Poster Group N - QI in Progress- BPSC2023

Improving documentation of Treatment Escalation Plans on Stroke Recovery Unit - a Quality Improvement Project

Ishan Sen, Nicola Lewis, Aukse Vijeikyte

SCALE OF THE PROBLEM

BACKGROUND

Treatment Escalation Plans (TEPs) are personalised recommendation plans for individual patients that ensure improved concordance between patients’ wishes and medical care, especially at end of life Proper TEP documentation clears all ambiguity regarding ceiling of care which is especially helpful during out-of-hours medical calls Benefits of having a well-documented TEP include reduction in inappropriate ITU referrals and non-beneficial treatments, reduction in economic costs associated with non-beneficial interventions and reduction in complaints [1,2]

AIMS

To identify and improve the number of patients who had TEPs documented on EPR and those who had them within 4 days of admission to the ward

It was observed that suboptimal documentation of TEPs on Electronic Patient Records (EPR) on the Stroke Recovery Unit made decisions difficult for medical emergency teams who were unlikely to have been involved in the care of these patients previously

METHODS

A baseline data collection was performed to identify the magnitude of the problem and the barriers to optimal TEP documentation on the ward The data collected were analysed and appropriate interventions were put in place (PDSA1) The second PDSA cycle was conducted a month later to determine progress and suitable adjustments were made via new interventions to improve results In order to accommodate the changeover of trainees and to measure sustainability, the third PDSA cycle was conducted after another 3 months

Although still suboptimal, significant improvement in TEP documentation was observed in this period following appropriate interventions

The relatively slow turnover of patients on the Stroke Recovery Unit made the project challenging, meaning an effective reflection of practices could only be achieved through appropriately spaced PDSA cycles

Further cycles have been planned to continue the progress and monitor the sustainability of the project Extensions of this project into other wards have been proposed to monitor current practice and improve overall performance of departments across the Trust

Quality Improvement Project: Are We Explaining, Documenting and Providing Further Information of Side Effects, When Patients are commenced on carbimazole?

Dr Rahul Khanna 1

Aim:

This QIP aims to improve patient care and safety in primary care, with the primary outcome ensuring patients are informed of the side effects to be aware of, when commencing carbimazole and whether these are documented.

1. Introduction

Carbimazole is a commonly prescribed drug in primary care, used to treat hyperthyroidism. It has adverse side effects, the most serious being, risk of bone marrow suppression and agranulocytosis. These adverse effects manifest in several ways. The BNF states the serious side effects are sore throat, mouth ulcers, fever/malaise, bruising and non-specific illness. These side effects prompt an urgent full blood count to be undertaken. Due to the risk of agranulocytosis, it is imperative to inform the patient to seek medical attention as soon as they develop any of the serious side effects.

2. Methods

• This was a retrospective project of patients who were commenced on carbimazole between 31/01/2021 and 31/01/2023

Step 1

Step 2

• The next cycle will take place in 1 years time following the interventions described below..

• A sample of 16 patients were identified via a search on SystmOne. Once inclusion criteria was applied, 10 patients were included in the study.

Step 3

Step 4

Step 5

• Results were based on several questions. These were: was side effect of sore throat documented? were other serious side effects from the BNF documented (fever,malaise, mouth ulcer, bruising/rash, non-specific illness)? was further information given to the patient following commencing medication? Was medication commenced by the GP?, Do women of childbearing age have effective contraception? Was the Ardens template used?

• Data collection and analysis was completed using SystmOne and Microsoft Excel. The results were then presented at a local meeting and disseminated through the GP practice via email and on the practice website.

• Interventions, such as using templates available on SystmOne, were recommended to improve patient safety. A second cycle will take place in one year following the recommendations.

3. Results

• Identify problem – Are patients being informed about side effects of carbimazole? Is it being documented?

• Identify all patients who had been commenced on carbimazole between 31/01/21-31/01/23.

Act Plan Do Study

Data was analysed using SystmOne and Microsoft Excel. Results were then presented to the GP practice partners, colleagues and practice managers. Results disseminated via email and practice website. Interventions to be implanted following the presentation.

4. Interventions

• From the identified patients,N=10, collect data answering the questions mentioned in the methodology.

Ø Presentation of results at the practice to partners, GPs and practice managers. This was so changes can be implemented at every level.

Ø Use of AccurX (text messaging service) for each new patient starting on carbimazole – link to the NHS website to be aware of side effects and when to worry.

Ø Utilise Ardens template – It has a list of the serious side effects that need to be mentioned and reminder around contraception!

Ø Document accurately - all side effects may have been mentioned but not documented

Ø Add in a reminder so it appears on patient home screen – if prescribed carbimazole then warning signs/symptoms on home screen

Ø Leaflets on the walls in consultation rooms to remember the side effects

5. Lessons Learnt

Ø Documentation of serious side effects to be aware of needs to be improved. In turn this will improve patient care as patients will know when to attend primary care for urgent investigations.

Ø Resources already available to the practice should be utilised more effectively.

Ø Presenting to the GP partners, colleagues and managers, encouraged constructive discussions surrounding how to improve practice which ultimately will improve patient safety. It also prompted further recommendations on how to implement changes effectively.

Ø The limitations of the study were that the sample size was small. This means having to wait one year, to ensure a sufficient enough sample size to observe changes following intervention.

Ø In the future, another cycle will be carried out using methodology and plan, do, study, act template to ensure implemented changes have been effective.

6. References

Ø Sore throat was mentioned in majority (90%) of patients

Ø Documentation of other main serious side effects were not present in most cases

Ø Only 50% of women of childbearing age had effective contraception

Ø In GP only 25% of patients were sent an AccurX

Ø Ardens template was not used at all

NHS England (2022) Plan, do, study, act (PDSA) cycles and the model for improvement, Plan, Do, Study, Act (PDSA) cycles and the model for improvement. Available at: https://www.england.nhs.uk/wp-content/uploads/2022/01/qsir-pdsacycles-model-for-improvement.pdf (Accessed: April 14, 2023).

Authors: Merson S1, Harvey S2

Standardizing the safe use of continuous cardiac monitoring across the University Hospitals Plymouth (UHP) cardiology department

Introduction

Continuous cardiac monitoring (CCM) is invaluable for safe observation of patients at risk of dysrhythmias. It can however have adverse effects by restricting mobilisation and increasing the risk of falls and delirium in susceptible patients. Its use should therefore be rationalised and regularly reviewed to ensure ongoing monitoring remains indicated.

There are currently no local guidelines to guide the use or review of CCM. This represents a barrier to regular, judicious review of patients’ ongoing need for monitoring. It may delay removal and unnecessarily prolong monitoring, hence increasing the associated risks.

Methods

Aims

To standardize practice and decision-making relating to CCM across the trust

To reduce periods of unnecessary monitoring

To develop resources promoting safe and consistent use of CCM including trust guidelines and teaching resources

Interventions:

1. Guideline for use of continuous cardiac monitoring in Cardiology patients at UHP.- Create, ratify and upload on Intranet and publicise on wards with cardiac monitors.

2. Arrange regular formal teaching system for nurses (for new nurses and refresher sessions for longstanding nurses) and juniors on the wards with cardiac monitors.

3. Add an information document regarding cardiac monitoring for junior doctors to the cardiology survival guide website.

Review results identified:

• Strengths: BHRS criteria for CCM -Majority of patients met BHRS criteria for CCM ( 67%).

Nurses formal training -Majority have had formal training in ECG rhythm interpretation (82%).

• Areas for improvement: Documentation -Only 45% had documentation indicating to start their monitoring. Only 45% had a documented review of their cardiac rhythm monitoring whist in situ.

Nurses confidence -Only 64% feel they have suitable knowledge of ECG rhythm interpretation.

PDSA cycle 1

October 2022

1. Assessed departmental practice against nationally recognized standards from the British Heart Rhythm Society (BHRS)

2. Audited the consistency of documentation when starting CCM.

3. Surveyed ward nurses to establish their confidence and prior training in responding to arrhythmia alarms and highlight any training needs.

Is the following happening?

Monitored patients:

1. Meet BHRS 2020 criteria for ongoing telemetry use.

2. Have documentation in their notes indicating to start their monitoring.

3. Have a documented review of their cardiac rhythm monitoring whist in situ.

Nurses:

1. Feel they have suitable knowledge of ECG rhythm interpretation.

2. Have had formal training in ECG rhythm interpretation.

Conclusion

Clear, readily accessible trust guidelines are required.

Documented decision-making regarding monitoring is needed to avoid unnecessary initiation, with prompting to ensure regular review of the need for continued monitoring.

Nurses need ongoing training in ECG rhythm interpretation in order maintain competence and confidence.

TRAUMA AND ORIENTATION: IMPROVING ORTHOPAEDIC INDUCTION FOR POSTGRADUATE DOCTORS

Dr Hamzah Niaz & Dr Harry Kinsey, North Bristol NHS Trust

Background

Commencing a new clinical rotation in a new hospital trust with unfamiliar systems can provide great challenges around the functioning of a department, wellbeing of staff and subsequent impact on patient safety.

At North Bristol NHS Trust, it was evident that the induction for new doctors left newcomers with a great deal of uncertainty surrounding the expectations of a rotation in trauma and orthopaedics (T+O)

Aims

The aims of this project include:

(i) to improve T+O induction for postgraduate doctors, (ii) to improve confidence and preparedness in carrying out the roles of a T+O doctor.

Patient Safety

The knowledge, experience, confidence, and thus wellbeing of postgraduate doctors directly impacts and shapes patient safety.

Methods

Postgraduate doctors within the T+O department (eg. F1s, F2s, CSTs) were surveyed at North Bristol NHS Trust multiple times throughout the academic year 2022/23, corresponded with the cohort changeovers. Data analysis included comparing quantitative and qualitative data, exploring attitudes towards: IT systems, contacting clinical teams, overall confidence and more.

Key Findings

necessity

Interventions

The following were included: new peer handover, digital cribsheet/guide to T+O, 1-month induction schedule, dedicated IT training & dedicated teaching from AHPs

Measured Outcomes

Rating and confidence scales of 1-5 were used in the survey for various domains, with comparison made of numerical means in addition to qualitative comments

Conclusions & Further Improvements

• Peer-to-peer handover, in combination with PDF guide and thorough explanation of daily duties, was deemed significantly helpful in improving confidence at the beginning of the rotation for postgraduate doctors

• New induction programme and sessions deemed valuable and generally improved confidence and satisfaction in a large number of domains

• Additional benefits for: patient safety, doctor wellbeing, department efficiency

• Consider improvement around: logistics of induction sessions accounting for absences, focus on F1 roles in fracture clinic and impacts of poor staffing on department

PDSA (1)

PDSA (2)

Table 1. Summary of % change in comparison of means for confidence ratings between cohorts 1 and 2

Improving VTE risk assessment and discharge summary performance in the Oxford Eye Hospital

Dr Tomasz Szeligowski

RESULTS

Timely and accurate completion of discharge summaries and VTE risk assessments are two of many essential components for ensuring patient safety both in the hospital and in the community. Research has consistently found that introduction of mandatory VTE risk assessment leads to a significant reduction in VTE-related readmissions to hospital and mortality 1 Likewise, delays in sending discharge summaries have been linked to adverse patient outcomes as a result of their impact on communication between hospitals and GPs 2 Despite that, both VTE risk assessments and discharge summaries are often missed or seen as purely administrative tasks leading to poor compliance with trust standards. In this project, I explored the reasons behind low compliance with these outcomes in the Oxford Eye Hospital, and designed ways to address them.

METHODS

1. Defining the sample - all patients flagged by the trust’s data collection system (ORBIT) as missing VTE risk assessments (68 patients) and discharge summaries (332 patients) between October 2021-March 2022

2. Analysis of EPR and Medisoft records to compare them with criteria used by ORBIT

3. Liaising with the nursing team, consultants, and IT team to introduce solutions.

4. Reassessing performance using the same methods after a period of implementation.

STANDARDS

Trust standards

1. 95% of VTE risk assessments done within 6h of admission

2. 98% of discharge summaries sent within 24h of discharge

Criteria for inclusion in ORBIT data as needing VTE risk assessment / discharge summary

1. Inpatient encounter type

2. Admission lasting beyond midnight

3. Correct completion of relevant form on EPR

KEY ISSUES IDENTIFIED

1. No emergency day case encounter type available, hence all emergency admissions are marked as inpatient even if the patient left the hospital on the same day

2. Some patients left the hospital before midnight but were only discharged on EPR in the morning, and hence were flagged as having stayed overnight

3. Discharge summaries and VTE risk assessments not done for short overnight admissions

4. Discharge summaries filled incorrectly, hence flagged as not done

INTERVENTIONS

1. Addition of clearing the bed boards before midnight to nursing team tasks

2. VTE risk assessment posters displayed in clinical areas

3. Step-by-step guide to correct discharge summary form completion on EPR

4. Introduction of emergency day case encounter type

PROGRESS

1. Overall improvement in compliance with trust targets (Table 1)

2. Improvement seen particularly in patients with delayed discharge on EPR

3. We are still awaiting introduction of emergency day case encounter type and will continue monitoring improvement in each issue identified

Discharge summaries

as not done inpatient encounter label for a day case incorrect discharge date combined reasons overnight admission, no discharge summary overnight admmission, incorrectly completed discharge summary overnight admission, discharge summary sent >24h

Table 1. Overall compliance with trust standards for VTE risk assessment and discharge summary timeliness

Figure 1. Posters displayed in clinical areas reminding staff of the need to fill in VTE risk assessment forms

Quality improvement project: End of life care in ICU Dr E Worley, Dr M Flory, Dr M Gibbins, A Chillingworth, N Ward & M Dyson

Introduction & Aim

Outcomes from ICU are continuing to improve. Despite this 15-20% of ICU admissions die during their hospital stay1. Therefore end-of-life care remains an important part of ICU. In sometimes very difficult, emotional circumstances, a collaborative MDT approach is gold standard, including early involvement of Palliative care1. End-of-life care should be an individualised approach; tailoring care to the patient and the illness2.

The continual turnover of staff in the ICU department and the need for individualised end-of-life plans presents challenges. Our aim was to improve the MDT communication with regards to end-of-life-care and increase involvement of the Palliative care team, leading to improved end-of-life care for ICU patients.

Problem analysis

Initial MDT questionnaire highlighted that communication and Palliative Care involvement were the keys areas to improve

“There is a lot of apprehension amongst some of the junior staff when it is time to WLST

Change ideas

• Education slides for ICU nurses on Palliative care/EOLC

• Creating Withdrawing Life -sustaining treatment (WLST) checklist for physicians

Despite WLST being a very individualised process, there are always ways we can improve communication between staff and specialties. It was clear that getting the stakeholders invested early was key to getting the checklist used promptly.

Our idea of organising a daily Palliative Care board round was unsuccessful. A lot of this was due to funds and staffing of the Palliative care team. This made it even more important to educate and prompt the ICU staff to seek expert Palliative care help when needed. Due to the constant flow of new staff, it was clear we had to continue advertising the WLST checklist and education slides for ongoing use.

Next Steps

• Continued advertising of the Education slides and WLST checklist

• Our change ideas will be a ‘topic of the month’ in ICU

• ‘Tea and Trolley’ teaching rounds with certificates for the nursing staff5

• Teaching days with the Palliative care team

• Link with NBT ICU department

• Re-questionnaire to show improvement of EOL care in ICU

References

1. https://www.ficm.ac.uk/sites/ficm/files/documents/2021-10/ficm-critical-condition_0.pdf [accessced 05/04/2023]

2. https://www.nice.org.uk/guidance/qs144/chapter/quality-statement-2-individualised-care [accessed 05/04/2023]

3. https://qilothian.scot.nhs.uk/pc-resource-pdsa [accessed 11/04/2023]

4. https://entrepreneurhandbook.co.uk/15-startup-ideas-that-can-change-your-life/ [accessed 11/04/2023]

5. Corbett L, Davies A, McDonald M, Kelly F, Jordan L (2020). ‘Bath Tea Trolley’ Training; Part 1. Royal College of Anaesthetists Bulletin; 119; 28-30 [accessed 11/04/2023]

6. https://www.rcoa.ac.uk/sites/default/files/documents/202204/TTT2%20What%20tea%20trolley%20training%20is%20and%20how%20it%20works%20word%2010th%20March%20202 2_0.pdf [ accessed 11/04/2023]

7. https://www.theglennursinghome.co.uk/end-of-life-care/ [accessed 11/04/23]

A safer emergency department: the patient handover

Background

• Patients are at risk at ESHT due to current junior doctor handover practices: a consequence of many competing human factors.

• There have been multiple instances where key information has been lost during the transfer of information & patients have subsequently been at risk of harm.

• The importance of good handovers is well referenced in current literature:

o At the RCEM Annual Scientific Conference 2015 patient handover was identified as a ‘critical safety and quality problem’ [1].

o The GMC recognises the importance of safe handover in ‘Good Medical Practice’ [2].

• ESHT doesn’t have any standardised handover guidelines. However, a recent switch from paper-based to electronic documentation does provide an opportunity to evaluate and improve handover practices.

Scale of the problem

• Qualitative data was collected using a Likert-scaled questionnaire to survey junior doctor attitudes towards patient handover practice [Figure 1].

Data found:

o 8% of junior doctors thought handovers were safe.

o 8% disagreed patients were directly at risk of harm.

o 62% felt uncomfortable by handovers.

• Patient notes were also reviewed retrospectively over a one-week period. This allowed us to see if handovers were documented, and what information was documented. This found:

o 17% handovers are not documented.

o 39% patients handed over do not have a documented plan.

o 61% patients handed over do not have a senior review.

• Finally, it is known time in department correlates to worse patient outcomes [3]. Thus, we wanted to see if patients handed over were spending longer in the department. Retrospective data over a one-week period showed handed over patients spend longer in the department than those who are not as demonstrated in Table 1.

Methods

• We produced a driver diagram to explore influences on junior doctor handover practices [Figure 2].

• We found our primary drivers included standardisation, senior input, time, documentation and fatigue.

• A PDSA cycle was created [Figure 3] to try and improve junior doctor handover practices.

ACT

• The study data was very interesting: junior doctor perception of handovers were better, however handover documentation, senior reviews and time in department all worsened.

• It is unclear why this is. This has been discussed in reflections and future directions.

STUDY

• Three weeks following implementation, we redistributed our Likert-scaled questionnaire. We found:

o 43% thought handovers were safe (vs. 8% pre-PDSA cycle).

o 43% disagreed patients were at risk of harm (vs. 8%).

o 43% felt uncomfortable by handovers (vs. 62%).

• Again, we retrospectively reviewed patient notes over a one-week period to evaluate handover documentation three weeks following implementation. We found:

o 40% of handovers were not documented (vs. 17%).

o 60% of patients handed over do not have a documented plan (vs. 39%).

o 68% of patients handed over do not have a senior review (vs. 61%).

• Finally, one-week retrospective data on time in department was collected three weeks following implementation. Compared to data collected pre-PDSA cycle, we found handed-over patients were spending longer in the department [Table 2].

Reflections and future directions

• It is unclear why handover documentation worsened following our QIP. Possibilities include:

PLAN

• For our first PDSA cycle, we wanted to focus on drivers we felt were easier to change. Thus, we considered how to improve documentation, standardisation & senior input.

• All handovers should be documented at ESHT. However, following discussions with the consultant body it was decided that all handovers must also be discussed with a senior (defined as an SpR or above) – this recognises the risk to patients.

• We needed a standardised proforma to reflect this.

DO

• We created a standardized handover proforma that all junior doctors had to use when handing over a patient within the department [Figure 4].

• This was shared within WhatsApp groups and via email, and proformas were put on all departmental computers to provide visual prompts.

o Perhaps the proforma was ambiguous and junior doctors got confused as to what was expected of them – although you’d expect this to be reflected on the questionnaire (and it wasn’t!).

o Was the week analysed especially busy or did it have worse rota gaps? We did deliberately avoid a strike week/week following a strike.

o Did we not actively engage the junior doctors enough? We did create awareness via WhatsApp and email, and put proformas on departmental computers, but arguably could have done more - e.g., attend departmental teaching or put-up posters in break rooms/toilets.

• Based on this, ideas for future PDSA cycles include:

o A pre-populated handover proforma on Nervecentre - this is being discussed with the IT department currently. This was not possib le with the first PDSA cycle as it requires significant time & planning.

o Changing shift times to ensure there is time for handover documentation – this is being discussed with the consultant body/administrative team currently.

o Having a departmental boardround in the afternoon to ensure plans are up to date & provide an opportunity for senior discussi

Aim: to improve handover practices between junior doctors and therefore improve patient safety

Figure 4. Example handover proforma distributed within the department

on.

Figure 2. Driver diagram

Table 1. Average time per patient spent in the department

Table 2. Average time in department pre-intervention and post-intervention for handed over patients

Figure 3. PDSA cycle.

Table 3. Attitudes of junior doctors on handovers using pre-intervention and postintervention using Likert-scaled questionnaire.

Improving local National Emergency Laparotomy Audit Documentation and Case Ascertainment

National emergency laparotomy Audit (NELA) is part of the National Clinical audit and patient outcomes programme (NCAPOP).

NELA was commissioned following evidence of high incidence of death and wide variation in provision of care and mortality in an emergency laparotomy.

NELA aims to enable the improvement of the quality of care for patients undergoing emergency laparotomy, through the provision of high quality comparative data from all providers of emergency laparotomy.

• Retrospective analysis of NELA inclusion cases to check compliance with NELA

During emergency laparotomy and Audit meeting discussion, it was noticed that a wide variety of patients who were high risk (NELA >5%) had no NELA mortality risk score. Therefore, no pre-operative ITU involvement.

METHODOLOGY

• Implementation of a NELA inclusion poster

• Updating WHO checklist for emergency laparotomy patients STUDY

1. To improve percentage NELA case ascertainment and mortality score documentation in notes, consent forms and NELA database

2. Improve percentage of preoperative ITU review to 100%, therefore benefit patient care.

• Disseminate results in Audit meeting and NELA meetings involving all stake holders

• 6 weeks Prospective analysis and data collection of Included NELA cases with each PDSA cycle

• Following intervention only 3 patients had been missed from the database, compared to 11 from the previous cycle

• Only 2 patients who were high risk using the NELA mortality index did not have ITU review prior to emergency laparotomy

• Important to involve all stake holders. Addition of NELA to WHO checklist made biggest improvement

Future Plans

• Implementing a NELA checklist prior to theatres, involving the multi-disciplinary team in the next cycle

Dr Daniel Thomas, Mr Pete Cripps, Dr Parinita Swarnkar, Dr Thomas Hardman, Dr Sisyena Gunaravi, Dr Kenneth Ngai

Failing falling patients: Ward Trauma Pathways in Secondary Care

Problem:

• Slips, trips and falls [Ward Trauma] are a major cause of patient harm in secondary care. Management pathways are poor.

• Initiating a ‘Ward Trauma Call’ (WTC) improves patient safety and outcomes.

(Ongoing) Aims:

Trust data [10/21 –01/22] revealed only 44% of qualifying ward trauma resulted in an appropriate WTC.

1) Exploring and addressing factors contributing to inappropriate WTC’s

2) Increasing the frequency of appropriate WTC’s being made

3) Reducing incidents of ‘under-triaged’ ward trauma.

Project Methodology / PDSA Cycles : Appropriate (correct) vs inappropriate (under/ over-triaged) WTC rates were quantified using incident reports and WTC data over quarterly periods. Contributing factors were surmised from a qualitative staff survey.

Cycle 1 [02/21–04/22]

We focussed on identifying modifiable causative factors and initiating our empirical change idea: an educational poster.

The staff survey and poster were disseminated broadly within our Trust, staff responses were used to inform developing change ideas which

We reviewed, refined and increased the reach of our core change ideas resulting from the staff survey, implementing:

1. Active educational interventions (simulation, induction training, teaching)

2. Passive educational interventions (posters, guidelines, peer-to-peer edification)

Cycle 2 [05/22–07/22]

Results:

Of surveyed staff (n=35) barriers to initiating WTC’s included:

• Uncertainty over whether it was indicated (57%)

• Confusion about the process itself (51%)

• Fear of inappropriateness (46%)

Eligible ward trauma remained at an average of 21.5 incidents/ month: throughout cycle one and two, call rates/ month increased from 11 to 16. Appropriate WTC’s increased by 11.2%. Under-triaged incidents of ward trauma (compromising patient safety, morbidity, and mortality) reduced from 55.7% to 44.4% at the end of cycle two.

Lessons Learnt: This PDSA approach led to stepwise improvements in managing ward trauma on our wards. Most importantly, under-triaged ward trauma was reproducibly reduced (to the benefit of inpatient safety). Our change ideas hold great potential for yielding cumulative results over time.

Project completed at Yeovil District Hospital

Author/ Co-Author: Dr Ellen Grose-Hodge; Dr Mario Munoz Jimenez QIP Team: Dr Gregory Wolosz; Dr WenHan Sia; Dr Katie Tsang; Dr Gustavo Gomez

Better outcomes for Ward Trauma at YDH

Call 2222 - state WARD TRAUMA - state LOCATION

With thanks to our amazing colleagues.