BPSC2022 Poster Group C - Full QI Project - Improving Care Pathways

18th May 2022 Poster Competition Group C Full QI Project Improving Care Pathways

For Acute Neurological conditions “ Dina Hanna1, Jaspreet Kaur1, Nikki Davey2 1St

BACKGROUND:

Finding out the investigations to order for common neurological conditions and doing them right is a challenge.

George’s University NHS Foundation Trust, 2QIClearn

DIAGNOSTICS:

We RACE and CHASE around for tests & tubes for blood and spinal fluid when investigating children for acute neurological diseases.

Time is wasted, mistakes are made and children can be harmed.

AIM & MEASUREMENT DEFINITION

CHANGE IDEAS: Acute Neurology investigation cards

Us CSF e Gre Glu y to cos p tu e - be 7d rop s

Key for sam ple s

PDSA cycles

• Plan

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RUN CHART: Baseline measure

Sampling after Change ideas

| qiclearn.com | londonpaediatrics.co.uk | @LondonPaeds | @qiclearn

Acknowledgements: Jane Runnacles

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IM PROVING DELAYS IN UPLOADING INTRAOPERATIVE IM AGES DURING TRAUM A SURGERY Dr. Kajal Joshi, Mr. Alistair Scott Parker (Supervisor) Trauma & Orthopaedics North Devon District Hospital, Barnstaple

BACKGROUND:

FINDINGS: Cycle 1: Oct ober 2021

Cycle 2: Jan u ar y 2022

no. of surgeries requiring II: 31

no. of surgeries requiring II: 32

Not uploaded on time: 12

Intra-operative images are an essential part of trauma surgeries, as they demonstrate

Not uploaded: 4

the nature of the surgery, help in identifying intra-operative complications, and also form an important medico-legal record of the patient's fracture and surgery.

Reducing delays in uploading intra-operative imaging invariably helps the team make

Uploaded on time: 19

Uploaded on time: 28

appropriate decisions on weight-bearing status, and streamlines discharge processes, without the need for unnecessary further check X-rays.

AIM : - To identify if there was a delay in uploading intra-operative images - To quantify this delay by thorough data collection - Liaise with radiographers team to combat any shortcomings or issues that they might face - Create a system in which images were uploaded and available to view during the trauma meeting the next day by the next data collection cycle.

M ETHODOLOGY

:

DO: Collect records of all patients undergoing trauma surgery during a 2-week period.

Review radiology software system next morning to check if intra-operative images have been uploaded on time before trauma meeting

PLAN :

STUDY:

Find out if there are delays in uploading intra-operative images through data collection

Make a note of the number of intra-operative images that did not get uploaded on time.

Create a system in which intra-operative images are uploaded by the next day trauma meeting.

Follow through over the next few days to check after how many days the images were uploaded .

ACT: Liaise with the radiographers team to find out the issues they face while uploading images.

Discuss with the Radiographer Supervisor to come up with long term solutions for fixing the delays.

LEARNING POINTS: The importance of recording and uploading intra-operative images cannot be stressed enough.

It is an important medico-legal record that leads to significant delays in patient care, if not handled correctly.

IM PLEM ENTATION OF CHANGE: The results of cycle one were discussed with the radiography team.

The issues raised by them were: - PACS Port in trauma theatre was not working despite flagging it several times to IT services.

- Only one Wi-Fi enabled machine available, which was too bulky to operate.

Following the discussion, new Wi-Fi enabled machines were installed in theatres, which allowed images to be uploaded by the simple click of a button, instead of plugging it into a PACS port .

Working together and seeking opinions from other teams, namely, the radiographer team, and radiation supervisor, along with IT services shed light on the issues that they have faced, thereby leading to more efficient long-term solutions.

The most important aspect of any QIP is maintaining the improvement that we have seen, hence, continuous monitoring via repeated cycles is a must . kajal.joshi1@nhs.net scott.parker2@nhs.net

References: https://www.gov.uk/government/publications/medical-radiation-patient-doses/patient-dose-information-guidance? https://bmjopenquality.bmj.com/content/4/1/u208243.w3274

?

Facilitating patient referrals by junior doctors and physician associates to the appropriate respiratory subspecialties A.ODEKUNLE1, C.IOSIFIDIS1, N.ODELL1, S.CHOI1, J.HOLME1 1Manchester

University NHS Foundation Trust INTRODUCTION

One of the major duties of junior doctors and physicians associates (PAs) is referring patients to the necessary specialties and pathways. Doing this inappropriately or incorrectly may adversely affect patient safety, satisfaction and outcome of treatment.

A report by the General Medical Council found that patients who were not satisfied with their referral experience were those that arrived at an appointment to see a doctor who was not expecting them or was unfamiliar with their case. In some cases, the referrals were lost entirely.1

AIMS a. To facilitate referrals by junior doctors and physicians associates to the appropriate respiratory subspecialties. b. To produce an easily accessible guide for referrals to the various respiratory subspecialties.

Subspecialty Allergy Clinic Virtual ward Pleural Team Lung cancer Cystic Fibrosis Sleep Services Long Term Vent Unit Lung Function Severe Asthma Gen Resp Followup Asthma Followup Rapid Hub CRT Followup RACU Long Term Oxygen Long Covid Clinic PE Clinic

1st cycle(%) 7.1 80 43.3 53.3 3.3 20 20 43.3 23.3 63.3 33.3 56.7 50 36.7 26.7 46.1 61.5

2nd cycle(%) 37.5 87.5 75 87.5 50 62.5 62.5 75 37.5 100 50 100 87.5 62.5 75 75 87.5

3rd cycle(%) 75 87.5 50 75 50 37.5 62.5 50 87.5 87.5 87.5 100 62.5 100 50 87.5 87.5

Fig.1.1 Percentage of responders who agreed that they are confident referring to the listed specialties in the 1st, 2nd and 3rd cycles

METHODS Sample population: junior doctors and physicians associates Data collection: online self-administered questionnaire

RESULTS The third cycle of data collection showed that there was only one subspecialty (out of 17) that the majority of participants did not know how to refer to.

This was a significant improvement from 12 and 4 subspecialties in the first and second cycles, respectively.

With all our standards of measurement, there was a positive impact of our interventions with each cycle. The standards measured were: I am confident referring patients to all of the above respiratory subspecialties (A) I find it easy to refer to all of the above respiratory subspecialties (B) Information available regarding referrals to the above respiratory subspecialties are up-to-date (C) and easily accessible (D) There is a simplified guide on referrals to the subspecialties (E)

Fig 1.2 Percentage of participants who agrees and/or strongly agrees with the statements of our standards measured

DISCUSSION The following interventions were made after the first cycle: Production of a simplified guide explaining how to refer to various respiratory subspecialties.

The guide was uploaded on to the Intranet, Induction mobile app, put on the Junior Doctors Briefings by the Chief Registrar and disseminated by emails to doctors and PAs.

CONCLUSION This QIP has demonstrated a substantial beneficial impact as 75% of doctors and PAs that responded now feel confident in referring patients to the various respiratory subspecialties and 75% also agreed that a simplified, up-todate and easily accessible guide to referrals is available.

REFERENCES 1 October 2019

-

CONTACT INFORMATION

Corresponding author: ayomikun.odekunle@gmail.com

Same Day Emergency Care Glangwili Hospital Understanding the Problem Same day emergency care have been successful in preventing avoidable hospital admissions in urgent care centres across the United Kingdom.

However the utilisation and scope for SDEC in Glangwili General Hospital has not been fully optimised with only 5% of emergency attendances managed through this pathway whilst the national ambition is around 30%.

Measures: How will we know a change is an improvement?

The following measurements were agreed with historic baseline data pulled for the 10 weeks prior to the project commencing

Scoping: Why do we have a low numbers of patients managed through AEC? (findings from PDSA 2)

The Theory of Constraints, data represented in the Pareto chart and Cause and Effect (fishbone) diagrams were used with the project team and wider stakeholders to understand the problem and identify the potential change ideas represented in the driver below.

Reduce hospitaldiagram admissions IA Project Driver Diagram Wave60 Marilize du Preez Aim

Primary Drivers

Secondary drivers

Potential change ideas Develop and introduce ambulatory care pathways for top 5 conditions

Ambulatory Care pathways Introduce GP/consultant connect

Triage processes Admission Avoidance

Improve emergency care flow through ambulatory care pathways by 20% by March 2020

MDT Communication

Suitable Ambulatory Care Area System flow

Goals: -Improve admissions to ambulatory care

Skilled AEC MDT workforce

Discharge process

- Reduce number of patients with LOS>24 hours in ambulatory care

Standardisation

Move steps in the process closer together

Extended AEC unit MDT working hours

Find and remove bottlenecks

Introduce clinical criteria for discharge in AEC unit

Develop operational definitions

Change the layout, door and chairs, remove beds Increase public messaging about ambulatory care

Give people access to information Use pull systems

Human factors

Reactive Community services

- Improve % of patients discharged home from ambulatory care

Change concepts

Accessible equipment, diagnostics and testing Red2Green

Deliver training to staff about ambulatory care pathways Develop a co-produced SOP for ambulatory care Use a patient story to demonstrate improved patient experience Make commodes/ frames available for issue 24/7

Reduce controls on the system

Reduce choice of features

Listen to customers

Conduct training

Smooth workflow

Change access entrance for ambulatory care to MIU reception

Improving SDEC flow will address key components of the 6 Domains of Quality in Healthcare: Timely – patients will be assessed, treated and discharged on the day of presentation Efficient & Effective – increasing flow through SDEC will reduce admission >24hours, releasing bed capacity and improving waiting times Safety – reducing admissions >24 hours will minimise the potential for hospital acquired infections and deconditioning Patient Centred – SDEC considers the individual needs and preferences of patients as well as the wishes of their families and carers

Changes: What changes can we make that will result in and improvement?

The project tested multiple change ideas identified by the project team and wider stakeholders in brainstorming meetings, process mapping and fishbone diagrams.

PDSA 1: Change the door of the unit to stop patients in beds being put in the unit. Adopt – learning: Stopped beds going into the unit but did not increase the number of patients going through the unit or aid identification of patients suitable for SDEC. Next steps to include: Testing a triage tool (AMB Score).

PDSA 14 Ramp 1: Multiple PDSA’s within 1 week. Rapid learning with Adopt, Adapt or Abandon approach.

Learning: Ring fencing SDEC is key to enable full utilisation, G admissions alone are not enough, needs pull from the emergency department and need to explore WAST pathways.

Involving others The project team: Senior Sister ED, Staff Nurse CDU, Advanced Nurse Practitioner, Consultant Acute Physician, Physiotherapist, Occupational Therapist, Improvement and Transformation Lead and Quality Improvement and Service Transformation Practitioners.

A Stakeholder analysis exercise and fishbone diagram was used to identify other individuals and groups that would be key to the success of the project.

Engagement consisted of: Regular meetings with the wider MDT/informatics/analysts GP cluster meetings QI collaborative team meetings SDEC/CDU meetings with clinicians and managers Staff survey and feedback Co-producing patient posters and leaflets

Reflection and the next steps Lessons Learned: • Ring fencing SDEC is key • Triage tool for SDEC (AMB Score) accurate in predicting same day care

The SDEC project is a co-design between partners- testing ideas and developing a model for SDEC together as equals.

Aim: What are we trying to accomplish?

To improve the number of patients managed through SDEC by 20% by March 2020

Future Improvement Projects: Health Board wide SDEC project informed by the learning from the GGH project

Achieving NICE transition-related standards of care for young people with long-term conditions A quality improvement project S Barrow, O Wilkey, North Middlesex Hospital

Diagnostics Fishbone Diagram

Background Moving from paediatric to adult services is a difficult time for young people with complex health needs. Evidence suggests that effective transition between services can improve longterm outcomes. There has recently been a drive to refine and improve the transition process through the NHS Long Term Plan.

Change Ideas

Aim

Regular transition workshops and progress meetings Implementation of the Ready, Steady, Go, paperwork Time-bound action points for each sub-specialty External talks from a transition improvement manager Joint transition clinics between paediatric and adult services for certain sub-specialities Application for funding for a new epilepsy transition specialist

This quality improvement project aimed to better achieve the NICE Quality standards for transition for 6 sub-specialties in one paediatric department, across a nine-month period as part of the transition paediatric improvement plan.

Measurement An initial gap analysis was undertaken using 11 NICE quality transition-focused standards of care to demonstrate current performance of services for transition for 6 sub-specialties: allergy, asthma, diabetes, epilepsy, HIV, and sickle.

PDSA Cycles 1.1

1.2

Results Run Chart

Run chart showing % of NICE transition quality standards met following implementation of change ideas for 6 paediatric sub-specialties.

2.1

Discussion Initial baseline measurement in April 2021, showed: 36% of standards were unmet, 18% of standards were partially met & 45% of standards were met across the 6 sub-specialties.

Following implementation of change ideas, met standards increased to 58%.

Specialties such as asthma & epilepsy showed significant improvement in partially meeting or meeting standards.

3.1

4.1

Reflections & Learning This QI project has enabled one paediatric department to better achieve NICE transition standards of care for young people with long-term conditions.

Further work is needed to ensure young people & their families are actively involved in the design, delivery, & evaluation of services for transition (standards 1&2).

Continuous work is required to ensure that transition-related standards of care are met for young people when moving to adult healthcare services.

Doctors Improving Referrals (DIRE) QIP Benedict RH Turner, EV Thorley, A Doshi Ealing Hospital, London Northwest Healthcare Trust, UB1 3HW

Background

Within the NHS, making referrals presents significant challenges for junior doctors. Delays to referrals have been documented to result in patient harm and junior doctors informally cite unpleasant experiences with making referrals. The aim of this study was to collect data on junior doctors’ experiences of making referrals, identify any barriers to referring, and the consequences of difficulties in referrals to both doctors and patients.

N=284 Figure 1 – Junior doctors’ confidence when making a referral

Methods

Junior doctors at the trust were surveyed on the referrals process, using a link on the ”Mind The Bleep” website (https://mindthebleep.com/improvingreferrals).

Results

N=284 Figure 2 – Barriers to making referrals

284 junior doctors, with representation from every deanery in the UK and all training grades, responded to the survey.

A referrals “cheat sheet” and a comprehensive list of trust inpatient and outpatient referrals information were generated to address issues raised by junior doctors

Interventions

Conclusions

Figure 3 – Consequences of referrals

Figure 4,5 – Excerpts from referrals cheat sheet

N=284

Figure 6 – Excerpts from referrals document

The interventions have been demonstrated has highly efficacious, are now recommended by the Imperial College NHS Trust simulation team. The interventions have been documented to improve patient care both locally and nationally. The cheat sheet has been downloaded X number of times

Bringing posterior strokes to the fore – Improving stroke recognition 1West

Ambreen Ali Sheikh1, Athanasius Ishak1, Sanja Zrelec1

Middlesex University Hospital, Kew Stroke Department, Twickenham Road, Isleworth, Middlesex TW7 6AF

INTRODUCTION: Between September 2018 - March 2020 there were 11 missed cases of stroke among inpatients (6 posterior circulation strokes, 5 anterior circulation strokes). 5/11 cases were deemed serious incidents and were all FAST screen negative (Table 1). A stroke survivor meeting was held, and some patients voiced concerns that screening methods did not correspond to their presenting symptoms.

Presenting complaint Ataxia + Drowsy

Misdiagnosed as DKA

Incoordination Vertigo + Hearing loss Bilateral leg weakness Vertigo

Nil acute Nil acute Nil acute Gastroenteritis

Table 1 – Serious incidents of missed posterior circulation strokes. All were FAST negative.

AIMS: 1.

To improve detection of inpatient strokes so that none are missed by introducing a new stroke screening tool.

2.

To introduce a stroke investigation and management protocol to improve timely stroke diagnosis and streamline transfer to HASU.

DO

üWe created posters and placed these in key areas of the hospital & on the intranet. üThe screening tool and guideline were presented at a grand round and at junior doctor teaching üVirtual and in-person training for doctors, nurses and HCAs

PLAN

ü Promote use of the BEFAST stroke screening tool ü Create a clinical guideline, as per the pan-London stroke pathway, about managing and excluding common stroke mimics and referring to HASU.

INPATIENT HYPER-ACUTE STROKE RECOGNITION MANGEMENT REFERRAL PATHWAY

- Check GCS, vital signs, capillary blood sugar while awaiting medical team (Arrange a MET call if deteriorating GCS).

BEFAST Suspected new onset stroke

STUDY (April-September 2021)

Balance (new onset of imbalance/disequilibrium) Eye- Visual loss, Diplopia Face Arm/Leg unilateral weakness/numbness Speech Time to call Medical Team URGENT

Qualitative data: ü “Easy to remember” ü “ The pathway is clear & straightforward”

-Perform focussed neurological examination: GCS, Cranial Nerves, NIHSS score (See below features of LVO) -Check functional status using Modified Rankin Score written below) If severely disabled or bed bound / on end of life care NOT for transfer to CXH. Discuss with local stroke team -HASU does not admit patients requiring NIV or ITU support. Such cases should be discussed with CXH ITU registrar at bleep 7487 07795 601650

B/ Glucose <4 mmol/litre TREAT HYPOGLYCEMIA - Nil by mouth - IV 100 ml 20% Glucose - If IV access not available IM Glucagon and re-try IV access - Repeat capillary Blood in 15 minutes

Quantitative data: üAverage delay to diagnosis: 7 days vs 36 hours ü4 inpatient strokes - none missed. üNo NIHSS score on first review

B/Glucose >4 mmol/l

B/Glucose <4 mmol/l

New onset seizures noticed with new neurological symptoms -Secure A, B, C first - Check B/Glucose and treat as per Hypoglycemia guidelines -IV benzodiazepine Lorazepam or Midazolam IV as per local availability

- Reassess shortly after -Repeat neurological examination suggestive of acute stroke, blue light transfer to HASU CT head locally -Transfer with IV 10% Glucose to avoid relapse of hypoglycemia

Number of missed inpatient strokes

- Continue treating hypoglycemia as before - Perform neurological examination to look for resolution or progression of signs/symptoms B/sugar <2.8mmol/l is a contraindication for thrombolysis

giving IV Benzodiazepine - Arrange non-contrast CT Head once stable /IEP images to CXH Seizure is a relative contraindication for thrombolysis

If suspicion is still high of acute stroke, blue light to CXH for HASU and follow stroke algorithm

ICH Follow ICH pathway If intubated, GCS <9 or posterior fossa bleed discuss with neurosurgery first at bleep 8075

0 - No symptoms 1 - No significant disability. Able to carry out all usual activities, despite some symptoms.

2 - Slight disability. Able to look after own affairs without assistance, but unable to carry out n all previous activities.

3 - Moderate disability. Requires some help, but able to walk unassisted.

4 - Moderately severe disability. Unable to attend to own bodily needs without assistance, and unable to walk unassisted.

5 - Severe disability. Requires constant nursing care, bed ridden Updated August 2020

ACT

- Blue light transfer to HASU once commonest stroke mimics Hypoglycemia and seizures ruled out and patient has persistent neurological features suggestive of stroke. head /CTA in such cases - Courtesy call to CXH Stroke SPR at 0383 for medical handover (specify definite onset of symptoms)

CT HEAD NORMAL

Modified Rankin Score (m-RS)

12 10 8 6 4 2 0 Pre intervention

-

Large Vessel Occlusion (LVO) Features of Anterior circulation stroke: Unilateral motor/sensory signs and symptoms, Speech disturbance, Gaze deviation, Visual/sensory neglect Features of Posterior circulation stroke: Cranial nerves involvement, diplopia, crossed signs, bilateral leg weakness

Refer to full Trust guidance for further information (intranet)

üTraining is ongoing üPlans for simulation training and inclusion as part of induction training üEvaluation of impact of protocol

Post intervention

CONCLUSIONS: Ø BEFAST is a useful stroke screening tool Ø Educational interventions can improve stroke screening Ø Detailed neurological examination is essential Ø Patient involvement is important for quality improvement

Classification: Internal

Getting Our Teeth Stuck into the Problem

Opportunistic Public Health Messaging within the A+E Department Rosanne Verow1, Nicola Davey2, Richa Ajitsaria2 1 Barts NHS Trust, 2 QIC learn

BACKGROUND 1 in 4 five-year-old’s have tooth decay with on average 3 or 4 teeth affected

DIAGNOSTICS

Tooth decay is the main reason for children to be added to the Child Protection Register for neglect in Tower Hamlet.

Our Doctors look in throats every day but often don’t spot or address this problem

CHANGE IDEAS AIM & MEASURE Aim: By the 1st March 2022 8 out of 10 children aged between 117 years old triaged to the paediatric A+E will have been asked the last time they visited a dentist.

Measure: Number of patients with a documented assessment in their notes of when they last visited a dentist.

PDSAs

10 PDSAs were performed during a one-month period. Six of the main interventions are shown below

Information Gathering Action: Share information with the staff

Brainstorm with dentist

(see PDSA cycle 2)

Information Sharing

Action: Have leaflets printed on how to find a NHS dentist (see PDSA 3)

Speak with parents and children

1B

1A

Confirmed we should be directing patients to their dentist for tailored advice

Face to Face discussions around the problem, the aim and change ideas

Didn’t know children (1-2yrs) needed to see a dentist. Having problems accessing a NHS dentist

Resources Action: Print the leaflet in other languages

Face to Face discussions in the A+E department

Teaching

Information provided to parents

Action: provide widespread departmental teaching to improve knowledge

NHS leaflets in English printed on how to book a free NHS dentist appointment

Share the problem and the project with the staff

Led to multiple informal teachings. People motivated by health implications more then safeguarding

Email to all paediatric A+E staff updating them about the project.

2

Incentives

Teach staff public health messaging around oral health

Action: Add a check box to the triage proforma to include ask about dentist

Motivate staff with fun competitive game

4

3 The forms offered clear advice and the staff felt empowered to give guidance

Action: Focus on excess admissions and health implications when discussing need

They were receptive to the learning and clearly had limited knowledge in this area

Microteaching with 4 SHOs from different training backgrounds

5

Triage nurses could get up to 12 patients per shift. Nurses reached higher numbers than doctors

Created a tooth fairy leaderboard for staff who ask the most patients

REFLECTIONS & LEARNING Was the patient asked when they last saw a dentist?

RUN CHART

Impact of PDSAs

This was a multi disciplinary project that involved patients and carers. It shows that A+E is an ideal place for health promotion with staff interacting with large numbers of children every day.

Yes

2

3

4

5 Median Line

1A 1B

No 1 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 65 67 69 Patient

Whilst we have not yet show a statistical change what we noticed was that staff started talking about oral health and based on self reported numbers and the amount of leaflets given out, a clear change has occurred within the department.

The next stage is to explore further with parents to see if increased awareness results in increased attendances to see a dentist.

RING THAT IRIBELL

A NOVEL DEVICE TO DECREASE INTERRUPTIONS IN CONTINUOUS IRRIGATION IN ENDOUROLOGICAL PROCEDURES Charan Muraleedharan, Ryan Beazley, Christina Fontaine, Nicholas Burns-Cox Musgrove Park Hospital

Introduction

The operating theatre is a busy environment requiring simultaneous monitoring of multiple aspects in endourological procedures. Large bags of irrigating fluid need regular monitoring and change by circulating theatre staff.

Situational awareness, communication and teamwork are of the utmost importance in ensuring continuous irrigation with minimal interruption; imperative for surgeon visibility and therefore patient safety. The IriBell is a novel device developed to alert the need to change irrigating fluid and thereby reduce interruptions in irrigation.

Figure: Iribell device attached to drip stand and Neptune

Method

A five-point graded pre-IriBell questionnaire was used to assess the need for the device.

Iribell was implemented, and questionnaire repeated.

Results

A total of 12 circulating theatre staff members completed the questionnaire. IriBell led to an 80% decrease in the number of stressful situations within the operating room, due to irrigation fluid. 92% (11) of staff found it easier to focus on different tasks during theatre with the use of the IriBell. 83% (10) felt irrigating fluid never ran out during cases, versus 0.1% pre-IriBell. It was also commented that the IriBell was of particular use during times of low staffing, or when there was a lack of experienced theatre staff. Furthermore, the majority of theatre staff found the IriBell easy to set up 92% (11) and easy to clean 92% (11).

Conclusion IriBell has been well received universally resulting in a positive impact on staff stress, situational awareness and reduced interruptions in continuous irrigation - improving patient safety. We aim to roll out IriBell Trustwide.

How to get an Orthopaedic Surgeon to complete a TEP The TEP Check Method A quality improvement project

By Rohit Chandegra, Jordan Bethel, Bhupal Shrestha, Mark Sykes and Simon Macmull Introduction Treatment Escalation Plans (TEP) are part of the admissions proforma for surgical patients. It is important these are completed. Especially with the increasingly co-morbid admissions where deteriorations can occur.

Secondly, given the COVID-19 pandemic and the risk of cross infection during hospital admissions it is important that these are done. During our nights shifts we identified a number of deteriorating patients where their TEP s had not been completed. We demonstrate our quality improvement project with regards to completion of TEPs. Method We carried out a prospective cross sectional audit of all patients admitted under the orthopaedic team. We looked at whether the TEPs were completed on admission, on the post-take ward round or at all. We carried out 3 completed PDSA cycles, each over a 1 week period with multiple interventions in between.

We should be 100% compliant with completing TEPs it is an admission requirement

PDSA Cycle 1 Results

Results - only 23% of TEPs were completed Poor compliance Interventions Posters placed in the oncall areas for orthopaedic surgery text messages to all the orthopaedics junior and registrar team

PDSA Cycle 2 Results

Results - an 11% improvement of TEPs that were completed at admission minimal improvement Interventions Posters placed in the oncall areas for orthopaedic surgery text messages to all the orthopaedic junior and registrar team TEP Check - Escalation to the consultant body for monitoring on Post-take ward rounds

PDSA Cycle 3 Results

Results a 90% compliance of TEPs that were completed at admission -Significant improvement Interventions Posters placed in the oncall areas for orthopaedic surgery text messages to all the orthopaedics junior and registrar team TEP Check - Escalation to the consultant body for monitoring on Post-take ward rounds

Conclusion This QIP proved to be very relevant to the COVID pandemic. There were patients within the Orthopaedic team who had caught COVID-19 during their admission. It is important that we are 100% compliant with filling in TEPs. The 90% compliance in the second cycle was very important. We feel that the consultant TEP Check on the post-take ward round proved to be the factor driving the completion of TEPs. Future Recommendations More PDSA Cycles No TEP, No admission to the Ward interventions would ensure 100% compliance Further training for junior trainees and middles grades who have trained abroad and any doctors who may not be familiar with TEPs Contact details Rohit.chandegra@nhs.net/ Bhupal.Shrestha@nhs.net