The plan is to introduce the same interventions on the second site and re-audit to see if the results are as encouraging.

REFERENCES Cardiovascular disorders: assessing fitness to drive. DVLA. March 2016. Available at: https://www.gov.uk/guidance/cardiovasculardisorders-assessing-fitness-to-drive

th 16

June 2021

Poster Competition Group O

Care of the surgical patient (1) First prize: Regional Quality Improvement Collaborative to Reduce Surgical Site Infection in Elective Colorectal Surgery Presenter(s): Miss Sarah Biggs & Miss Lauren Dixon Organisations: Gloucestershire Hospitals, , Great Western Hospitals, Royal United Hospitals Bath, North Bristol Trust, University Hospitals Bristol and Weston on behalf of PreciSSIon and West of England Academic Health Science Network Second Prize: Improving the confidence of ENT trainees in assessing and managing nasal fractures Presenter(s): Dr Sachin Patel, Dr Syed Shah, Dr Zohaib Siddiqui Maidstone and Tunbridge Wells NHS Trust

Urology compliance Shujhat Khan, Sima Al Asad, Areeb Mian, Faizaan Ahmad Introduction 7-day service goal:

Quality hospital care that will provide 100% of the population with access to the same level of consultant assessment and review, diagnostic tests and consultant-led interventions every day of the week by 2020

Current guidelines: All emergency admissions must be seen and have a thorough clinical assessment by a suitable consultant as soon as possible but at the latest within 14 hours from the time of admission to hospital At MKUH the medical director has noted in 2020:

General surgery achieves the 14 hour target with 35% of their patients Urology achieves the 14 hour target with 25% of their patients

First audit Aim: To review whether patients receive a documented urology consultant review within 14 hours of presenting at the emergency department.

Parameters: Patients admitted through ESC or ED (not elective) Patient admitted (not discharged from ESC) Adults >18 years Patients seen by the urology dept in the last 2 weeks: 15/05/20 – 29/05/20.

Results: 39% (11/28) of patients during May 2020 admitted in the urology dept did not have a documented consultant review within 14 hours.

Re-audit methods Patients seen by the urology dept in the 3 months between July – Sept 2020.

Data source: eCare documentation Patient documentation was examined to measure the following time points:

1. Time taken by the ED to refer to urology/surgery from triage.

2. Time for documented SHO review from ED referral 3. Time for documented registrar review from ED triage 4. Time for documented consultant review from ED triage

Nature of PC and diagnosis Day of the week that the patient came to ED. Type of Consultant Documentation

Table 1: Patients admitted in the urology department between July- Sept 2020 (n= 135). 35% (47/135) of patients between July – Sept 2020 admitted in the urology dept did not have a documented consultant review within 14 hours, compared to 39% (11/28) patients during May 2020.

Average time taken for review:

May Audit

8pm -8 am 30% (n=40)

8 am - 5pm 33% (n=45)

Reaudit

Average time for ED to refer to urology/surgery:

2 hours 36 mins

1 hour 42 mins

Average time to be reviewed by SHO from ED referral:

36 mins

1 hour 29 mins

Average time to be reviewed by registrar from ED triage:

6 hours 55 mins

6 hours and 7 mins

Average time for consultant review from ED triage:

11 hours 27 mins

5pm -8 pm 37% (n=50)

Figure 5: Distribution of patients that receive a consultant review after 14 hours by time referred to urology by ED:

12 hours

Distribution of patient presentation at ED

Recommendation from first audit

30 25 20

Email all urology/gen surgery SHOs, urology registrars and consultants regarding the 14 hour target.

Ask juniors to have discussions with urology consultant on- call if patient admitted before 8 pm and document conversation.

15 10 5 0 Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Day of the week the patient present to ED May-20 Day of the week the patient present to ED July-Sept 2020

Figure 1: Distribution of patients who presented on each day of the week in May 2020 and between July-Sep 2020

Distribution of patient presentations at ED with consultant review after 14 hours

14 12 10 8 6

Documentation should be as a separate progress note.

Patients admitted between 5-8pm, urology registars or surgical SHOs must discuss patients with the urology consultant and document.

All overnight admissions should seen as a priority in the morning. Consultants should aware of new admissions and advise a plan either in person or remotely.

Overnight ward cover should hand over in person to urology registrar and update urology list with new admissions.

Patients that are known to urology should be referred to urology directly by the ED.

4 2 0 Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

References

Sunday

Day of the week the patient present to ED May-20 Day of the week the patient present to ED July-Sept 2020

Figure 2: Distribution of patients who presented on each day of the week and were also reviewed by a consultant in May 2020 and between July-Sep 2020

First Audit (May 2020)

Ward round addendum 36% Intra-op documentconsultant surgeon present 18%

Consultant Remote Review progress note 18%

Separate progress note 28%

Figure 3: Distribution of patients who presented on each day of the week in May 2020 and between July-Sep 2020

Reaudit (July- Sept 2020)

Intra-op documentconsultant surgeon present 4%

Ward round addendum 22%

Consultant Remote Review progress note 11%

Separate progress note 63%

Figure 4: Distribution of patients who presented on each day of the week in May 2020 and between July-Sep 2020

1. National Health Service (2015). Delivering the Forward View: NHS planning guidance 2016/17 – 2020/21. Retrieved from https://www.england.nhs.uk/seven-day-hospital-services/ourambition/ 2. Improvement.nhs.uk. (2019). Board Assurance Framework For Seven Day Hospital Services | NHS Improvement. Available at: <https://improvement.nhs.uk/resources/board-assurance-frameworkseven-day-hospital-services/> [Accessed 17 January 2021].

3. Wennberg JE. On the status of the Prostate Disease Assessment Team. Health Serv Res. 1990;25:709–716.

4. Sung JC, Curtis LH, Schulman KA, Albala DM. Geographic variations in the use of medical and surgical therapies for benign prostatic hyperplasia. J Urol. 2006;175:1023–1027.

5. Yu X, McBean AM, Caldwell DS. Unequal use of new technologies by race: the use of new prostate surgeries (transurethral needle ablation, transurethral microwave therapy and laser) among elderly Medicare beneficiaries. J Urol. 2006;175:1830–1835. discussion 1835 6. Wei JT, Calhoun E, Jacobsen SJ. Urologic diseases in america project: benign prostatic hyperplasia. J Urol. 2008;179:S75–S80.

7. Wharam JF, Sulmasy D. Improving the quality of health care: who is responsible for what? JAMA. 2009;301:215–217.

8. Berwick DM. Measuring physicians' quality and performance: adrift on Lake Wobegon. JAMA. 2009;302:2485–2486. [ 9. Nichol MB, Knight TK, Priest JL, Wu J, Cantrell CR. Nonadherence to clinical practice guidelines and medications for multiple chronic conditions in a California Medicaid population. J Am Pharm Assoc (2003) 2010;50:496–507.

10. Warren JL, Klabunde CN, Schrag D, Bach PB, Riley GF. Overview of the SEER-Medicare data: content, research applications, and generalizability to the United States elderly population. Med Care. 2002;40:IV-3–IV-18.

11. Strope SA, Elliott SP, Smith A, Wlit TJ, Wei JT, Saigal CS. Urologist Practice Styles in the Initial Evaluation of Elderly Men with BPH Urology. 2010 in press.

12. Diez Roux AV, Merkin SS, Arnett D, Chambless L, Massing M, Nieto FJ, Sorlie P, Szklo M, Tyroler HA, Watson RL. Neighborhood of residence and incidence of coronary heart disease. N Engl J Med. 2001;345:99– 106.

Post-Operative Check X-rays following hip replacement surgery: A Quality Improvement Project Dr Henry Poon, Dr Chloe Paylor

Introduction Performing of post-operative check X-rays on patients who have had hip replacement surgery is an accepted standard. The Getting it Right The First Time (GIRFT) programme, in association with the British Hip Society, British Orthopaedic Association and NHS Resolution, suggest: “Within the initial course of post-operative care, it should be considered standard practice for an anterior/posterior and lateral x-ray to be performed.”

The rationale is to ensure that the hip is in joint, the position of the components is satisfactory, that there is no evidence of bony injury or any unexpected concern with regard to component orientation or fixation, specifically to exclude dislocation, component mal-position, and an unexpected fracture.

We commenced an audit at Queen Alexandra Hospital to assess the extent to which these guidelines are being followed, and to see whether these might be improved post-intervention.

Method

Results – first cycle

Data collected retrospectively from Minestrone notes of general orthopaedic trauma patients that underwent THR or hemiarthroplasty operated on during period of 01/11/2020 to 30/11/2020.

Total number of operations = 21 (2 THR, 19 hemiarthroplasty)

Data recorded included type of operation, whether check Xray done and what day post-operatively it was carried out.

Check X-rays ordered = 16 (1 THR, 15 hemiarthroplasty) Percentage of total patients with check X-ray = 76.2% (50% THR, 79% hemiarthroplasty)

Pre-intervention

Post-intervention

Intervention 12%

Information poster placed in D4 seminar room, SHO room, D1/D4/D6 wards and D5 on-call room (23/12/2020)

24%

76%

WhatsApp message on junior doctors group

88%

Ordered

Not ordered

Ordered

Not ordered

Results – second cycle Total number of operations = 26 (6 THR, 20 hemiarthroplasty) Check X-rays ordered = 23 (6 THR, 17 hemiarthroplasty) Percentage of total patients with check X-ray = 88.5% (100% THR, 85% hemiarthroplasty)

% of total check X-rays ordered

Improvement of 12.3% following intervention 40 35

Discussion & further work

30

Whilst the proportion of patients with post-operative check X-rays ordered did increase significantly, the timeliness of when these X-rays were carried out was shown not to have significantly improved, with several of the cohort patients having x-rays outside of the desirable day 1 to day 2 range.

25 20 15 10 5 0 Day 0

Day 1

Day 2 Day 3 Day 4 Day 5 Day (post op) when XR is ordered First round

Day 6

Day 7

Second round

References: GIRFT Best Practice For Hip Arthroplasty Documentation – hip-arthroplasty-documentation.pdf

Possible areas for improvement might include further teaching for junior doctors with emphasis on time factor with a view to a later reaudit to assess whether change is sustained.

https://gettingitrightfirsttime.co.uk/wp-content/uploads/2017/07/1a.-GIRFT-BHS-and-BOA-Best-Practice-

Wound closure of general orthopaedic trauma during the COVID-19 pandemic: a Quality Improvement Project Dr Chloe Paylor, Dr Henry Poon —Queen Alexandra Hospital, Portsmouth Introduction The British Orthopaedic Association Standards for Trauma Orthopaedics (BOASTs) released a COVID-19 specific guideline in April 2020 to advise on management of general orthopaedic trauma patients during the COVID-19 pandemic. This included advice on preferred wound closure material. An audit was commenced in December 2020 to assess whether the Orthopaedic department at Queen Alexandra Hospital was following the updated guidance.

COVID BOAST - Management of patients with urgent orthopaedic conditions and trauma during the coronavirus pandemic – 21st April 2020 “General Orthopaedic Trauma...

14. .Use absorbable sutures and warn patients of the small risk of a mild inflammatory reaction to the sutures.”

Rationale: The use of absorbable sutures rather than non-absorbable wound closure materials can reduce the need for follow up visits and future healthcare contacts, reducing covid-19 exposure risk to patients and reducing strain on primary care services during the pandemic.

Method Data collected prospectively from operation notes of general orthopaedic trauma patients operated on during period of 16/12/2020 to 22/12/2020.

Exclusions – Procedures not requiring wound closure e.g. MUAs, K-wires Also included for comparison - all elective patients operated on during period of 16/12/2020 to 21/12/2020 (cessation of elective operating due to the pandemic)

Audit Results—First Cycle Trauma: Total operations—31 Wound closure with absorbable suture material/adhesive (AS): 12 vs wound closure with non-absorbable sutures/clips (NAS): 19 = 38.7% Elective: Total operations—23 Wound closure with AS: 4 vs wound closure with NAS: 19 = 17.4%

Interventions Email to consultants and registrars with updated BOAST guidance and explanation of rationale behind audit.

Information poster placed in morning trauma meeting room and orthopaedic theatre office.

Re-Audit and Results—Second Cycle Data collected prospectively from operation notes during extended period of 11/01/2021 to 31/01/2021 in order to achieve a similar sample size to the first cycle. No data collected for elective operations due to cessation of elective work.

Total operations—28 Wound closure with AS: 24 vs wound closure with NAS: 4

Percentage of patients managed with AS following intervention: 85.7%

Discussion and Further Work Following implementation of the above interventions and updating the department on the current guidance, we achieved a significant increase in guideline compliance from 38.7% to 85.7% for patients undergoing orthopaedic trauma operations. This is reducing the need for further follow up appointments to remove clips or non-absorbable sutures and reducing strain on primary healthcare services.

We would like to take this audit further by re-auditing elective operating practices and auditing any potential adverse events from this change in practice such as rates of local skin infections or wound dehiscence.

References: COVID BOAST - https:// www.boa.ac.uk/resources/covid19-boasts-combined.html

Sandwell and West Birmingham NHS Trust

The pitfalls of new technology: Improving the quality of operation notes in the trauma and orthopaedic department Jasvir Chaggar FY2 • Piers Taylor FY1 • Mr S Gella Consultant Background

Results Cycle 1 vs Cycle 2

Good record keeping is essential to all aspects of medical and surgical practice. [1]

•

Anaesthetist present in 18 cases (7 under LA)

•

1 case no incision needed (n=24)

•

Ensures proper information is available to all healthcare workers looking after the patient.

•

Tissue removed in 7 cases

•

Improves decision making.

•

Saves time.

•

Reduces safety issues.

•

Important from medico-legal point of view. [2]

•

Since the introduction of a new electronic patient record system we noticed a decrease in quality of operation notes.

•

There was often missing information, including consultant, site and laterality of procedure.

•

Standard

Aim

% compliance Cycle 1

% compliance Cycle 2

Date and time

100%

100%

Elective / Emergency

100%

100%

Name of surgeon and assistant

100%

100%

Named Consultant

88%

100%

Name of anaesthetist*

39%

30%

Procedure

92%

100%

100%

100%

Side (L/R)

72%

100%

Incision*

92%

100%

Operative diagnosis

96%

92%

100%

92%

71%

79%

100%

100%

96%

96%

ABX prophylaxis (where applicable)

52%

88%

DVT prophylaxis (where applicable)

75%

100%

Post-op instructions

100%

100%

Signature

100%

100%

Site

Operative findings

Audit the quality of operation notes in the T+O department following the introduction of new software.

Complications

n/a

Extra procedure

n/a

Tissue removed* Prosthesis used Closure technique

Standard

Anticipated blood loss

•

Royal College of Surgeons (England) – Good Surgical Practice.

•

1.3 Record your work clearly, accurately and legibly.

Ensure that there are clear (preferably typed) operative notes for every procedure. The notes should accompany the patient into recovery and to the ward and should give sufficient detail to enable continuity of care by another doctor. The notes should include: • • • • • • • • • • • • • • • • •

Date and time Elective/emergency procedure Names of the operating surgeon and assistant Name of the theatre anaesthetist Operative procedure carried out Incision Operative diagnosis Any problems/complications Any extra procedure performed and the reason why it was performed Details of tissue removed, added or altered Identification of any prosthesis used, including the serial numbers of prostheses and other implanted materials Details of the closure technique Anticipated blood loss Antibiotic prophylaxis (where applicable) DVT prophylaxis (where applicable) Detailed postoperative care instructions Signature

In addition to this, we wanted to ensure the following was also included.

n/a

Results Cycle 1 vs Cycle 2

Results •

Some fields are populated automatically giving 100% compliance (date, time, signature etc).

•

Site

•

We noticed a lot of drop down options on op-notes are not included on the final op note.

•

Side

•

•

Consultant

E.g. Surgeons will input laterality (left/right) in a drop down box. This is then not included or visible when the op note is saved and submitted.

Intervention

Compliance Aiming for 100% in all areas

Method

•

Education at daily trauma meetings to include information commonly missing into main text.

•

Discussion with IT team to resolve software issues.

Re-audit.

•

Op notes gathered retrospectively, at random by trauma coordinator, following the introduction of the new software.

•

•

Cycle 1 - Mixture of elective and emergency cases. (N = 25)

•

Cycle 2 - Emergency cases only due to Covid-19. (N=26)

Call logged with IT and Staff education and awareness

•

Data input into spreadsheet and analysed.

Conclusions

Results Cycle 1 •

N = 25

Results Cycle 2 •

N = 26

•

All Emergency case – Covid-19

48% (12) 52% (13)

n Elective n Emergency

•

Overall much improvement with the quality of operation note record keeping.

•

2nd cycle showed 100% compliance with Left/Right side, which was one of the bigger issues identified.

•

Named consultant compliance increased to 100%.

•

This audit is worth repeating and keeping under review to ensure the quality of record keeping is high and improved upon when needed.

References [1] GMC Good Medical Practice (19-21) [2] Mathioudakis A, Rousalova I, Gagnat AA, Saad N, Hardavella G. How to keep good clinical records. Breathe (Sheff). 2016;12(4):369–373

Quality Improvement Project on Management of Unstable Ankle Fracture Jian Zi Poh Scunthorpe General Hospital

Introduction

Results

In Scunthorpe General Hospital (SGH), little emphasis is placed on ankle fracture as compared to hip fracture Hence, an audit was done to compare management of unstable ankle fracture in adherence to British Orthopaedics Association (BOAST) guidelines It was found out that few aspects of management in A&E were inadequate Analyzing the root cause of non-adherence to guideline can lead to better care for these patients

Aim Primary aim is to ensure that ankle fractures are treated effectively in line with BOAST guidelines.

Secondary aim is to ensure that ankle fractures are treated in a timely manner.

Neurovascular assessment and skin integrity in A&E 89%

100% 80% 60% 40% 20% 0%

57%

1st Audit Result

2nd Audit Result

Adequate views of radiographs on ankle 92%

90%

90% 88%

86%

86% 84%

1st Audit Result

Methods Prospective data is collected.

Patients with unstable ankle fracture who are admitted in SGH are assessed in regards to BOAST guidelines based on medical notes, PACS and computer system via a data collection sheet.

Additional X-ray or CT for proximal fracture 80% 60% 40% 20% 0%

60%

0% 1st Audit Result

Change in Practice Poster displaying algorithm for ankle fracture management is displayed in A&E. Orthopaedics doctor to reduce fracture after first failed attempt.

2nd Audit Result

2nd Audit Result

1st Audit Result

2nd Audit Result

4

4

3

3

2

2

1

1

0

0 Lack of theatre time

Leg swelling

Others

Lack of theatre time

Leg swelling

Others

Conclusions After the quality improvement project, few areas showed major improvement.

Documentation of neurovascular assessment and skin integrity in A&E improved by 57%.

Number of additional X-ray or CT done for clinical suspicion of proximal fibula fracture in A&E improved by 60%.

Adequacy of reduction in A&E before transfer to the ward improved by 25%.

Hence, patient care and satisfaction is greatly improved.

•

•

•

References BOAST – The Management of Ankle Fractures https://www.boa.ac.uk/resources/boast-12-pdf.html

Lessons learnt Small changes can make a big difference.

Good communication and teamwork between different departments is the best way to provide better care for patients.

Dr L Gundle, Mr C Aliozo, Mr M Ahmad University Hospitals Dorset, UK

Pre Intervention Results

Intervention

IMPROVING SENIOR REVIEW RATES FOR ELECTIVE SURGICAL PATIENTS Dr M Moffat, Dr N Gallagher, Ms N Bullen, Mr A Kimble

⓵ Introduction The Royal College of Surgeons England’s standards for Good Surgical Practice 2014¹ recommend consultant or senior clinical review of elective inpatients at least once in 24 hours, 7 days a week.

Due to changes in part associated with the Covid-19 pandemic it was noted that a breakdown in this system had occurred.

Aims ● Audit senior review rates to identify the scale of the problem ● Instigate changes to improve patient safety ● Ensure that support levels for foundation doctors were optimized

⓷ The intervention 1.

Discussion at morbidity and mortality meeting

2.

An electronic inpatient list of elective colorectal patients

3.

Ward round rota for the senior registrars

FY1 Survey Results Strongly Disagree

⓶ Method An audit of 16 elective colorectal surgery patients was conducted in October 2020. Data collected included frequency, timing and seniority of ward round reviews and post-operative morbidities.

A Likert Scale (Score 1 Strongly Agree to 5 Strongly Disagree) was used to survey surgical Foundation Year 1 (FY1) doctors on levels of support and ease in attaining senior review of patients.

The interventions were performed.

A re-audit of 12 elective patients and re-survey of current surgical FY1s was completed for February 2021.

⓸ Project Results In October, 63% (10/16) of patients had a senior review on every day of their admission. In February this improved to 83% (10/12 patients).

Weekend reviews improved from 57% (9/16) to 100% (12/12).

No significant morbidity was incurred from lack of review.

The foundation doctor questionnaire showed significant improvement in ease of getting senior review and knowing who to contact with issues (Average improved from 4.7 to 2.0).

Strongly Agree

⓹ Conclusions Patient Audit Results

The Covid-19 pandemic has affected the surgical team structure. Use of an electronic patient list and formal ward round scheduling has improved the frequency of senior patient review and consequently patient safety. Support levels for foundation doctors were also improved.

References 1. The Royal College of Surgeons England. Good surgical practice. 2014.

Section 1.2.1 p13.

Regional Quality Improvement Collaborative to Reduce Surgical Site Infection in Elective Colorectal Surgery S. Biggs, L. Dixon, B. Clayphan, L. Jordan, S. Dalton & A. Pullyblank on behalf of PreciSSIon Collaborative

Introduction

Method

Surgical site infection (SSI) refers to wound infections following invasive surgical procedures. SSI constitutes a major healthcare burden accounting for 14.5% of all hospital acquired infections in the UK and an estimated 34226% increase in associated costs. It is also a significant cause of patient morbidity including increased length of stay, readmission, wound dehiscence, hernia, need for intensive care, as well as death. SSI is more common after colorectal surgery where wounds are frequently contaminated by bowel content and rates are reported between 8-30%.

The Institute for Healthcare Improvement’s (IHI) Breakthrough Series collaborative model was used. Quarterly learning and sharing events with QI coaching were used to implement a mutually agreed, evidence based wound care bundle in elective colorectal surgery across the 7 hospitals.

Measures: Public Health England SSI surveillance questionnaire was used to attain 30 day patient reported SSI data Compliance with the bundle and questionnaire response rates were measured at each hospital

The PreciSSIon collaborative (Preventing Surgical Site Infection across a region) is a collaboration between 7 NHS hospitals in the West of England with the aim of reducing SSI after elective colorectal surgery.

Accurate data of prevalence of infection

Bundle

Aim

Develop a local measurement plan that aligns with the local improvement

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

To reduce surgical site infection in colorectal surgery by 50%

by March 2021

Reliable use of the surgical site infection bundle

Implement bundle: 2% chlorhexidine Use of wound protector Repeat dose of antibiotics after 4 hours operating time Triclosan-coated sutures for mass closure and skin Learn from and design reliable pathways of care

• •

Establish optimum data collection (phone/letter/email/inpatient data) Audit tool in theatre

• •

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

• •

Laminated signs in theatre Procurement of sutures: remove alternatives and monitor reordering Operation cards for colorectal cases Training for Anaesthetists and OPD re antibiotics Give responsibility for each component

• • •

•

Develop and promote evidence based information

Results

18.8%

9.6% 49% SSI reduction

Hospital

Baseline Post SSI (no. bundle patients) SSI (no. patients)

Compliance (%) 2% Antibacterial Antibiotics Wound Chlorhexidine sutures after 4 protectors hours

PROMS Response rate

1

15%(198)

7% (187)

89%

58%

32%

34%

74%

2

8% (128)

8.6% (197)

91%

68%

34%

33%

63%

3

22% (74)

6% (136)

100%

90%

85%

90%

100%

4

12% (44)

8.5% (193)

84%

86%

98%

83%

86 %

5

30% (208)

15% (175)

100%

100%

67%

61%

0%

6

20% (197)

11% (217)

100%

100%

100%

91%

93%

7

20% (54)

7% (42)

100%

71%

100%

100%

68%

Mean

18% (903)

9% (1147)

95%

82%

73%

70%

69%

103 SSIs prevented

£234,000 Estimated saving

Results and Discussion All 7 hospitals had implemented the care bundle by February 2020 and by February 2021 1,147 patients has received the intervention. Average SSI rate was reduced from 18% (n=903) to 9.5% (n=1,147), which is a 49% reduction in 30-day SSI after elective colorectal surgery across the whole region (data collection is ongoing). Patient response rate was 69%. Average compliance to each of the 4 bundle elements was high (70 – 95%) and a relationship between increasing bundle compliance and decreasing SSI rate was suggested.

We have demonstrated that using a collaborative approach to quality improvement can be effective in improving patient outcomes on a regional scale.

Improving the confidence of ENT trainees in assessing and managing nasal fractures Dr Sachin Patel, Dr Syed Shah, Dr Zohaib Siddiqui, Mr Iain McKay-Davies Maidstone and Tunbridge Wells NHS Trust Introduction Nasal fractures are the most common type of facial bone fracture.1 It is important they are examined thoroughly as they can be associated with complications such as skull base fractures and septal haematomas. Patients undergo a manipulation under anaesthetic (MUA) to improve cosmesis or function and this can be either under a general anaesthetic (GA) or local anaesthetic (LA).

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

Aims and Objectives 1) Drive improvement in the quality of care for patients with nasal fractures 2) Improve the knowledge and confidence of ENT trainees when assessing and managing patients with nasal fractures 3) Reduce the number of patients needing manipulation under GA, instead performing the procedure under LA in our clinic

Methodology A baseline questionnaire was completed by the trainees which included 5 domains, each scored on a 10-point Likert scale (0= not confident at all, 10 = completely confident). The domains required them to subjectively assess their confidence in identifying anatomy relating to a nasal fracture, taking a focused history, examining a nasal fracture, assessing and recognizing complications and performing a manipulation of a nasal fracture under LA on their own. The same baseline questionnaire was then repeated after both of the interventions. 12 trainees completed all 3 questionnaires.

Plan-Do-Study-Act cycles: 1) Formal lecture 2) Objective structured clinical examination (OSCE) style video that included history taking, examination and an MUA performed under LA on a real patient

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

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

6 patients with nasal fractures have needed manipulation in our clinic. 5 were done under LA and 1 patient did not want it done under LA.

Conclusion Our project has positively impacted 3 groups: 1) The patients - Reduced GA risk, time in hospital and therefore COVID-19 risk 2) The ENT trainees - Improved confidence surrounding nasal fractures - Learnt a new procedure 3) The trust/department - More theatre slots available - Saved £2306.05 since January (GA £486.21 vs LA £21 per patient). Potential to save roughly £27,000/year (based on pre COVID-19 data as lockdown reduced the number of nasal fractures)

Future Work We are currently running a concurrent project aiming to improve the documentation surrounding history taking and examination of nasal fractures. We aim to implement a proforma.

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

References 1. Kim, S.H., Lee, S.H. and Cho, P.D., 2012. Analysis of 809 facial bone fractures in a pediatric and adolescent population. Archives of Plastic Surgery, 39(6), p.606.

Local Closed Loop Audit on COVID-19 Screening in Elective Gastrointestinal Surgeries Khaing T. Thu*, Fran Bassett* *Foundation Year 1 Doctor, Hull University Teaching Hospitals

Background

Aims

•

A systematic review and meta-analysis published in Patient Safety in Surgery reported a 20% post-operative mortality among patients with COVID-19 globally.[1]

•

To determine the proportion of the patients undergoing elective gastrointestinal surgeries are being swabbed within 72 hours prior to surgery

•

Intercollegiate General Surgery Guidance on COVID-19 (RCS England): “Patients undergoing elective surgeries should be isolated for 14 days, screened with questionnaire and tested by throat swab within 72 hours of surgery before undergoing surgery in a COVID-cold site”

•

To make changes to practice if not meeting the standards of care and to increase the proportion of the patients being swabbed within 72 hours of gastrointestinal surgeries to ≥ 80% by December 2021

•

Local guidelines: All elective surgical patients must have a COVID-19 PCR test within 72 hours before surgery

Method •

Patients who underwent elective gastrointestinal surgeries in the following periods were identified using the Operating Room Management Information System application (ORMIS): • 1st January 2021 to 31st January 2021 (Initial audit) • 1st April 2021 to 30th April 2021 (Re-audit)

•

Electronic patient records were subsequently accessed to record each patient’s age, sex, date and time of COVID-19 PCR test, date and time of admission and date and time of surgery (figure 1) on Excel Sheet. If the patient had more COVID-19 PCR tests between the admission and surgery, the last date and time of the COVID-19 test before surgery was further recorded. From the raw data, interval between COVID-19 swab and admission, COVID-19 swab and surgery and percentage of the patients who met the criteria of being swabbed less than 72 hours before the surgery were calculated.

Age

Sex

Date and Time of COVID-19 PCR test

Date of Time of COVID-19 Date and Time of PCR test (2) Admission

Date and Time of Surgery

Figure 1. Headings of the parameters recorded on the Excel Sheet

Results and Recommendations In the initial audit conducted in January, there were 14 elective surgeries in upper gastrointestinal (UGI) department and 13 elective surgeries in the colorectal department. The number of total elective surgeries in each specialty increased to 47 and 68 cases in UGI and colorectal departments respectively in May (Figure 2).

Initial Audit (January 2021)

Re-Audit (May 2021)

•

In January, the mean number of days between COVID-19 swab and admission was 3.1 days in UGI department and 3.2 days in colorectal department (Figure 3).

•

In May, the mean number of days between COVID-19 swab and admission was 3.11 days in UGI department and 2.87 days in colorectal department (Figure 3).

•

In addition, the mean number of days between COVID-19 swab and surgery was 3.6 days and 3.5 days for UGI and colorectal departments respectively (Figure 3).

•

In addition, the mean number of days between COVID-19 swab and surgery was 2.94 days and 3.37 days for UGI and colorectal departments respectively (Figure 3).

•

Unfortunately, only 57% of the patients were swabbed within the 72 hours in UGI department and even less percentage (38%) of patients were swabbed within 72 hours in the colorectal department (Figure 4).

•

Nonetheless, 89% of the patients were swabbed within the 72 hours in UGI department and 59% of patients were swabbed within 72 hours in the colorectal department (Figure 4).

Initial Action Plan

Further Action Plan

1.

Presentation at M&M meeting of Upper GI department to increase awareness of the guidelines among clinicians and senior nurses

1. Send an email to a senior matron of pre-assessment unit and the clinical lead of the colorectal department to increase awareness of the 72- hours guideline and make them aware of the results of the re-audit

2.

Ensure all staff at surgical pre-assessment are aware of 72-hours guideline

3.

Re-audit in April

2. Presentation at M&M meeting of Upper GI department to increase awareness of the guidelines among clinicians and senior nurses 3. Re-audit in August

4.00 3.50

100%

3.50 3.20

3.60 3.10 3.11

2.94

2.87

3.00

89%

90%

3.37

80% 70%

13

14

2.50

47

2.00

68

59%

57%

60% 50%

1.50

40%

1.00

30%

38%

20%

0.50

10%

Colorectal

UGI

Colorectal

January

UGI

0.00

Mean Days between swab and admission

May

Mean Days between swab and surgery

Mean Days between swab and admission

Colorectal

Total Elective Surgeries

UGI January

Figure 2. Pie Charts representing total elective surgeries in Colorectal and UGI departments in January and May.

Mean Days between swab and surgery

May

0%

Percentage of surgeries meeting Percentage of surgeries meeting the target of <72 hours the target of <72 hours Colorectal

UGI January

May

Figure 3. Bar chart representing the mean number of days between COVID-19 swab and admission, COVID-19 swab and surgery Figure 4. Bar chart representing the the percentage of surgeries which met the target set by the national and local guidelines in January and May.

Conclusion After the initial intervention, the percentage of patients who were swabbed within 72 hours increased by over 20% in each department (32% increase in UGI department and 21% increase in colorectal department) (Figure 4). Therefore, both departments of gastrointestinal surgeries are on target with achieving our aim of increasing the proportion of the patients being swabbed within 72 hours of gastrointestinal surgeries to ≥ 80% by December 2021.

Reference: 1. Abate SM, Mantefardo B, Basu B. Postoperative mortality among surgical patients with COVID-19: a systematic review and meta-analysis. Patient safety in surgery. 2020 Dec;14(1):1-4.

th 16

June 2021

Poster Competition Group P

Care of the surgical patient (2) First prize: Reducing the number of appointments for fibroepithelial polyps (FEPs) Presenter(s): Dara Murphy Oral and Maxillofacial Unit Ulster Hospital

Second Prize: Standardising Surgical Ward Round Documentation Presenter(s): Leila Ellis and Sophie Howlett Torbay and South Devon NHS Foundation Trust

Cutting down whilst cutting open: Prospective trial of low-cost surgical treatment in abscess management Dr Saniya Saiyed, Mr. Christopher Briggs, Mr. Bassem Amr

Background:

Results:

Cutaneous abscesses are very common presentations requiring surgical drainage in most cases. There is a wide variation across the United Kingdom in the surgical practice dealing with such common problem.

The aim of this study is to reduce theatre costs incurred in surgical drainage of acute skin and soft tissue abscess.

A consequential saving of £13,962 was achieved during the study period. Between October 2019 and October 2020, 322 patients with soft tissue abscesses underwent incision and drainage by general surgeons. A total cost of £55.26 per patient was calculated based on basic surgical items listed in (Figure 1). We have designed and implemented a new theatre protocol specifically for this procedure, resulting in a substantial reduction of the costs to £11.90 per patient (proposed items). The total savings did not include other savings caused by abscess drainage under local anaesthesia and does not calculate the savings that occurred due to shorter length of stay.

Methods: A detailed financial analysis of the costs involved in surgical drainage of cutaneous abscesses under general anaesthesia was performed.

A pilot study trialing a low-budget surgical kit was conducted. We also introduced a new abscess drainage pathway for patients who would require surgical drainage under general anaesthesia and initiated dedicated abscess drainage slots on theatre list twice a week.

Lastly, a prospective one-year trial was carried out using the new protocol and total savings were calculated.

Inclusion and exclusion criteria: Our inclusion criteria: • Patient sixteen years or older • Patient systematically well • Patient under general surgery Our exclusion criteria: • Patient under sixteen years old • Diabetic patient with unstable blood glucose level • Patient requiring intravenous antibiotics • Patient with complex peri-anal abscess/ fistula requiring expert opinion • Systematically unwell eg- septic, confused patient etc • Patient requiring significant opiate doses • Patient with groin abscess where false aneurysm needed to be excluded first before surgical intervention • Patient with breast abscess

Changes we made after the first cycle

Items

Current

Price

Proposed

Price

Savings per case

Surgical drapes

Basic pack

£10.44

LA pack

£5.50

£4.94

Surgical kit re- Perineal set £10.90 sterilisation

Abscess set

£6.20

£4.70

Gowns (per 2 persons)

Gowns

Apron

13p

£2.27

Gloves (per 2 persons)

Sterile £1.46 (Latex free)

Non-sterile

7p

£1.39

Microbiology culture and sensitivity

Swab every £30.06 patient

No swab unless indicated

Total cost

£2.40

£55.26

Figure 1 showing current and proposed costs of surgical abscess drainage

£30.06

£11.90

£43.36

Figure 1 showing current and proposed costs of surgical abscess drainage

Conclusion Considering the increasing financial burden on the NHS, we achieved significant savings of nearly 80% of the operative costs of surgical drainage of a cutaneous abscess.

This has successfully achieved by implementing simple modifications in the current surgical pathways without compromising patients' safety.

Reducing the number of appointments for fibroepithelial polyps (FEPs) Dara Murphy, OMFS DCT2 Nicola McCurley John Hanratty

BACKGROUND

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

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

• The OMFS department currently has long waiting lists.

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

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

WHO BENEFITS?

OUTCOME MEASURES

AIM STATEMENT

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

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

No further time off work Covid concerns Access concerns re car parking/ childcare

PROCESS MEASURES

Appointment can be used by someone else Waiting list reduction Cost of outpatient appointment

Number of appointments of each patient

IMPROVEMENT METHODOLOGY Driver diagram:

PDSA cycles:

OUTCOMES

RESULTS

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

RUN CHART Number of appointments given 6

2019

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

2020

5

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

4

3

NEXT STEPS

Median

• 2

Goal

•

Change implemented Jan 2020 1

Runs of 5 or more consecutive points

• 0 80

79

78

77

76

75

74

73

72

71

70

69

68

67

66

65

64

63

62

61

60

59

58

57

56

55

54

53

52

51

50

49

48

47

46

45

References:

44

43

42

41

40

39

38

37

36

35

34

33

32

31

30

29

28

27

26

25

24

23

22

21

20

19

18

17

16

15

14

13

12

11

10

9

8

7

6

5

4

3

2

1

Each patient seen

Reaudit process to ensure change is sustainable Consider spreading: can a results letter be implemented in other spoke hospitals?

Can we consider a similar approach for other pathologies?

1. GIRFT reports. Available from URL: http://gettingitrightfirsttime.co.uk/girft-reports/ Last accessed September 2020 2. Lees, T., Bogdashich, L. and Godden, D., 2021. Conserving resources in the diagnosis of intraoral fibroepithelial polyps. British Journal of Oral and Maxillofacial Surgery, 59(1), pp.e9-e12.

Improving management of patients admitted with chest trauma Dr J.Gregory, Dr M. Azher-Anwer, J. Batty, Mr R. Craig, Mr S.Deo

Background

Aims

Inappropriate management of patients suffering chest wall injuries can have a detrimental effect on prognosis. Optimising available treatment options is essential to reduce morbidity and mortality. This is particularly important in patients with severe injuries as they are at greater risk of developing complications including hospital acquired pneumonia (HAP) and sepsis. Battle et al. (2004) have quantified this using a scoring system. The British orthopaedic association audit standards for trauma have produced guidelines (BOAST-15) to optimise management of these patients.

An audit by James et al. (2019) had shown poor performance against the BOAST-15 guidelines at Great Western Hospital (GWH). This led to the development of a chest trauma protocol based on the Battle score (chest injury score) to inform analgesia choice.

This project aimed to evaluate adherence to the BOAST-15 guidelines for patients with chest wall injuries admitted to Great Western Hospital, namely: 1. Prescription of an agreed analgesia protocol, including patient-controlled analgesia (PCA) where indicated 2. Referrals made to the pain team 3. Chest physiotherapy and time to commencement

Additional standards included: a. Use of the chest trauma protocol b. Prescription of antibiotics for subsequent HAP

Chest Trauma Management Protocol Rib fractures confirmed on CT

Patient name:

Has a chest drain been inserted?

DOB: Hospital number:

If not, check indications for insertion of trauma chest drain (below):

Absolute indication:

Methods Adult patients admitted to GWH with rib or sternal fractures, or blunt chest wall injuries in a 10-week period (20/08/20 - 29/10/20) were included in this sample. Severe chest injuries were defined as those with a Battle score of 21 of higher.

Records were obtained using ICD-10 codes written on discharge summaries, as well as diagnoses included on the electronic Trauma Patient list. Results were then compared with those of the previous audit.

• Tension pneumothorax • Haemopneumothorax • Large traumatic pneumothorax (>2cm at level of hilum) • Patient ventilated with pneumothorax

31

125%

Trauma co-ordinator informed Silver trauma referral Chest physio referral Please label chest wall with rib #’s:

Relative indication: • Small traumatic pneumothorax • Small haemothorax • Flail segment

Calculate chest injury score (CIS): Consideration referral to cardiothoracics:

Chest Injury Score:

Results

MDT involvement:

• • • •

Age: +1 for every 10 years over 10 Rib fractures: +3 for each fracture Chronic lung disease: +5 Anti-coagulant / anti-platelet use: +4 (exclude aspirin 75mg) • O2 sats: +2 for every 5% decrease under 95% breathing room air

≥3 #s or flail chest + one of: • Chest wall deformity / mechanical compromise • Ventilator / NIV dependent • Uncontrolled pain • Worsening hypoxia • Persistent air leak

Analgesia (based on CIS):

Patients met the inclusion criteria

Increase in PCA use for severe chest injuries

• 0 – 10: Prescribe fracture protocol on EPMA*. Consider discharge if pain well controlled.

• 11 – 20: Prescribe fracture protocol on EPMA. PCA. Admit.

• >21: Oral analgesia. PCA. Intensive care referral for consideration of thoracic epidural. Consider referral to thoracic surgeons if suitable for fixation.

• If unable to cough / deep breathe / worsening hypoxia escalate analgesia • *Use hip fracture protocol if over 65 Chest Trauma Protocol, June 2019- James M, Crosswell S, Fowler T, Deo S Reference: BOAST 15, BTS, NICE guidelines

53%

2/3

40%

73%

Increase in pain team

Patients were prescribed

Prescribed

referrals

codeine

Underwent chest physio within 24

antibiotics for HAP

Conclusions Performance against BOAST-15 guidelines leaves room for improvement at GWH. Of particular interest was the correlation of inappropriate pain management using codeine, which causes respiratory depression and supresses cough, with a significant number of patients requiring antibiotics for HAP. This audit inspired a further QIP to improve analgesia prescription for patients with chest trauma, by adding a PCA guide to the chest trauma proforma and implementing a new hospital-wide electronic prescribing ‘Chest Trauma protocol’ to reduce the use of codeine. Additionally, communication with the Acute Medicine and Care of the Elderly teams at the hospital has been improved, as both specialties frequently manage patients with chest wall injuries.

THE A-E OF EXCELLENCE – measurements of excellence in junior staff members in the Neurosurgery department at NBT 91%

1st Audit 2nd Audit

Antibiotic

93%

96%

90%

81%

96%

66%

49%

stewardship How appropriate is our antibiotic prescribing?

48/72h REVIEW COMPLETE

GUIDELINES/MICRO APPROVAL

DURATION DOCUMENTED

INDICATION DOCUMENTED

Basic post-op (imaging) How promptly are we getting post-op imaging?

1st Audit

2nd Audit

2 months (assessment 1) - 2 written compliment and 57 cards and edible gifts

Compliments Are our patients and their families satisfied with our performance?

Drug chart

1 month (assessment 2) - 0 written compliment and 12 cards, 10 other gifts and 25 edible gifts

-

Data displayed reports figures from clexane prescribing only

-

Cases where only TEDs/flowtrons were requested on the opera:on note

(VTE prescribing) How well are we reviewing our post-op VTE?

-

How quickly are we getting our medically fit patients back to their local hospitals?

1st audit 2nd audit

51%

21% 11%

Pa:ents discharged prior to their intended review date

On :me

Exiting (repatriation)

67%

Exclusion criteria:

1 day late

7%

7%

2 days late

9% 11%

12% 4%

>2 days late Never reviewed

Time between being MFFD and repeat form being sent

79%

1st audit 2nd audit 47%

35% 18% Same Day

14%

Next day

7% > 1 day

Elizabeth Tan ST1 Laura Brennan F2 Paul Karamura F2 Thomas Hodgson F2 William Harper F2

β-HCG Testing in Females of Childbearing Age Referred to General Surgery: Re-Audit Mr G. Finch | Ms S. Riaz | Mr A. Mahmoud | Dr V. Sivabavanandan | Dr A. Al-Sakban | Dr M.Zayed

Objectives

Background

• To assess the percentage of urine β-HCG testing.

A radiological never-event instigated this audit to improve the safety of pregnant acute

• To put in place prompts to ensure 100% testing rates.

surgical patients aged 15-55.

• To identify the current process of testing.

Method Prospective data of β-HCG test results was reviewed from the Emergency

Conclusion

Department and Same Day Emergency Care admission documents.

Target group: General

Surgery referred females aged 15-55.

We found worsening outcomes following implementation.

Intervention •

•

1st Cycle: JUN - JUL 2020 2nd Cycle: JAN- FEB 2021

We placed posters in A&E and SDEC to prompt staff to carry out β-HCG testing.

We advised senior staff to prompt their teams on the need to carry out β-HCG testing.

Results In the first cycle, out of the 54 patients that were identified, 55% had a β-HCG test carried out. st

1 Cycle

We identified the following contributing factors to our outcomes: 1. Regular change over of staff (Nurses and Doctors).

2. Multiple posters in clinical areas, making them blend into the background.

3. No designated field for β-HCG documentation on the proformas.

Future Recommendations

In the second cycle, out of the 68 patients that were identified, 31% had a β-HCG test carried out. nd

2 Cycle

To improve outcomes in the future, we recommend the following:

1.Education of junior doctors and all members of staff during induction, about the significance of β-HCG. 2.Prompt to posters at induction.

3.Create a documentation field on the proformas.

4. Create unavoidable electronic prompts when requesting scans.

STANDARDISING SURGICAL WARD ROUND DOCUMENTATION Dr L Ellis, Dr S Howlett and Mr J Parvin BACKGROUND

Accurate, comprehensive, legible and contemporaneous recording of doctor-patient interactions is essential for patient safety, quality of care and medico-legal purposes. The often fast-paced nature of surgical ward rounds can compromise communication and promote inaccurate or incomplete documentation.

AIMS

INTERVENTIONS

METHODOLOGY

DATA COLLECTION

To standardise documentation of daily surgical ward rounds.

To ease ward round preparation for junior doctors.

To aide handover between all healthcare professionals.

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

CYCLE 1

CYCLE 2

79%

proforma use

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

• Useful for afternoon ‘safer’ meetings.

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

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

6/7 junior doctors prefer to use continuation sheets for this additional documentation as fear elsewhere may be overlooked by the MDT. • 2/7 juniors doctors reported the proforma was often not integrated in chronological order in the notes.

• Added discharge criteria text box.

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

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

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

Figure 1. Current version of surgical ward round proforma.

Retrospective analysis of 117 surgical ward round entries.

Questionnaires and verbal feedback from junior doctors and multidisciplinary team members (MDT).

4

5

5

Introduction of a daily surgical ward round proforma.

Education sessions for F1 doctors and physician associates.

Informal advertising to the wider surgical team.

19

7

CYCLE 3

74%

proforma use

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

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

2

20

• Inconsistent availability of the proforma.

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

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

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

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

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

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

1

92%

proforma use

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

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

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

24

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

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

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

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

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

QUANTITATIVE RESULTS

QUALITATIVE RESULTS

Baseline (N=40) Cycle 1 (N=19) Cycle 2 (N=20) Cycle 3 (N=24) NEWS 77.5% (31) 94.7% (18) 75% (15) 100% (24) Blood Results 65% (26) 78.9% (15) 95% (19) 100% (24) Fluid Balance 2.5% (1) 0% (0) 0% (0) 41.7% (10) Exam 42.5% (17) 31.6% (6) 55% (11) 75% (18) Dietary Plan 22.5% (9) 31.6% (6) 5% (1) 33.3% (8) Antibiotics Plan 27.5% (11) 21.1% (4) 35% (7) 33.3% (8) Bleep 90% (36) 100% (19) 70% (14) 100% (24) 1st VTE Assessment 95% (38) 89.5% (17) 70% (14) 83.3% (20) 2nd VTE Assessment 75% (30) 73.7% (14) 50% (10) 45.8% (11) TEP Form 17.5% (7) 15.8% (3) 40% (8) 12.5% (3) Table 1. To assess compliance with best practice standards, these 10 measurable parameters were selected for monitoring based on local Trust guidance and wider literature review. Green = ≥10% improvement from baseline, Orange = ≥10% decline from baseline.

CONCLUSION

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

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

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

Corresponding Author: Leila.Ellis1@nhs.net

Impact of using intraoperative 2D vs 3D tomosynthesis breast specimen imaging on re-excision rates of breastconserving surgery Hse Juinn Lim1, Sharat Chopra2, Anna Powell-Chandler3 Breast Centre, University Hospital Llandough, Cardiff, UK

Positive margins where radial margin <1mm from invasive or <2mm from DCIS

Introduction • Breast-conserving surgery with adjuvant radiation has been shown to be at least equivalent, or even superior, to mastectomy for treating early-stage breast cancer.

• Procedure is considered successful when margins are negative while ensuring cosmesis.

Positive margin (%)

• Positive margins will require further surgery (re-excision or margins or mastectomy), which increases anxiety and costs for patient, along with worsening cosmetic outcomes and delay in starting adjuvant treatment.

• Re-excision rates for breast conserving surgery for cancer has improved since the introduction of intraoperative specimen imaging.

Objectives

0

• Retrospective review of 124 breast-conserving surgery performed in a single tertiary centre by five surgeons for breast cancer from December 2019 to February 2020 and from December 2020 to February 2021.

• Localisation with either iodine-125 titanium radioactive seed (RS) or wire localization (WL) was done for non-palpable lesions.

• We compared patient demographics, tissues characteristics, histology, and re-excision rates between 2D and 3D using a two-tailed Student’s t test and the chi-squared test for continuous and categorical variables, respectively.

Results

10

15

20

25

20 15 10 5 0 Re-excision

Mastectomy 2D group

Further disease present

3D group

Patients who had positive margins 90 80 70 60 50 40 30 20 10 0

Pa lp W ab ire le /s (% kin ) m ar k( Sc % re ) en NA in g en (% do ) cr in Pr e e(% op ) siz e (m m Po ) Sp st ec -o p im siz en e w ei gh t( In g) va siv e on In ly sit u/ m ixe d

Methods

5

Outcome of positive margins

• We studied 2D versus 3D breast specimen imaging for wide local excisions and compared it to the post-operative histopathology report and need for further surgery.

• We reviewed decision-making of surgeons intra-operatively based on the specimen images on whether there is a need for additional margin excision during initial operation.

3D group 2D group

Positive margin

Negative margin

Conclusion • Same number of breast conserving surgery cases.

• Less screening cases, possibly due to COVID pandemic.

• Size and type of tumours are similar.

• Massive increase in use of endocrine neoadjuvant endocrine therapy.

• Number of positive margins are higher in symptomatic patients, patients not on neoadjuvant therapy, larger tumours, patients with DCIS, and patients with smaller specimens intraoperatively.

• Although one re-excision surgery is still outstanding, the reexcision rate in the 3D group is relatively lower than the 2D group. Increased use of neoadjuvant endocrine therapy may also play a role in reducing re-excision rates.

• Overall, there is a reduction in additional operations required in 3D group, thus causing less stress and anxiety to patients.

DR MOHAMMED SNOBER, DR LUKON M AH, M SS ANNA FA RCLOUGH

BACKGROUND

AIMS

General Medical Co ncil GMC standards for patients ndergoing in ima e e amina i n ere p blished in et compliance to and doc mentation of these standards emain Patients presenting ith eme genc general s rgical conditions freq entl req ire intimate e aminations incl ding e amina i n e ec m PR breast and genitalia e aminations and sho ld ha e appropriate d c men a i n of c n en and cha e ne e ence for these e aminations

The aim of this a dit as to identif hether in ima e e amina i n ere being appropriatel doc mented and to f rther impro e o r d c men a i n c m liance ith the GMC anda d looking partic larl at PR e amina i n gical being performed d ring admi i n

METHODS

RESULTS

P ec i e a di of the notes of all emergenc general s rgical patients ndergoing PR e am d ring a ne m n h e i d in J ne looking at doc mentation of

Thi and en nine e aminations ere carried o t in the first and second c cles respecti el C n en d c men a i n increased from and cha e ne d c men a i n from fig re Doc mentation of cha e ne name and le increased from and respecti el to fig re

EXAM NAT ON CONSENT

CHAPERONE PRESENCE

CHAPERONE NAME/ROLE

T o c cles of e a di took place o er the same time period follo ing in e en i n d ring No ember and Jan ar

2ND C CLE P

a a

3 D C CLE

PR

a

a

b

a

a a+ a

a

a

a a

a

In o r third c cle hi f e aminations ere recorded C n en and cha e ne e ence as doc mented in of e aminations fig re and cha e ne name and le in and respecti el fig re indicating a ained im emen In o r third c cle fi e e aminations ere performed sing n n icke clerking pro formas i h o r ne consent section In these e aminations c n en and cha e ne e ence as doc mented in and respecti el fig re and cha e ne name and le in fig re

+ a

.

CONCLUSION We demonstrated a ignifican im emen in compliance to GMC standards for e aminations thro gh the im lemen a i n of o r e amina i n icke E en in instances here the sticker as not sed e sa an inc ea e in d c men a i n demonstrating the im ac of staff ed ca i n and increased a a ene

F

1 (ab

): C

a

a

a

a

FUTURE DEVELOPMENTS We aim to contin e to im e rates of doc mentation for PR e amination and e and the se of the consent sticker We are c rrentl e anding the project to incl de all intimate e aminations We hope to inc a e o r sticker into other hospital doc mentation be ond s rgical clerking pro forma

F R

: (1)

a

2 (ab a

a

a

): C a ,G

a a M

a C

a (2013) G

a a

a

L

, GMC

Improving the consent process in plastic surgery M. Nyeko-Lacek1, S. Leong1, D. Dhillion1, S. Tarassoli1, P. Cripps1, Z. Jessop1,2, C. Sin-Hidge1, N. Wilson-Jones1.

1Welsh

Centre for Burns and Plastic Surgery, Morriston Hospital, Swansea, 2ReconRegen Research Group, Swansea University Medical School

Introduction Informed consent for any surgical intervention is essential in patient care and the patient-surgeon relationship. Despite clear guidance from the GMC and RCS England in optimising this, there remain multiple human and systemic factors hindering consent in all surgical departments across the UK. This includes a high workload and an absence of patient resources. Improving informed consent encourages patient compliance resulting in optimised post-operative outcomes, and reduced patient complaints and litigations.

Aim To evaluate departmental compliance with consent form completion as per GMC Decision making and consent (2020) and RCS England Consent: Supported Decision-Making (2018).

Method Audit cycle 1 - A retrospective review of all consent forms in burn surgery, elective skin cancer and plastics trauma completed within a six-month period was performed by three assessors.

Intervention - the results were presented at the departmental Morbidity and Mortality (M&M) meeting, a poster was created and a message was placed in the weekly rota email, reminding doctors to complete consent forms accurately.

Audit cycle 2 - the consent forms were re-audited using the same method.

Before intervention 100%100%

After intervention

100%100% 94% 95%

94% 93%

86% 86%

66% 56%

15% 5% Patient details Clinician job title

Clinician name legibility

Proposed procedure legibility

No Laterality Consent form abbreviations documented offered

Results 169 consent forms were analysed across Burns and Plastic Surgery (pre-intervention: 114 and postintervention: 55) . There was excellent compliance with patient (100%) and consenting clinician identifiers (100%) as well as indications and complications of the procedure. Initially only 5% of our patients were offered a physical copy of their consent form, which improved to 14.8% following the intervention. In some areas there was a perceived decrease, which may be incidental but demonstrates a need for ongoing reminders and more widely spread awareness.

Learning points The intervention was successful in producing an improvement in some areas of the consenting process, particularly reducing use of abbreviations and provision of physical copies of the consent form to patients.

Regular reminders of the consent process may be necessary due to trainee changeover. We have noted an improvement in patient and trainee confidence as a result of this project. Ongoing development of this project will involve creating written resources for patients to further enhance the consenting process.

References: General Medical Council (2020) Decision making and consent. Available at: https://www.gmc-uk.org/-/media/documents/gmc-guidancefor-doctors---decision-making-and-consent-english_pdf-84191055.pdf?la=en&hash=BE327A1C584627D12BC51F66E790443F0E0651DA (Accessed 5 May 2021).

Royal College of Surgeons of England (2018) Consent: Supported Decision-Making [PDF]. Available at: https://www.rcseng.ac.uk/standards-andresearch/standards-and-guidance/good-practice-guides/consent/ (Accessed 5 May 2021).

Save the date

BPSC National Poster Competition 2022 Open for poster entries now: https://bit.ly/2ZhcoUw Deadline

th 9

March 2022

Categories include Quality Improvement and Audit Independent, online conference, designed to share learning nationally Shortlisted entrants will be invited to present their th poster at our conference on 18 May 2022 and will receive a certificate – poster presented at a national conference

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