Dr Roberto Galea, Dr Martha Anne Apap Bologna, Dr Catherine Dimech, Dr Anton Grech
The COVID-19pandemicnecessitated social measures to curb the spread ofdisease This disrupteddailyactivities & social interaction with attendant impact on mental well being,as well as mental health service provision The study aims to investigate first contactcommunity psychiatry referrals tothe Mtarfamental health clinic before & after the onsetof COVID -19 & the adequacyof the service response.
236new case appointments were identified: 92beforeand144after the onsetof COVID-19 with an increasein mean numberofnew referrals from 7.4 to 21.2 per month after thefirst wave (Figure 1).
Mean waiting time decreased from 21.6 to a steady 7.4 weeks after The proportionofnew case referrals was stable acrossallagegroups except for men and women aged60-80 (Figure 2).
The majority of referrals are Maltese nationals,bothbeforeandafter the onsetof COVID-19
Primarily referrals are made by community General Practitioners from Mater DeiHospital & the Accident & Emergency departmentarealso encountered
Trends in reason for referral showed a change priorandduring COVID pandemic: anxietydropped from 38% to 32%, depression increased 33% to 40% while psychosisdoubled (2% to 4%)& alcohol misuse halved (2% to 1%) after the onsetof COVID-19 (Figure 3).
This studycomprises three phases – one year before the onset,during the first wave & the six months after the COVID-19pandemiconset
The increased referral of retirement agepatients may reflect healthanxiety & adverse impact of isolationin this agegroup Referrals in otherage groups remained stable
A 286% increasein newappointments was met by a fivefold increasein clinic frequency, successfully decreasing waiting timefrom 21.6 to 7.4 weeks Constituting in a 66% drop in waiting time despite a threefold increasein workload
The combined effectsof the Psychiatric Outpatients Department closing downandprobable increased demand for psychiatric communityservices has resulted in a median fivefold increasein demand This was met byan increasein clinic frequency and staff allocation - increasing the monthly numberofnew case appointments from 7 to 20
Analysis ofpresenting complaint revealed a relative increasein depression and a drop in anxiety The latter deficit may beobscuredby imposed proportionalanalysisand/or the changingcase mix after the onsetof COVID-19
Following necessaryapprovalsan index ofnew case appointments was constructed fromthe register at MtarfaMHC from 11 March 2019 to 31 December 2020 & cross referenced with eMR The imposition of social distancingon12 March 2020 was used to separate the date into before & after the onsetof COVID-19
Following closure of the Psychiatric Outpatients Department at Mater DeiHospital, patients were redistributed to community mental health clinics simultaneously achievingbetter social distancing, limiting potential COVID-19 transmission & allowing for better communityservice provision COVID-19posed significantchallenges Major service restructuring through decentralisation increased the demandon community mental health clinics These challenges were met through staff redeployment & increasing clinic frequency - successfully meeting a threefold increasein new case appointments & decreasing waiting time by twothirds
This study focuses on the early stages of the COVID-19pandemic & itislikely that mental healthburden will continue to increase with time Further studies would be well-placed to assess longer-term effects
• Infantile haemangiomas (IH) are the most common vascular tumour of infancy1
• Propranolol is the first-line treatment for complex IH (Figure 1).
• The Dermatology department at Birmingham Children’s Hospital (BCH) recommend and follow the 2018 British Society for Paediatric Dermatology (BSPD) consensus guidelines on the treatment of IH with oral propranolol2
Oral propranolol for IH is initiated by multiple specialties at BCH and practice amongst these specialties varies
To establish the current practice for managing IH across the different specialties at BCH and to assess adherence to the BSPD guidelines
• An online survey was distributed to 19 consultants and registrars from multiple specialties at BCH
• The survey consisted of 14 questions based on the BSPD guidelines
• Data were collected anonymously
• The survey had an 89% response rate (Figure 2)
• Results showed inconsistent practice amongst specialties when initiating oral propranolol for IH
• A variety of different guidelines are being followed (Figure 3) and dosing regimens vary (Figure 4)
• Only 60% of responders perform a full cardiovascular examination prior to commencing propranolol (Figure 5) and only 23% of clinicians report feeling confident doing this (Figure 6)
• Results were discussed at each department’s audit meeting
• On discussion with clinicians from each specialty we discovered that several departments are still inappropriately admitting patients for propranolol initiation despite them being low risk
• This impacts on both patients and hospital services and delays commencement of therapy
No 53%
• Results of this audit confirm that there is a lack of consistency when initiating patients on oral propranolol for IH
• Not all departments use the BSPD guidelines when initiating patients on oral propranolol for IH
• Differing guidelines, dosing regimens and treatment pathways are currently being followed
Yes 23% Somewhat 24%
• This audit supports the need for a single BCH guideline to be used across departments. We are currently liaising with the teams to develop this
- During the COVID-19 pandemic general practices (GPs) have revolutionised the way in which they operate consultations, moving from the majority being face-to-face (FTF) to mainly remote consulting.
- Triage systems have been created in order to prioritise patient complaints and to allocate them to either a remote or limited FTF appointment. However, for some patients a remote consultation led to a secondary FTF appointment due to the nature of their problem. These occurrences, referred to as ‘double bookings’, lead to reduced efficiency and resource availability within GPs.
1. Identify the demographics of ‘double bookings’ that occurred within a one-week period.
2. Identify the types of complaints that led to these ‘double bookings’.
3. Provide recommendations to assist in the allocation of FTF appointment.
To significantly reduce the number of ‘double bookings’ that occur in GPs, leading to a more efficient and cost-effective service.
Figure 1 shows a large proportion (18%) of patients were under 10 years of age and an even larger majority (28%) over 71 years, suggesting that perhaps at each extreme of age there is more of a clinical requirement for a FTF consultation. This could be due to the fact that children have a lower threshold for physical examination, and many of the elderly population are living with chronic conditions.
Figure 2 shows that the large majority (64%) of FTF appointments were for physical examinations. This demonstrates that it is impractical for a GP to only offer remote consulting as there is still a definite clinical need for physical examinations to take place.
Figure 3 shows that out of the 7 patients (10%) requiring an intimate examination, the majority (4) were for per rectal (PR) examinations. 3 out of the 4 PR examinations were conducted on patients who had presented with ‘rectal bleeding’. Rectal bleeding is a common presentation within primary care and has a positive predictive value (PPV) of 8% for colorectal malignancy in those over 50.
Figure 4 breaks down investigations with the majority (5) needing to provide a urine sample. All of these patients presented with clinical symptoms indicative of a urinary tract infection (UTI). This suggests that these patients could have been identified prior to telephone allocation as needing a FTF or even as needing to provide a urine sample in advance of a telephone consultation thus reducing the number of ‘double bookings’.
- From the results, a lower threshold for the allocation of FTF appointments is being recommended for the following complaints:
- Any patient under the age of 16 or over 71
-Any patient, over the age of 50, presenting with ‘rectal bleeding’ as this may warrant a PR examination
- Any patient presenting with clinical signs suggestive of a UTI as they may require urine sampling
- Therefore, GPs should triage their patients and prioritise F2F appointments based on the presenting complaint and/or via the adoption of a selection criteria e.g. for any patient who may require a physical examination, intimate examination, investigation or child assessment as demonstrated in this investigation. Further studies are needed in order to provide a more evidence-based selection criteria.
Authors: J N Parekh1; S Vijayakumar1; M Mian1
1ENT Department; Sandwell and West Birmingham NHS Trust
Introduction:
Ear, Nose and Throat (ENT) Surgery is a speciality where a significant proportion of operations are performed as daycaseoperations. Patients therefore can attend and leave hospital on the same day. Getting it Right First Time (GIRFT) is a national standard andguidance to promote collaboration and a set standard to enable departments to achieve the best outcomes for patients. Nationally, the GIRFT review has identified significant degree of unwarranted variation which can cost up to a combined approximate cost of over £3 0 million.
Aim:
1) Review and inform local ENT department compliance with GIRFT standards following COVID-19 pandemic
2) Identify ways to improve standards to reduce Length of Stay (LOS) and streamline the day case pathway
3) Identify key operations that may not meet GIRFT standards and address them
Methods:
• Retrospective data collection from electronic patient notes and discharge summaries over a two month period identifying all patients who underwent an operation in the ENT department.
• Data was stratified by LOS, reasons for prolonged LOS, operation type and if it was adult or paediatric patient.
• This data was matched to GIRFT standards to identify if patients were having prolonged stays.
• A patient was classed as having a prolonged admission if their inpatient stay was >23 hours (unless previously indicated as planned and reasoning justified). Data was then tabulated in a table.
• Operations of interest included (adeno)tonsillectomy, polypectomy, manipulation of nasal bone fracture under anaesthesia, septoplasty amongst others.
• Key GIRFT standards included:
• Day case paediatric tonsillectomies is 80% (UK average is 55%)
• OSA operations should be done early to facilitate same discharge
• Septoplasty day case rates should be 78%
• Day case adult tonsillectomies is 81% (UK average is 70%)
• No clear guidance on thyroid surgery
Conclusions:
184 operations performed in first audit cycle. 178 included for analysis. 65 were paediatric and 113 were adult patients. Initial audit demonstrated excellence in meeting standards in 80% day case rates were achieved with 93% of adult tonsillectomies having a same day discharge. Paediatric tonsils showed the lowest with 69% with a target of 80%.
The key area to improve was within paediatric day case surgery as most cases for prolonged admissions were secondary to monitoring for obstructive sleep apnoea (OSA). Consultants were advised of current guidance and pre-operative planning of lists. Discussions took place with bookings team for theatre as well. GIRFT has direct recommendations for improving day case rates for OSA patients. These were implemented.
Reaudit Results
Following discussions and implementation of changes, a reaudit was performed 4 months following this. A shorter period was reviewed, with 62 patients included. 20 were paediatric, 113 were adult patients. The key target was to identify if day case rates improved in paediatrics. Adult day case rates remained stable. Paediatric day case rates and adeno-tonsillectomy day case rates improved significantly up to 93%
Identification of problem areas and addressing them can improve day case rates in ENT surgery. We clearly identified an area which could be improved, implemented changes and successfully improved day case paediatric surgery rates.
Dr R Anderson, DrD Kalathil
• The prevalence of diabetes mellitus in the UK continues to rise, making diabetic foot infection an increasingly significant public health issue.1
• Diabetic foot infection has substantial effects on patient livelihood, mobility, and social participation.2,3
• Early involvement of a multidisciplinary diabetic foot service has been shown to improve patient safety, through reducing admission length, lowering mortality rates, and reducing severity of amputation 4
• NICE guidance recommends that patients admitted with diabetic foot infection are referred to the diabetic foot service within 24 hours of assessment. 5
• To evaluate whether referral to the diabetic foot service was completed for patients presenting with diabetic foot infection within 24 hours of assessment in A&E.
• To measure the time from referral to review by a member of the diabetic foot MDT.
• A business information request identified 165 spells with a primary diagnosis of diabetic foot infection, attending the hospital within a specified 3 month period.
• Spells were excluded if the admission was elective, if ulcers were chronic and non-infected, or if the patient took their own discharge prior to full assessment.
• After patient selection (see diagram below), there were 60 spells, for which information about referral to the diabetic foot MDT was extracted.
• Information was collected from hospital notes and the ICE computer system, and inputted into a password-protected spreadsheet.
information request, n = 165
Referral to the Diabetic Foot MDT:
• In 10% of spells (n=6) analysed, referral was not completed when clinically indicated.
• Factors contributing to this included being on a medical outlier ward, and diagnosis later in admission. Time from Referral to Review:
• 51% of patients were reviewed by a member of the diabetic foot service within the first 24 hours of admission.
• In the 2 spells where the patient was not seen by an MDT member until >72 hours into admission, this was related to late referral.
The following interventions are being implemented:
1. Educational posters in A&E and AMU in areas where clinicians complete clerking documentation, to encourage referral at the time of initial assessment.
2. Addition of quick reference guide for managing diabetic foot infection to hospital handbook phone application and intranet, targeting patients who may be diagnosed later in admission.
• Patients were reviewed in a timely manner once referred, however referral to the diabetic foot service could be improved.
• This has implications for patient safety as evidence demonstrates early involvement of the diabetic foot MDT results in better patient outcomes.
• A multi-departmental approach is required to ensure buy in at each stage of the patient journey.
• Next steps include re-auditing of the outcome measures to evaluate the impact of interventions.
References:
(1) Diabetes UK (2019). Diabetes Statistics. Retrieved from Diabetes UK: www.diabetes.org.uk/professionals/position-statements-reports/statistics
(2) Edmonds, M., Manu, C., & Vas, P. (2021). The current burden of diabetic foot disease. Journal of Clinical Orthopaedics & Trauma, 88-93.
(3) Crocker, R., Palmer, K., Marerro, D., & Tan, T.-W. (2021). Patient perspectives on the physical, psycho-social, and financial impacts of diabetic foot ulceration and amputation. Journal of Diabetics and its Complications, [Online].
(4) Buggy, A., & Moore, Z. (2017). The impact of the multidisciplinary team in the management of individuals with diabetic foot ulcers: a systematic review. Journal of Wound Care, 324-339
(5) National Institute of Health & Care Excellence. (2015, August 26). Diabetic foot problems: prevention and management. Retrieved from NICE Guidance: www.nice.org.uk/guidance/ng19/chapter/Recommendations#diabetic-foot-infection
Sedation for MRI scans in the paediatric population is common to reduce fear and anxiety and to minimise movement for the procedure1
Sedation itself is unpredictable and carries risks including airway obstruction, apnoea, hypoxia and cardiopulmonary arrest2
Over 50 children were sedated to facilitate MR imaging in 2020 at our hospital, a district general in the North West.
This was a retrospecLve audit of 27 paLents sedated for MRI between Jan 2020 and Feb 2021.
Paper and electronic notes, including the sedaLon proforma, were reviewed.
The process of sedaLon was audited against the local guideline for sedaLon for painless procedures in children in 15 separate standards.
Results and recommendaLons were presented at the local clinical audit meeLng and changes implemented.
•Evaluate current pracLce in the paediatric department by reaudiLng against local guidelines
•Assess whether the implemented changes from a 2016 audit have resulted in an improvement in pracLce
•IdenLfy further areas for improvement and implement changes to improve care
standards reached 90% adherence
1. Development of a ‘doctors quick guide’ to improve assessment for sedaLon and facilitate escalaLon to specialists where appropriate. This guide is being reviewed for piloLng in the department.
There was evidence of some improvement from the 2016 audithowever, updates to the guideline and changes to the pro-forma meant that direct comparison could not be drawn.
2. AddiLon of a box for exact weight and exact >me since last oral intake to be added to the sedaLon pro-forma.
3. Sub-standard observaLon frequency remains an important issue and further work in parallel with nursing colleagues is needed to explore ways to improve this.
‣ This service is provided by a multidisciplinary team and, as such, all parties should be included in the audit process and generating ideas that can lead to meaningful change
‣ Simple processes can help reduce error and affect change without much increase in workload e.g. two extra elements to the pro-forma checklist
‣ There are both benefits to and limitations of retrospective studies and using ‘proxy data’ such as documentation to audit practice
Aditya Trighatia, Nadia Youssef, Thomas Kerr, Mamdouh Elbannan, Adithya Varma
Aneurin Bevan University Health Board
• Fluid management constitutes a significant part of medical prescribing, especially on surgical wards where patients are often nil by mouth.
• As itis prescribed routinely and often thoughtlessly, the adverse effects of IV fluids are frequently overlooked.
• NICE has identified that errors in IV fluids prescriptions commonly occur in surgical wards due to lack of relevant critical care experience and knowledge
Evaluate the adherence to the IV fluids NICE guidelines in the Trauma and Orthopaedics' department at the Grange University Hospital.
• Two audits were performed four weeks apart on all T&O inpatients who were prescribed IV fluids
• Prior to the second cycle, medical staff received teaching on the current IV fluid guidelines.
• In the first cycle patients received an average of 2.8L of IV fluids during their hospital stay This reduced to 2.3L in the second cycle.
• Most commonly prescribed fluid type was Hartmann’s solution, and the main indication was maintenance, followed by replacement.
• 13.6% of patientshad their weight recorded in the first cycle, compared with 0% in the second cycle.
• Collected data: Patient’s weight; type, amountand duration of IV fluids prescribed; indication; and anyadverse effects
• When IV fluids are prescribed incorrectly,it results in adverse effects such as AKI and electrolyte imbalance
• Teaching alone didnotproduce fruitful outcomes.
• We propose a collaboration with pharmacists to introduce a drug chart which encloses a protocol for IV fluid prescription
*Volume of maintenance fluid prescribed
Correctly prescribed Cycle 1 Cycle 2 Under 27%
CYCLE 2 Nice.org.uk. 2017. Overview | Intravenous fluid therapy in adults in hospital | Guidance | NICE. [online] Available at: <https://www.nice.org.uk/guidance/cg174> [Accessed 11 April 2022].
CYCLE 1 Over 7% Correct 50%
Under 43%
• Most common adverse effect of incorrect IV fluid prescription was electrolyte disturbance
0% 10% 20% 30% 40% 50% Cycle 2 Cycle 1
Endoscopic retrograde cholangiopancreatogram (ERCP) with endoscopic sphincterotomy and stone extraction is considered the treatment of choice for bile duct stones.1,2 In patients with irretrievable biliary stones, endoscopic insertion of a plastic stent into the common bile duct (CBD) can facilitate biliary drainage whilst awaiting an elective laparoscopic cholecystectomy.1,2
Current European Society of Gastrointestinal Endoscopy (ESGE) guidelines emphasise that stenting in these circumstances should be temporary (3-6 months), as long-term biliary stent placement is associated with higher morbidity and mortality.1 Complications of long-term biliary stenting include cholangitis and stent dysfunction (migration or occlusion). 1,2 Patients usually require a second ERCP to remove or replace the stent as appropriate. Other indications for temporary biliary stent insertion include benign bile duct strictures and bile leaks.1 Endoscopic biliary stent insertion may be considered definitive management for bile duct stones in patients with high surgical risk2 or palliation in malignant biliary obstruction. 1
Endoscopic placement of pancreatic duct (PD) stents forms part of the management for inflammatory pancreatic diseases and prevention of postERCP pancreatitis.3,4 In contrast to CBD stents, PD stents usually pass spontaneously. At this trust, an abdominal X-Ray is performed 10-14 days after insertion to confirm spontaneous passage of the stent. Occasionally, PD stents are retained and subsequently require removal by ERCP.
Recently within the trust, two patients suffered adverse outcomes as a result of temporary biliary stents that were ‘lost to follow up’ and subsequently not removed (CASE 1 and CASE 2). Local guidance for the duration and follow up of temporary plastic biliary and pancreatic stents does not exist.
CASE 1
Oct 2016 Bile leak post-laparoscopic cholecystectomy. ERCP and CBD stent insertion. No further follow up; stent not removed.
Jun 2020 Patient admitted with sepsis secondary to cholangitis and multiple liver abscesses.
CASE 2
Jun 2013 Presented with obstructive jaundice secondary to bile duct stone. ERCP and CBD stent insertion.
Feb 2014 Elective laparoscopic cholecystectomy. No further follow up; stent not removed.
Jun 2020 Patient presented with abdominal pain and deranged liver function tests. Ultrasound abdomen demonstrated CBD stent and 4cm stone.
Aug 2020 Longitudinal choledochotomy performed to remove CBD stent and stone.
CBD and PD stents
1. Patient and stent details recorded on the database at the time of stent insertion by the endoscopist.
Pathway for CBD stents
2. Endoscopist to notify General Surgeon of stent insertion and details / timescale for follow up.
3. General Surgeon to complete referral to Gastroenterologist requesting endoscopic s tent removal when appropriate (for example, once Laparoscopic Cholecystectomy performed).
4. Endoscopist to update database when stent removed
Implement local policies to standardise the follow up of endoscopic stent placement, and thereby reduce the potential for adverse events associated with stents ‘lost to follow up’.
• For the purpose of this audit, 6 months was considered the standard of best practice for maximum duration of temporary biliary and pancreatic stent placement in accordance with ESGE guidelines1
• Patients who had a plastic CBD or PD stent inserted during a 3-year period were identified. Each patient’s endoscopy report, corresponding discharge summary, relevant clinic letters and radiology results were reviewed to establish the indication for stent insertion, duration of stent placement and subsequent follow up arrangements.
• Patients for which stent insertion was considered definitive management, patients referred to tertiary hospitals for further care and patients who moved out of area were subsequently excluded.
• Patients with stent duration >6 months were considered ‘lost to follow up’ if the documented follow up arrangements did not occur.
• All patients with stent duration > 6 months, stents not removed, stents lost to follow up or adverse outcomes associated with stent duration > 6 months were reviewed in a virtual clinic.
During the 3-year period, nearly 800 patients underwent ERCP, of these, 64 patients had plastic CBD or PD stents inserted (FIGURE 1). Stent placement was considered definitive management in 28 cases. 10 cases were excluded due to patient relocation or referral to tertiary hospitals. Of the remaining 26 cases, 14 stents were removed or had passed spontaneously within 6 months, corresponding to 54% compliance with the audit criteria. On further review, 3 patients had been lost to follow up and 4 patients had associated adverse outcomes including cholangitis, pancreatitis and irretrievable stents.
• 28 cases: stents considered definitive management
• 10 cases: referred to tertiary hospitals or moved out of area
• 14 cases: stent removed or passed spontaneously within 6 months
• 8 cases: stent duration > 6 months and no recorded adverse outcomes
Pathway for PD stents
2. Endoscopist to book a follow up abdominal X-Ray, documenting the timescale to be performed.
3. Endoscopist responsible for reviewing the X-Ray and endoscopic stent removal if required.
4. Endoscopist to update database when stent removed
CBD and PD stents
5. Database to provide an alert when stent duration approaches 6 months with repeat alerts thereafter if required. Database monitored regularly by a responsible clinician to identify patients with temporary stents that require review for possible stent removal or replaceme nt.
Our results emphasise the importance of timely follow up for patient safety. Subsequently, Gastroenterology and General Surgery teams have implemented a cross-speciality pathway and stent registry to standardise local follow up arrangements and thereby reduce the potential for adverse events associated with stents ‘lost to follow up’ (outlined in FIGURE 2). We plan to re-audit 1 year following implementation.
Key learning points:
• A number of follow up arrangements were in progress during initial data collection, consequently a second round of data collection was required to update the results. In the future, we recommend delaying data collection to avoid this.
• Our results also highlight implications of the COVID-19 pandemic on routine patient follow up and subsequently patient outcomes.
Endoscopy 44, 277–298 (2012). // 2.Sohn, S. H., Park, J. H., Kim, K. H. & Kim, T. N.
World J. Gastroenterol. 23, 622–628 (2017). // 3.Testoni, P. A. Endoscopic pancreatic duct stent placement for inflammatory pancreatic diseases. World J. Gastroenterol. 13, 5971–5978 (2007). // 4.Dumonceau, J. M. et al. ERCP-related adverse events: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy 52, 127–149 (2020).
DR HANNAH NOONE, DR GEORGINA SANDERSON, DR AJEYA SHETTY & MR AWAD SHAMALIIntroduction:
In 2018, the Royal College of Anaesthetists published its national audit project (NAP6), which identified that peri-operative anaphylaxis has an incidence of 1 in 10,000(1) .
Although rare, its consequences are often a lifethreatening emergency. For this reason, follow-up after peri-operative anaphylaxis was recommended within 100 days; to allow safe practice for future anaesthetics.
Methodology:
The “in-house” anaesthetic alert database was used to identify all patients who had experienced perioperative anaphylaxis. The Anaesthetic alert database is continually updated when new events occur.
Electronic records of each patient were scrutinised to identify if patients were referred to allergy clinic and if so, how long it took for follow up to occur. Records were also reviewed to look for evidence of relevant clinic letters.
Results:
Aims:
This audit project aims to evaluate the incidence of peri-operative anaphylaxis in Aneurin Bevan University Health Board (ABUHB) and the subsequent timing to follow up clinic. This was in comparison to national standards; set out by the NAP6 project. A secondary aim was to establish the availability of written documentation following allergy clinic appointments.
• Between 2006 & 2021 there were 46 peri-operative anaphylaxis events that occurred at ABUHB.
• Data for the five-year period of 2017-2021 demonstrated an incidence of 0.85 in 10,000 operations.
• Of the 46 patients, 62% were subsequently followed up in allergy clinic; with a mean time to follow up of 8.4 months.
• Allergy clinic letters/documentation was available in 47% of patients.
Analysis & recommendations for change:
• Local incidence of peri-operative anaphylaxis, at ABUHB, is in line with what was observed nationally.
• Time to allergy clinic follow up is significantly delayed compared to the national recommendation, potentially compromising on patient safety.
• A change to the anaesthetic allergy clinic referral process has been recommended; facilitated now by a regional service rather than an individual clinician.
• We recommend re-audit in 12 months to evaluate the new service.
Hyperkalaemia is a commonly encountered electrolyte abnormality with potentially life-threatening complications.
NHS Improvement released a Patient Safety Alert in 2018 [NHS/PSA/RE/2018/006] following a report into 35 cardiac arrests, local guidance was found to be not evidenced based and management was variable. We have conducted an audit investigating the safety and quality of acute hyperkalaemia management at the Royal Cornwall Hospital, Truro.
To investigate the current management of hyperkalaemia by comparing our practice to standards of care derived from the latest UK Renal Association guidance 2020. This guidance included two recent updates of particular interest:
- The use of Sodium Zirconium Cyclosilicate (Lokelma) in severe hyperkalaemia
- Prophylaxis of iatrogenic hypoglycaemia
We identified all adult inpatients with life threatening hyperkalaemia (K+ ≥ 6.5mmol/L) over a six-month period. Following the application of exclusion criteria -a cohort of 29 patients was formed. Case notes and the electronic patient records were scrutinised to assess adherence to our standards of care derived from the UK Renal Association.
Pertinent patient outcomes were also recorded –mortality, duration of admission, iatrogenic hypoglycaemia and AKI
1. Initiation of treatment should occur within 1 hour
2. All patients should be treated with IV calcium salts
a) The preferred prescription is 30ml of 10% Calcium Gluconate
3. All patients should receive oral Sodium Zirconium (Lokelma)
4. All contributing medications should be suspended
5. Patients with a pre-treatment blood glucose less than 7.0mmol/L should receive a 25g glucose infusion after the insulin infusion
ü Improved local guideline – our new guideline clarifies the indication for Lokelma, steps to prevent iatrogenic hypoglycaemia and monitoring requirements.
ü Getting the word out – we used grand round to raise awareness and uptake of the new guideline.
ü The next cycle – we plan to re-audit to ascertain whether we have made an impact to local management of hyperkalaemia.
6. Patients should have a 12-lead ECG within 15 minutes
7. Patients should have urine output monitoring
8. Patients should have continuous ECG monitoring
9. Blood glucose testing should occur within 1 hour of completing the insulin/glucose infusion
10. A repeat ECG should be obtained 5-10 minutes following IV calcium salts
11. A repeat serum potassium measurement should occur within 6 hours of initial result
Only 55% of patients received Lokelma. Mostly this followed senior review – there was a delay in prescription.
22% of patients had an episode of hypoglycaemia following insulin treatment. Half of these had a low pre-treatment blood glucose. None received a prophylactic glucose infusion.
• Clear local guidance improves patient care, where this was already available there was better compliance
• Lokelma is currently under-prescribed by junior doctors
• Poor awareness of risk of hypoglycaemia
• More focussed data collection on our behalf could help drive further change
Introduction
Choroidal naevi are common with an estimated prevalence of 5-8%.1 They can transform into melanomas, the commonest intraocular malignancy.1,2 Nearly 50% of patients with choroidal melanomas die from metastatic disease, despite tumour eradication.3 Robust monitoring guidelines for these patients are extremely important for early diagnosis, treatment and improved patient outcomes. The MOLES score is a new evidence-based choroidal naevus risk stratification tool.4
Aim
Evaluate impact of transitioning from previous (2015) to new (2021) choroidal naevus monitoring guidelines.
2 audit cycles undertaken with implementation of new guidelines based on MOLES scoring system between cycles
Cycle 1
Based on 2015 guidelines
January-February 2020 n(naevi)= 288
Cycle 2
Based on new 2021 MOLES guidelines
April-August 2021 n(naevi)= 97
Adherence to criterion 3 especially, was low. More than 50% of patients were being followed up in hospital for unnecessarily long periods of time.
Existing 2015 guidelines scored many patients as high risk which means they are followed up in hospital for longer.
MOLES risk factor grading score for developing melanoma
Mushroom shape 0 (absent), 1 (incipient), 2 (definite)
Orange pigment 0 (absent), 1 (dusting), 2 (clumps)
Large size 0 (<3DD + <1mm), 1 (3-4DD +/ 1-2mm), 2 (>4DD, +/ >2mm)
Enlargement 0 (none), 1 (possible), 2 (definite)
Subretinal fluid 0 (absent), 1 (trace), 2 (significant)
Most of the same patients were low risk with the proposed new MOLES score. This would reduce unnecessary hospital follow up.
MOLES score Follow
0 (common naevus) Discharge to community optometrist
1 (low-risk naevus) Follow-up for 3 years overall
2 (high-risk naevus) Follow-up for 3 years overall
3 (probable melanoma) Same day referral to ocular oncology
A novel risk stratification tool called the MOLES score4 was introduced and imaging and follow-up guidelines changed
Initial results showed that poor adherence to follow-up guidelines resulted in >50% of patients being followed up for unnecessarily long periods of time in a tertiary centre. The new MOLES score and improved imaging pathways were introduced and incorporated into guidelines.
Post-intervention, adherence to follow-up guidelines improved by 45% and to imaging guidelines by 26%. This allowed us to safely focus our resources on a smaller patient cohort with high-risk naevi. We plan to re-audit in December 2022.
The nature ofhavingasurgicalprocedureincreasesthe riskofapatientdevelopingavenousthromboembolism (VTE)1.BothNICE and local Trust guidelines state that patientsundergoingasurgicalprocedure must be assessed fortheirthrombosis and bleedingrisk and thenreceivethe appropriate VTE prophylaxis.
• 100%of VTE risk assessments must be accurately completedforpatientsadmittedforelectivesurgery.
• 100%ofpatients assessedas being at riskofdevelopinga VTE should have theappropriatethromboprophylaxis prescribed
To determine if patients undergoing elective surgery at King’s Mill Hospital received an accurate VTE assessment and subsequent appropriate VTE prophylaxis prescribed.
82 VTE risk assessment forms were reviewedin conjunctionwiththepatient’smedicalhistory. The forms were assessed againstour VTE data collectionproforma and receivedpointsfor accurate completion. The maximum number ofpointsthatcould be attainedfor each section was 1.
The resultsrevealed severaldeviations and discrepancies fromthenationalcompliancecriteria,whichincludedmissed patient and admission related factors.
Initial Audit Results
31% VTE assessment forms were accurately completed. 73% of patients received the appropriate VTE.
Re-audit Results
33% VTE assessment forms were accurately completed. 77% of patients received the appropriate VTE.
• Teaching session for surgeons, anaesthetists and trainees.
• Production and distribution of a poster and audit report highlighting the considerations missed during assessment.
• High BMI isassociatedwithvenousthromboembolisms2 and it was afactorthat was often under appreciated.
• Procedural length includingthedurationofsurgery and totalanaesthetictime was poorly assessed It isthe responsibilityofboththeSurgeon and Anaesthetist to consider and discussthis,inorder to completethe assessment appropriately.
• Poordocumentationof date, time, name and designation was identified, lead to thesuboptimal VTE assessments.
• Disaggregate sections on the VTE assessment formsso that more significantsections weigh more than others e.g. bleeding and thrombotic risk weigh more thandate and time.
• To encourage cliniciansto further complete VTE assessmentsaccurately, review Datix systemfor entries that answer thequestion: ‘Has therebeenpatient harm or potentialpatient harm as a result of incorrectVTE assessment completion or prescribing?’
• To further investigate patient safety, correlatethe VTE thromboprophylaxisprescribedtothe VTE thromboprophylaxis administered tothepatient
A complete audit cycle assessing how accurately VTE prophylaxis assessments were completed for elective surgical patients at King’s Mill Hospital.
Antiplatelets are one of the most prescribed medications in the UK.
Reduce vascular mortality by 15% and nonfatal vascular events by 30%.
Aspirin increases gastrointestinal bleeding risk by 60%, and of these bleeds 10% are fatal.
Gastrointestinal bleeding is the greatest cause of hospital admission or death due to adverse drug reactions.
PPIs decrease the risk of GI bleeding by 80%.
NICE guidance is summarised below:
Co-prescription of a PPI with antiplatelet should be considered in 100% of high-risk patients.
How many patients aged over 70 and on antiplatelets were not on gastroprotection? How many patients had this been discussed with?
Contact patients to discuss the benefits and risks of starting PPI.
64.2% decided to start gastroprotection. Older patients were more likely to choose gastroprotection.
The most common reason for patients to decline was that they were currently asymptomatic, followed by concerns of side effects, and taking too many medications.
Reasons for declining gastroprotection
Benefits, risks and side effects were standardised.
53 patients had a discussion regarding gastroprotection with PPI.
The majority of patients chose to start gastroprotection, particularly older patients. Demonstrated the importance of involving patients in decision making.
Emphasis given on silent GI bleeding. Initiation of antiplatelet may be the best time to discuss gastroprotection.
Opportunistic discussion at medication reviews with annual re-discussion.
Findings were presented locally to increase clinician awareness.
Option for SystmOne warning prompt.
Phoning the patients was time consuming, as many wanted to discuss other complaints also.
Next time, phone patients ahead to book appointments into dedicated slots.
Next step is to reassess in 12 months – are patients still being co-prescribed gastroprotection? Are more patients being offered gastroprotection at initiation or medication review?
Cancerpatientsare at higher risk of venous thromboembolicevents (VTE), andthis risk increases again post-operatively1.Datasuggeststhe risk of VTE without prophylaxis afterabdominal surgery can be between 15 -40 % 2. This can result in adverse events such as pulmonary embolism and deep vein thrombosiswith associatedmorbidity and mortality. Trihn et al found there to be a five fold increase in mortality (OR 5.3, p<0. 001 ) for majorcancer surgery patients who had been found to havea VTE in comparison to those who had not3
As aresult, NICE best practice guidelines recommend an extended 28 day course of VTE prophylaxis to reduce the risk of VTE both during theinpatientstayandalso whilst recovering at home Previousauditwithin Royal Hampshire CountyHospital (RHCH) showed poor adherence withthese recommendations,with one patient experiencing postoperative VTE as a result
Consider extending pharmacological VTE prophylaxis to 28 days postoperatively for people who have had major cancer surgery in the abdomen 2 .
Assess localtrustadherence to thenational NICE guidelines
Establish if there is a difference in adherence when patientsaredischarged by less experienced team members out of hours
Establish if there is variation in adherence around junior doctorchangeover
Assess whetheranypatients whowere not prescribed appropriate VTE prophylaxis on discharge suffered any serious complications as a result
The localcolorectaldatabase was used to identify eligible patients.
Inclusion criteria: All patientsadmitted under the colorectalteambetween1/7/2020 -31 /12 /2020 withthe diagnosis of cancer who underwent surgery This was inclusive of bothelectiveand emergency admissions.
Reauditpatients: All patientsadmitted in the 28 day periodbefore andafterfoundationdoctorchangeover; 10 /3/21 -7/4/21 and8/4/21 -10 /5/21
Exclusion criteria: Patientswith diagnosis of cancerthat didnotundergo any form of surgery.Patients who underwent endoscopic procedure only.Patientsstill in hospital at thetime of audit
Definitions: Serious complications were defined as any complication requiring readmission to hospitalwithin 30 days of discharge.
Withthanks to Dr Waltersand Dr Collins for allowing us to use the previous auditdata from 2017 and 2018 for comparison.
Proportion of patients discharged with extended VTE prophylaxis
Patients prescribed extended VTE prophylaxis on discharge
Patients not prescribed extended VTE prophylaxis on discharge
42 patients underwent operativeintervention for an abdominalcancer.
Two patients(4. 76 %) were notprescribed appropriate VTE prophylaxis on discharge
There were no serious complications found Both patients were discharged out of hours
Proportion of patients prescribed 28 days of VTE prophylaxis
Patients prescribed a course of 28 days of VTE prophylaxis
Patients prescribed a course of VTE prophylaxis that was not 28 days in length
Fifteen percent of patients did not receive the correct number of doses of enoxaparin
Sixty seven percent of thesepatients were discharged out of hours
SurgicalF1verbal introduction when starting theirsurgical rotation
Posters put up in surgical wards reminding juniors of the guidelines.
Proportion of patients prescribed the correct number of days of VTE prophylaxis postintervention
Patients prescribed a course of VTE prophylaxis that was not 28 days in length
Patients prescribed a course of 28 days of VTE prophylaxis
100 % of patients were dischargedwithappropriate VTE 90 % of patients were dischargedwiththe correctcourse of VTE prophylaxis.
The discharge in questionwas out of hours
The error occurred after junior changeover.
Percentage of patiets discharged with extended VTE prophylaxis
There is good adherencewiththenational VTE prophylaxis guidelines, with evidence showing increased adherencewith every audit cycle
Simple measures such as increasededucationandputting up posters as physical aide memoirs can helpincrease compliance.
Shortfallsrepeatedlyhappen when patientsare discharged out of hours
This is possibly becausethe out of hours team do not normally work withinthecolorectalteamandmay be less familiarwiththe guidelines
Looking at a flow chart of thepatient's journey withinthe hospitalallows us to see where interventionscan beput in place to ensure informationaboutthe VTE guidelines is correctlycommunicatedand put intopractice, as seen in thediagram below
1. Clear instructions in operationnote post-operative plans. This aims to act as a prompt for juniors who arethe most likely to order dischargemedication.
2. Highlight the need for extended VTE prophylaxis in ward round plans.
3. Educate juniors on the guidelines
4. Educate pharmacystaff on guidelines as theyarethe teamthat check allmedications prior to discharge.
5. Aim for thepatient'sregulardayteam to complete discharge paperwork to reduce out of hours errors
1. Felder S, Rasmussen MS, King R, Sklow B, KwaanM, Madoff R, Jensen C. Prolonged thromboprophylaxis with low molecular weight heparin for abdominal or pelvic surgery. Cochrane Database Syst Rev. 2019 Mar 27;3(3):CD004318. Update in: Cochrane Database Syst Rev. 2019 Aug 26;8:CD004318. PMID: 30916777; PMCID: PMC6450215.
2. Geerts WH, Heit JA, Clagett GP, Pineo GF, Colwell CW, Anderson FA et al. Prevention of venous thromboembolism. Chest 2001; 119(Suppl ): 132S 175S.
3. Trinh VQ, KarakiewiczPI, Sammon J, et al. Venous Thromboembolism After Major Cancer Surgery: Temporal Trends and Patterns of Care. JAMA Surg. 2014;149(1):43 49. doi:10.1001/jamasurg.2013.3172
4. National Institute for Health and Care Excellence. Venous thromboembolism in over 16s: reducing the risk of hospitalacquired deep vein thrombosis or pulmonary embolism [Internet]: NICE; 2018 [updated 2019 Aug; cited 2021 Mar 24 ]. (Clinical guideline [CG89]). Available from: www.nice.org.uk/guidance/ng89
Catheter -associated urinary tract infections (CAUTIs) represent a large proportion of nosocomial infections.
of patients are catheterised during their hospital stay.
Sharwini Paramasevon, Freda Chen, Iuliana de Jong of hospital -acquired UTIs are associated with urinary catheter use.
CAUTI risk increases by 3 -7% for each day an indwelling urinary catheter is in place. 1
Risk of developing a catheter- associated UTI Length of time a urinary catheter is kept in situ.
To compare the current practice of catheter care against NICE guidelines Identify measures to reduce CAUTI incidence among elderly care patients
their risk of infection minimized by the completion of specified procedures necessary for the safe insertion and maintenance of the catheter and its removal as soon as it is no longer needed
NICE Quality Standard 61 for Infection prevention and control -Apr 2014
Prospective audit over 8 weeks involving 50 patients from the care of the elderly ward (mean age of 83) who were catheterised during November -December 2021.
unnecessary urinary catheterisation
Two main concerns identified
Average duration of unnecessary catheterisation
Insert only when indicated.
Departmental teaching sessions for nurses on catheter maintenance
Clinicals skills sessions on aseptic insertion
Re -audit in 6 months
Action Plan
Simplified form for urinary catheter insertion pathway
LocSSIP for urinary catheter insertion
prolonged catheterisation due to lack of regular reviews
Removal plans ASAP!
Robust system for daily reminder
Timely removal contributes to improved patient experience and reduces overall NHS burden.
Insert catheters only for appropriate indications and leave in place only if needed
Regular reviews to assess the need of catheterization.
1. Complex admissions taking longer time for discharge.
2. Advanced age itself is a predisposition to urinary tract infection.
A multi-drug resistant organism (MDRO) outbreak of Klebsiella species on the spinal rehabilitation wards has prohibited new admissions, slowed rehabilitation processes and put additional strain on healthcare staff. MDRO organisms are driven by inappropriate antimicrobial use.
To evaluate the appropriateness and accuracy of antimicrobial prescribing in spinal rehabilitation patients
An audit toolkit was created, based on the ‘Start SmartThen Focus’ (SSTF) antimicrobial stewardship initiative for secondary care.
All antibiotics prescriptions for the 34 spinal rehabilitation inpatients between January and September 2021 were included.
16 patients were prescribed antibiotics, totalling 53 prescriptions of antibiotics. The indication is detailed in the table below; the majority were for UTIs, largely catheterassociated (CAUTI).
Documentation of indication was generally good, but duration less so, particularly by on-call teams, presumably leaving it to the day team to rationalise and decide on duration.
40% of antibiotics did not have a documented senior review within 72 hours
Both day teams and on-call teams rely heavily on discussion with Microbiology for help in prescribing for spinal rehabilitation patients, which can be impractical and timeconsuming.
Microguide is rarely used to guide choice. Reasons for this could be:
• Non-specific symptoms in rehab patients; spasms, increased tone and temperatures, poorly localised pain
• Complexity of medical history
• Unclear pathways for e.g. CAUTI – requires you to follow upper UTI guidelines and give IV gent which is not always appropriate nor practical
Intended duration is poorly documented, and senior reviews are not reliably carried out.
1. Implement long-stay Antibiotic Review Kit (ARK) charts on the spinal rehabilitation wards. This necessitates a 3-day review and prompts continual assessment.
• Being trialled in a nearby local health board
35 of the prescriptions (66%) were made by on-call teams, while 18 (34%) were made by the day team
The choice of antibiotic was ‘ appropriate’ in 89% of cases (based on Microguide, Microbiology advice or culture & sensitivities). Day team and on-call team prescribed appropriately 97% and 72% of the time, respectively.
Both the day and on-call team relied heavily on microbiology advice in choosing antibiotics. None of the prescriptions made by on call team were based on Microguide
• This should encourage regular review of antibiotics
2. Spinal injury-specific sections on Microguide (e.g. suprapubic catheter, long-term catheter infections and bladder colonisation) to educate and guide doctors
• Discussed at the Antimicrobial Management Group for Cardiff & Vale University Health Board
3. Re-audit by new juniors on spinal rehab ward
Antimicrobial Stewardship: Start Smart – then focus. (2011). Public Health England. Available at: https://www.gov.uk/government/publications/antimicrobialstewardship-start-smart-then-focus
For any further information, please email: serena.linley-adams@wales.nhs.uk
Background
Approximately 67,000 cholecystectomies are performed every year in the UK, with 92% of these performed laparoscopically. Leve l 1 evidence shows that perioperative antibiotics do not significantly reduce the risk of surgical site infections or overall nosocomial infections in patients undergoing elective cholecystectomies.1 Due to the lack of clinical benefit, and the risks of unnecessary antimicrobial use, current national guidelines do not recommend prophylactic antibiotic use in low-risk elective laparoscopic cholecystectomies, reserving their use for high-risk patients only.2,3
The aim of this audit was to assess compliance with local and national guidelines on antibiotic usage for laparoscopic cholecystectomies, to identify areas of improvement, implement change and re-audit to assess the effectiveness of this change.
Data was collected retrospectively between 01/05/2021 and 01/08/2021 for patients undergoing elective laparoscopic cholecyste ctomies. Following the initial data collection, we presented the results at a local clinical governance meeting and implemented change by attaching pre-printed stickers of local antibiotic prophylaxis guidance to pre-operative notes. We prospectively re-audited between 01/11/21 and 01/12/21 to assess the effectiveness of this change.
n = 41
Pre-printed stickers of local antibiotic prophylaxis guidance attached to pre-operative notes and anaesthetic charts
In the initial three-month period, 24.4% (10/41) of elective cases received correct antibiotic prophylaxis, with 58.5% of patients prescribed unnecessary post-operative antibiotics in the post-operative plan. Following the implementation of change, in the re-audit period there was a significant improvement, with 55% (11/20) of elective cases receiving correct antibiotic prophylaxis, and only 25% prescribed unnecessary post-operative antibiotics
Conclusion
We show that pre-printed stickers are a simple intervention that can improve adherence to local guidance and reduce injudicious use of antibiotics. Improving antibiotic prescribing for laparoscopic cholecystectomies, procedures, highlights the potential for significant cost savings and improved antimicrobial stewardship.
Antibioticprophylaxisis NOTrecommended butshouldonlybeconsideredfor highriskpatients *
* High risk patients: intraoperative cholangiogram bile spillage conversion to laparotomy acute cholecystitis/pancreatitis
If antibiotic prophylaxis is required:
First line Co-amoxiclav 1.2g IV
Alternative regimens:
jaundice
pregnancy
immunosuppression
insertion of prosthetic devices
Single dose at induction ONLY
Penicillin allergy Low riskCefuroxime 1.5g IV AND Metronidazole 500mg IV at induction ONLY
High risk Ciprofloxacin 400mg IV AND Metronidazole 500mg IV at induction ONLY
ALL patients: If MRSA positive ADD Teicoplanin 400mg IV at induction.
Intravenous Fluid(IVF) is one of the most common treatment received by Adult surgical patient.
As per the National Confidential Enquiry into Patient Outcome and Death, Estimated harm from inappropriate fluid & electrolyte management is 1 in 5 patients. It was observed that almost all Acutely admitted surgical patients receive either Normal Saline or Hartman’s solution only.
to ensure that maintenance IVF prescribed for all adult surgical patients is up to the standard of the NICE guideline, and if not, to improve the prescription through several interventions to reach the standard.
Through
- Review patients’ IVF charts and compare prescription to NICE Guideline for Intravenous fluid therapy in adults in hospital.
- Identify the defect in the Volume and Content of prescribed IVF.
- Investigate the causes of the defect and how to improve it.
All adult surgical patients who were acutely admitted through surgical triage unit between 25/11/2021 and 25/02/2022 who were kept nothing per mouth (NBM) for 24 hours and have been prescribed maintenance intravenous fluids. We included all the patients that we were able to obtain their IVF charts after excluding those who do not meet the inclusion criteria(On sliding scale or receiving DKA treatment).
Our aim was to collect 50 patients.
The type and content of IVF prescribed for 24hr has been compared to the NICE guideline.
An anonymous questionnaire aimed at level 1& 2 doctors was performed in November 2021 to set the par of knowledge about NICE guideline for IVF.
A review of available IVF bags in the surgical wards was also done.
Upon review of available IVF types in surgical wards, all types used per NICE guideline are available
Mandatory teaching session to level 1,2&3 doctors about NICE guideline for IVF prescription and to be repeated on induction for new surgical members.
IVF Algorithm poster to be present in doctors’ room in surgical wards.
Modification of current IVF chart to include a table of the 5R of IVF and a column for reason of IVF( see below).
Pocket card for IVF prescription to be given to Level 1& 2 doctors. Re-audit
be conducted after implementation to assess improvement.
Routine maintenance, Replacement, Redistribution and Reassessment.
Seek expert help if patients have a complex fluid and/or electrolyte redistribution issue or imbalance, or significant comorbidity
for resuscitation, Use ABCDE approach All others need daily reassessments of clinical fluid status, laboratory values fluid balance charts,
Introduction
• Neck of femur fracture (NOF#) is a major contributor to morbidity and mortality.
• National Hip Fracture Database ‘Best Practice Tariff’ (BPT) criteria outline the gold standard of NOF# care.
• Appropriate assessment and management of NOF# reduces delays in surgery, and pre and post operative complications.
Aim
• To maximiseadherence to BPT standards to improve care quality and patient outcomes.
• RetrospecKve data collecKon of adherence to NOF# BPT criteria for pre-operaKve:
• Assessment: blood tests, AMT10, fracture classificaKon, ECG, chest X-ray.
• Management: prescripKon of analgesia, laxaKves, VTE prophylaxis, regular medicaKons, intravenous fluids, fasci iliaca blocks.
• Replaced paper NOF# clerking document with digital ‘NOF# clerking proforma’.
• Measured compliance to BPT criteria at 2 and 4 weeks a[er introducKon of pro forma.
• Significant Improvement of NOF# classification, preoperative blood tests and AMT10 completion (graph 1).
• Widespread improvement in prescribing of analgesia, laxatives, regular medications and VTE prophylaxis (graph 2).
• Correct IV fluid prescription fell whilst postoperative AKI increased (table1).
• Reduced pre-op ECG (88% to 80%), CXR requests (84% to 81%) and fascia iliaca block (64% to 57%).
• PosiKve feedback for ‘NOF# clerking proforma’ - “Half the work”.
• Data demonstrates the fantasKc work by the T&O team in pre-operaKve assessment and prescribing.
• Rising levels of AKI demonstrate the importance of appropriate IV fluids Future audit cycles will look to improve this.
• Our team are looking at ways to ease the workload of A&E staff by:
1. Training T&O staff to do fascia iliaca blocks
2. Developing an early alert system of possible NOF# paKents
Completion of Treatment Escalation Plan (TEP) and Do Not Attempt
Cardio-Pulmonary Resuscitation (DNACPR) form in Acute Medical Unit/ Same Day Emergency Care for Medicine for Older People Department
Introduction
Treatment escalation plans (TEP) and Do Not Attempt Cardio -Pulmonary Resuscitation (DNACPR) forms aid clinicians in making appropriate decisions whilst managing patients who are deteriorating1. Ideally, these decisions on the ceiling of care and resuscitation should have been discussed with the patient when they have capacity2 when necessary. This project aims to identify the completion of TEP form when patients under the Medicine for Older People (MOP) team are admitted through the Acute Medical Unit (AMU) or Same Day Emergency Care (SDEC) unit, and assess if the discussion of DNACPR was performed and subsequent completion of form.
Patients who were under the MOP Team were audited in July 2021 (n=125). This was re-audited in November 2021 (n=124) after distributing results to department. Patients on the MOP work-list were selected, regardless of ward location in the hospital. The clerking booklets were reviewed. Standards involved valid TEP completion, valid DNACPR form completion and reasons of incompletion for both.
UHS Guidelines
Conclusions and Implications
Similar rates of completion after 3 months of distributing information, with slight improvement in TEP and DNACPR completion
A teaching session was delivered on 17 March 2022 to Medicine for Older People Department junior team, presenting results, introducing guidelines in hospital and importance of completion A re-audit will be performed in 2 months to see if there is an improvement in completion rate.
Title
Cognitive assessment in older people: an Emergency Medicine audit
Introduction
Undiagnoseddeliriumcontributesgreatly to mortality and morbidity in EmergencyDepartments.Theassessment is oftenmissed in the ED.
Standards Fundamental-doing a cognitive assessment in eligible patients
Developmental-inclusion in ED discharge letter
Aspirational-assessment using a delirium bundle
Changesintroduced:
Cycle 1
1st June- 30th November 2021
• Recommendation in TopTips
• Teachingsessions for doctorsand ENPs
• Reminderemails to doctors
• Introductionof AMT4
Cycle 2
15th April-14th October 2021
Cognitive assessment in 9%
• Induction for new starters
Cognitive assessment in 24%
Lessons learnt: We need to spread awareness among Emergency medical staff on the importance of cognitive assessment in older people in order to reduce morbidity and mortality from Dementia and Delirium.
Royal College of Emergency Medicine standards:
rates were analysed in four domains:
1.Care in ED overall about the next steps in their care about how to catheter
Number of received catheter care equipment on discharge increased across all domains, with ED improving from
ED in line with the RCEM standards. robust speciality follow-up. Displaying of posters and visual prompts within the emergency department.
How do we know change is an improvement? By comparing our results to RCEM standards, alongside impact of each implemented change.
to improve access for all members of
An old unused catheter trolley with outof-date and inappropriate equipment was updated and relaunched. This included the design of a bespoke home kit for discharge - complete with all catheter home care needs. A copy of appropriate follow up.
1.Sustainable change adapts system processes to allow new ways of thinking to become normal. system. Empowering and developing specialist nurses
to project progression.
approach whilst allowing easy mapping of change.
An informal management style and a visible presence in a department can give you vital informal feedback.
1.Further review of the VTWOCC sustainability. re-design of discharge process. management to arrange access to with AUR out-of-hours as this is not currently available in the ED. Review process map and target new
Dr. S Cowan, Dr. O Rushworth, Miss K Knowles
Dr Alexandra Ross, Dr RoshanGunasekera, Dr Rohit Bhide Sheffield Teaching Hospitals
Ø Patients discharged from Sheffield Teaching Hospital’s Spinal Injuries Unit are commonly prescribed neuropathicpain agents
Ø These drugs can have considerable side effects and potential for abuseoraddiction (Murnion, 2018)
Ø Adiagnosis of neuropathicpain should be clearly documented on the discharge summary to ensure appropriate prescription and to improve communication with the General Practitioner
Ø Some discharge summaries were noted to omit the diagnosis of neuropathicpain
Ø Discharge summaries of patients prescribed neuropathicpain agents between April and September 2020 were analysed (n=41)
Ø Those without adocumenteddiagnosis of neuropathicpain were identifiedand the case notes reviewed
Ø The percentage of patients discharged with neuropathicpain agents who had adiagnosis of neuropathicpain in their notesbut omitted from their discharge summary were calculated for each two-week time period
Ø Reasons for omission were considered andanintervention was implemented between October and November 2020
Ø Data collection was repeated for discharges between December 2020 and May 2021 (n=37) andanalysedon a run chart
Ø Adischarge summary template was updated to emphasise neuropathicpain documentation (see Figure 2)
Ø This was distributed to junior doctors andadvanced nurse practitioners by email and displayed on the unit notice board
Pain • If present and management
• If on Neuropathic agent, confirm presence of Neuropathic pain (with patient) and document in Diagnoses.
Figure2. Extract from the updateddischarge summary template
Ø Quantify the omissionof neuropathicpaindiagnoses on discharge summaries for patientsprescribed neuropathicpain agents
Ø Reduce the percentage of patientsdischarged with neuropathic agents without anaccurate diagnosis of neuropathicpain on the discharge summary within one year
PLAN
Analysed discharge summaries (n=41). Considered reasons for omission of diagnosis
ACT
Continue to distribute the new template for each cohort of new clinicians. Consider future interventions
DO Updated discharge summary template and distributed this to junior doctors and advanced nurse practitioners
STUDY
Repeated the data collection after 6 months (n=37). Conducted a run chart which showed a significant change
After the intervention, there was a significant reduction in the percentage of patientsdischarged with neuropathic agents without anaccurate diagnosis of neuropathicpain on the discharge summary
Ø Shift of eleven pointsbelow the median on the run chart and a reduction in the median from 50% at baseline to 16.7% after the invention
Ø Although the samplesize was limited, the project met itsaim ofimproving discharge summaries within one year
Ø Perhaps the template prompted clinicians to document the diagnosis or to review and/or stop the prescription of the neuropathicpain agent
Ø This intervention had a positive outcome buthasnot eliminated the problem. Future PDSA cycles might involve a teaching session for clinicians
Ø The updated discharge summary template continues to be used and distributed to clinicians via email, notice boards and aninduction booklet
Figure 3.Run chart showing percentage of patients discharged with neuropathic agents without accurate documentation on the discharge summary.
Ø While this project was specific to neuropathic agents for discharges from one department, similar templates might be assessed for the use ofother drugs, for example antibiotics, to improve documentation and communication with the General Practitioner in a wider setting
Why?
Positive induction experiences effect employee job satisfaction, commitment, quality of work and job retention(1–3). NHS Employers state that the induction process is ‘crucial’ for staff retention(4). The British Medical Association recently identified that the NHS is short of over 49,000 full-time-equivalent doctors(5). Inductions are essential now, and for the future sustainability of the NHS.
What?
A QIP to assess and improve Acute Care Common Stem (ACCS) trainee satisfaction with their induction to University Hospitals
Sussex (UHSx, East sites) via selfreported satisfaction scores.
How: PDSA timeline
Aug 2019 ->
• New intake of ACCS trainees
• All ACCS trainees surveyed
Jan 2020 ->
• Findings and suggestions presented to ACCS Local Faculty Group
• Changes implemented
Cycle 1: Baseline trainee satisfaction
• 20% induction ‘poor’ or ‘very poor’
• 80% induction ‘satisfactory’ or better
• Mean satisfaction score: 2.6/5
Target # Plan
1 All trainees to be aware of how their training is structured and delivered locally on commencing their training in August
Aug 2020 ->
• New intake of ACCS trainees
• All ACCS trainees surveyed
Jan 2021 ->
• Findings and suggestions presented to ACCS Local Faculty Group
• Changes implemented
How: Interventions and their effects
Aug 2021 ->
• New intake of ACCS trainees
• All ACCS trainees surveyed
Aim
For no ACCS trainee to rate their induction as ‘poor’ or worse; thus ‘satisfactory’ or better within 24 months.
Jan 2022 ->
• Findings and suggestions presented to ACCS Local Faculty Group
• Changes implemented
Stakeholders
ACCS trainees (54 questionnaires distributed; 30 responses obtained), Local Faculty Group members: trainee representatives, consultants, administrators, HR
Do Study Act
Develop induction presentation for August induction
2019: Prior to QIP 55% found this helpful
2022: Post QIP 67% found this helpful
• Re-introduce face-to-face induction post-COVID-19
• Introduce social welcome event
2 All trainees to know which speciality they will start in prior to commencing their training in August
3 All trainees to know their Educational and Clinical supervisors (ES & CS) prior to, or within 2 weeks of starting their training in August
Develop trainee handbook and distribute in their induction email prior to commencing in August
Inform trainees of their starting specialty prior to commencing in August via their induction email
Inform trainees of their clinical and educational supervisors prior to commencing in August via their induction email
Lessons learned and future plans
2019: Prior to QIP Handbook not being used
2022: Post QIP 100% found this beneficial
2019: Prior to QIP 64% knew starting speciality
2022: Post QIP 89% knew starting speciality
2019: Prior to QIP 57% knew ES & CS
2022: Post QIP 78% knew ES & CS
• Responding to trainee feedback can improve satisfaction with their induction
• Induction email and training handbook complement but do not replace face-toface inductions. The loss of face-to-face inductions as a result of COVID-19 measures negatively impacted on trainee satisfaction with their induction. Plan to re-introduce face-to-face inductions for this coming August intake
• Involving all stakeholders is essential for positive change to be sustained
• Plan for a mentorship scheme for new trainees as the next target for change
• Induction email to be distributed prior to commencing training in August containing:
o Trainee handbook
o Starting speciality
o ES and CS
Cycle 3: Post-QIP trainee satisfaction
• 0% ‘poor’ or ‘very poor’
• 100% ‘satisfactory’ or better
• Mean satisfaction score 3.5/5
from: https://www.nhsemployers.org/your-workforce 5.British Medical Association. Medical staffing in England: a defining moment for doctors and patients. 2021;1
Water is essential for life, and maintaining the correct balance of fluid in the body is crucial to health. 1
Maintaining adequate fluid balance is of paramount importance, especially for at risk patients and incorrect fluid balance levels increase the risk of Acute Kidney Injury (AKI) or fluid overload and delaying our patient's recovery.
To help ensure patients have appropriate fluid balances, it is important to accurately monitoring and documenting fluid charts. Although the Trust and the National Institute of Clinical Excellence have guidance to help ensure fluid balance is monitored efficiently, there was poor compliance to the recommendations. Although previous work to improve this had been done, improvements had not been sustained, therefore a multi-disciplinary approach was adopted, that included patient involvement.
All patients continuing to receive IV fluids need regular monitoring, this should include daily assessment of clinical fluid status, laboratory values and fluid balance charts along with weight measurement twice weekly
AIM:
accurate input, output and balance by February 2022.
Continued Improvement and Involvement of other teams/hospitals. Early detection of imbalance and intervening accordingly. Avoiding potential health implications of dehydration and overload. Delivering holistic patient care as per NICE guidelines.
DRIVER DIAGRAM
The following driver diagram was developed by the multi-disciplinary team to help achieve the above goals.
FISHBONE DIAGRAM
The following diagram was developed by the multi-disciplinary team to tackle the reasons for poor fluid balance monitoring.
As well as developing a driver diagram, a range of QI tools and methodology was used to ensure to achieve the aims. For example, PDSA cycles were used to test changes on a small scale and then refine and scale them up gradually across the Trust and beyond, based on learning. An example of a PDSA cycle is provided below:
PLAN Interventions to raise awareness of the QI project and baseline data developing a team approach to improving fluid balance monitoring on the ward
PLAN
DO
Displayed posters to educate and remind staff on the QI project and the importance of fluid balance charts placing it near the nursing station and in each bay
Ensured that the fluid balance charts were used and present in the correct set of notes i.e., bedside notes
Engaged the ward team, attending safety huddles
Ward leaders reviewed compliance with available fluid balance training
STUDY There was some improvement due to our initial interventions, but we still needed to achieve our target.
ACT
Tested proformas to involve able patients in fluid balance monitoring.
Placed copies of the project poster in bedside patient notes next to the fluid balance charts. Position and placing of equipment and documentation required was moved closer to where staff need it to be
Project Run chart showed a median improvement of 90% with 100 % achieving the targets at some points; compared to only 10% compliant to the guidelines at the baseline and 70% QI Results /Impact. The QI model reflects a great teamwork with patients, nurses, house asked to implement our QI project to other areas in the trust. AMU will be our next station to Improve. Project is in line with Nice Guidelines/Trust policy.
1.The valueof a multi-disciplinary approach was the key of success toachieveour goals and improve the quality of care.
2. Involving patients was challenging at first but worth it. As a understood the importance for his health. Highlighting the impact patient education can have on their own care.
3. Regular and effective communication between all staff members in Board/Ward rounds and safety huddles regarding fluid balance monitoring status.
4. Continuous monitoring of achieved improvement and re-auditing.
5. Transfer of improvement to other Trusts and wards.
The work is already being scaled up across the Trust and there are plans to scale up further. Further work is ongoing to ensure that there is more consistent data to maintain the improvements.
Thank you to the multidisciplinary team and patients who took part in this work.
Improving the delay in blood gas sampling in the Neonatal Intensive Care Unit (NICU)
Blood gases are done and run by doctors, not nurses in our neonatal unit.
This unusual situation delays decisions about the care of our babies and causes friction between our two tribes.
Currently, only 2 out of 10 blood gases will have been carried out within two hours of the decision being made.
Aim: By the end of February 2022, blood gases in the neonatal unit should be completed within 2 hours of the decision. The aim is to achieve this in 8 out of 10 blood gases performed.
Measurement:
Length of time (in minutes) between when a decision was made to do a blood gas and when this was actually carried out. PDSA CYCLES
• Agree with nursing staff a convenient time when a blood gas can be carried out (before a feed, after cares have been done, before cot linen has been changed)
• Raise awareness to staff.
• Provide training to use blood gas machine.
• Provide log-ins to staff with no access to blood gas machines
• Teach junior nurses how to run a blood gas
• Teach junior nurses how to do capillary blood gas Educational sessions around blood gas interpretation
• Allocate a doctor to do all the blood gases in the unit.
• Explain to parents what a blood gas is and why it is important. They could remind staff to carry out the blood gases.
Using the model for improvement I was able to tailor and adapt my interventions to the people that I wished to influence, easily seeing what interventions were helping and which were not. Testing small changes led to more ideas!
My primary aim was to reduce the delay in blood gas sampling by encouraging teamwork – doctors, nursing staff and parents
My next steps will be to review whether these changes are sustained and suggesting further changes e.g. whiteboards to write plans for babies, organising further POC training and access…
Acknowledgements:
Dr Molly Nichols, Jane Draper and Dr Jessica Webb
BACKGROUND:
• Echocardiography is a non-invasive diagnostic and monitoring tool
• Most widely used cardiac imaging modality
• Good understanding of echocardiography and accurate report interpretation is essential for patient safety and care
AIM:
• To improve understanding of echo amongst junior doctors
• To improve confidence with echo report interpretation amongst junior doctors
Developed a teaching session for junior doctors to improve understanding of echocardiography and confidence with report interpretation
Survey responses highlighted a lack of prior echo education and low levels of confidence and understanding amongst junior doctors
After struggling with echo report interpretation in my job role, I wanted to gain an understanding of echocardiography education received in the UGME and PGME settings and assess perceived understanding of echo and confidence with report interpretation amongst juniors
Designed and distributed a survey for FY1 and IMT doctors regarding echo teaching received, echocardiography understanding and involvement in job role
Significant average increase in mean confidence/ understanding across all areas:
• FY1 49%
• IMT 46%
PROBLEM: Only 6% of junior doctors felt confident at echocardiography report interpretation
88% of doctors of doctors interpreted an echo report ≥1x/week 94% thought it was an important skill
Plan to establish echo teaching in the annual FY1 and IMT teaching schedule, to expand for delivery to FY2 doctors, to develop a practical echo course alongside lecture based session
100% found the teaching relevant to their job role 91% would recommend the teaching
After reviewing the survey responses, I aimed to improve confidence and understanding of echo and report interpretation skills amongst FY1 and IMT doctors
Survey responses displayed significant increase in confidence and perceived understanding of both groups in echo report interpretation, understanding of echo components, identification of pathology/emergencies and clinical management of echo findings
Delivered a teaching session on echocardiography for FY1 and IMT doctors involving an interactive case based quiz. Designed and distributed a survey following the teaching to assess efficacy of the intervention
CONCLUSION The quality improvement project has been shown to make a positive impact on the confidence and understanding of echocardiography and report interpretation amongst junior doctors. Going forward, I hope to assess how this translates to improved patient care through more appropriate referrals, better recognition of pathology and improved patient management.
Method
1) Questionnaire and quiz (preintervention)
2) Flowchart widely circulated
3) Questionnaire and quiz (postintervention)
Additional qualitative data collected from wider ENT team about their experiences
The ENT team reported:
Reduction in patients seen in ambulatory clinic, unnecessary admissions, overnight telephone referrals
No reduction in patients missed during handover
PRE:
• 71% of SHOs felt ‘not very confident’ in managing ENT patients
• Themajority (57-86%) were unaware of various referral destinations and processes
POST:
• 100% of SHOs felt ‘somewhat’ or ‘very’ confident in managing ENT patients
• 100% of SHOs knewwhereandhow to refer patients
• Local presentation of QIP resulted in wider sharing of the flowchart across IT systems in the Trust
• Inclusion of the flowchart in induction presentations for new surgical SHOs – survey of new SHOs found that 100% found the flowchart useful
• Opportunity to adapt and distribute the flowchart to the Emergency Department
• Further improvement needed in quality of handover from SHOs to Registrars
E Seite, R Sawhney, M Innab
Adetoro Akintunde, Sashini Iddawela
General surgery at Good Hope Hospital is typically a fast-paced, ward cover centred job for a Foundation year 1 (FY1) doctor which requires learning a lot of administrative skills specific to not only the Heartlands, Good Hope & Solihull (HGS) trust but also Good Hope Hospital (GHH) specifically. The administrative skills may not be commonly exercised among seniors - who have different job requirements – and consequent reduced understanding or reduced transference of such skills may delay the process of adapting to the job.
§ To aid FY1 transition into the general surgery job.
§ To improve confidence of FY1s working in general surgery.
Dr S. Iddawela authored an informal guide style document for FY1s and distributed it to the GHH GS cohort commencing the FY1 role on 04/08/21 (cohort 1).
Qualitative and quantitative feedback for this guide was obtained via online survey.
This feedback was used to update, reformat, and add to the information within the guide; the updated guide was then distributed to the next cohort of GHH GS FY1s commencing the job from 01/12/21 (cohort 2).
A graph to show the difference between the quantitative feedback of two different general surgical FY1 cohorts following guide improvement
Favourite things about guide:
Cohort 1:
• ‘Written by someone with boots on the ground experience’
• ‘Had info I may not have been able to receive from seniors’
Cohort 2:
• ‘Gastrograffin protocol, easy to understand format, reassuring tone’.
• ‘Good brief summary of tasks expected of F1’
Areas for guide improvement:
Cohort 1:
Confidence about the role before receieving the guide
Relevance of information within the guide for surgical FY1 role
Information within the guide was easy to understand
Guide offered useful resources
Ease of guide navigation & reference
Cohort 1 Cohort 2
Guide improved transition into role of surgical FY1
Despite general lack of confidence around starting general surgery, a guide specific to FY1s improved their transition into the job. Further improvements of the guide based may allow for the guide to stay up to date and relevant to the ever changing cohorts. Future work may involve continually collecting feedback for this guide, updating, and improving it for future cohorts to refer back to.
References:
• More information regarding different IT systems like CARMAH
• Format and layout, clarity of information resources and topics in the guide.
Cohort 2:
• Length/structure
• tips on what is expected from night on calls
• Information about the handover list/ booking TWOC clinics/ M&M.
More than 237 million medication errors are made each year in England, according to a recent BMJ analysis (1)
Prescribing errors in the UK cost up to £98 million and more than 1700 lives each year (1). Potentially harmful errors are three times more likely to occur in prescribing for paediatrics than for adults (2)
Errors in paediatric prescriptions are common nationally, approximately 13.2% of prescriptions contain an error (3).
This QIP aims to:
Assess the adherence of prescriptions on the paediatric ward to national standards
To reinforce the prescribing standards we expect from doctors in common practice
To improve the quality of prescribing through weekly educational emails highlighting areas for improvement
Each week a random selection of 5 drug charts were collected from the pediatric ward. These drug charts were scored according to a selection of national prescribing standards that, after discussion with our MDT - including pharmacists, were commonly unmet on the ward. The proportion of charts meeting these standards were plotted onto a run chart each week.
Educational weekly emails were sent to all Paediatric Trainees and Consultants highlighting areas of prescribing improvement that week.
Common prescribing errors seen:
Chart 1
70% of the prescribing standards audited were not met prior to the intervention.
Targeted educational emails increase the proportion of prescriptions meeting national standards
Improvement following six PDSA cycles was seen in 100% of prescribing standards assessed; 30% of prescribing standards were met across all six PDSA cycles
The greatest scope for improvement remains in: writing prescriptions in capitals, signing and dating discontinued drugs
Paediatric prescribing is complex, departments should offer appropriate education to ensure standards are met
A targeted approach to increasing awareness of common errors improves team prescribing practice Despite education, prescribing errors will happen and we should develop a blame-free culture to ensure mistakes are learned from
Future directions: Prescription practise and personalised feedback for trainees, explaining common errors using examples
Background
Resuscitation UK advise that a debrief should occur after an inhospital cardiac arrest to guide reflection, learning and psychological support[1].
Problem
A survey was sent to all junior doctors (F1-SpR) to gain qualitative data and develop an understanding of the experiences of an in-hospital cardiac arrest at UHD Trust. The key finding was that when part of a cardiac arrest team many junior doctors felt moderate levels of stress. The area of improvement that received the most support was of a debriefing session post-arrest. There were no documented debriefs post-cardiac arrest at UHD Trust prior to this project.
The implementation of the debriefing prompt on the online medical emergency form occurred on the February 1 st 2021. Post-implementation, an aim to increase the number of documented debriefs that occur after an in-hospital cardiac arrest by 20%, between February 2021 and May 2021 was set.
Aim
Outcome
Measure
A review of the medical emergency form where all cardiac arrests are documented was reviewed retrospectively (February 2021 to May 2021) and the number of debriefs completed and themes discussed was recorded.
How
how does that make you feel? (n=62)
Unable
Increase the frequency of debriefs occurring after inhospital cardiac arrest
Resuscitation Team
Junior Doctors
Lack of established debriefing documentation for cardiac arrest
Adherence to Resuscitation UK Guidance
Junior Doctor experiences of inhospital cardiac arrest
Creation of a model fit for purpose locally
Update the online medical emergency form
Junior Doctor Survey
Meeting with key stakeholders to understand how a debrief can be implemented
Trust wide meeting to discuss findings of QIP
Literature review of debriefing models
Working with IT to implement debriefing on online medical emergency form
1.By introducing a debrief tab to the Medical Emergency Record from we were able to trigger the process of debriefing post -cardiac arrest.
2.The feedback from consultants and junior doctors from this QIP at a local audit meeting was very encouraging. This helped fulfil another improvement idea ascertained from the survey which was of a hospital meeting to discuss the QIP.
3.The debriefing tab will be introduced at a partner hospital once an online medical emergency form has been implemented to replace paper cardiac arrest forms.
4.The Resuscitation Teams have received formal training in debriefing.
5.A debriefing lead within the resuscitation team is being organised to monitor the debriefing process.
The COVID-19 pandemichas resulted in profound changes in dental service provision in both primary and secondary care settings. King’s College Dental Hospital has served as a prominenturgentdental care hub in London, and has lead to anincreased volume of patients seeking access to emergency dental services
The hugedemandhas resulted in the need for triagingof incoming calls, enabling identification of patients who are clinically appropriate for treatment, who are then assessedand treatedon the Acute Dental Care (ADC) Department Patient details are collated daily from the dental emergency telephone line to be triaged by clinicians
Triaging can be a stressful experience for staff and many see this as the least enjoyable part of their day.
• To improve staff satisfaction and reduce staff anxiety and stress during the dental triage process
• To ensure patients are appropriately triaged to be seen on ADC
The majority of clinicians reported that telephone triaging is a stressful experience due to limitationsin thetriaging system, specifically a lack of acceptance criteria. An updated triage pro-forma which includes clear acceptance criteria was created to facilitate information gathering.Improvements and relevant adviceaddressing reported concerns were disseminatedduring a departmental staff meeting. Clinician experience was re-measured to evaluate the impact of said improvements on staff experience.
There is a need to telephone triage patients to assess suitability for treatment.Improvements can be made to the telephone triage system which can potentially reduce stress levelsin staff members Clinicians responded positively to the new form and the inclusion of access to a generic email have made the process easier.
First Cycle
Feedback from clinicians and the relevant changes made to the system.
Second Cycle Results
The new pro-forma for information gathering.
Fig. 3 Responses show a small reduction in those reporting triaging as a stressful experience (6 and over) after the implementation of changes
Whilst the reduction in clinicians reporting triaging as a stressful experience is reassuring, the results are indicative that further measures could be taken to address outstanding concerns and demonstrates scope for further improvement
Fig. 1
Fig. 2
Safeguarding in ED is important and a product of adequate training and professional curiosity. From the problem statements below, a multidisciplinary and multimedia theme-based educational programme was organized.
Educational Barriers
• Busy department with unpredictable workload
• High staff turnover with COVID-19 limitations
• Poor staff compliance with level 3 safeguarding training
• Lack of dedicated departmental safeguarding support
Service Provision Concerns
• Estimated 5% increase in safeguarding concerns from the previous year according to the Office of National Statistics.
• Safeguarding on hospital risk register as a high CQC* priority
Methods/Media Specifications
Formal sessions Nurse, SHO and Registrar weekly departmental teaching
Informal discussions Daily reminders/updates at doctor and nurse handovers
‘Tea trolley’ teaching Multidisciplinary, small focus groups
‘bogBlog’ Posters on the back of staff toilet doors (Figure 1)
Social media Facebook, Twitter
Direct e-mail 'All ED staff’ list used
Visits by wider safeguarding team
Members of Adult Safeguarding, IDVA** and Learning Disability services available in the department
Before and after surveys were conducted to obtain cross sectional data on staff attitudes towards and compliance with safeguarding training and practices.
• Despite compliance with mandatory training, staff lacked confidence in their delivery.
• 100% of staff surveyed had received information from one or more of the methods utilised. (Figure 2)
• Common attitudinal barriers towards safeguarding identified (Figure 3)
• Overall improvement in staff confidence (Figure 4)
40 staff - Where have you seen information on safeguarding?
How confident are you with....
Capacity, MCA and MHA
Patients who abscond
Who the IDVA is and role
Asking parents and children about…
Asking patients about domestic abuse
Referring an adult with safeguarding…
Referring a child to MASH
Before safguarding month
After safeguarding month Figure 4
Senior staff were able to identify common themes regarding staff delivery of safeguarding consequently consider solutions to rectify highlighted issues.
• The need for dedicated departmental safeguarding support and training
• The need for consolidation of available resources for ease of access
• Replication of this educational month to enable collection of quantitative data
It was also concluded that the use of theme-based, opportunistic departmental teaching creates an educational forum of discussion and is an effective method of delivering teaching in the unique ED environment.
The clinical handover process is an essential part of providing continuity of care . Issues surrounding handover can lead to avoidable errors and can affect patient safety. Our Urology department noticed significant problems with the handover process including patients not being added to the inpatient list, and therefore not being seen on the ward round, lack of or inaccurate clinical information, and poor communication between general surgical teams covering Urology out of hours. The current standard was a simple list of inpatients including their name, hospital number and location.
Our aim was to improve the clinical handover process using a three-pronged approach:
• Increase the confidence of clinicians in accepting and giving handover
• Ensure all Urology admissions were added to the list to avoid patients being missed
• Improve the clinical information available to enhance continuity of care and patient safety.
Plan, Do, Study, Act (PDSA) Cycles were led by a team of junior doctors who undertook a questionnaire to determine healthcare professional’s views on the current Urology handover process and to identify issues that need to be addressed.
Cycle 1: The current standard was replaced by a word document list (WDL). This included clinical information, blood results and outstanding jobs. Time inefficacy and lack of access and confidence in using this list proved to be significant issues.
Cycle 2: The word document was replaced by a digital list using the Electronic Patient Record ‘Cerner’. This built on the Cycle 1 list, however moving online allowed for clinical details to be pre-populated and autofill of blood results, which improved the efficiency of the handover process. However, clinician access remained an issue.
Cycle 3: A general access list was created using the Care Team Handover on Cerner so that all medical staff could access the list, enabling them to add patients and their clinical progress.
Cycle 1: Our questionnaire showed patients were not added to the handover list ‘often’ 20% (N=2 of 10) or ‘occasionally’ 50% (N=5 of 10) of the time. This improved to ‘rarely’ with the implementation of the WDL, 75% (N=6 of 8), shown in Figure 3. However, the WDL was time consuming to update and unfortunately 44.4% (N=4 of 9) did not feel confident adding patients to the list (shown in Figure 4). There were also clinical governance issues relating to saving and accessing the WDL. There was increased confidence in handing over and a preference for clinical details being available.
Cycle 2: Feedback studies showed improved access and use of the Cerner list but patients were still being missed, particularly when admitted out of hours. Data showed that only 71% (N=5 of 7) of general surgical doctors had access to the Urology List, which was most likely the cause of patient’s being missed therefore it became clear that a general access list was required.
Cycle 3: Our final questionnaire showed that 100% (N=9 of 9) of general surgical doctors had access to edit the list and 100% (N=15 of 15) of the urology team reported that patients were rarely missed off the list.
DATA:
Lessons: The new Urology inpatient list and handover process ensures that patients are handed over and continuity of care and patient safety has improved as a result. There has been a significant improvement in patient’s being added to the list particularly when admitted out of hours and the care team handover list has provided all general surgical doctors access to the Urology List.
Considerations for the future: We could further improve by giving new general surgical doctors compulsory Cerner training on how to add patients to the Urology List and how to edit this list. This would hopefully avoid changeover period causing a lack of continuity in accurate handover.
Figure 3: Improvement in how often patients were missed with implementation of WDL Figure 4: Lack of confidence In using the WDL was an issue Figure 5: Care Team Handover List gave all general surgical team members access Figure 2: The final list using Care Team Handover Figure 1: The Current StandardAuthors: Dr MohannadAbuomar(ACCS trainee), Dr Harry Alker (FY2 trainee)
Contributors: Dr Gareth Hardy (ICM/EM Consultant),Tessa Walmsley (anaesthesia associate), DrAnukiranRavichandran (ACCS traine e)
Peripheralintravenouscannulation(PIVC)is the mostcommoninvasiveclinicalprocedure required in hospitalized patients in whom 10- 24% is reported to have difficultvenousaccess(1,2).Blackpoolhospital has a cohort of patientswitha high prevalence of identifiedindependentriskfactorsfordifficult IV access e.g., intravenous drug users (3), leading to delays in peripheralvenous accessand thereforeinvestigationand criticalmedicationadministration. We aimed to achieve:improvedpatients' experience, 50%reductionincalls to anaestheticsforassistancewithdifficult PIVC and 50%reduction in the number of vascular access related clinicalincidents in the hospital.
Introduction and aims Clinical
No
Methodology + PDSA cycles
To achieve our aim
50% Reduction of: -Cannula calls -Incident reports Improved Patient Satisfaction
We needed to ensure...
A team who take ownership of difficult IV access
Which required...
-Pilot study on small group - Training acute response team (ART) members
Missed/delayed administering: (IV antibiotics, IV fluids,peripheral TPN, electrolyte replacement,insulininfusion for DKA, analgesiaand bloods Suboptimal
Ideas to ensure this happened
- ART to feedbackperformance and patientsatisfaction FAILED
-Teaching faculty
4 Objective data collection (Figure 2)+ USC teaching faculty set-up.
3 Engaged with stakeholders proposing service set up.
2 Pilot study on USC - 10 trained with good performance and patient feedback.
1 Staff survey (Figure 1)
Learnt
Everyone's responsibility +/- service setup
Address unexpected results
Wider regular USC teaching
5 Engaging with community vascular access team andaddressing unexpected results. Consider alternative peripheral access with longer dwelling time
Use of ultrasoundguidancehad been successfulin the pilot study thereforeawiderultrasoundteaching and sign-offprocesswas developed.IMT2 and FY2training program teachinghas been establishedand we aim to have thisavailableforfuture trainees also.Following7teaching sessions of 32 candidates the number of calls to anaestheticsdropped by over 50%(Figure3).Vascular access service remainsnecessary and the project results have been shared with the communityvascularaccess team to supporttheirbusinesscase.
We learnedthatwith departments stretched already,placing an extra service on them was too much to ask .Therefore,spreading the skill of USC throughout the hospitalwasaproductive alternative.
We had troublegainingfeedbackfromtraineesdue to requestinga paper form. Alternatively, we would have liked to use a QR codeforthis.
Contact details: mohannad.abuomar@nhs.net, harry.alker@nhs.net
Acknowledgements: Emma Wiper (Quality improvement programme manager), Dr Ben Pope (ACCS trainee), James C.R. Rippey (Senior Clinical Lecturer at University of Western Australia + creator of online curriculum)
No. of calls
-Adopting online curriculum https://sonocpd.com/
-Creating phantom limb
-Adjusting sim suite set up
-Booking rooms for teaching
-Sending out advertisement
-Implemented into trustbased teaching program targeting all IMT2/FY2 doctors
-Midline utilisation data
-Raise midline awareness
-Share results with community vascular access team
Number of anaesthetic calls for PIVC assistance over time
3 teaching sessions
2 teaching session s
2 teac hing sessions
2-week cumulative intervals
Note drop in calls
References:
1.Rodriguez-CaleroM et al .RiskFactors for Difficult PeripheralIntravenous Cannulation. The PIVV2Multicentre Case-ControlStudy.[Internet]. 2020 [cited 20 April 2022];9(3):799 Available from: https://www ncbi nlm nih .gov/pmc/articles/PMC 7141318/
2.Rodriguez-CaleroM et al .Defining risk factorsassociatedwith difficult peripheral venous Cannulation :Asystematicreview and meta-analysis.ScienceDirect. 2019;49(3):273-286
3. Drugs Lancashire County Council Available from: https://www lancashire gov uk/lancashire-insight/health-andcare/health/lifestyle/drugs/
• Epistaxis is a prevalent ENT emergency seen in the emergency department.
• The high incidence is compounded by the frequent re-attendance rate of its sufferers.
• Many patients return due to lack of knowledge or confidence in managing epistaxis.
• Improve patient education around management of epistaxis by providing patients with a patient information leaflet.
• Improve self-management of this condition, which in turn helps reduce morbidity and readmission.
A questionnaire was designed by doctors and other stakeholders in the department, focusing on patient confidence in management of epistaxis. A Likert scale was used to measure their responses.
Throughout February 2022:
• Patients admitted with epistaxis were given the questionnaire.
• They were then provided with the patient information leaflet.
• The questionnaire was repeated after they had read the leaflet.
Data from the questionnaires was assimilated and analysed using a combination of excel and SPSS
• Analysis showed a significant difference in self-reported confidence in managing epistaxis.
• As the sum of the positive ranks are larger than the negative ranks, it can be deduced that patient confidence in managing epistaxis improved after the implementation of the patient education leaflet
Self-reported confidence in managing epistaxis
Before intervention After intervention
Providing patients with a patient information leaflet improves their confidence in managing epistaxis.
• Ensuring a constant supply of leaflets in accessible locations around the hospital to ensure lasting change.
• Future cycles of this QIP to be carried out to establish whether this intervention reduces admissions to hospital with epistaxis
• Ward listsareimportance sources of information transfer between members of the clinical ward team
• Large volumes of information on ward lists can make it difficult to identify key information or the clinical status of patients
• This difficulty is compounded by high turnover of staff, requiring frequent transfer of large quantities of information
Create a visual aid using colourcodes to quickly identify patient clinical status andimproveinformation sharing between the clinical team on ward lists.
• Improve identification of key information on ward lists
• Survey to assess stakeholder needs/view of problems:
Qn: Are you able to quickly identify when the clinical status of a patient has worsened?
Qn: Is the current list design appropriate/sufficient in helping identify patients who are MFFD? n
• A colour coded traffic light system may be a useful tool in helping to identify key patient information on surgical lists
• Consistency is key when implementing a reliable change
• Difficulty implementing a change in a shifting clinical environment. Importance of a consistent stakeholder.
1)Identify a ‘champion’ stakeholder to improve consistency of change
2) Further reduce colour codes to simplify and reduce admin burden:
RED: Requiring ongoing medical input
GREEN: Medically Fit for Discharge
Create a ‘traffic light’ code focusing in 3 main patient categories:
RED: Worsened clinical status
AMBER: Awaiting investigations/theatre
GREEN: Medically Fit for Discharge (MFFD
• Short teaching sessions provided to stakeholders on planned change
• Implement traffic light visual aid on ward lists for 8 weeks on surgical wards
• Re-survey stakeholders to determine if planned intervention has been successful
Qn: Were you able to quickly (on first glance of the list) identify MFFD patients/worsened clinical status patients with the colour codes?
Did you find the colour codes useful in updating the list?
n = 10
“If you were updating the list when a patient had distinctly improved or deteriorated, the traffic light system was a clear way of ensuring this would be communicated to the team”
“More effort to update the list but also easier to hone in on MFFD or unwell patients. However, it wasn’t always updated fully so not all MFFD/unwell patients were highlighted which made me trust the system less”
Rhian Bevan, Dolapo Thompson & Dale Thompson. Royal United Hospitals Bath
• Liaison psychiatry services provide diagnosis and treatment services for patients admitted to the general hospital setting with concomitant physical and mental health needs.
• Despite this, patients can be acutely unwell with mental health illness and approximately 5.2% of patients reviewed are ultimately transferred to a psychiatric hospital.(1)
• During psychiatric assessments, the interview often involves discussing personal information, which patients may feel uncomfortable disclosing in ward bays.
• Locally, we have observed that access to private spaces for assessments is not always possible and this may have an impact on accurate risk assessment and management.
This survey aimed toidentify the current availability of private spaces for psychiatric assessments on inpatient wards in general hospitals.
• Multicentre cross-sectional survey design of inpatient wards based at four general hospitals.
• Wards were identified that the adult liaison psychiatry department commonly received referrals from. A single-assessor attended each hospital and surveyed the Nurse In Charge (NIC) during normal working hours.
• On each ward the nurse in charge (NIC) was identified and a brief verbal explanation of purpose and importance of the survey was given. If the NIC consented to being involved in the study, they were then sequentially asked the following questions:
1. Is there a designated private space on the ward to have sensitive conversations with patients? (Yes/No)
•Measure the availability of private spaces and its importance.
•Analyse the data to identify if private spaces impact patient care.
•Carry out a multicentre survey across the same NHS trust.
• The Psychiatric Liaison Accreditation Network (PLAN) guidelines recommend: “Where clinically appropriate, the team has access to, and use of facilities that offer dignity and privacy to conduct assessments.”(2)
• Wards where a private room was not available had a higher incidence of interruptions.
• This could result in communication failures and patients withholding sensitive information.
Ø This PDSA cycle has highlighted the lack of availability to private rooms that liaison psychiatry teams have when assessing patients in general hospitals and has presented this to hospital management to facilitate trust-wide changes inpatient wards.
Ø The lack of private rooms increases the risk of patients being interrupted during assessments which put patient dignity at risk and may lead to substandard care.
Ø To rectify this hospital management should assess the feasibility of allocating private rooms on each inpatient ward in general hospitals.
Ø Further PDSA cycles plan to reassess the availability of private spaces now that the issue has been highlighted to hospital management and provide teaching to nursing staff to emphasise the importance of preserving private rooms on wards.
1F2,
Correspondence: aayenah.yunus1@nhs.net
Patients with severe mental health illness have a lower life expectancy of 13 -30 years compared to the general population, with a significant proportion of excess mortality secondary to physical conditions 1, including dyslipidaemia, diabetes, and cardiovascular disease3. Acute inpatient psychiatric admission provides an excellent opportunity to screen for physical illnesses and to effectively manage these to reduce morbidity , improve patient outcomes, and increase cost effectiveness 2. We found that absence of up -to -date information hindered our ability to make management decisions.
Aims
• Improve assessment and documentation of physical health assessments
• Ta rget compliance - 100% of patients being offered physical examination, blood tests and ECG withing 24 hours of admission
• If not completed, a reason should be documented in the patient’s notes
• Implement sustainable interventions to improve compliance in our unit
Establish baseline Increase staff awareness Optimise task handover
DoClinical poster Email all ward staff Highlight outstanding tasks
Review inpatient paper notes and systems Identify shortfalls
Draft staff information email
Create guideline poster Daily ward reminder
To obtain a baseline measurement, we retrospectively reviewed current inpatient notes (n=30) and collected data from their physical healthcare folder, digital patient notes (Rio) and blood test result reporting system ( WebV ) using a standard proforma.
The process was repeated by retrospectively collecting data for new patients for each PDSA cycle over a 2-week period.
Documentation rates improved from 18.5% à 50% for ECG and from 20% à 50% for blood tests, however there was a marginal decline in documentation rates for physical examination from 34.8% à 33.3%.
Barriers identified included lack of awareness of the guidelines, suboptimal handover between clinical staff, and limited res ources during out of hours shifts. Our interventions addressed these issues by improving awareness of the guidelines and by increasing comm unication between all clinical staff by establishing a daily reminder to discuss outstanding investigations. Our project yielded effective sustainable improvements in patient care, which can be expanded on in the future. We recommend that the dedicated daily ward round reminder continue, as well as the aide-mémoire poster be posted in all clinical areas as an important and effective tool to summarise guidelines and supplement other interventions.
etal . Physical illness in patients with severe mental disorders. I. Prevalence, impact of medications and disparities in health care. World Psychiatry. 2011 Feb;10(1):52-77. Park A, McDaid D, Weiser P, Von Gottberg C, etal . Examining the cost effectiveness of interventions to promote the physical health of people with mental health problems: a systematic review. BMC Public Health. 2013;13(1). 3.Osborn D, Burton A, Hunter R, etal . Clinical and cost-effectiveness of an intervention for reducing cholesterol and cardiovascular risk for people with severe mental illness in English primary care: a cluster randomised controlled trial. The Lancet Psychiatry. 2018;5(2):145-154.
IV accessand blood samples frequently form clinical management plans. On the surgical wards, the junior doctors perform these and need to be prompt when dealing with acute situations like sepsis, perforation, bowel ischaemiaand acute bleeds. The treatment rooms should facilitate quick identification and collection of basic items to minimize delays to patient assessment and treatment. Across the four general surgery wards in Queen Alexandra Hospital, Portsmouth, each treatment room is different with equipment difficult to locate and reach. This wastes time in critical situations and daily ward jobs.
By decreasing the time taken by junior doctors to identifyand collect vital equipment from the surgical treatment rooms we aim to reduce delays in patient assessment and treatment.
15 Junior Doctors were asked to enter the Surgical Assessment Unit treatment room to collect the equipment needed to gain IV access using a cannula, obtain samples for routine bloods, blood cultures, and blood gas syringe- as they would do for a deteriorating patient. The use of cannulation packs which have some of the items pre-packed was allowed. The doctors were advised to use their usual method to gather the equipment and to leave it unopened.
Items to Collect:
Alcohol wipe, tourniquet, cannula, syringe/adapter, purple & yellow blood bottles, aerobic & anaerobic blood bottles, needle, blood gas syringe, gauze, extension cannula sticker and saline flush.
Some of the doctors worked on the SAU and some were treating outlied patients (so were less familiar to the treatment room layout).
The doctors were timed from when their ID card granted them access to the room until the time they exited.
The treatment room drawers were then re-organized. The equipment needed for cannulation and venepuncture were organized into one column and in order of use. The blood gas syringes and remaining items were in the neighbouring column, with new, clear labels applied.
After the intervention, the average time decreased by over 25% and SE decreased from 12.6s to 8.9s showing the doctors had become quicker in the more organized treatment room. Additionally, the range before the intervention was 199s (min 60s; max 259s) and after the intervention it had nearly halved to 104s (max 147s; min 43s).
We sampled junior doctors who were caring for outlied patients on the surgical assessment unit. These doctors were unfamiliar to the treatment room layout and naturally took longer to locate the equipment. We invited these doctors to participate withthe rationale that every doctor should be able to enter and identify the key equipment they need. Often in critical circumstances, the doctors assessing and treating the patient are not based on that ward, so would need to be able to use the treatment room for its purpose, with minimal delays due to disorganization or counterintuitive layouts.
For the second PDSA cycle we will reorganize the remaining three surgical wards in a similar layout with the same labels. After 2 months we will time doctors again. This is an appropriate time to acclimatize to the new layout and will be before junior doctors rotate to their next rotation.
Based on a 25% improvement after organizing one treatment room, we recommend standardizing the surgical treatment rooms to a similar layout, where cannulation and venepuncture equipment are grouped together. This would mean doctors based across the surgical wards would spend less time searching for basic equipment, and in the event of a deteriorating patient,would be able to access equipment to gain IV accessand blood samples quickly. Standardising would reduce discrepancies between the wards and take a doctor less time to acclimatize to each room’s layout. We found arterial blood gases particularly poorly labelled and would recommend all equipment to have a designated area and clear label which would further reduce time spent searching for anitem that may be outof stock completely.