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Bristol Patient Safety Conference 18th May 2022
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Entry IdLead Author TitleLead Author NameLastJob TitleOrganisationCo-author names and job titlesPoster titleProject Introduction and Aims (120 words maximum)Project Methodology / PDSA Cycles (120 words maximum)Project Results and Lessons Learnt (120 words maximum)
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4DrTrinoCruz CerveraAnaesthetist trainee/Chit Wong, Foundation DoctorPerioperative blood glucose monitoring10-15% of patients presenting for surgery have diabetes (over 323,000/ year). They are associated with longer length of stay ( on average 3 days), medication error and complications. Proper glycemic control is essential to prevent long term complications and to reduce overall disease management cost. This project aimed to look at/ improve the standard of perioperative blood glucose monitoring within the York teaching hospital.We retrospectively collected data from 38 diabetic patients undergoing general anaesthesia for a surgical procedure between 02/11/2020- 13/11/2020. List was obtained from clinical records, requested notes and reviewed notes. Standards used: Joint British Diabetes Society for Inpatient Care (JBDS-IC)- The Management of Perioperative Care guidelines (endorsed by the RCoA) What we looked at? 1) was the blood glucose measured hourly for diabetic patients (if not, where was this (theatre/PACU), allowing us to obtain a target audience for any changes/teaching) 2) Was the blood glucose maintained between 6mmol/l – 12mmol/l perioperatively. 3) In those where inadequate monitoring or poor blood glucose control, any immediate post-operative consequences. Out of the 38 patients, the anaesthetic time for 10 of the patients are <60mins and 28 are >60mins with 8 and 21 had a documented CBG during perioperative stay respectively. 24% carried out hourly CBG measurement in the theatre and 58% did in the PACU. Only 32% of those patients with an anaesthetic time >60mins had an hourly measurement of CBG in the theatre. 50% of the patients maintained CBG in range, 29% were outside the range and 21% were not documented.3 patients required starting of VRII in PACU and 1 patient required x2 stat doses of 20% glucose. 4 patients were discharged from PACU with CBG outside range and 2 with CBG >18mmol/l with no hyperglycemia management started.
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5DrNadaKhalilFoundation Year 2 DoctorLondon North West NHS TrustLeah Mapara- Dermatology SpR
Randa Alhajjar - Dermatology Consultant (supervisor)		Compliance of BAD advice on the safe prescribing of isotretinoin Oral Isotretinoin (Roaccutane) is a very effective treatment used for moderate and severe acne vulgaris. Careful assessment and close monitoring is imperative when prescribing this medication given its side effects and teratogenic nature. The British Association of Dermatology (BAD) have created clinical guidelines on the safe introduction and continued use of isotretinoin. There are 5 clinical audit points based on these guidelines that every specialist prescribing isotretinoin must adhere to. The aims of this project were to assess the safety of isotretinoin introduction and monitoring at Northwick Park (NPH) and Ealing Hospital (EH) Dermatology clinics. We also sought to identify areas of improvement within clinical practice when prescribing and monitoring isotretinoin in order to promote safe practice among clinicians. A total of 38 dermatology patients (29 female and 9 male) who had been prescribed isotretinoin at NPH between January and April 2018 were analysed. Following the first audit cycle a pharmacy led isotretinoin clinic using a checklist compliant with BAD guidance was set up. We also introduced a SHO led acne clinic for new patients where newly created guidelines using the NICE 2021 guidance were provided to use in clinic. A further cycle was performed on 66 dermatology patients (37 female and 29 male) from NPH and EH between September 2020 and May 2021. Exclusion criteria included missing and incomplete clinical records. Our electronic database for clinic letters and blood results were analysed and relevant information recorded. Results of the initial cycle showed variable compliance with BAD guidance; whilst there was 100% compliance with lipid level monitoring, only 68% of female patients had a record of receiving information on the pregnancy prevention programme. This improved to 97%. 100% compliance was seen in audit points 2-4 post-intervention. Initially, 79% had mood documented at baseline, with 51% documented at follow-ups. Post-intervention, 68% was documented at baseline and 91% at follow-ups. To improve compliance further, we have uploaded the isotretinoin checklist onto our online system to ensure all documentation is in one place. We will also ensure a BAD leaflet and ‘Roaccutane alert cards’ is provided to better inform patients about the risks of the medication, in particular its teratogenicity.
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6DrLeahFaganFoundation Year 2The Royal Derby Hospital - TrentChioma JamesA complete audit cycle assessing how accurately VTE prophylaxis assessments were completed for elective surgical patients at King's Mill Hospital.The sheer nature of having a surgical procedure increases the risk of a patient developing a venous thromboembolism (VTE). Considering this, both NICE and local guidelines state that patients undergoing surgical procedures must be assessed for their thrombosis and bleeding risk. Following this assessment, the patient must receive the appropriate VTE prophylaxis, whether it be pharmacological or mechanical. This audit was performed to determine if patients undergoing elective surgery at King’s Mill Hospital received an accurate VTE assessment and subsequent appropriate VTE prophylaxis.The VTE risk assessment forms were reviewed in conjunction with the patient’s medical history and assessed against our VTE data collection proforma. Each aspect of the VTE assessment that satisfied the questions on the proforma received one point. A total of twelve points could be awarded, indicating that the audit criteria was met. The results revealed a number of deviations and discrepancies from the national compliance criteria. The results were presented at the surgical division wide learning event which led to a debate and a discussion about how we can enhance patient safety by improving the compliance of accurate VTE assessments. A poster highlighting these findings was circulated amongst each surgical speciality and a re-audit took place.Initially 33% of VTE forms were accurately completed. Poor compliance was observed in recognising the significance of the patient’s thrombotic factors, the use of spinal anaesthesia, the combined anaesthetic and surgical procedural time and the time/date of the assessment. A total of 77% of patients received appropriate thromboprophylaxis. The remainder had errors in the choice of VTE prophylaxis on the form and errors on the corresponding prescription chart. A re-audit was performed which had an increased sample size. This ensured an even representation of cases within each speciality. The findings showed a 2% improvement in the accuracy of completion of the VTE assessments alongside a 4% improvement in the accuracy of the VTE prophylaxis prescribed.
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7DrDaisyWilliamsFY2 DoctorNottingham University Hospitals NHS TrustGastroprotection for patients aged over 70 on antiplatelet therapyAntiplatelets are one of the most prescribed medications in the UK. They are licenced for secondary prevention following cardiovascular event, and prolonged antiplatelet therapy reduces vascular mortality by 15% over 2 years. Aspirin increases gastrointestinal bleeding risk by 60% and of these bleeds 10% are fatal; in high-risk patients, co-prescription of proton pump inhibitor (PPI) should be considered. PPIs are associated with a decrease of 80% in gastrointestinal bleeding risk, however, they are associated with risks of their own.
This audit assessed how many patients aged over 70 and on antiplatelet therapy were not on gastroprotection, and how many patients had this discussion. Patients would then be contacted to discuss the benefits and risks of starting gastroprotection with PPI.
NICE guidelines state that a significant risk factor for antiplatelet-induced gastrointestinal adverse events is older age, especially over 70 years. If one of more risk factors is present, patients are considered high risk and PPI should be considered. A search was conducted on SystmOne for patients aged over 70, on antiplatelets and not on PPI which identified 74 patients. 16 patients were excluded as they were on a PPI or H2RA, no longer required antiplatelets, died or moved surgery. 53 patients met the eligibility criteria, and were contacted for PPI discussion. Benefits, risks, and side effects of gastroprotection were standardised to reduce risk of bias.64.2% of patients decided to start gastroprotection. Of the patients that declined, the most common reasons were no symptoms suggestive of gastrointestinal disturbance (36.8%) and concerns regarding side effects (26.3%). Older patients were more likely to accept gastroprotection. 10 patients had additional risk factors, including previous gastroduodenal ulcers and concurrent NSAID use. 81% had never had discussion regarding gastroprotection.
We must emphasise to patients that gastrointestinal haemorrhage can develop asymptomatically. The best time to discuss gastroprotection may be at initiation. Medication reviews are the optimum time to identify these patients, and must be thorough and structured. Giving patients sufficient information to make informed decisions is essential, as is discussing their concerns and expectations.
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8DrCharlesCareyF2Manchester University NHS Foundation TrustDr Shanthi Natarajan - General PractitionerImproving Patient Education About Pre-Diabetes in the CommunityPre-diabetes is a common condition that precedes type 2 diabetes and may potentially lead to early forms of diabetic neuropathy, retinopathy and macrovascular disease. The development of pre-diabetes is heavily linked to lifestyle factors such as high carbohydrate intake and a lack of exercise and many patients are unaware of what changes they can make to improve their condition. Unwin et al have shown that one-to-one consultations between patients and GPs focused on reducing carbohydrate consumption can be effective at improving pre-diabetes and have created a diet fact sheet. The aims of this QIP were to improve patients' understanding of pre-diabetes and encourage a reduction in their carbohydrate intake in a primary care setting.Pre-diabetic patients were identified using EMIS reports. Patients were included if they had 2 HbA1c levels between 42 - 48mmol/mol and the ability to make dietary changes independently. A questionnaire was constructed based on the UK Diabetes and Diet Questionnaire and used to ask patients about their concern about pre-diabetes, knowledge of foods that contribute to the condition and the frequency at which they consumed various carbohydrates via telephone consultation. Advice about reducing carbohydrate intake was given verbally and patients were provided with the diet sheet produced by Unwin et al. Patients were called again after 7 - 14 days to assess the impact of the advice provided and whether they had made changes to their diet.31 eligible patients responded to the initial telephone call of which 58.1% were concerned about pre-diabetes and 38.7% mentioned at least 1 food high in carbohydrate as a cause of pre-diabetes. 90.3% of patients consumed food high in carbohydrate on at least 4 days of the week. 22 patients responded to the follow up telephone call of which 63.6% reported reducing their carbohydrate intake, 95.5% felt they knew more about pre-diabetes and 90.9% found the dietary advice and leaflet helpful. The data therefore suggest that patients' awareness of the contribution of carbohydrates to pre-diabetes was improved significantly following the consultation and that pre-diabetic patients should be given verbal and written information about lowering carbohydrate intake at GP consultations.
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9DrCharlotteSandbergFY2North Hampshire Hospitals NHS Foundation TrustMr Matthew Archer, Core Surgical Trainee
Mr Omar Aly, Speciality registrar in General Surgery		Post-operative VTE prophylaxis in patients undergoing abdominal cancer surgeryEvidence shows that cancer patients are at higher risk of venous thromboembolic events (VTE), and that this increases in the post-operative period.

Cochrane review from 2019 analysing prolonged Thromboprophylaxis with LMWH after abdominal surgery found overall prolonged use significantly reduced risk of VTE.

As a result, NICE Guideline NG89, states that surgeons should ”Consider extending pharmacological VTE prophylaxis to 28 days postoperatively for people who have had major cancer surgery in the abdomen.''


The aims of our audit were to establish whether our clinical practice reflected these guidelines and ascertain, as a secondary aim, whether potential non-compliance with the guidelines resulted in any harm to patients.		Patients were identified using an established local colorectal database. The patients' discharge summaries were reviewed to establish whether they had been prescribed extended thromboprophylaxis on discharge.

Inclusion criteria: All patients who were admitted to RHCH colorectal team between 1/7/2020 – 31/12/2020 who had the diagnosis of any form of cancer. This was inclusive of elective and emergency admissions. N=42

Second audit cycle (after intervention) inclusion criteria: all patient’s admitted in the 28 day period before and after changeover (10/3/21-7/4/21 and 8/4/21-10/5/21). N=10


Exclusion criteria: Patients with diagnosis ‘cancer’ that did not undergo operative intervention. Patients who underwent endoscopic procedure only. Patients who were still in hospital at the time of audit.		We found that whilst VTE prescribing was good overall, it was not perfect.

Overall 95% of patients were discharged with extended VTE prophylaxis. However, only 85% of patients recieved the correct number of doses on their discharge summaries.

Most notably, when looking into the errors that resulted we found that these happened disproportionately when patients were discharged out of hours, at a time where it was less likely that the doctor completing the discharge summary was from the patient's regular team.

After intervention of an information session and putting up posters to highlight the NICE gudeline the second audit cycle was completed.

This showed 100% of patients were discharged with extended VTE prophylaxis and 90% with the correct length.
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10DrRosalind + AimeeBeckett + LeadbetterCT1 + IMY3RUH, Bath Dr Rosalind Grace Beckett CT1 ACCS
Dr Aimee Leadbetter IMY3
Dr Clare Marchand Respiratory Consultant
Dr Sharon Sturney Respiratory Consultant
Improving safe sedation practices in bronchoscopy at a District General HospitalProject Introduction:
Procedural sedation and analgesia (PSA) practice varies, with minimal standardisation in bronchoscopy. The British Thoracic Society published Quality Standards in 2014 to ensure high standards of care for all patients undergoing bronchoscopy.

Aims:
Identify areas for improvement in PSA
Increase PSA awareness amongst bronchoscopists
Improve use of safe recommended doses of sedation agents
Improve clarity of documentation
We performed a retrospective review of 113 bronchoscopy and 59 endobronchial ultrasound (EBUS) reports (September 2019-September 2020). May 2020 was excluded due to COVID19.

Three interventions were implemented:
1. Virtual local departmental teaching to raise awareness of safe PSA.
2. Implementation of a bronchoscopy-suite poster detailing local anaesthetic (LA) dose conversions.
3. Introduction of specific LA fields on our online bronchoscopy reporting system.

Bronchoscopy and EBUS reports were re-audited following each intervention (total 19 cases).
Maximum recommended doses of midazolam in ≥70yrs were exceeded in 19% of EBUS and 5% of bronchoscopy cases pre-intervention. Following virtual teaching, 0% exceeded.

Maximum recommended dose of fentanyl was exceeded in 22% of EBUS and 4% of bronchoscopy cases pre-intervention. Following virtual teaching, maximum dose exceeded in 1.6% of EBUS, 0% of bronchoscopies.

Pre-interventions, lidocaine and instillagel use correctly documented in only 17%, and 33% of procedures, respectively. Significant improvement in correct documentation of local anaesthetic use post-intervention.

(1) Virtual teaching for bronchoscopists increased awareness of safe PSA, thus reducing previously exceeded recommended doses of sedatives.
(2) Implementation of a bronchoscopy suite poster, and specific recording fields for LA, has improved documentation practices.
Methods introduced continue to be used.


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11DrBeth Hancox Junior Clinical FellowSherwood Forest Hospitals NHS Foundation Trust Dr Migara Seneviratne - Consultant Anaesthetist Anaesthetic Consent: Information leaflets and patient recollection – could we be doing more?The Covid Pandemic has resulted in fewer elective patients attending pre-operative clinic in person to discuss their anaesthetic options; a lot is now being done over the phone and on the day. Conversations with patients before their surgeries highlighted that many weren’t retaining key information on the risks and benefits of the anaesthetic they were about to receive. Objectives of this project were therefore to establish barriers to patient understanding and what could be modified to improve patient engagement with the process. It is hoped that resulting discussions with the pre-operative department and production of supplementary patient leaflets as part of the project will improve patient motivation and enable more joint decision-making.Plan: Questionnaire designed to gauge patient understanding of their anaesthetic, including the risks and benefits and enquiry into utilisation of information leaflets.

Do: Patients were approached with these questions on the day of their elective surgery. An immediately apparent recurring theme was the feeling that this wasn’t their decision to make.

Study: Results were collated and presented to the anaesthetic department. Surprisingly high percentages of patients couldn’t recall a single risk of their anaesthetic – engagement seemed a key issue.

Act: Initial steps were to design a patient infographic to display in pre-operative areas and to liaise with the head of department about the focus of pre-op appointments and potential to hold more of these face to face. 		The project demonstrated that although most patients recalled the type of anaesthetic they were receiving, almost half retained no risks at all. Many also felt overwhelmed by the volume of information received and didn’t see the relevance of it to them, rather that it would be the anaesthetist’s decision. The data has highlighted an issue with patient engagement with the process of anaesthetic consent and a resulting lack of awareness of the risks. Presentation to the surgical division revealed similar concerns in their department; they plan to undertake a similar study. It is hoped that the posters will help engage patients and encourage them to participate in the decision-making process as an initial step towards improving consent across the trust.
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12DrZafraanZatharIMT 2 DoctorSandwell and West Birmingham NHS Trust Dr Hanfa Karim - registrar
Dr Ziaudeen Ansari - Respiratory Consultant
Dr May Yan - Acute Medicine Consultant		Clots and COVID: Strategies to minimize COVID-19 related venous thromboembolic diseaseCOVID-19 primarily affects the respiratory system, however, it predisposed patients to higher incidence of arterial and venous thromboembolic disease (VTE). These patients not only had inpatient VTE complications but also were at a higher risk shortly after discharge.

COVID-19 complicated by VTE is associated with high mortality, morbidity and longer hospital stay. Those with severe disease, as defined by critical care admission or non-invasive ventilation (NIV), are most at risk. Due to the novelty of COVID-19, optimal thromboprophylaxis strategy was unclear and this was the focus of multiple studies. Therefore, we designed a QIP to review local VTE prescribing practices and developed strategies to improve adherence to evolving local and national guidance in order to improve patient safety		This was a single center QIP performed over five months. Eligible patients were adults (>18 years) presenting with both symptoms and laboratory confirmed COVID-19. First PDSA cycle was conducted over a 30-day period in October 2020. Following data analysis, intervention was undertaken in the form of staff education (teaching and memory aid posters). Second PDSA cycle was undertaken over a week. Observed outcomes include demographics, critical care admission, inpatient prescribing practice, discharge medication, re-admissions and mortality. Patients with body weight >80kg or needing >40% FiO2 or active cancer or previous VTE qualified for enhanced thromboprophylaxis in the form of enoxaparin 40mg twice daily. Patients on critical care or needing NIV qualified for extended thromboprophylaxis on discharge for 7 days.In the first PDSA cycle, 103/138 (75%) patients received VTE prophylaxis in keeping with Trust guidance. Of the 10/138 (7%) eligible patients, none were sent home with extended VTE prophylaxis. Following intervention, adherence to VTE prophylaxis improved to 64/70 (91%). Furthermore, 4/5 (80%) of qualifying patients were sent home with extended VTE prophylaxis. Patients receiving their first dose thromboprophylaxis <14hrs since admission did not differ between the two groups (85.6% to 86.4%).

We have successfully demonstrated that despite evolving clinical guidance, staff education through spiral learning in the form of regular teaching improved adherence to VTE prescribing practice. Furthermore, a single easy to read poster summarizing guidance was well received and key to our success
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16DrGraceHillsmithFoundation DoctorGateshead Healthcare NHS Foundation TrustDr Emma Gravett - Foundation Doctor
Dr Bhaskar Dutta - Consultant Anaesthetist
An Audit of COVID 19 Vaccination in Elective Surgical PatientsGrowing numbers of elective surgical patients have received COVID-19 vaccinations​. The Royal College of Surgeons have released guidance on vaccination in regards to elective surgery​ that there should be a 7 day gap between vaccination and any elective surgery. Consistent documentation of vaccination status is imperative to ensure patient safety ​and adherence to the guidelines. The aims were to prevent ambiguity for patients and staff and prevent on the day cancellations by improving documentation, and to complete the audit loop by reassessing the data following intervention.This was a retrospective audit using a proforma of questions asked to patients pre-operatively over a period of 2 weeks. The patients notes including preassessment documentation, surgical and anaesthetic notes were reviewed.Increasing numbers of elective patients are fully vaccinated and boosted as the vaccine rollout continues across the UK​. Implementation of the policy of a 7-day gap between vaccination and surgery has been successful, with the majority of patients receiving the correct advice​. Documentation of vaccination status has improved but is not yet 100%. We recommend introducing a specific question on the preassessment document regarding COVID-19 vaccination to improve documentation to 100%
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17DrHui LynnOoiSpecialty DentistKing's College Hospital Chuin Jian Ung (Dental Core Trainee)
Amrita Rai (Dental Core Trainee)
Oladapo Akintola (Consultant Oral Surgery) 		A Great Place, For Great People, To Do Great Work- Quality Improvement Project To Improve Staff Experience of the Dental Emergency Phone Triaging System The Covid-19 pandemic has greatly impacted the access of patients to their regular dentist. This has caused overwhelming demand at King’s College Dental Hospital (KCH), an urgent dental care hub in London.

Prior to the pandemic, there was no triaging; appointments were booked on a first-come first-serve basis. Clinicians at KCH started carrying out a telephone triaging service to prioritise patients most in need of emergency dental treatment.

This project aims to improve staff satisfaction when triaging as an initial pilot survey in December 2020 showed that 6 out of 12 clinicians found the process very stressful, and 8 clinicians had low work satisfaction. Clear links have been shown between improved staff satisfaction and better patient care. 		An online survey with a 10-point Likert-like scale was used to assess staff satisfaction with open and closed-ended questions created based on the Job Demands-Resources Model. Staff satisfaction was measured by the cumulative mean scores of the questions which assessed job resources and stress level. Improvement ideas were sought from respondents by incorporating transformational leadership.

The quality improvement method of PDSA cycles allowed planning of change-ideas, and the implementation of changes. 3 cycles have been performed from December 2020 to September 2021.

The interventions are: designing a new triage proforma; creation of a departmental e-mail; introduction of daily morning staff huddles; signposting towards wellbeing services; ensuring senior staff support; identifying a project champion and utilising an external triaging service. 		Results showed a mean improvement in staff satisfaction of 23.7% when comparing the 1st and 2nd cycles.

As triaging was then outsourced to an external company, the questions of the 3rd cycle were changed to measure staff experience of this new system. 76.5% of clinicians found this new triaging system preferable; 70.7% reported a positive impact on their clinical time. Overall, 64.7% of staff see improvement in their clinic experience.

Projects focused around improving staff experience should be a priority and aligns with the NHS People Plan to support the wellbeing of the NHS workforce.

Further cycles including a cost-benefit analysis will be useful to allow investigation into effectiveness and efficiency of the service.
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18DrDina HannaST7St George's Hospital Jaspreet Sokhi-Clinical fellow
Nicola Davey -QIClearn-QI clinic		Deck of CardsIt is a challenge for trainees to correctly order investigations for common neurological conditions for children. Insufficient or error samples or tests not ordered right is a common occurrence. Establishing the right tubes for blood and spinal fluid often involves many calls to the laboratory or questions to other senior colleagues. Time is wasted, mistakes are made, care is delayed and children are harmed.
Our aim was for Paediatric trainees to easily access the right Investigations for common neurological conditions first time and thereby improve the patients’ management.
The project was conducted over 6 months. Diagnostics included a high-level process map to help us locate the problem and a fishbone diagram to understand the contributing causes and focus on the ones we could influence. Observing the current situation showed trainees needed to search for the correct list of investigations for acute admissions and call different colleagues or laboratories to get more information on sample volume and tubes. We performed 3 PDSA Cycles to test our change ideas. The first was designed to gain feedback from the Paediatric Neurology Consultants about the idea to implement virtual investigation cards.Two further PDSA cycles were undertaken to test the impact of introducing the investigation cards on trainees ability to order neurological investigations.Our baseline measure showed that 100% of trainees (n=19) did not know with confidence where to access the right investigations and 94 % did not know what tubes to use for specific tests .Following the introduction of the cards 75 % (3 out of 4) of trainees knew where to access investigations lists and how to order the tests needed.
Virtual investigation cards and a poster displaying all the cards are now available in the Neurology office for all trainees to use.
Small changes and choosing one thing can sometimes make a big difference.
Further PDSA cycles will be needed with more data points to test and understand if the changes introduced so far will result in a sustained change.
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20DrNadaKhalilDrLondon North West NHS Trust Katie Edgeley (FY3 doctor)
Payal Kotecha (FY2 doctor)
Yonis Ali Elmi (FY2 doctor)
Improving Central Venous Catheter (CVC) line documentation in Northwick Park Hospital Intensive care unit (ICU)Insertion of central venous catheters (CVC) is one of the most common procedures to be performed in Intensive Care Units. Mechanical complications arise early after the insertion of a CVC and long-term complications, such as catheter-related infections, thrombosis and chronic venous stenosis, later in the course. CVC-related complications are associated with increased morbidity and mortality as well as increased costs. High quality documentation and follow up of CVC insertions form the basis of reducing these healthcare related complications. The aim of this project was to establish how often CVC lines were documented in accordance with the NICE and London North West NHS Trust guidance in Northwick Park ICU and implement interventions to improve subsequent documentation and patient safety. Data was initially collected on the 4th October 2021 using our online electronic system. We used NICE guidance and the London North West Trust paper CVC checklist to establish a gold standard framework for CVC line documentation. Data was then collected from all ITU inpatients with CVC lines on that date. Three interventions were implemented to improve documentation: a teaching session took place via Microsoft Teams to inform colleagues of the importance of correct documentation and outline the information essential to include; creation of a template to aid electronic documentation of CVC insertions; and posters were put up around the unit as a visual reminder. Post interventions, there was an improvement in 13 out of the 26 domains included in our gold standard template. Our 3rd cycle showed sustained improvement in 11 of these domains, and an improvement in 8 further other domains. Areas where there was poorer compliance post-audit was related to there being no documentation on our electronic system at all. This was generally seen when patients were referred to ITU initially and a CVC line was inserted prior transfer. When the template was being used for documentation, there was nearly 100% compliance with documentation in all domains. Further work will aim to address barriers to documentation e.g. time pressure or lack of computer availability in emergency situations.
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21DrEhsanHassanED consultantNorth Middlesex HospitalTalia Barry ED consultant and governance leadA safer environment for NIV in our emergency departmentTo introduce a new guideline to our ED for use of NIV and improve documentation and NIV prescribing
Using QI and MDT working and development of CPG (clinical patient group) to instill a safer way of recording treatment using using BTS guidelines. After serious incident related to transferring patient on NIV to ITU with very poor documentation and the patient was in intubated in ITU in peri arrest situation with Saturation of 45%. Due to COVID , we are treating more patients with NIV .We also looked at safety related to using Oxygen cylinders. We have Respironic Trilogy 202 NIV machine with no formal training done onto how to respond to alarms and change settings. 		29 patients treated with NIV from 3/12/2021 to 3/Jan 2022 in our A&E . Poor documentation regarding NIV setting , ABGs and change in setting . After meeting with ITU consultant , respiratory consultant We introduced NIV prescription chart in A&E with teaching and training to our A&E doctors and nurses . We also looked at NHS improvement safety alert related to using Oxygen cylinders. Documentation improved . Doctors and nurses have better knowledge on to how to operate the NIV machine. Oxygen cylinders . The patients on NIV have better safer care in our department . Indication, ceiling of care , ABGs , Machine setting, Nursing documentations all improved . Feedback from all involved was excellent.
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26DrRobertoGaleaDrMater Dei HospitalDr Catherine Dimech - consultant psychiatrist
Dr Martha Anne Apap Bologna - basic specialist trainee (psychiatry)
Prof Anton Grech - consultant psychiatrist & head of department
Impact of first wave of COVID-19 on referrals to Mtarfa Mental Health Clinic and evaluation of service responseThe COVID-19 pandemic necessitated social distancing measures to curb the spread of disease. The disrupted daily activities and social interaction with attendant impact on mental well-being, as well as mental health service provision. The study aims to investigate first contact community psychiatry referrals to the Mtarfa Mental Health Clinic (MH) before and after the onset of COVID-19 and the adequacy of the service response. Hypothesis: the rate of referrals augmented due to COVID-19 and as the associated restrictions were implemented. Time between and review decreased following the introduction Following necessary approvals an index of new case appointments was constructed from the register at Mtarfa MHC from 11 March 2019 to 31 December 2020. This was cross referenced with eMR. The imposition of social distancing on 12 March 2020 was used to separate the date into before and after the onset of COVID-19. A total of 236 new case appointments were identified, 92 of these records preceded the onset of COVID-19 and 144 records followed. The date of referral was available in 105 of the 136 appointments attended. The waiting time could be calculated in 77.2% of these appointments, 76.4% before the onset of COVID-19 and 77.8% after. The mean number of new case referrals received per month increased from 74 before the first wave to 21.2 after, a three-fold increase. Mean waiting time was 21. weeks prior to the onset of COVID-19 which decreased to 7.4 weeks when a steady state was observed after the first wave.
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27DrTaliaBarryemergency medicine consultantnorth middlesex hospitalnatalia.fairhurst2@nhs.net - emergency doctor F2

Natalia Fairhurst		Reducing violence and agression - joining the dotsOur staff survey revealed significant levels of violence and agression in our department. This project aim was to quantify levels across all staff groups using a safety cross (What is a safety cross? ✓ A safety cross is a visual data collection tool that we can use to identify areas for improvement. ✓ A safety cross is a calendar in the shape of a cross in which we can record a metric and the number of occurrences). A working group was then set up to develop ways of reducing these unpleasant occurrences focusing on our waiting room area where the majority occurred.Review of datix to collate violence and aggression occurences with realisation of under reporting

Staff survey

Use of safety cross over 4 week period of data collection

Analysis of data and triggers

Working group established with expert help from NHSE and patient experience group to offer solutions with secondary art project using local sixth formers to provide pictorial representation of the audit


High levels of agression and violence, directed mainly at reception staff due to the long waits/lack of clarity over process

The audit had exposed the issue and reinforced the need for solutions. The working group used posters/artwork and different languages to improve the waiting area alongside some more generic additions (removing screens, plants, water fountain, clock and waiting times board). The work is in progress and will be re-audited monthly.

A safety cross is an easy way of recording events and probably gives a more accurate reflection of what is happening. A safety cross is a good way of improving safety and is low cost and requires little time.
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29MrsLizBerryClinical Skills LeadSomerset Foundation TrustKaty Baker - Clinical Skills Facilitator
Jude Glide - Larch Team
Clare Thompson - Social Care Trainer
Charlie Herbert - Social Care Trainer
James Costley - Social Care Trainer

Setting up a Social Care training Team - a cross system projectDemands for clinical skills training and assessment of competence in social care have increased markedly over the last few years, with patients becoming increasingly complex. A business case was approved for a new team of band 4 Social Care Trainers. Funding was secured for 6 months and the team started working in November 2021. The team are supported by the Trust Clinical Skills Team.
The aim of this project is to enable timely discharge from hospital and to maintain safe and effective care for patients, where clinical skills are required. The team train home care and care home staff, as well as microproviders and relatives. The training is based on the level of care a relative could be trained in. 		We have focused on PEG care as that is the most prevalent request for training/competency assessment. The team have set up some initial processes and a list of skills they can train in. We have baseline data and case studies of unmet need and delayed discharges. We are measuring the number of requests for and the number of social care/family carers trained in PEG care; the number of delayed discharges where the team could have helped; who referrals are from; feedback from carers who have received training; And what other training is requested outside of the initial list. We review the data and any challenges weekly, and tweak the processes and training list and then retest. In the first 7 week the team have trained 440 staff. Average score of 6/6 for training and staff are reporting feeling more competent and confident. Referrals from and signposting to District Nurses, Home managers, Specialist nurses. Deterioration avoided in 14 patients, discharge enabled for 1 patient, and admission avoided for 1 patient. Challenges include requests for training that has to be delivered by a registered nurse or a specialist. Reviewing the team structure to add in a Registered Nurse. And delayed discharges because services don't yet know about the team - regularly repeating the comms about the team and focusing on discharge teams. Innovations include 3D printing of stomas, gaining over 800 twitter followers!
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30MsCatrionaDalyCore TraineeSomerset NHS Foundation TrustMr Andrew Stevenson - consultant trauma & orthopaedic surgeon
Ms Amanda Thorne - consultant oncoplastic breast surgeon
Dr Janet Fallon - consultant respiratory physician and guardian of safe working		Appropriate Junior Doctor Staffing improves Patient Safety, Training and Doctor WellbeingCross-covering of medical and surgical specialities out-of-hours (OOH) is a problem in many hospitals, leaving junior doctors responsible OOH for patients they have never met, in specialities where they do not normally work. This has implications for patient safety and doctor wellbeing. In our Trust, a decision 15 years ago due to increasing medical admissions resulted in SHOs from Trauma & Orthopaedics and ENT being reallocated OOH to medical ward cover. This left one SHO covering all surgical specialities, including General surgery, Urology, Vascular, ENT, T&O and Spinal surgery. This unsustainable workload resulted in negative trainee surveys, GMC reports and numerous Immediate Safety Concerns (ISC). This project aimed to improve patient care and medical training through adequate and appropriate staffing.Two business cases were presented to the Trust Board, highlighting the concerns raised and suggesting sustainable solutions. In essence, funding for an additional 17 junior doctors was required to create a new tier in the surgical OOH rota. This recruitment of 5 surgical, 3 T&O and 9 medical clinical fellows would end the cross-covering of specialities and enable adequate staffing throughout all departments. This was implemented in August 2021, and qualitative evidence was gathered by surveying affected junior doctors before and after the change, in order to assess its impact on doctor well-being and training, as well as perceived patient safety. Quantitative analysis of Exception Reports and ISCs submitted during this period was also used as evidence to demonstrate improvement. The survey results were overwhelmingly positive, showing significant improvement in workload, rest breaks and continuity of care for patients. Foundation doctors reported higher levels of confidence and enhanced training due to more consistent supervision. Job satisfaction improved, with 81% of surgical SHOs reporting they would recommend their job, compared with 42% previously. There have been fewer Exception Reports and no ISCs raised OOH in surgery since July 2021, compared with 11 in the previous 18 months. This project shows that historic short-term fixes can have detrimental long-term effects. It has shown that the use of data to demonstrate these longstanding problems can be used to advocate for funding and systemic change that improves the welfare of patients and doctors alike.
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32DrStephanieCowanDoctorSouth Warwickshire Foundation TrustDr Oliver Rushworth (FY1 Doctor)
Ms Kimberly Knowles (Final Year Medical Student)		STAURM: Streamlining Troubles in Acute Urinary Retention ManagementAcute urinary retention (AUR) is a common urological emergency affecting 10% of men aged 70 and 33% of men in their 80’s. The timely assessment, treatment, and disposition of these patients is challenging for emergency departments (ED’s).

Patient DG attended ED floridly septic, with an indwelling urinary catheter. This was inserted 6 months prior with no follow-up arranged.

Consequently, an internal ED audit demonstrated a specialty follow-up rate of 17%. Patient and staff narrative highlighted concerns for patient safety and dissatisfaction in the quality of care afforded to this cohort of patients.

The STAURM team aimed to implement a robust mechanism that would address critical patient safety issues and improve quality of care for all newly catheterised patients in ED.		A process map highlighted several safety concerns. A driver diagram summarised key objectives culminating in four distinct PDSA cycles.

Cycle 1 introduced a novel, virtual Trial Without Catheter Clinic (VTWOCC) integrating key stakeholders from ED, urology, and continence. This implemented a robust mechanism for speciality follow-up, provision of patient equipment, written advice, and electronic outcomes. Cycle 2 trained staff in standards of AUR, cemented in cycle 3 with the implementation of visual prompts. Cycle 4 redesigned a catheter trolley to streamline working.

After each cycle, notes were scrutinised, and a satisfaction survey conducted for patients and staff. Primary outcomes were improvements in the rates of follow up and satisfaction. This was evaluated using run charts and improvement analysed for sustainability. 		The number of patients with documented follow up increased over the project period from 17% to 100%. The patient satisfaction rates increased from an average of 3.6/5 to 4.7/5 in the assessed domains.

The change cycles improved the quality and safety of patient care by mandating speciality follow up in accordance with the Royal College of Emergency medicine (RCEM) standards, including a demonstrative increase in staff and patient satisfaction rates.

The most effective intervention was the initiation of VTWOCC demonstrating a sustainable improvement in patient care.

STAURM learned that frontline staff and patients are experts in quality care. It empowered specialist nurses and highlighted the important link between primary, community and emergency care in providing safe and effective patient care.
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33DrAlexandraRossJunior DoctorSheffield Teaching HospitalsRoshan Gunaseker, Sport and Exercise Medicine Specialist Registrar
Rohit Bhide, Consultant
Improving accuracy of discharge summaries for spinal injury patients receiving neuropathic pain agentsIt is common for patients to be discharged from the Spinal Injuries Unit at the Northern General Hospital in South Yorkshire whilst receiving neuropathic pain agents. The diagnosis of neuropathic pain should be documented on the discharge letter to ensure appropriate use of these drugs and to improve communication with the GP.
The aim of this study was to decrease the percentage of discharge summaries without an accurate diagnosis of neuropathic pain, using an intervention to target junior doctors writing these summaries.
The discharge summaries of patients discharged whilst receiving neuropathic agents between April and September 2020 (n=41) were analysed. Of those, patients without a documented diagnosis of neuropathic pain were identified and the case notes reviewed. The percentage of patients discharged with neuropathic agents who had a diagnosis of neuropathic pain in their notes but without a diagnosis of neuropathic pain stated on their discharge letter were calculated for each two-week time period.
The intervention was then implemented, consisting of updating the discharge summary booklet, an email reminder and an updated checklist on the junior doctor notice board.
The data collection was subsequently repeated between December and May 2021 (n=37) and analysed using a run chart.
After the intervention, there was a significant reduction in the percentage of patients discharged with neuropathic agents without an accurate diagnosis of neuropathic pain on the discharge letter, as demonstrated by a shift of seven points below the median on the run chart and a change in the median from 50% to 16.7%.
Therefore, a similar intervention at the start of each rotation of junior doctors is likely to improve accurate documentation of discharge summaries. Similar interventions might be useful for improving the appropriate use of other drugs and ultimately improving patient safety.
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34DrElizaHutchisonClinical Teaching FellowUniversity Hospitals Bristol and Weston NHS Foundation TrustDr Samantha Ibbs - Consultant in Paediatric Dermatology, Birmingham Children's Hospital

Dr Malobi Ogboli - Consultant Dermatologist, Birmingham Children's Hospital 		Oral Propranolol in the Treatment of Proliferating Infantile Haemangiomas Infantile haemangiomas (IH) are the most common vascular tumour of infancy. Propranolol is the first-line treatment for complex IH. The Dermatology department at Birmingham Children’s Hospital (BCH) recommend and follow the British Society of Paediatric Dermatology (BSPD) consensus guidelines on the treatment of IH with oral propranolol, published in 2018. The aim of this audit was to establish the current practice for managing IH across the different specialties at BCH and to assess their adherence to the BSPD guidelines. An online survey was distributed to 19 consultants and registrars from the Dermatology, Ophthalmology, ENT, Plastic Surgery and Paediatric departments at BCH. The survey consisted of 14 questions based on the BSPD guidelines. Data were collected anonymously and quantitative data were analysed using descriptive statistics. The survey had an 89% response rate. Results of this audit confirm that not all departments use the BSPD guidelines when initiating patients on oral propranolol for IH. Results showed inconsistent practice amongst specialties when initiating oral propranolol for IH. A variety of speciality guidelines are being followed and dosing regimens vary with only 47% of responders initiating patients on the BSPD-recommended starting dose. Only 60% of responders perform a full cardiovascular examination prior to commencing propranolol and 24% of clinicians report feeling confident doing this.

Results were discussed at each department’s audit meeting. We discovered that several departments are still admitting low-risk patients for propranolol initiation who would be eligible for outpatient initiation of treatment. This impacts on patients and hospital services. 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.

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35DrRachelNigrielloST2 DoctorRoyal United Hospital, BathDr Chris Waters - Core surgical trainee
Dr William Mears - Senior House Officer
Ms Helen Maria-Osborn - Transfusion Specialist		Blood, sweat and tears – improving the time taken to get blood into patients with a new major haemorrhage protocol, algorithm and virtual reality simulation.On average, there are three major haemorrhage (MH) calls a week at the Royal United Hospital (RUH), Bath. As junior doctors working in different departments, we observed varying practice and confusion about how to utilise the MH call. A survey of staff revealed 85% had no training in how to put out an MH call and no staff could identify correctly the exact personnel on the MH team. A baseline audit of time to initiate transfusion showed a mean of 28 minutes with the largest delay between blood being ready and being collected. The main aim of our project was to reduce the time taken to get blood products into patients during an MH call by 25% by December 2022.The following steps were implemented to understand the current situation:
- Process map involving transfusion lab, ward doctors and ward nurses to identify areas of error and delay.
- Baseline measures of time from MH call activation to transfusion and staff survey to identify gaps in knowledge.
- ‘Point of care' simulation to evaluate human factors affecting the MH call.
- Key stakeholders of transfusion committee and trust patient safety leads supported the following interventions:
o Development of new MH algorithm.
o Development of electronic prescribing ‘prepack’ for MH.
o Amendment of personnel alerted when MH call initiated.
o Hospital wide innovative virtual reality simulation to test new pathway. This is currently on PDSA cycle 1.
Baseline process measures collected at the first simulation demonstrated that no medical staff attended and there were misconceptions about who attended the MH call. This patient safety issue was registered on the risk register and triggered immediate amendment of the MH team.
Data collection is ongoing due to scope of project. Outcome measures include time between MH activation and start of transfusion, measures of staff confidence and measures of knowledge surrounding MH call before and after virtual reality simulation.
Process measures include % use of electronic prepack to be collected by pharmacists. We also plan to hold focus groups following whole hospital point of care simulation to collect qualitative data evaluating the new algorithm and process.
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38DrKajalJoshiSHO, Trauma & OrthopaedicsNorthern Devon Healthcare TrustMr. Scott Parker - Consultant, Trauma & OrthopaedicsImproving delays in uploading intra-operative images: a QIPIntra-operative images are an essential part of trauma surgeries, as they demonstrate the nature of the surgery, help in identifying intra-operative complications, and also form an important medico-legal record of the patient's fracture and surgery.
Reducing delays in uploading intra-operative imaging invariably helps the team make appropriate decisions on weight-bearing status, and streamlines discharge processes, without the need for unnecessary further check X-rays.

The aim of the project was to identify if there was a delay in uploading intra-operative images, liaising with the radiology team and dealing with issues which led to a delay, and thereby creating a system in which images were uploaded and available to view during the trauma meeting the next day.		Patients undergoing surgery in the trauma list were identified over a two-week period, from 29/10/2021 to 12/11/2021, and data was collected to see how many of them had their intra-operative images uploaded by the trauma meeting next day at 8:00 am. After collecting the data and quantifying the delays, the issue was highlighted to the radiographers and their concerns were taken into account.

The second cycle of data was collected in a similar manner, from 14/1/2022 to 27/1/2022, and the findings of the quality improvement project were discussed in the weekly departmental meeting.
It was found that 34% of the surgeries had delays in uploading images, as significant as 7 days late.
The main issues causing the delays were outdated, bulky machines, and dysfunctional PACS ports in theatres, which the radiographers had raised with the IT services several times. The problem was then highlighted to the head radiographer, following which, new Wi-Fi enabled machines were incorporated into theatres.
The next data collection cycle started after the new Wi-Fi enabled machines went live, and showed a significant improvement. Only 12.5% of images had delays during out-of-hours surgeries, with the longest delay in uploading being 2 days.
This showed how we were able to achieve optimal results, by simply liaising with the radiology team.
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39DrAyomikunOdekunleIMT 1East Lancashire Hospitals NHS TrustChristos Iosifidis - Junior Clinical Fellow
Sally Choi - Junior Clinical Fellow
Natasha Odell - Junior Clinical Fellow

Facilitating patient referrals by junior doctors and Physician Associates to the appropriate respiratory pathways/subspecialtiesOne of the major duties of junior doctors and PAs is the referral of patients to the necessary specialities and pathways. Doing this inappropriately or incorrectly may adversely affect patient safety, satisfaction and outcome of treatment. In a report by the General medical council, it was found that in patients who were not satisfied with their referral experience, it is more likely they arrived at an appointment to see a doctor who was not expecting them or familiar with their case and in some cases, the referral got lost entirely.
AIMS:
To facilitate referrals by junior doctors and physicians associates to the appropriate respiratory subspecialties.
To produce an easily accessible guide for referrals to the various respiratory subspecialties.
Sample population: Doctors and physician associates
Data collection: Online self-administered Questionnaire

Standards measured : 3 PDSA CYCLES
1.How confident doctors and physician associates are in referring patients to various respiratory pathways/subspecialties. The pathways considered include, but are not exhaustive to, sleep service, long term ventilation, long term oxygen service, lung function, severe asthma, general respiratory follow-up, asthma follow-up, rapid hub, community respiratory team (CRT) follow-up, respiratory ambulatory care unit (RACU), general long Covid-19 clinic and pulmonary embolism clinic.
2.Availability of a simplified, up-to-date and easily accessible guide to referrals to the various respiratory pathways.
At the end of the third cycle, the QIP demonstrated a substantial beneficial impact as 75% of doctors and PAs that responded now feel confident in referring patients to the various respiratory subspecialties, this was 6.7% in the first cycle while 75% also agreed that a simplified, up-to-date and easily accessible guide to referrals is available, this was 3.3% in the first cycle.
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40DrUltanWatsonDoctor: Acute Care Common Stem TraineeUniversity Hospitals Sussex NHS Foundation TrustEnhancing job satisfaction when the NHS is under pressure: The importance of inductionPositive 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.
The aim of this quality improvement project was to assess and improve Acute Care Common Stem (ACCS) trainee satisfaction with their induction to University Hospitals Sussex (UHSx, East: Royal Sussex County Hospital and Princess Royal Hospital) via self-reported satisfaction scores. An additional aim was for no trainee to rate their induction as ‘poor’ or worse, thus ‘satisfactory’ or better. 		An online questionnaire was sent to all ACCS trainees (Core Trainees in any of their first to fourth year of training) working at UHSx after the August intake of new trainees in 2019, 2020 and 2021. The questionnaire was designed to obtain qualitative and quantitative data assessing their experience of their induction to ACCS training and to obtain ideas for improvement. Between 2019-2021, a total of 54 questionnaires were distributed; 30 responses were obtained. The results of the questionnaire, along with proposed improvements, were fed back each year to the Local Faculty Group (a body of consultants, trainee representatives, training administrators and human resources representatives overseeing ACCS training) at UHSx for consideration of implementation.The initial questionnaire identified that 60% of trainees found their induction satisfactory or better. Mean satisfaction scores were 2.6/5. 1 in 5 trainees described their induction as ‘poor’ or ‘very poor’. Over the following two years, using feedback obtained from the questionnaire, trainees were provided with an up-to-date induction presentation, a trainee handbook, the speciality they were starting in, and their educational and clinical supervisors prior to commencing training. Each intervention went through a PDSA cycle. Mean satisfaction scores improved to 3.5/5; no trainee reported their induction as ‘very poor’ or ‘poor’. Additionally, the impact of the COVID-19 pandemic significantly limited the feasibility of face-to-face inductions. Their absence was consistently fed back as an improvement for the future.
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42DrSharwiniParamasevonFoundation Year 2 doctor Cardiology department James Cook University Hospital Dr. Freda Chen - Foundation Year 2 doctor , ITU James Cook university hospital
Dr. Iuliana De Jong - Care of the elderly Consultant James Cook university hospital 		Catheter associated urinatry tract infections in the elderly - can we do better? Catheter associated urinary tract infections(CAUTIs) represent a large proportion of nosocomial infections. 15-25% of patients are catheterised during their hospital stay and 75% of hospital acquired UTIs are associated with catheter use. Hence, it is wide to ensure that catheters are inserted only if indicated and plans should be made to remove them as soon as possible. This will not only reduce the incidence of CAUTI but also lead to a better patient experience and reduce overall NHS burden. The aim of this audit is to identify whether the catheter care pathway is being filled as per standards set by NICE guidance and to identify whether the catheter care pathway needs to modified to reduce the incidence of CAUTI. This is a prospective audit that was conducted over 8 weeks involving 50 patients from the care of the elderly ward who were catheterised during November to December 2021. Data was obtained from urinary catheter care pathway, case notes, discharge summaries and microbiology results. A proforma was designed to aid the data collection process and was then input and analysed on an excel spreadsheet. We looked at the quality of documentation of rationale of catheterisation, whether or not regular reviews of the need of catheterisation was done, and the quality of documentation on removal of catheter and on documentation on discharge for patients discharged with a urinary catheter. The risk of developing CAUTI is directly proportional to the length of time a catheter is kept in situ. Only 9 out of 50 patients we assessed had daily reviews done and documented.The decision to remove catheter in 40% of the patients who had successful removal of catheter was only done 1-3 days prior to discharge date. 40% of our sample size were treated for CAUTI.A prolonged length of catheterisation has been identified in majority of these patients, on an average of 10-12 days, when in fact trial without catheter could have been attempted much earlier if there was a robust system in place to remind the medical team to review the need for the catheter on a daily basis.
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43DrAyeshaAhmedFY1 DoctorWest Suffolk HospitalDr Adel Khalifa (Specialty Registrar Cardiology)Improving Driving Advice Provided to Cardiology Patients at West Suffolk HospitalMany cardiac conditions can restrict the ability of patients to drive. It is the responsibility of the doctors involved in the care of the patients to educate and inform them of any driving restrictions and is particularly important after certain diagnoses and procedures. The DVLA publishes detailed guidance for patients and healthcare professionals on medical restrictions to driving in order to safeguard patients, passengers, pedestrians and other drivers. The aim of this study was to increase the adherence and provision of appropriate driving advice provided to patients on discharge from a cardiology ward and enhance the knowledge of the DVLA guidelines among healthcare professionals. Baseline data were collected by first auditing a selection of patients discharged over a 1 month period, from 1 December to 31 December 2021, with either acute coronary syndrome (ACS), new arrhythmia or requiring pacemaker insertion. A total of 41 patients were included in the study. A spreadsheet was used to record the date of discharge, primary diagnosis, other relevant diagnoses or comorbidities, management and presence or absence of driving advice. Exclusion criteria included deceased patients, patients admitted for heart failure management, and all patients who were transferred to other hospitals. Using a questionnaire, we then evaluated our doctors’ knowledge of current DVLA guidance. Out of the 41 patients discharged in the month of December, only 1 patient had DVLA advice included in the discharge summary. Out of the 10 doctors who were sent the questionnaires about the DVLA guidance in cardiology patients, only 2 doctors said they were confident in giving driving advice to patients. Only 1 doctor said they regularly included driving advice to patients' discharge summaries and only 4 doctors said that they regularly asked their patients for their driving status on admission.
Recommendation:
Making an e-care alert for all cardiology patients on admission to record their driving status, a reminder to give driving advice verbally and include it in the discharge summary.
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46MrGovindMalhiDentistSmileTogetherThe recording of dental anxiety in the emergency dental services: A quality improvement projectDental anxiety can be defined as experiencing stress anxiety or fear when associated with a dental setting. According the Adult Dental Health Survey 2009 (ADHS), 11.6% of the adult population in the UK have dental anxiety. As a result of this anxiety, patients may avoid seeking out dental treatment until their issues becomes much more serious.

It is for this reason that the reporting of dental anxiety was chosen as the topic for this project. Through the project, it is hoped that more detailed information can be gained as to the causes of dental anxiety in these patients. This will then allow dental care professionals to tailor their appointments accordingly to improve patient care and safety.		A fishbone diagram was developed to analyse the different possible causes of the under reporting of dental anxiety in the emergency dental service.

Leading cause: lack of interactivity on the dental note taking software.

A PDSA cycle was developed to observe whether a change can be made to improve the reporting.

Plan - analyse fishbone diagram to find leading causes of issue
Do - alter medical history form on software to allow patients to explain in more detail the reason for their anxiety
Study - analyse results after 3 months to see if improvement has been made
Act - discuss with company directors the results of the first cycle and recommended a permanent change be made to medical history forms		The results of the first cycle will be analysed at the end of March 2022 to see if an improvement in the recording of dental anxiety has been made.

After the first cycle, patients will be surveyed to see if their anxieties had been addressed and either fully or partially alleviated after which they will be asked if they are more likely dental treatment more quickly in the future

So far the main lesson learnt would be to involve more people in the QIP so a wider patient base can be reached and different methods to improve care can be discovered.
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47MrsBernadetteChubbMidwifeYeovil District Hospital NHS Foundation TrustRebecca Cockings - Midwife
Emma Symonds - Equality, Diversity and Inclusion Lead
Janine Valentine - Research Nurse
Dr Vanessa Heaslip - Lecturer and Researcher Bournemouth University
Does training impact midwives understanding of implicit bias and care of babies from black, Asian and minority ethnic babies?Black women are four times more likely and Asian women are twice as likely to die than white women (Knight et al 2019) and these disparities affect the babies of black and Asian women. Asian babies have a 60% higher risk of dying while Black parents are 45% more likely to experience this devastating loss than White parents.

The shocking statistics motivated the authors to enter a Quality Improvement competition aiming to open conversations around bias and microagressions impacting on care for families. After winning, we worked with the EDI lead and produced a training package for midwives addressing bias, structural racism and clinical care including the use of black resuscitation mannequins



PLAN
Development of training package with EDI lead and input from research team within trust
Development of anonymous surveys as method of evaluation and baseline knowledge of midwives
DO
Delivery of training package with midwives
STUDY
Evaluation of quantitative and qualitative data from surveys
ACT
Further developing training to include more aspects of clinical care including assessment of the unwell mother and allow more time for discussion and questions
Some changes to the survey questions to gain more in depth knowledge
The teaching sessions were well evaluated, 98% of midwives would change their practice following training (this included documentation, language used and advice given to parents) and 98% gained new knowledge and understanding. It evidenced a lack of previous understanding of implicit bias and the impact this can have demonstrating a need for this training. There were midwives who were not aware of the disparities in outcomes and highlights the need for raising awareness.
The time constraints placed on us for conducting the training prevented going into as much depth as required however the outcome data demonstrated its impact. Further development including the need to extend will be incorporated for the regional role out of training.
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49DrJonathanReidFY2Bolton NHS FTLawrence Pugh, FY2.
Sarah Thornton, Consultant in ICU/Anaesthetics.		Bolton NHS FT Critical Care Extubation ChecklistDuring the COVID-19 pandemic, there has been a significant increase in the number of mechanically ventilated patients across critical care units. The 4th National Audit project of the Royal College of Anaesthetists (NAP4) found that over a quarter of the cases discussed involving major airway complications occurred at the end of anaesthesia or in recovery. NAP 4 found that an unstructured approach to airway management complications led to poor outcomes. Checklists help guide staff through complex procedures and to plan for adverse events. The B@EASE checklist for emergency intubations is widely used throughout the Greater Manchester region. Inspired by this, we have designed and implemented an extubation checklist at Bolton NHS FT to guide staff through this often life-threatening procedure. The checklist was initially designed by a team of medical and nursing staff. A survey was then conducted within the department, obtaining feedback from the multi-disciplinary critical care team. All staff surveyed (n=22) stated that they thought that a checklist would be of at least some benefit, with 82% stating that they would find it very beneficial. Over 1 in 5 critical care staff members were not confident being part of an extubation team. The original checklist has since been re-designed based on the qualitive feedback and experience of using the checklist. Other extubation guidelines are used in other trusts, however, based on our feedback we aimed to create a one-page checklist, uniform for all critical care patients. Our checklist details three phases of extubation: Preparation, procedure and post extubation care, and a section on complications. Our preparation section addresses patient and human factors within the team, ensures appropriate equipment is available, and that a plan for anticipated difficulties and emergencies is made. We have a procedure flowchart standardising an approach that the team can follow. Our post extubation care section includes monitoring and possible further management. We have then outlined common complications and their management for reference in an emergency.
We anticipate that this checklist will both improve the safety of extubation and confidence of staff members to participate safely in an extubation team. We are open to collaborating with other trusts to further develop this resource.

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50DrVasilikiBisbinasFY2 TtraineeGloucestershire Hospitals NHS Foundation TrustImogen Pulley, FY2 Trainee
Hanna Tunbridge, Clinical Audit Manager		NG89 Venous thromboembolism: reducing the risk for patients in hospital: Re-auditVenous thromboembolism (VTE) is a primary cause of preventable deaths in hospital, (25,000 deaths/year in the UK with 55-60% occurring during or following hospitalisation. Inpatients on psychiatric wards may be at higher risk due to reduced mobility, poor fluid intake, restraint, catatonia, sedation and antipsychotic use. Evidence suggests anti-psychotic use may be an independent risk factor for developing VTE. The current standards according to NICE guidance is a 100% rate of VTE assessments on admission. The aim of this study is to assess staff adherence and to ensure that patients at risk of VTE are being recognised, managed appropriately and re-assessed.
This is the 3rd cycle of this audit - the 2nd cycle showed a decline in compliance in comparison to the 1st cycle.
The sample selected for the audit was all patients who were discharged from the Trust’s mental health inpatient units during September 2021. An online audit tool, based on the audit tool used in previous audits and devised using criteria taken from the NICE guidance NG89 was created. The data for the audit was collected from patients’ RiO records, the electronic patient file system used by the Gloucestershire Health and Care NHS Foundation Trust.		Overall compliance has improved compared to previous cycles of this audit at 82%, with 68% in December 2019 and 76% in September 2019. There was an increase in patients assessed within 24 hours of admission and evidence of re-evaluation of VTE prophylaxis in the case of a change in their condition. A decrease was noted of evidence in MDT discussion of VTE prophylaxis in the inpatient progress notes.
Recent changes made to VTE risk assessment mean a re-audit is necessary once introduced. It is also recommended that a brief teaching should be a part of the induction of new junior medical staff. Finally reminders to senior medical staff is recommended for this to be assessed during ward rounds and MDTs.
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52DrSelineIsmail-SuttonFoundation year 2 doctorRoyal Bournemouth HospitalRebecca Allan, palliative care speciality registrar, Macmillan Hospice, Christchurch
Megan Howarth, palliative care consultant, Macmillan Hospice, Christchurch		Driving communication forward - Improving communication with palliative care patients about driving on opioid analgesics The number of people requiring end of life care is set to rise over the next 15 years [1]. In the last three months of life, patients symptoms are often managed with opioid analgesics.
Given the sedative side effects of opioids, there are significant implications for patients who drive. However, having this conversation with patients is often overlooked. In a time where quality of life is vital, any opportunity to optimise this and maximise freedom must be grasped.

Aim: Increase amount of documented evidence on recorded driving status and discussion on opioid driving rules with palliative care patients at Macmillan Hospice, Christchurch. This should be achieved by March 2022.

Chosen measure: documented driving status and discussion on opioid driving rules.





Inclusions: Patients with ECOG 0-3. Exclusions: Patients admitted with acute deterioration who did not improve, patients with an ECOG 4.
Data collection: Review notes every 2-3 weeks.


1: P:Raise issue awareness with MDT. D:Discuss in morning MDT meeting. S:Documented evidence remained low. A: Add prompt to clerking proforma to record driving status.

2: P:New prompt for recording driving status. D:Box on clerking proforma for this. S:Improvement, some unfilled, did not always lead to discussion. A:Add reminder poster to discuss this as part of discharge routine.

3: P:Encourage this discussion to be in discharge routine. D:Reminder poster to discuss in discharge routine. S:Some improvement, not all team members engaging. A:Increase discussions during admission via prompt on consultant ward round sheet.








At baseline, driving status and driving rules discussion were documented in 11.5% of cases.
First intervention had the least improvement of 3.9% in both.
Second and third interventions yielded greatest improvement in documented driving status and driving rules discussion, and after the third cycle, these were documented in 65.2% and 60.9% of cases, respectively.

Reflections: Whole team did not engage. Informal MDT discussion noneffective. Formal team discussion e.g. presentation on current progress, likely more effective.

Recording driving status did not always result in discussion. Prompt may be better on ward round sheet. If so, may need removing from clerking proforma to avoid unnecessary work load.

Consider applications in community palliative care teams, and if this setting more
appropriate for discussions.


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53DrAreenHassan HaleemFoundation Year 1 Doctor Portsmouth University Hospital Trust Yasmin Jessa - FY1 Doctor
Kristen Medalla - FY1 Doctor
Zhan Ng - FY2 Doctor 		Introduction of an Electronic Handbook and Video Resource for Foundation Doctors in General Surgery: A Quality Improvement ProjectThe transition from medical student to Foundation Year One (FY1) doctor can be challenging, especially in a fast-paced specialty as General Surgery. New FY1s often face a steep learning curve in acquiring ward-based knowledge while providing patient care. The aim of this project was to ease the transition period for new foundation doctors in General Surgery by creating an electronic handbook and video resource for both learning and reference purposes. Through three Plan, Do, Study, Act (PDSA) cycles, we designed and implemented resources aimed at improving patient safety and efficiency of foundation doctors in completing ward-based tasks.PDSA Cycle 1: Identifying the improvement focus. An online questionnaire was completed by FY1s prior to their rotation in General Surgery (n=6) to assess baseline knowledge and confidence levels in various ward-based tasks, and identified what they would like included in a reference guide. We designed an electronic handbook and video resource based on the questionnaire results.

PDSA Cycle 2: Formal feedback. The resources were reviewed and edited by members of the multidisciplinary team including nurses, pharmacists, junior and senior clinicians.

PDSA Cycle 3: Evaluating project impact. Following implementation of the electronic handbook and video resource, a post-intervention questionnaire was completed by the same cohort of FY1s (n=6) to assess the impact of the resources on their daily job.
In the pre-intervention questionnaire, half of the FY1s (n=3/6) reported that they did not feel prepared to work on General Surgery, and one third (n=2/6) reported insufficient resources to answer ward-based questions. We tailored our project to gaps identified.

In the post-intervention questionnaire, all FY1s (n=6/6) agreed that the handbook and video resources have improved their confidence at work in all individual ward-based tasks assessed. All respondents (n=6/6) agreed that the resources answered common ward-based questions.

We learnt the importance of the multidisciplinary team’s input when developing an essential user-friendly electronic handbook and video resource. We will continuously collect feedback from future cohorts of FY1s to update the resource and ensure sustainable improvements in patient care.
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54DrHamzehAL-ArqanConsultant GIM/Diabetes and EndoBlackpool Teaching Hospital NHS foundation TrustMuhammad Usman Khan (IMT2)
Dr Michael Guirguis (SHO)
Jessica Braithwaite (Nurse in charge ward C)
Improving Fluid Balance Charts on Ward C medical ward (a 32beds) (Q093)NICE CG174- 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.
The project team noted that fluid balance charts were being poorly completed on the ward against our trust recommendations .
Aims :100% of fluid balance charts on ward C to have accurate input, output and balance

Potential benefits for patients and the organisation:

Early detection of imbalance and intervening accordingly

Avoiding potential health implications of dehydration and overload

Delivering holistic patient care as per NICE guidelines
Improvement in overall outcome measures reflecting hospital quality for example reduced mortality, safe and effective care and a reduced readmission rate



Baseline sample data collected for 1 month (November 2021) from 10 patients at random on ward C. Data collected on age, diagnosis and gender,5 males, 5 females
Documentation and accuracy of:
Fluid input
Fluid output
Fluid balance
Fishbone root cause analysis to understand variation in fluid balance monitoring .Driver Diagram followed also
Interventions to raise awareness of the QI project and baseline data developing a team approach to improve monitoring. Posters to educate and remind staff on the QI project and the importance of fluid balance.
Fluid balance charts were used and in the correct set of notes i.e., bedside notes . Effective ward round reviews of fluid balance and review of available monitoring equipment (jugs, weighing scales).Patients effectively engaged.




Run chart to show the proportion of fluid balance charts completed correctly on ward C (Sample date )Between 22 Nov-2022 to 24th Feb -2022 showed a median improvement to 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 involvement ,nurses ,house keepers, junior and senior doctors .We have been asked to implement our QI project to other areas in the trust .AMU will be our next station
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56MrsMarilizeDu PreezImprovement and Transformation leadHywel Dda University Health BoardSame Day Emergency CareSame day emergency care have been successful in preventing avoidable hospital admissions in urgent care centres across the United Kingdom. However the utilisation and scope for SDEC in Glangwili General Hospital has not been fully optimised with only 5% of emergency attendances managed through this pathway whilst the national ambition is around 30%. The impact of this has had a significant impact of patient flow, emergency department efficiency, ambulance handovers, and patient and staff experience. The project was delivered through a collaborative Enabling Quality Improvement in Practice programme with the support of an designated improvement coach.

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




QI methodology using the Model for Improvement
- Understanding the problem (process mapping, fishbone analysis, theory of constraints presented via Pareto charts, driver diagram, links to the 6 domains of quality)
- stakeholder mapping and engagement
- co-production ladder
- Measurements of time outcome, process, balancing measures(including baseline data)
- Identifying change ideas
- PDSA cycles and PDSA ramp (14 cycles)
PDSA 1: Change the door of the unit to stop patients in beds being put in the unit. Adopt- learning: Stopped beds going into the unit but did not increase the number of patients going through the unit or aid identification of patients suitable for SDEC. PDSA 2: Testing a triage tool (Amp score)
- SWOT analysis

Aim achieved: 20% increase in the number of patients managed through SDEC

Lessons learned:
- A culture of enabling/ empowering front line staff to identify and implement changes without having to ask permission is key
- Providing project team with QI knowledge/ skills and support helps drive change
- Focussed and protect time to focus on the project through a collaborative programme provided momentum and drive
- linking projects to organisation objectives with executive support/sponsorship is a key enabler

Practical learning:
Ring fencing SDEC key in optimising flow
Triage tool for SDEC (Amb score) accurate in predicting same day care


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58DrMaroKyriacouFoundation Doctor Nottingham University Hospital Trust An audit identifying ‘double bookings’ within primary care and exploring whether they could be reduced during the COVID-19 pandemicDuring 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 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.
The aims of this audit is to identify the types of complaints that lead to these ‘double bookings’ and to provide recommendations to assist GPs in the allocation of FTF slots at first patient contact.
Collection of patient data was conducted via SystemOne to identify all of the patients who had more than one clinical journal entered into their medical records within a one-week time period. Analysis of 65 patients, each of which had ‘double bookings’, was conducted to determine the demographics, presenting complaint and reason for a necessary FTF appointment slot after an initial remote consultation. These were further sub-divided in order to give a more detailed insight into the reasons for why a FTF consultation with a GP was clinically required.
From the results of this audit, 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 and any patient presenting with clinical signs suggestive of a UTI as they may require urine sampling.
Therefore, GPs should triage their patients in a more efficient way based on presenting complaints. Any patient where there is a strong chance that they will need a physical examination, intimate examination, investigation or child assessment should be prioritised in the allocation of F2F appointments.
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60DrSarahBarrowPaediatric Registrar North Middlesex HospitalDr Olu Wilkey, Consultant Paediatrician Achieving NICE transition-related standards of care for young people with long-term conditions – a quality improvement project Moving from paediatric to adult services is a worrying and challenging time for young people with long-term conditions. Evidence suggests that effective transition between services can improve long-term outcomes, yet national data implies that transition is often overlooked with little recognition as an area of importance within healthcare. However, there has recently been a drive to refine and improve the transition process through the NHS long term plan. This quality improvement project aimed to better achieve the NICE Quality standards for transition for 6 sub-sepcialties in one paediatric department, across a nine-month period.
An initial gap analysis was undertaken using 11 NICE quality transition-focused standards of care to demonstrate current performance of services for transition for 6 sub-sepcialties: allergy, asthma, diabetes, epilepsy, HIV, and sickle. Diagnostic tools including a process map, fishbone diagram and histogram were completed to help define the problem further. Following this, change ideas were generated and several PDSA cycles were conducted through regular transition workshops and progress meetings, along with implementation of the Ready, Steady, Go, paperwork and time-bound action points for each sub-specialty. Highlights included: external talks from a transition improvement manager, joint clinics between paediatric and adult services for asthma and epilepsy, along with asthma transition clinics within the local community. Baseline measurement following the initial gap analysis showed that only 18% of standards were partially met and 45% of standards were met across the 6 sub-specialties. Diabetes, HIV and Sickle showed better performance, meeting at least 6 out of 11 standards of care for transition. Following several PDSA cycles, the baseline measurement for meeting standards increased to 58%. Measurable progress has been made in improving the transition process, however; further work is needed to ensure young people and their families are actively involved in the design, delivery, and evaluation of services. Ongoing work is required to ensure that transition-related standards of care are met and provided for young people when moving from paediatric to adult healthcare services.
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61DrAlexandraMcNishFoundation Year 1 DoctorUniversity Hospitals Bristol and Weston NHS Foundation TrustYsabelle Embury-Young
Core Surgical Trainee		Electronic VTE Prophylaxis Risk Assessment and Prescriptions in Thoracic Surgery, Bristol Royal Infirmary - A Quality Improvement Project.Bristol Royal Infirmary trust guidance recommend that all inpatients should have electronic venous thromboembolism (VTE) prophylaxis risk assessments completed within 24 hours of admission. Thoracic surgery was among the lowest performing departments (26th out of 34) in completing VTE risk assessments. This quality improvement project aimed to assess and improve thoracic surgery VTE risk assessment completion and prescriptions in accordance with trust guidance.Retrospective review of all thoracic surgery admission case notes between 01/09/21 - 30/09/21. Data collected on; completion of VTE risk assessment, VTE prescription on drug chart including drug prescribed and dose correct for weight and renal function as per trust guidance. Used PDSA cycles to implement an initial round of interventions of educating rotating junior doctors and updating the induction handbook. A second cycle was performed between 01/12/21- 31/12/21. In the initial time period 1/9/21 - 30/9/21, 42 patients were identified. 21% (n=9) VTE prophylaxis electronic risk assessments were completed, with 16.6% (n=7) completed within 24 hours. 100% of patients had correct VTE prophylaxis prescribed, with no prescription errors when adjusted for weight and renal function. After an initial intervention the second cycle between 01/12/21 - 31/12/21 identified 31 patients. 12.9% (n=4) had electronic VTE risk assessment completed, with 6.5% (n=2) completed within 24 hours.

Although drug chart prescriptions are of a high standard, despite education of junior doctors, further intervention is required to improve completion of electronic VTE assessments. We aim to implement a sticker reminder/highlight on doctor's office TV as our next intervention to improve completion rates.
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62DrMeganFosterF1 Doctor Somerset NHS Trust Dr Ryan Beazley, F1 doctor Trust Specific Lanyard FlashcardsJunior doctors rotate regularly to different trusts and hospitals. It is a recognised issue that trust specific guidelines can be difficult to keep up with during these rotations, sometimes at the cost of patient care. The aim of our QIP is to improve usage of trust specific guidelines at Musgrove Park Hospital (MPH) by creating a set of flashcards that may be attached to lanyards, in order to improve accessibility of this information. MPH currently has excellent trust guidelines that may be found on the intranet, however these are difficult to find. We aim to reduce the time taken to access these guidelines alongside improving confidence amongst juniors in dealing with acute scenarios. - Our first PDSA cycle collects data from juniors on which guidelines are difficult to access/understand, alongside a survey on which management scenarios are the most challenging. We collected quantitative data on the time taken to reach commonly required guidelines. After this, we trialled the first draft of flashcards on a small number of junior doctors and recognised that they were effective at tackling our aims, however required improvement in certain areas to increase usage of the cards.

- Our second PDSA cycle will look to re-distribute the cards to a larger group of junior doctors and observe the impact on our aims on a larger scale. We will look to improve usage in this cohort.		Our first PDSA cycle informed us that the cards were less likely to be used in those who felt they were cumbersome on their lanyards/too much information was included. We used this information to modify the cards size to fit more comfortably on lanyards and made the information more concise.

The first cycle also reflected that some other information would be more useful, such as advice on dealing with acute delirium. We teamed up with our acute frailty unit to construct an additional flashcard that included screening tools and recommendations from Consultant Geriatricians.

Our second cycle will hopefully identify further areas to improve usage of the cards and hence reach our aims.
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63MrsKirstyGreavesDeputy Head of PhysiotherapyGloucestershire Health and Care NHS Foundation TrustLisa Langford, Deputy Head of Occupational therapy
Jenny Smith, QI Manager and Occupational therapist		Identifying and Escalating the Deteriorating Patient AppropriatelyTherapists working within the Home First service of Gloucestershire's community teams were not always sure how to identify and escalate concerns when treating a potentially deteriorating patient. Therapists across the county have varying levels of competency and confidence at identifying when a patient is deteriorating and access to associated equipment to evidence their observations. Some therapists had NEWS2 training, others not. The project aims to ensure an all therapists working across 5 localities in Gloucestershire can identify a deteriorating patient using the NEWS 2 scoring system and appropriate equipment and where this triggers the need for a response, ensure that the patient is escalated appropriately and receives the same level of care regardless of where they live.The project is ongoing. Following the Model for Improvement, a stakeholder map identified project team members who completed a driver diagram which identified a number of change ideas. Baseline data identified inconsistencies in the confidence and competence of physiotherapists and occupational therapists in identifying and escalating deteriorating patients which supported the project hypothesis. PDSA cycles were then used to test and upscale consistent training in use of equipment and NEWS2 as well as following a pre-determined escalation pathway. PDSA cycle 1 (of 3 currently) tested the change idea in one rural locality initially followed by a second PDSA to test modifying the escalation pathway and the 3rd PDSA will test in a different urban locality before further upscaling is undertaken.Initial PDSA results showed an increase in therapist's confidence and competence in identifying and escalating appropriately and consistently deteriorating patients in their care using the NEWS 2 tool. Lessons learnt from this cycle resulted in an adaptation to the change idea before PDSA 2 was carried out, changing the escalation pathway to bring it in line with national guidance. The 3rd PDSA will now test in a different locality (the first was rural with bordering counties and the second is mainly urban and central to the county). Lessons learnt so far, enable a prediction that there will be an increased demand on other acute services such as rapid response but as a balancing measure that will ultimately improve patient care.
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64DrGemmaCrossinghamConsultant AnaesthetistUniversity Hospitals PlymouthMaryam Basheab, Medical Student, University of Plymouth
Nima Sabah, Medical Student, University of Plymouth
Theadora Shearing, Medical Student, University of Plymouth
Eleanor Gray, Medical Student, University of Plymouth
Louise Wegbe, Medical Student, University of Plymouth
Itawosim Oram, Medical Student, University of Plymouth
No Accident: Psychological Safety and Civility in a South West Maternity UnitIn 2020, a Health Safety Investigation Branch (HSIB) report on delays to intrapartum care concluded one principal recommendation: “the CQC....assess relational aspects (such as multidisciplinary teamwork and psychological safety) in its regulation of maternity units”. [1] Psychological safety is the belief that one will not be penalised or humiliated for sharing ideas, concerns, queries or mistakes. A key component of a psychological safety is a ‘civil’ culture. The ‘Civility Saves Lives’ campaign has highlighted the importance of respect, professional courtesy and valuing colleagues in the delivery of quality care. This medical student-led project therefore aimed to assess the level of civility and psychological safety within our maternity unit and co-create interventions to improve both elements using quality improvement methodology.A literature review of psychological safety and civility measurement articles was conducted in order to identify relevant questions to be utilised in a department-wide survey. Questions were initially long-listed if relevant to psychological safety or civility. Short-listing of questions occurred by iterative discussion amongst 7 authors to identify the 15 most relevant questions. A mixture of open and closed questions about positive and negative experiences were included to achieve a balanced overview. Questionnaires were distributed to all maternity unit staff via email, roaming i-Pad and QR code displayed on posters. Quality improvement methodology (serial PDSA cycles), were used to test and refine interventions to improve civility and psychological safety, allowing timely refinement of potential interventions. Seventy-nine staff responded to the survey. 96% felt psychological safety was extremely important to safe and effective functioning of the unit, and 89% considered their work colleagues as friends. Conversely, 28% felt that other staff members undermined their efforts in the last month and 47% experienced one or more incidents of incivility.

A number of interventions are being co-designed: 1) Application and integration of the RCOG ‘workplace behaviour toolkit’ [2] and development of departmental specific tools and posters to support this. 2) Use of facilitated discussions session at monthly PROMPT courses to reflect on positive experiences of psychological safety and civility which have been collected through our own learning from excellence scheme (ie. Positive reporting scheme).

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65DrDavinaDingClinical Teaching FellowThe Great Western Hospital NHS Foundation TrustDr Natalie Whitton, Emergency Medicine Consultant"Simplifying Safeguarding Month" - Changing culture in the Emergency DepartmentSafeguarding needs have increased significantly over the last year and this is expected to continue. With the Emergency Department often being the first and only contact vulnerable children and adults have with safeguarding procedures, it has placed a greater importance on the ability of staff to deliver timely and effective referrals, which are ultimately a product of professional curiosity and moral obligation. We recognise the challenges faced by educators in not only changing the mindset of staff, but also doing so in a busy, working Emergency Department (ED) and propose a model of theme-based multimedia education to generate an atmosphere of opportunistic learning and interest. Staff of the Great Western Hospital (GWH) ED were surveyed to identify common attitudinal barriers towards initiating safeguarding, training compliance and confidence about their knowledge and the procedures involved. A multimedia, multidisciplinary programme dubbed “Simplifying Safeguarding Month” was organised. Information and teaching were delivered in various formats including informal and formal teaching for nurses, junior doctors and registrars, (“bogBlog”) posters, social media, direct e-mails and visits by the wider safeguarding team. Staff were then re-surveyed following the month-long programme.Shared attitudes and concerns towards safeguarding procedures were established amongst the wider ED team in GWH who saw them as important, but time-consuming. Despite adequate completion of e-learning training modules, staff surveyed scored their confidence levels in addressing specific aspects of safeguarding as average on a 5-point Likert scale. Post-programme surveys of 40 staff suggested all of them had received some form of information from all of the media utilised and there was an overall increase of confidence in their delivery of safeguarding services. Senior staff were also able to identify common barriers amongst staff regarding their practice including referral system complexities and lack of departmental support which has allowed the initiation of processes to improve the existing services.
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68DrJulia Sanpera-IglesiasPaediatric RegistrarCroydon University HospitalNicola Davey, Quality Improvement Practitioner
Jane Runnacles, Paediatric Consultant		Hurry up with those blood gases! Improving the delay in blood gas sampling in the Neonatal Intensive Care Unit.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 two hours of the decision. The aim is to achieve this in 8 out of 10 blood gases performed. My measurement chosen was the length of time (in minutes) between when a decision was made to do a blood gas and when this was actually carried out.		I carried out 6 plan-do-study-act cycles to test a change or group of changes on a small scale to see if they resulted in improvement. These were as follows:

-Giving doctors, nursing staff and parents clear instructions with a time frame of when a blood gas should be carried out.
-Discussion with the neonatal nurse educator, senior nurses and matron to raise awareness
-Persuading the senior nurses to carry out blood gases
-Arranging teaching sessions for doctors and nursing staff on how to interpret a blood gas
-Training junior nurses how to run a blood gas
-Arrange training sessions to demonstrate how to correctly use the blood gas machine and grant access.		-Despite being the most time consuming, the most effective measures were training junior nurses how to run a blood gas and granting access to the Point of Care machine. This translated to more hands readily available to process samples.
-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 next steps will be to review whether these changes are sustained and suggesting further changes to be tested e.g. whiteboards to write plans for babies and organising further POC training and access.
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69DrCatherineJamesAcademic Foundation Year 1 DoctorCardiff & Vale University Health BoardDo they need a top up? A Quality Improvement Project to promote the consideration of blood transfusions for patients with a fractured neck of femur (NOF) Neck of femur (NOF) fractures are a common serious injury in older people and are associated with a high morbidity and mortality. The Wales Fragility Fracture Network and Association of Anaesthetists suggest that: “Patients who have undergone surgical repair for NOF fracture should have their post-operative haemoglobin (Hb) maintained above 90g/L, and above 100g/L for those with a history of heart disease"

Maintaining postoperative Hb aids mobility and rehabilitation, helping patients to return to their feet more quickly. It also helps to reduce the rate of postoperative complications, such as heart disease and acute kidney injury. Therefore, current practice at the University Hospital of Wales involves patients having day one post-operative bloods to consider their need for a blood transfusion.		Data was collected retrospectively from the notes of general orthopaedic trauma patients who had sustained a NOF fracture during the period of 01/02/2022 – 28/02/2022. Data recorded included type of operation, if day one post-operative bloods were taken and whether there was any medical note about Hb/transfusion within 24 hours of operation.

The intervention was an information poster placed in the orthopaedic on-call room, theatre office and wards (01/03/2022) in addition to a WhatsApp message in the junior doctors group.

This quality improvement project is in progress and the second cycle is due to be carried out from 01/04/2022 – 28/04/2022 to assess for any improvement. 		The total number of patients included in the first cycle was 25. 100% of patients had their day one post-operative bloods taken. However, 40% of patients did not have the results of their blood tests documented in their notes within 24 hours. Therefore, we cannot tell if these results were reviewed and whether the need for a blood transfusion was considered, based on their Hb.

Depending on the results of the 2nd cycle, if the current intervention is unsuccessful in improving the reviewing of patients day one post-operative bloods, other interventions may need to be considered, such as adjusting the NOF fracture proforma or a sticker in patients notes to prompt consideration for transfusion.
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72DrShu-Yi ClaireChanDoctorBristol Royal InfirmaryJessica Macready (Doctor)
Bridget Kemball (Doctor)		Atrial Fibrillation: Changing an Irregular PracticeNew atrial fibrillation (AF) is a common acute medical presentation. Management of this condition is multifaceted and may involve rate or rhythm control, anticoagulation and structural imaging. A variety of methods are available for achieving these purposes and choices often vary based on local practice.

Anecdotally, patients with new AF were being managed inconsistently. This QIP aimed to identify areas for change and provide a solution to ensure standardised care for all patients.

An initial audit confirmed inconsistent management and outdated guidelines at the Trust. Therefore, phase two aimed at creating a new Trust-wide guideline covering medication choice, treatment escalation and patient stratification for specialist follow-up. Phase three is a re-audit to assess the impact of the newly implemented guideline.
Phase one: Initial audit
We reviewed case notes for all patients presenting with new AF between June-July 2020 and analysed management of each case, showing inconsistencies in patient care.

Phase two: Creation and dissemination of new Trust-wide guidelines
New guidelines were written in consultation with relevant specialties (cardiology, acute medicine, haematology) and incorporating national guidance. These were ratified in October 2021. PDSA education cycles were then carried out for key groups of medical staff and demonstrated a clear improvement in clinicians’ knowledge of standardised care.

Phase three: Re-audit
Having implemented the new guidelines, a re-audit is currently underway that will cover Jan-Feb 2022 and assess the impact of change.
Our initial audit identified significant shortcomings, with 12% of patients with new AF inappropriately discharged without anticoagulation and 25% inappropriately not referred for further imaging. Existing guidelines were outdated and no longer reflected local care pathways and national guidance.

We created an updated guideline and carried out PDSA education cycles for key clinicians. Pre- and post-education surveys showed they were highly effective in raising awareness about new standards of care.

The re-audit, which will be complete by March 2022, aims to assess the impact of our implemented changes.

Lessons learnt:
1. New AF requires complex decision-making that is often inconsistent between clinicians.
2. Clear and up-to-date guidelines are necessary to ensure a standardised approach in line with current best practice.
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75DrLasithRanasingheSHOImperial College Healthcare NHS TrustZaid Alsafi (ED SHO St Mary's Hospital)
Aruni Mathyalakan (ED SHO St Mary's Hospital)
Arabic Language Prompts to Facilitate TriageSt Mary's Hospital A&E caters to a large number of Arabic-speaking patients with little or no English ability. As a result, Arabic-speaking members of staff were often pulled away from their clinical duties to help interpret during triage. This not only interrupted their day to day activities but also made the triage process less efficient. Often, only basic information is required for triage purposes (main complaint, duration). PLAN: Assess the difficulties in triaging Arabic-only speakers in triage and the impact that being called at short notice to interpret has on the Arabic-speaking members of staff.
DO: Send questionnaire to triage nursing staff and Arabic speaking members of staff to understand the nature of the issue.
STUDY: Learn about the different presenting complaints in ED and the information that triage nurses require. Appreciate the disruption that requiring ad hoc interpreters causes to staff and the triage process.
ACT: Create Arabic Triage Sheet and place in triage rooms and make nurses aware.

Thus far, it is evident that Arabic-speaking members of staff are often disturbed multiple times per day to attend triage to interpret. For junior doctors, it has led to reduced opportunities to see interesting cases and, hence, compromising their training. Triage staff often find that needing to find an Arabic-speaking member of staff is time-consuming and causes delays to the triage process. We have implemented the Arabic language crib sheet and hope to collect data soon.
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76DrTianHuangGP st1Yeovil district hospital Dr Ziya Motala ACCS-EM CT1
Dr Rebecca Rodrigues ACCS- EM CT1
Dr Zoe Bleything FY2
Dr Thushanee Ramajayan FY2		Decreasing urine dips in >65s and catheterised patients and decreasing unindicated UTI antibiotics prescription in the emergency departmentFrom November 2019 to January 2020, Yeovil district hospital had the highest amounts of UTI antibiotics prescribed in the south west out of all acute trusts. Pharmacy did a check and found a lot of the antibiotics prescribed were pivmecillinam in ED TTO packs. We wondered if reducing unnecessary urine dips in people over the age of 65 and in catheterised patients in ED would lead to reduced prescription of UTI antibiotics when not indicated. The guidelines we looked at were the SIGN guidelines in 2012 and NICE quality statements 2015 on UTI management. We aimed to reduce unindicated urine dips and unindicated UTI antibiotics prescribing. We looked at urine dips done in ED between 01/05/2020 and 01/08/2020,how many were done in people >65, how many were done in catheterised people, and whether these unnecessary dips lead to antibiotic prescribing in people with asymptomatic bacteriuria. We did 3 PDSA cycles: and remeasured these variables.
PDSA 1: Education session for doctors + advice to fill in tick box prescription sheet before prescribing UTI antibiotics.
PDSA 2: Education session for nurses
PDSA 3: Presentation at ED clinical governance meeting.
On reading through the notes, we did note a decrease in the number of patients who were prescribed UTI antibiotics without clear indication after our PDSA cycles. However, there was no decrease in the number of urine dips in >65s and in catheterised people. This suggests our education sessions helped to remind people of indications for prescribing UTI antibiotics. We thought perhaps the unnecessary urine dips were still being done because they were done by HCAs or ordered at triage. Our next steps would be to arrange teaching for HCAs and triage nurses and to put posters up in the department.
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77DrWilliamWaldockJunior DocotrChelsea and Westminster NHS TrustDr Kieran Walsh (Clinical Director at BMJ), Dr Callum Chapman (Consultant Cardiologist), Ms Cindy Supan (Cardiology Ward Manager)

QI short report: A multidisciplinary, patient education and empowerment approach to improve fluid balance in patients on a cardiology ward Heart failure (HF) is one of the most common reasons for admission to hospital; it is associated with long in-patient admissions, and has a high in-hospital and post-discharge morbidity and mortality. Accurate fluid balance measurements are a vital part of management with intravenous diuretics for patients with decompensated heart failure and fluid overload. On our review of the data collection on Syon 1 Ward (West Middlesex Hospital), there was great variability and poor recording of fluid balance.
The SMART (Specific, Measurable, Applicable, Realistic, and Timely) aim of this Quality Improvement Project was to improve fluid balance recording accuracy from 65 to 75% on Syon 1 (cardiology ward at WMUH) in two months.
We carried out three Plan-Do-Study-Act cycles to assess and then improve the quality of fluid balance monitoring on Syon 1 ward compared to NICE guidelines standards. In the cycles we promoted access to the BMJ Best Practice topic on heart failure to members of staff; we offered BMJ Best Practice patient information leaflets to Heart Failure patients on Syon 1 to highlight the importance of fluid balance in their recovery; we finally offered patient empowerment training so that patients could be more active in their own fluid balance recording. BMJ Best Practice is freely available to all NHS staff. After implementation of three separate interventions of staff education, patient education, and patient empowerment, median fluid balance accuracy improved from 65% to 80% over two months on Syon 1 WMUH. Patient education with patient information leaflets and subsequent patient empowerment seemed to have the greatest effect on improving the accuracy of fluid balance monitoring. We also noted that it is considerably easier to measure fluid balance in those who are catheterised and only receiving IV fluids, compared to those self-mobilising to the lavatory and drinking independently. We plan to use patient information leaflets more frequently to enable improved independence and empowerment.
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78DrMollyNicholsFoundation TraineeGuy's and St Thomas' NHS Foundation TrustDr Jane Draper - Clinical Scientist in Cardiology, Physiology Lead for Heart Failure
Dr Jessica Webb - Consultant Cardiologist, Clinical Lead for Heart Failure		The Echo Report Understood - Improving Echocardiography Education for Junior DoctorsAs a non-invasive, time and cost effective diagnostic and monitoring tool, echocardiography is the most widely used cardiac imaging modality. Although familiarity with echocardiography is necessary for day-to-day practice for junior doctors, it has been acknowledged that education on echocardiography is lacking. A poor understanding of echocardiography has the potential to lead to inappropriate referrals, inaccurate interpretation of echocardiography reports and unsafe patient management.
The purpose of this study is to gain a better understanding of the echocardiography education received by junior doctors and to gain insight into the level of confidence and understanding of the topic amongst this cohort. This project aims to oversee the delivery of high-quality echocardiography teaching to achieve an improved confidence and understanding.
Prior to the intervention, an anonymised online questionnaire was provided to assess previous education received on the topic, at medical school and in the post-graduate setting. In addition to qualitative answers, the questionnaire included Likert rating scales to establish the baseline confidence and understanding of echocardiography amongst junior doctors.
The intervention involved the delivery of a hybrid, face-to-face and virtual, lecture to FY1 and IMT doctors containing definitions of key terms, advice on diagnostics and treatment, echocardiography videos and clinical cases. Understanding was evaluated via an anonymised interactive case-based quiz. A post-teaching anonymous questionnaire assessed the quality of the teaching and the resultant efficacy of the intervention.		The pre-teaching questionnaire identified a lack of echocardiography education in the undergraduate and postgraduate setting. Over 90% of doctors did not feel confident at echocardiography report interpretation despite 88% of the group carrying out this skill at least once a week.
Following the lecture, there was a significant increase in understanding of echocardiography report components, confidence with report interpretation and the subsequent identification and management of cardiac emergencies. All doctors found the teaching relevant to their job role, with 91% recommending the session.
This study identifies a need for further echocardiography education to improve confidence and understanding of the topic. In turn, patient care can be optimised through improved management of cardiac patients and better recognition of pathology from echocardiography.

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81DrMeganRotherhamFY1 DoctorUniversity Hospitals SussexAudit of Patients with Severe Ulcerative ColitisBetween 15-25% of patients with UC will require admission for an Acute Severe Ulcerative Colitis (ASUC) flare at some stage during their disease. Audit completed to assess the care of patients admitted with severe ulcerative colitis over a one year period, using the recommendations of the British Society of Gastroenterology (BSG).

BSG guidelines indicate 67% of patients with ASUC showed a response to steroids, 29% required a colectomy and there is a mortality rate of 1%. ASUC patients’ risk of VTE is 2-3 times higher than inpatients without IBD. C. difficile infection has been associated with a worse outcome in hospitalised IBD patients. Investigations, prescribing and management plans were assessed according to those deemed necessary by BSG.
Participants were included in the audit if they met Truelove and Witt’s criteria or if they were identified as having Severe Ulcerative Colitis requiring intravenous steroid treatment by a Gastroenterologist between July 2019 and July 2020.
Truelove and Witt's criteria is 6 or more bloody stools in 24 hours plus systemic toxicity.
Patients were also assessed according to the Oxford Criteria for the response to steroids at 72 hours.
Patients medical notes, drug charts, investigations, imaging and any endoscopy or surgery notes were reviewed to source the information		43 patients were admitted with ASUC between July 2019 and July 2020. 58.1% of patients (25) met Truelove and Witt’s Criteria. 19 patients required Infliximab and 14 patients required surgery.
38 patients (88.4%) received imaging within 24 hours.
This audit found 62.8% did not sufficiently respond to steroids, with 32.6% requiring a colectomy and a mortality rate of 0%.
Additional training with regards to sending stool samples with C. diff testing, prompt IV steroids and VTE prophylaxis all within 24 hours. Improvement must be made in the number of patients who have a flexi-sig within 24 hours. Improvement required in the documentation of stool frequency and CRP testing at 72 hours to monitor steroid response.
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82DrLukeGloverFoundation Year 1 DoctorRoyal Devon and Exeter NHS Foundation TrustSimon Brackley (Foundation Year 2 Doctor)
Miles Edwards (Foundation Year 2 Doctor)
Georgia Wright (Foundation Year 1 Doctor)
Lauren Eddy (Foundation Year 1 Doctor)
Lucy Andrews (Foundation Year 1 Doctor)
Riordan Deehan Jackson (Foundation Year 1 Doctor)
Smruthy Chakka (Foundation Year 1 Doctor)		Dishonourable discharges - Improving the timely sending of discharge summaries at the Royal Devon and Exeter hospitalThere is often a delay in sending discharge summaries at the Royal Devon and Exeter Hospital (RD&E), made measurable by the introduction of a new electronic patient record system (EPIC) in 2020. Discharge summaries are a vital part of ongoing patient care and often contain important follow up requests for the patient's GP. Delayed sending creates additional workload for GPs, hospital doctors and administrative staff and poses potentially serious patient safety issues.

Our overall aim is to increase the percentage of discharge summaries sent to a patient's GP within 2 days of discharge to 90%, across all departments at the Royal Devon and Exeter Hospital, by 14th July 2022. 		Using a “report” within EPIC, we audited all discharges from the RD&E from October 2nd 2021 – January 14th 2022. Reports allow searching of EPIC’s extensive data with user-defined criteria. This gathers a dataset containing information on all RD&E patients over a defined time period who have a delayed discharge summary. We stratified this by location, specialty, discharge method, day of week and hour of day.

Using this dataset, we designed initial tests of change on a respiratory ward, and patients who are discharged as deceased.

Our interventions so far include targeted posters, and altering the way junior doctors use EPIC so that their inpatient lists automatically include discharged patients with missing discharge summaries, encouraging completion of the relevant paperwork.		Our data confirm a widespread issue: in 3.5 months, 18% of discharge summaries were not sent within 2 days. Anecdotal reasons for this include unawareness of the need for discharge summaries in certain situations, work-load, and discharged patients automatically falling off patient lists.

In the two weeks after our poster-based intervention for discharges as deceased, we have seen an increase in percentage of discharge summaries sent within 2 days of discharge from 44.5% to 68.7%. More data to enable statistical testing is awaited.

Next steps include collecting more data on our initial PDSA cycles and implementing further changes across the hospital. We now appreciate the scale of this problem and hope to use QI methodology to address this issue.
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83DrBenedictTurnerSenior House OfficerSt Mary's HospitalEmma Thorley, Senior House Officer
Akash Doshi, Medical Rergistrar
DIRE: Improving the Referrals Process Nationally The Doctors Improving Referrals (DIRE) group was founded to improve the referrals process after a baseline survey of junior doctors demonstrated profound difficulties: undermining behaviours, unnecessary aggression and poor morale were common experiences of the cohort and were shown to negatively impact delivery of patient care. The primary aim of this prospectively registered quality improvement project was to enhance the process of referrals for junior doctors, by targeting areas of weakness identified in the baseline survey including not knowing how to reach the specialist and not knowing what information to include in the referral.
A google form was posted online onto Facebook groups for doctors. The survey contained questions about the challenges of making referrals, the consequences of poor referrals, and ideas for improvement. The data were analysed qualitatively and coded into themes.

A series of interventions were then implemented at both trust and national level, resulting in 5 PDSA cycles. A national referrals cheat sheet was generated with feedback from different speciality colleagues across the country. A comprehensive, cloud-based list of all inpatient and outpatient referrals information was also created at trust level.
The referrals cheat sheet has been improved over multiple PDSA cycles based on the feedback from junior and senior colleagues and has been downloaded by nearly 500 people, who have reported excellent feedback. The referrals specialty list has been demonstrated to be highly effective, resulting in less wasted time for junior doctors, faster time to referral and fewer perceived delays to patient care.

We therefore propose that the referrals list and cheat sheet be used as a springboard for new doctors, to enhance their efficacy when learning how best to refer. It has been demonstrated as safe, useful and effective to enhance the quality of patient care delivered as well as the job experience for junior doctors.
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84DrSerenaLinley-AdamsFoundation Year 2 DoctorCardiff & Vale University Health BoardDr Swaroop Shanbhag, Consultant in Rehabilitation Medicine
and Wan Yee Lee, Antimicrobial Pharmacist		An audit into appropriate antimicrobial prescribing for spinal rehabilitation patients, in the context of an MDRO outbreak A multi-drug resistant organism outbreak on the spinal rehabilitation ward in the Cardiff and Vale University Health Board has prohibited new admissions, slowed rehabilitation processes and put additional strain on healthcare staff. Many patients on this ward are colonised with an MDR Klebsiella species, which has caused significant morbidity and mortality.
Since the MDRO outbreak, antimicrobial prescribing for these patients has not been critically evaluated. Spinal rehabilitation patients present differently and often more vaguely compared to other cohorts of patients, with poorly localised pain, autonomic dysreflexia, increased spasms and fevers.
The aim of this audit was to evaluate the appropriateness and accuracy of antimicrobial prescribing in spinal rehabilitation patients, given that inappropriate prescribing can fuel MDRO outbreaks.
Using an audit toolkit based on the ‘Start Smart Then Focus’ (SSTF) antimicrobial stewardship initiative for secondary care, we evaluated the following aspects of prescribing:
• Antibiotic indication, including documentation
• Antibiotic duration, including documentation
• The guidance used to choose the antibiotics
• Differences in prescribing between day teams (who regularly treat these patients) and on call teams.
• Senior reviews within 72 hours (as advised by the SSTF guideline)
We used notes and online clinical portals to access this information.
All 34 patients admitted on the spinal rehabilitation unit between January and September 2021 were included in the audit, totalling 53 courses of antibiotics.
The majority of infections prescribed for were urinary tract infections (42%) or ‘unknown sepsis ?cause’ (32%). Antibiotic choice was considered ‘appropriate’ (based on local guidelines i.e. Microguide app, Microbiology advice or culture and sensitivities) in 89% of prescriptions. None (0%) of prescription choices by the on-call team were based on Microguide (day team 26%), instead relying on on-call Microbiologist advice (77%).
30% of prescriptions did not have a duration plan documented, and 40% of prescriptions were not reviewed by a senior within 72 hours.
Future implications: a mandatory regular review could be implemented on the long-stay drug charts. A spinal rehabilitation-specific section on Microguide could guide on-call and day teams, rather than calling Microbiologists, which can be time-consuming and impractical.
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85DrLivia Samara O&G ST1Southmead HospitalDr Hesham Abdulgawad - Specialty registrar Have you seen the b-hcg?: Improving documentation of emergency gynaecology clerking through implementation of a proforma Clerking documentation provides one of the most important sources of information for subsequent reviews of a patient. In gynaecology in particular, speciality specific aspects of the history can be extensive. The aim of this quality improvement project was to develop an emergency gynaecology clerking proforma designed to incorporate all aspects of the gynaecology history and examination as well as results of investigations in order to improve documentation.An initial audit was carried out assessing the documentation of key information including history, examination and results of investigations at the Great Western Hospital in October 2021. A pre-proforma questionnaire was then carried out by junior doctors working in the department investigating which aspects they thought would be helpful. Based on the results of the audit and the questionnaire a proforma was developed. Following implementation in the department a further questionnaire was carried out to assess for improvements in documentation of history, examination and investigations, as well as confidence in clinicians in clerking such patients in January 2022. The next PDSA cycle will involve teaching on clerking documentation and the proforma at the next junior doctors' induction. The results demonstrated an improvement in documentation of history, examination and investigations as well as improved confidence amongst junior clinicians in clerking patients. The proforma also helped to prompt more senior reviews in complex patients prior to the consultant ward round. The use of a specific emergency gynaecology proforma improves the quality and consistency of clerking documentation and is now used as standard in the Emergency Gynaecology Unit at the Great Western Hospital.
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87DrAlexandraBurgessST5 in Geriatric and General Internal MedicineSwansea Bay University Health BoardDebra Clee (1) - Emergency Nurse Practitioner
Dr Elizabeth Davies (1) - Consultant Geriatrician
Dr David Burberry (1)- Consultant Geriatrician
Dr Leigh Keen (2) - Welsh Ambulance Services NHS Trust Health Board Clinical Lead
1. Older Person’s Assessment Service (OPAS), Morriston Hospital, Swansea Bay University Health Board (SBUHB)
2. Welsh Ambulance Service (WAST).
CWTCH in the community - Improving education to reduce adverse outcomes for patients who fall in Nursing Homes (NH). Falls have significant morbidity and mortality, and are more likely to cause significant harm in Nursing home (NH) residents. We have proposed that an educational intervention offered to Nursing Homes will reduce the number of 999 calls and reduce adverse patient outcomes. NH residents are at risk of recurrent falls as intervention and risk factor modification is often more complex. We have already established an Older Person’s Assessment Service (OPAS) within the emergency department (ED). This provided rapid access to specialist assessment, continued access to Elderly Care services, avoided exposure to coronavirus related admissions and the risks of nosocomial infection and is MDT based with specialist ANP, physio and OT and consultant Geriatrician. Phase 1 Welsh Ambulance (WAST) calls between 01/01/2020-30/01/2022 from NH in Swansea Bay UHB concerning Falls and ?Falls (Haemorrhage/lacerations, Unconscious/fainting, traumatic injuries, sick person, convulsions/fitting) were included. A survey was sent out to all SBUHB NH to investigate how staff treated falls.

Phase 2 The team prepared an education package delivered to all NH managers and other staff members encouraging staff to consider CWTCH
· Can we move them
· Will it harm them? (neck pain, back pain),
· Treat them – pain relief, dressing wounds
· Can – eat & drink
· Help – when to call 999).
We then surveyed staff to see if they felt more confident post intervention and whether this would change their practice. 		Phase 1 Out of 4709 calls, 825 were falls (17.52%) and 988 ?Falls (20.98%), 60.49% conveyed to hospital. The survey revealed 47% of NH do not have falls guidelines and WAST were always contacted by 88.24%.

Phase 2 Education was delivered to 11 NH (65 staff). Feedback showed 100% feel more confident in giving food and drink, moving patients and all found the session helpful with 84.61% less likely to contact 999. There is a clear educational need as 67.69% had not received prior training.

Falls remain a significant burden on WAST and ED and a rapid falls intervention would improve care as 39.51% patients remained at scene. Future directions include offering this intervention to all NH in SBUHB.
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88DrHui MeiWongFoundation Year 1 doctorWhittington Hospital - Streamlining electronic venous thromboembolism (VTE) risk assessments and enhancing safe prescribing in acute admission unitsA key national quality requirement in the NHS Standard Contract is to assess for venous thromboembolism (VTE) risk in 95% of all inpatients aged 16 and above. In the 2020/2021 year, the Whittington Hospital did not achieve this requirement and it was a priority for the Trust to increase VTE risk assessment compliance to a national standard of 95%. The Whittington Hospital uses an almost fully electronic system; this includes the VTE risk assessment form, which is audited annually to assess whether the trust meets national quality requirements. This project aims to increase the VTE risk assessment and appropriate prescription of VTE prophylaxis within the acute admissions units to the national target of 95%.Data was collected on Wednesdays and Fridays over 18 weeks (11/8/2021-17/12/2021). Data on thromboprophylaxis prescriptions and VTE risk assessments was collected from the acute medical and surgical units (AMU/ASU). Pre-intervention data was collected and doctors were asked to complete a questionnaire regarding the existing VTE risk assessment system.

A total of 4 PDSA cycles were conducted. The interventions were guided by the questionnaire feedback and after each intervention result was studied and assessed. The interventions were: 1. Mandatory teaching to raise awareness, 2. introducing a mandatory tick-box prompt on the medical and surgical admissions proforma, 3. integrating the risk assessment checklist into only the medical admissions proformas, 4. integrating this into both the medical and surgical admissions proformas.
The pre-intervention questionnaire identified multiple issues with the existing system. Doctors reported that this form was difficult to find and completing multiple online forms on different platforms was ill-suited to a busy shift. Following the changes, the overall VTE assessment improved from 20% to 85.5%. The overall appropriate prescription of thromboprophylaxis increased from 88.0% to 95.7%.

Admission pathways which do not use the medical or surgical clerking proformas (surgical day cases, O&G) contribute to the remaining gap in risk assessment. Compliance can be further improved if the risk assessment tool was integrated into these respective proformas. Ultimately, a key learning point (applicable also to non-electronic systems!) is that streamlining systems can enhance VTE risk assessments and improve patient safety.
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90DrLucyFoxFoundation Year 1 DoctorChelsea and Westminster HospitalSecond Author: Miss Sarah Brown (Senior Clinical Fellow Urology)
Supervised by: Mr Hama Attar (Urology Consultant)		Digitalising and improving the Handover process for Urology at a North West London District General Hospital The clinical handover process is essential for providing continuity of patient 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 surgical teams covering Urology out of hours.

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 admissions were added to the list to avoid patients being missed, and improve the clinical information available to enhance continuity of care and patient safety.
A team of doctors created a questionnaire to identify issues surrounding the Urology Handover process.

The current standard was a simplistic list of patients name, hospital number and location.

PDSA Cycle (C) 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 to the WDL proved a significant issue.

C2:
The WDL was digitalised using the Electronic Patient Record ‘Cerner’. This was more time-efficient as clinical details and blood results were pre-populated. However clinician access still remained an issue.

C3:
A Care Team Handover List (CTHL) was created using Cerner, granting access to all medical staff to edit patients and their clinical progress.
C1: Our questionnaire showed patients were often or occasionally, 70% (N=7 of 10), missed off the list. This improved to rarely 75% (N=6 of 8) with the WDL.

However, the WDL was time consuming to update and 44.4% (N=4 of 9) did not feel confident in using it.

C2: Feedback studies showed improved access and use of the Cerner list but patients admitted out of hours, were still being missed.

C3: Our results showed that 100% (N=9 of 9) of doctors had access to the CTHL and 100% (N=15 of 15) of the Urology team reported patients were rarely missed.

The CTHL ensures that patients are handed over and continuity of care and patient safety has improved as a result.
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92DrMatthewMcMillanFY2Swansea Bay Health BoardDr Alexandra Burgess, ST5 in Geriatrics and GIMPrescribe, Review, Now! – an assessment of adequate PRN analgesia and associated laxative prescribing using HEPMA (Hospital Electronic Prescribing and Medicines Administration) Intro:
HEPMA (Hospital Electronic Prescribing and Medicines Administration), has recently been introduced to our District General Hospital. It was noted that patients’ analgesia use was poorly reviewed on a regular basis, and there is no way to notify a prescriber if patients are regularly accessing PRN (as-required) analgesia. Previously All-Wales paper drug charts were used, which had a distinct PRN section.
Aim:
To assess how well prescribers identify a patients’ use of PRN analgesia, and the necessary escalation of the WHO analgesic ladder and whether laxatives were prescribed with opioid analgesia, due to the increased risk of delirium in older adults.

Cycle 1
Using HEPMA, we reviewed a) prescribed and PRN analgesia, b) whether PRN analgesia was used 3 or more times in 24 hours and c) whether laxatives were prescribed for every medical inpatient. Posters were designed and placed on each medical ward as a cue to a review and change analgesia when appropriate “Prescribe, Review, Now!”. This poster was circulated electronically to all the medical doctors in the hospital.
Cycle 2
HEPMA was re-reviewed after 2 weeks to determine if there was any improvement in appropriately prescribed analgesia and laxatives for all the medical inpatients.
Cycle 3 will be completed, following a teaching session.
Cycle 1:
167 inpatients surveyed, 58% female, 42% male, mean age of 78 (13.4). 37%had appropriate prescriptions of both analgesia and laxatives, 31%inadequate analgesia, 19% inadequate laxatives, and 13% inadequate laxatives and analgesia.
Cycle 2:
159 inpatients surveyed, 65% female, 35% male, mean age of 77 ( 15.7). 58% had appropriate prescriptions. 19% inadequate analgesia, 15% inadequate laxatives, and 8% inadequate analgesia and laxative. This is a significant improvement (p= 0.003).
We have shown that PRN analgesia is not regularly reviewed and escalated in HEPMA. Our intervention showed an improvement in appropriate prescriptions. Future directions include holding a teaching session on appropriate analgesia use (WHO pain-ladder) and laxative prescriptions especially in older adults. We will conduct a third cycle afterwards.
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94DrMatthewHow Saw Keng Doctor Great Western Hospital Dr. Kathryn Ryland, Dr. Sabarigirivasan Muthukrishnan
"STICKING to the correct dose". A Quality Improvement project to reducing incorrect lorazepam prescriptions in elderly mental health patients Lorazepam is widely used in mental health inpatient settings. This project focused on prescribing patterns in an acute psychiatry ward for complex dementia patients.
The BNF advised a maximal of 2mg in a 24hour period for those over the age of 65. An initial audit showed 100% of patient’s prescriptions were exceeding this limit. Over sedation in the frail elderly population carries significant morbidity and mortality risks. This project aimed to achieve full compliance with BNF prescribing limits within 4 months. This was done in a multidisciplinary approach involving pharmacists, ward doctors, Specialty Doctor in Old Age Psychiatry, Consultant Old Age Psychiatrist and nurses.		An initial audit collected evidence on current prescribing habits; the number of patients on lorazepam, the maximum dosage prescribe and actual daily usage. Patients who had a Second Opinion Appointed Doctor (SOAD) (n=2) were excluded.
Interventions included; prescriptions rewritten manually, addition to the ward round proforma to prompt weekly review, an educational mass message to the doctors working on the unit and then finally the introduction of pre-filled prescription stickers that required doctors to date and sign on completion. The interventions were all carried out in a PDSA cycle format.		All patients (average age=79) were prescribed Lorazepam as required. Initially all prescriptions exceeded the BNF recommended limit. However, the majority of patient’s use was in line with or below 2mg in 24hrs with only one patient receiving 3.5mg in a 24hr period. The first three interventions had a positive impact but after doctor change-over and a flurry of new admissions to the ward this was not sustained. The pre-populated stickers ensured 100% BNF compliance and provided longevity. The sticker provided the most sustainable solution and although small demonstrated that even small changes make can provide a long lasting positive change.
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95DrDavidMcMasterFY1 DoctorLondon North West University Healthcare NHS TrustDr Sohail Singh
Dr Hussein Elghazaly
Dr Payman Dahaghin
Dr Muhammad Shaikh
Mr Hemant Sheth		An audit cycle of antibiotic prophylaxis for laparoscopic cholecystectomyBackground/Aims: 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. The aim of this audit was to assess compliance with local and national guidelines for antibiotic usage for laparoscopic cholecystectomies, to identify areas of improvement, implement change and re-audit to assess the effectiveness of this change. Method: Data was collected retrospectively between 01/05/2021 and 01/08/2021 for patients undergoing elective laparoscopic cholecystectomies. Following the initial data collection, we 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.Results: 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.

Conclusions: We show that pre-printed stickers are a simple intervention that can improve adherence to local guidance and reduce injudicious use of antibiotics in the pre- and post-operative periods. Improving antibiotic prescribing for laparoscopic cholecystectomies, one of the United Kingdom’s most common surgical procedures, highlights the potential for significant cost savings and improved antimicrobial stewardship.
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96DrMohannadAbuomarCT2 doctorBlackpool Victoria HospitalHarry Alker FY2 doctorDifficult peripheral intravenous access in Blackpool Victoria Hospital Peripheral intravenous cannulation (PIVC) is the most common invasive clinical procedure required in hospitalised patients, for whom 1 in 3 is reported to have difficult venous access. Blackpool Victoria Hospital has a cohort of patients with a high prevalence of identified independent risk factors for difficult intravenous access e.g. intravenous drug users, obesity. We are aiming to improve patient experience, reduce the burden on anaesthetics and reducing the number of vascular access related clinical incidents in the hospital. Total of 5 PDSA cycles performed so far:
We first identified the magnitude of the problem through surveys questioning patient safety and satisfaction. Training a group of 10 on ultrasound guided cannulation followed and positive feedback was gained. We then met the deputy medical director and proposed a difficult intravenous access service set-up, however inadequate funding was a barrier and our evidence was subjective.We therefore collected data on vascular access related clinical incidents and also the burden on anaesthetics for cannulation assistance. A teaching faculty was set-up and well received regular training on ultrasound cannulation is being delivered with post-training support. Short dwelling time of cannulae triggered data collection of midline usage leading to an ongoing trust midline awareness campaign.		Difficulty/failure in gaining timely peripheral intravenous access causes delays in administering critical medications and having necessary imaging along with patient dissatisfaction and being a burden on anaesthetics. Use of ultrasound guidance has been successful in the pilot study and therefore a larger ultrasound teaching programme with a formal sign-off process was developed. A vascular access service remains necessary and the project results have been shared with the community vascular access team to support their business case for expansion. Enthusiasm, persistence and good communication have been the project's drive so far.
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98DrNadiaEdenDoctor FY2Whipps Cross University HospitalDr Mishka Venables (Joint first author)

FY2 Doctor Royal London Hospital, Barts and the London NHS trust

We were both previously F1 doctors at Homerton University Hospital		"Anyone know how to refer to... ?!": Improving ease of referral pathways at Homerton University Hospital A large part of medical practice is making sure patients are referred to the appropriate speciality in a timely manner. Difficulties in accessing those specialties can lead to a delayed diagnosis, prolonged hospital stays and generally a poorer outcome for patients.

When we first started as F1s at Homerton, a busy central London teaching hospital, we soon realised that there was no single point of access to find out how to refer to a specialty. There were several different methods of referring and the only way to find out was through word of mouth.

Aim:
to improve the process and ease of referring to specialties by 25% by August 2021.		1.
Plan/Do:a survey was distributed to identify barriers to referral, the preferred referral pathways and suggestions for improvement.
Study:
-44.8% of doctors rated difficulty in referring as </5, 10 being extremely challenging
-There was no single preferred method of how to refer
-50% wanted a single unifying method of referring
Act
-an online referral directory was created and widely distributed

2.
Plan/Do: resurvey to evaluate if there was an improvement in ease of referral and their experience of using the directory
Study:
-53% of doctors rated difficulty in referring as </5
-82.3% rated the directory >/4 out of 5 for ease of use
-Most common improvement suggestion was regarding ease of access.
Act:To convert the directory into an app		Results:
-improvement in ease of referral by 8.2% with implementation of the directory
-Positive feedback and good engagement e.g.
"It’s amazing!! So so helpful , thank you for making it"
"Excellent resource! Hugely helpful!"
-82.3% rated the directory >/4 out of 5 for ease of use
-88.2% used the directory when they were unsure how to refer

Lessons:
-Did not reach our 25% improvement target, potentially due to access to the directory, phrasing/scaling of survey questions and poorer response rate for 2nd survey.
-82.4% were aware of the directory however there are still areas for improvement from feedback:
"Added to more place and posters around the hospital"
"More easily available i.e. intranet or S drive. Could be a good app"
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99DrSidharthanIlangovanDoctorBarking, Havering and Redbridge NHS trustDr Tanday Raj, Dr Montana JacksonCreation of Treatment Escalation Plans for patients admitted to a general medical wardA Treatment Escalation Plan (TEP) is a communication tool which is helpful for inpatients as they have the potential for acute deterioration and some may be coming towards the end of their life. There are situations where doing everything possible may lead to more harm and suffering rather than less. This may not be in the best interest of the patient (or in line with the patient’s wishes). Thus TEPs provide on call teams access to guidance during times of crisis and act as a communication tool between clinical teams that takes into account the patient's wishes. This audit aims to assess the proportion of inpatients who have a TEPs documented and implement actions to improve the rate to 100%.All Patients admitted to a general medical ward at King Georges Hospital for a 2 week duration were used as a representative sample.

Methodology

Cycle 1:

1. Examination of case notes was the primary method used to identify if patients had a TEP

2. Forms of TEPs accepted for this study are as follows;

- Filled up treatment escalation plan proformas
- Detailed written treatment escalation plans not utilising a proforma

3. The patient notes were examined to locate the aforementioned forms of TEPs and the data was recorded in an anonymised and password protected excel sheet

Cycle 2:

1. Action plans from the first cycle were implemented

2. Steps 1 to 3 of cycle 1 were repeated to assess the effectiveness of the interventions

Results of Cycle 1:
91 patients were admitted of which only 37 had a Treatment Escalation Plan (40.65%)

Lessons Learnt:
1. Doctors on the ward required more education on the improtance of TEPs
2. Staff needed ready access to tools that aided TEP creation

Action plan:
1. Education
- Presentation during local ward teaching and induction weeks
- Poster which explained the improtance of TEPs and their creation was designed and displayed
prominently on the ward
2. Access to tools for TEP creation
- TEP proformas were created, printed and placed prominently in the doctors office of the ward

Results of Cycle 2:
66 unique patients were admitted of which 57 had a TEP representing (86.36%) thus a significant improvement


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100DrPeterMooreF2 Acute Internal MedicineNorthern Health and Social Care TrustDr Mark Hoey, Medical Registrar Dept MedicineDoes the introduction of a cardiac arrest huddle improve recognition of members roles?Cardiac arrest teams have been shown to improve patient outcomes in emergency settings. More recently it has been shown that communication between team members is integrally linked to patient safety. In our hospital, feedback raised concerns that the members of the cardiac arrest team were uncertain of their roles within the team. An allocation of roles sheet was in place already but this was not often completed and there was not a formal team meeting. Our aim was to evaluate if the introduction of a cardiac arrest team huddle improves the allocation or roles and the recognition of other team members.Pre-intervention, we audited a random sample of 39 entries in the arrest allocation book. An anonymised online survey was distributed to the medical team to understand their attitudes and confidence within the cardiac arrest team. A morning cardiac arrest team huddle was established as our intervention. This 9 am meeting was led by the medical registrar and all members of the arrest team were expected to attend. Here individuals were allocated a role, signed on a updated template and members introduced themselves. A post-intervention reaudit of 29 entries was collected and the same semi-qualitative survey distributed.Sign-in rates increased for example team leader from 78% to 93% and IV access from 73% to 100%. Qualitative aspects also showed improvement. Pre-intervention only 84.6% of the surveyed were aware of the arrest allocation book, this increased to 100%. 63.6% knew their role in the arrest team which increased to 76.7%. This QIP remains in progress and has started a conversation within our hospital about how we run our cardiac arrests. Despite the introduction of the huddle there is still room for further improvement. Next steps are to try to improve huddle attendance by all cardiac arrest team members by evaluating where and when the meeting occurs.
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101DrHafsaShaikhFoundation Year 1 DoctorBarts Health Trust Simon McCluney - Surgical SpR
Andrea de Zanna - Surgical SpR
Essa Zabrook - Medical student 		Responsible Clinician Documentation in General Surgery, can we do better? On CRS (the online system used at Barts), every general surgical patient has a named consultant for the appropriate encounter. This is important for patient safety, appropriate clinic follow up, and to ensure that investigation results are actioned by the correct person. We noticed that often, CRS would have the wrong named consultant, as compared to the Surgical Access list which is updated daily by each surgical firm, and that this led to inappropriate workload. Our aim was to identify why this was likely to happen, to introduce an intervention to reduce the likelihood of the incorrect consultant being named on CRS, and to see if this led to an improvement.
Plan: Identify why the named consultant on CRS was often incorrect. Aim was to have 100% correct named consultant. Before intervention, in June 76% of surgical patients had the correct consultant for the week audited.
Do: Identified that it was often patients admitted through ED where the wrong consultant was named. Liaised with ED matron, switchboard, rota co-ordinator and junior doctors, reiterated the importance of ensuring the day consultant on call was the admitting consultant at all times.
Study: In July, post intervention, 100% of patients had the correct consultant for the week audited.
Act: Presented first cycle to surgical junior doctors, ensured they knew how to change the consultant if it was incorrect. Re-audit, with all surgical in-patients included.

Identified that the named consultant errors were most frequently happening in ED, and better communication was needed from the surgical department and rota team to the ED team, to ensure the on call consultant was put as the admitting consultant. Junior doctors were also informed of the importance of this, and taught how to transfer consultant on CRS if they were incorrect. First data was collected pre-intervention in June 2021, 76% correct, July post intervention 100%, re-audited in December 89% correct.

Need to ensure that when junior doctors rotate, they are informed about the importance of this and how it impacts patient care. Should continue to be re-audited, can be improved by also checking the named Discharge Consultant.

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104DrJamesMurdochFoundation Year 2 Gloucestershire NHS foundation TrustImproving Patient Education on Epistaxis Epistaxis is the commonest ENT emergency seen in ED and CAS clinics. Its high incidence is compounded by the frequent re-attendance rate of its sufferers, the majority of whom are elderly. Many return to hospital due to a lack of knowledge or confidence in their condition, which unnecessarily exposes them to the risks of admission, including Covid 19.

The aim of this project was to improve patient education around the management of epistaxis, most importantly its self-management. This, in turn, then aimed to reduce epistaxis morbidity and hospital readmissions. The primary intervention to enable this was to provide a patient information leaflet on discharge, outlining basic management of epistaxis.
To measure the level of patient knowledge a questionnaire was drawn up by doctors and other stakeholders in the department. The main questions focused on patient confidence in managing their own nosebleeds and their understanding of basic management and prevention techniques. A Likert scale was employed to measure their response.

The testing occurred throughout the month of February 2022:
1. A cohort of epistaxis patients admitted to hospital either via ED or CAS clinic was given the questionnaire.
2. They received the patient information leaflet.
3. The questionnaire was repeated on the same cohort after they had received this leaflet.

Data from the questionnaires was assimilated and analysed via Excel.
Data revealed that provision of a patient information leaflet improved patient confidence in their management of epistaxis (2/5 confidence prior to leaflet; 4/5 afterwards). The majority cited the fact that it was helpful to have written information that they could refer back to once home. Hospital can be a very overwhelming environment for patients; often, doctors’ verbal advice can get forgotten in amongst the stress of admission. Thus, introducing simple measures, such as this leaflet, can improve patient safety and confidence.

To further implement this intervention, I have left a supply of the leaflets in the doctors’ office and CAS clinic.
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105DrLouisaMorrisGeneral Practitioner and Clinical Lead for Quality Improvement Hywel Dda University Health Board, NHS WalesLeah Williams - Quality Improvement Practitioner Developing GP led Same Day Emergency Care in a District General Hospital Introduction:
-Prince Philip Hospital (PPH) Llanelli is a 223 bed DGH within Hywel Dda University Health Board.
-PPH ‘Front of House’ consists of Acute Medical Assessment Unit (AMAU) and GP-led Minor Injuries Unit (MIU).
-Pressures on existing services analysed using retrospective data collection from Feb 19-Feb20 (pre COVID-19)
-New challenges Mar 20 onwards resulting from COVID-19 and social distancing requirements.

Aims:
-Schedule unscheduled care where possible
-Reduce overcrowding in hospitals – ‘SDEC first’ principle
-Community management where possible
-Reduce admissions to AMAU by 30%
-Stream acute medical patients away from MIU
-Provide rapid access to investigations and senior doctor decision (aim 4hr turnaround)
-Health Board wide project– each site developing SDEC as part of wider urgent and emergency care plan

-Core working group established – two Clinicians / one QI Practitioner
-Business case secured pilot funding until 31 March 21
-Engagement exercise undertaken
-Location and staffing model agreed
-Phase 1 pilot: 8 hrs/day 16-19 Nov 20 (PDSA 1)
-Phase 2 pilot: extended hrs 7 Dec 20 – ongoing (10hrs/day Mon-Fri) (PDSA 2)
-Initial pathway based model moving to process based model (PDSA 3)
-Clinical pathways developed for common acute medical conditions
-Defined exclusions to SDEC
-Use of triage tools: AMB / NEWS scores plus ‘clinical conversation’ for patient selection
-Business case for ongoing funding - proposed 12 hr / 7 day service
-Ongoing PDSA cycles – introduction of ANP / focus on PROMS / triage of all GP referrals

-Application of project management and QI methodology
-Influence of organisational culture
-Over a 12 month period (Feb 21 - Feb 22):
-Patients seen = 1018
-SDEC saw an average of 34% of medical take during opening hrs and 19% of medical take over a 24 hr period
-95 % of patients seen and discharged same day
-Mean length of stay = 160 minutes
-84% had ongoing care managed outside hospital
-Commonly used exit strategies were hot clinics, local review, community follow up (ART)
-Observed reduction in length of stay up to 24 / 48 and 72 hrs compared with 12 months ago but no reduction from pre COVID-19 data. Needs further analysis
-Possible missed SDEC opportunities identified
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106DrEnoraSeiteFY2 ELHTRiya Sawhney FY2, Mira Innab ENT registrar (supervisor)

Streamlining on call referrals to ENT: A clinical decision flowchartSenior house officers (SHOs) form a significant part of the workforce in secondary care. Surgical specialties with off-site seniors, such as ENT, are especially reliant on SHOs triaging and making appropriate referrals out-of-hours. However, surgical SHOs range from second year foundation doctors to first year specialty trainees: often, these trainees start in ENT with only limited previous exposure in medical school.

It was noted that there was an increasingly large volume of patients inappropriately admitted as in-patients or attending the Surgical Ambulatory Care Unit (SAECU). Preliminary qualitative data found that SHO confidence in dealing with ENT patients on-call was low. The aim of this quality improvement project was to implement a clinical flowchart to streamline the referral system to ENT.
A pre-intervention questionnaire was given to all surgical SHOs at a large district general hospital to assess baseline knowledge of referral routes to the ENT team. This also included 8 quiz questions on common conditions and how to manage them. A clinical flowchart was then designed, implemented and widely distributed within the Trust. Subsequently, the same questionnaire was circulated to the same SHOs to assess improvement in knowledge and self-reported confidence, closing one PDSA cycle.

A separate questionnaire was also handed out to the ENT team, including specialty registrars and advanced nurse practitioners. This was to assess the effects of the intervention on the frequency of inappropriate referrals.
The preliminary assessment found that 71% of SHOs felt ‘not very confident’ in managing ENT patients. The majority (57-86%) of SHOs were unaware of the various referral destinations (in-patient admission, emergency clinic, outpatient clinic, SAECU) and processes.

Post-intervention, 100% of SHOs reported feeling ‘somewhat’ and ‘very’ confident in managing ENT patients. Furthermore, 100% of SHOs now knew where and how to refer these patients.

There was also a significant increase in the mean quiz scores from 4.14 to 6.75 (95%CI: -4.90, -0.31, p = 0.03) of a possible 8. The ENT team further reported a reduction in the volume of patients seen inappropriately in SAECU and admitted as in-patients, and fewer overnight telephone referrals.
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108DrKatiePriorF1Royal United Hospital BathDr Sarah Burge F1 (Royal United Hospital Bath)Improving documentation of VTE prophylaxis prescriptions in surgical ward round notesHospital admission and surgical intervention are well-documented risk factors for thromboembolic events. Whilst systems exist to ensure patients are prescribed appropriate venous thromboembolism (VTE) prophylaxis on admission, surgical patients present a unique group who may require temporary suspension of VTE prophylaxis. Without ongoing measures in place to monitor VTE prophylaxis prescriptions, surgical patients may be at increased risk of inappropriately omitted VTE prophylaxis.
Local guidelines recommend that if VTE prophylaxis is withheld, this should be documented. Guidance given to new foundation doctors suggests that VTE prophylaxis status should be a routine part of ward round documentation. However, this is rarely monitored. During our QIP project, we aim to audit and improve documentation of VTE prophylaxis in surgical ward round notes.
Baseline data: We examined ward round entries for inpatients and recorded how many times VTE prophylaxis was documented in ward round notes over a period of seven days. These data were also categorised by specialty.
PDSA cycle 1: An intervention was targeted only at junior doctors working in general surgery, highlighting the importance of checking and documenting VTE prophylaxis when preparing ward round notes.
PDSA cycle 2: The intervention was extended to surgical registrars, examining the hypothesis that senior leadership could improve concordance.
For both cycles, the intervention involved sending a written message outlining our project to the target group. Post-intervention data was collected one and three weeks after each cycle.
Baseline data showed very poor documentation of VTE amongst all specialties. This was with the exception of Hip Fracture and Geriatric patients, where 100% had VTE status documented at least twice in the preceding week. Surgical specialities in general performed poorly.
After PDSA cycle 1, there was a moderate improvement in VTE documentation in general surgical ward round notes, however it was notable that this varied greatly between individual doctors. We also found that after PDSA cycle 1 documentation on outlying wards, with patients from a mix of specialities, remained poor despite intervention. Specialities where there had been no intervention saw no significant improvement in VTE documentation.
Results following PDSA cycle 2 in progress.
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109DrGuyFletcherIMT1West Middlesex HospitalAlice Ditchfield - FY1
George Ashton - FY1		Reducing Time Taken for Treatment Escalation Plan CompletionThere can be a significant time delay between consult decision regarding treatment escalation, including resuscitation, and formal completion of the DNAR/TEP form. This can lead to difficult decisions having to be made out of hours and suboptimal care. The aim of this study is to reduce the time from admission to the Care of the Elderly ward to formal completion of DNAR/TEP form, in order to improve the patient care and legality of medical decisions, particularly those made out of hours. The problem was analysed by a focus group including medical and nursing staff. A process map and fish bone diagram were made to further identify critical issues.
Data was collected monthly as a snapshot and included time of first consultant decision regarding TEP, time of admission to ward, and time of TEP form completion.
PLAN1: Change idea – adding TEP status to the clinical handover.
DO1: 1 month given to assess the impact to allow sufficient ward turn over
STUDY1: Data analysed
ACT1/PLAN2: Change idea – allocated member of staff highlight uncompleted TEP forms at handover
DO2: 1 month
STUDY2: Data analysed
ACT2: Plan to extend QIP methodology to other medical wards and continue to reaudit
Pre implementation it took an average of 3.56 days to complete a TEP from ward admission (6.26 days including TEP forms yet to be completed). At the end of the first PDSA cycle, this was reduced by 43% to 2.03 days on average. By the end of the second PDSA cycle, this further reduced to an average of 1.94 days. There was a reduction in time from consultant decision to TEP form completion by 70% by 1.96 to 0.59 days.
This project demonstrates how simple and time-efficient changes can increase the level of patient care and legality of documentation, without increasing the workload of staff. It also highlights the valuable role that junior staff have when empowered to speak up.
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112DrAdeAkintundeFoundation Year 1 DoctorUniversity Hospitals BirminghamDr Sashini Iddawela - Foundation Year 2 DoctorGeneral Surgery F1 Survival GuideGeneral surgery at Good Hope Hospital (GHH) 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 GHH but also the Heartlands, Good Hope & Solihull (HGS) trust. These administrative skills may not be commonly practiced among senior clinicians and consequent reduced understanding or reduced transference of such skills may delay the process of FY1s adapting to the job. A guide style document was distributed among FY1 doctors at GHH with the intention of making the transition into this job smoother and the efficiency of the surgical team greater. The first edition of the guide was distributed to GHH general surgery FY1s starting on 04/08/21 (cohort 1).

Qualitative and quantitative feedback for the guide was obtained from cohort 1 via online survey. This data included that the cohort were not confident about the role before starting and that the guide improved their transition into the job. The feedback also highlighted areas for improvement.

This feedback was used to update, reformat, and add to the information in the first guide; this updated guide was distributed to the next cohort of GHH general surgery FY1s starting on 01/12/21 (cohort 2).
The feedback form was later distributed to cohort 2; questions remained the same to allow for clear comparison between both guides.		Cohort 1 were not confident about the role before starting but felt that the guide included information relevant to their role and improved their transition into the job.
The average data also highlighted areas for improvement within the guide: the format and layout of the information within the guide was not easy to understand and cohort 1 wanted more resources as well as information topics.

Cohort 2 were less confident about the role before starting but rated the updated guide more positively in comparison to cohort 1’s feedback of the original with regard to relevance, structure, information clarity and overall improvement in transition.
The average data also highlighted areas for improvement within the guide: more detail surrounding the handover list.
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113DrSashiniIddawelaFoundation Year 2 DoctorUniversity Hospitals BirminghamDr Ryan Prince, MBChB FRCGP MMedEd - General Practitioner, Hampton-in-Arden Surgery, Solihull; Co-chair National GP Recruitment Steering Group; Associate Postgraduate GP Dean - Health Education England Improving prostate cancer surveillance in primary care Active surveillance of prostate cancer is a key aspect of long term management of patients who have been diagnosed or treated with this disease, performed in primary care. With the range of treatment options, ranging from prostatectomy and HIFU to radiotherapy, the surveillance strategy should be patient focussed, with individual PSA thresholds. A quality improvement project was undertaken to establish these thresholds, set up monitoring pathways and invite patients to participate in annual reviews focussed on prostate cancer. Patients who have prostate cancer in a single GP practice in the West Midlands were studied, to determine those who have been discharged and whose monitoring responsibility lies with the GP. Of those, the monitoring thresholds and frequency of PSA measurements were determined. These patients were invited for an annual review, with an offer of an examination along with discussion of their urinary and sexual function. 41 patients were identified, of which 18 were discharged. Five were lost to followup and three were highlighted to NHS services. Two were from private services, and self-discharged or were lost to followup. One patient had several PSA values above his threshold that had not been referred. Monitoring was inconsistently advised upon – seven patients had no limits specified, consultations and letters were sent to their treating consultants or NHS urology services to determine these.

Mechanisms are being developed in the practice to devise a reminder system to recall patients for their PSA monitoring and annual examination. In addition, we are communicating with clinical urology leads regarding the inconsistent communication of PSA monitoring and thresholds upon patient discharge.
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114DrRhianBevanFoundation Year 2 Doctor Royal United Hospitals, Bath1) Dr Rhian Bevan - F2, RUH Bath (joint first authors)
1) Dr Dolapo Thompson - F2, RUH Bath (joint first authors)
2) Mr Dale Thompson - Registar, RUH Bath		Can visual aids help identify patient status on ward lists? A preliminary quality improvement project. This quality improvement projects aims to develop the traditional surgical ward list by using colour codes to identify patient status. Ward lists are importance sources of information transfer between members of the clinical team. The volume of clinical information can make it difficult to identify key information or clinical status of patients. This difficulty is compounded by high turnover of staff which requires frequent transfer of information.

During the project we introduced three colour codes applied to the ward list: Red – Change in clinical status, Amber – Awaiting theatre; and Green – Medically fit for discharge (MFFD). The project aims to use colour codes as a visual aid to quickly identify clinical status.		The project used a ‘plan, do, study, act’ cycle approach. Initial questionnaires were sent out to clinical staff that use the surgical lists for stakeholder analysis. Data was collected on how efficient users perceived the current ward list to be as a communication tool for identifying the clinical status of patients. Before the implementation of the three-colour code system, a short teaching session to stakeholders was given, primarily to educate on the planned change but additionally to gain further feedback. The colour code system was subsequently trialled for 8 weeks before a second questionnaire was delivered to reflect on the impact of the change and assess for unintended or adverse effects. Currently the project is planning the next change cycle.90% of those surveyed responded that the colours made it easier to identify clinically deteriorated patients, 70% agreed the same for MFFD patients and majority agreed that using the colours did not increase the time needed to update the list. Overall, most responders found the traffic light system clinically useful. Suggestions were made to include additional codes to highlight patients to be discussed at the morbidity and mortality meetings and patients receiving ‘priorities of care’.

Potential issues with consistency in using the colour codes when making changes to the list were raised. The project plans to address these balancing measures during the next cycle.
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115DrJamesBookerAcademic Foundation DoctorUniversity Hospital SouthamptonNathan TM Huneke MRC Clinical Research Training Fellow Tariq Islam Consultant Liaison Psychiatrist
Vicky Cleak Consultant Liaison Psychiatrist.		Multicentre survey of inpatient wards to identify private spaces for psychiatry assessmentsEffective communication is the cornerstone to any interaction with a patient in a clinical setting. It is well-established that effective communication leads to: (1) greater diagnostic accuracy, (2) increased patient satisfaction and (3) greater adherence to treatment and advice.

When gathering a history in psychiatry, the interview often involves discussing personal information. Private spaces are crucial to preserving patient dignity whilst gathering salient information during psychiatric assessments.

Locally, we have observed that access to private spaces for assessments is not always possible. Therefore, we carried out a survey to identify the proportion of inpatient wards that have suitable private spaces where psychiatry assessments can be carried out.
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.

The NICs were sequentially asked the following questions:
1. Is there a designated private space on the ward to have sensitive conversations with patients? (Yes/No)
2. If so, is a private space always available? (Yes/No)
3. How likely is a conversation to be interrupted at this location? (never, unlikely, neither likely or unlikely, very likely, always)

Following collection of data at all of the hospital sites descriptive statistics were generated using RStudio V1.4.1103.



Fifty-seven inpatient wards were surveyed with 31% having a private space. In the absence of a private space, NICs reported repurposing alternative rooms when required, most commonly staff rooms (55%). Where a designated room was available, NICs subjectively felt there was a low risk of being interrupted. In contrast, when alternative rooms were used, there was a higher perceived risk of being interrupted during conversations.

The current availability for private space for psychiatry assessments is low and this could lead to communication failures and suboptimal patient assessments. This survey has been presented at hospital and trust-wide mental health meetings and has started the process of instituting changes to increase the availability of private spaces on inpatient wards.
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116DrADESHAJMANIFY2Warrington HospitalDr Joesph Evans (cons radiologist)Re-audit to optimise computed tomography kidneys, ureters, bladder (CT KUB) imaging in invesitgation of renal colicAn audit was carried out to assess if patients being investigated for renal colic with non-contrast CT KUB at STHK were being over-scanned and received unnecessary radiation. They had found that those having CT KUB for investigation of renal colic were being scanned as per the audit standard in 26% of patients; where patients had been over scanned, it had been difficult to see the upper pole of the kidney in 24/74 patients in the coronal scout. The aim of this re-audit is to assess if there's been an improvement since the previous audit to ensure patients are not being over scanned and are scanned as per the standard. To assess how current practice is compared to best practice.This audit is following the standard from the local STHK guidelines which outlines that 100% of CT KUB scans carried out should not exceed >10% excess scan length. PACS was used to search patients between 6/5/2019 - 17/6/2019 who had CT urinary tract without contrast. A total of 201 patients were identified but data from 100 patients was used through systematic sampling -every second patient was selected. The scan was in coronal view to measure the distance between the upper pole and the top of the scan in mm. Then the total length of scan in mm. The distance above the upper pole of the kidney was divided by the total length of scan multiplied by 100 to generate percentage. The results have shown that 38% of patients had not been over scanned. This is an improvement since the last audit when only 26% patients had been scanned as per standard. Whilst there's an improvement in the results, we need to ensure patients are not being over scanned and therefore subjecting them to unnecessary radiation exposure. Although there has been an improvement in the number of patients getting over scanned, it was found that 3 patients had been under scanned. In one case a second series had been done. This meant that the patient was exposed to higher levels of radiation dose. This re-audit results mean positive feedback can be given to staff but to encourage further vigilance when scanning.
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117DrMohamedElfekyTrust grade doctor General SurgeryNorthern care alliance NHS TrustDr. Bihu Malhotra(Foundation year 1)
Mr. Islam Mabrouk (Specialty registrar)
Mr. Usman rafique (Specialty registrar)
Comparison of routine maintenance Intravenous fluid prescription in Adult surgical patients in a District General hospital to NICE guideline standardIntravenous 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.
This audit is to compare the IVF prescribed for acutely admitted adults surgical patients who were admitted ,kept nothing per mouth(NBM) for 24 hours due to their provisional diagnosis and had been prescribed IVF for maintenance to be compared against the NICE guideline for IVF prescription in adults.
All adult surgical patients who were admitted through the surgical triage unit in a District general hospital between 25/11/2021 and 25/02/2022 who were kept NBM for 24 hours and prescribed IVF for maintenance have been included. The IVF chart for these patients has been reviewed, compared the type, amount and content of IV fluid prescribed to the standard of NICE Guideline. 50 patients were included. An anonymous questionnaire regarding the knowledge about IVF prescription among the level 1 and level 2 doctors was used to set the par for their knowledge about IVF prescription.It was found that 49 out of the 50 patients included were prescribed below the standard of NICE guideline in regard to Glucose content and potassium content.
Proposed interventions are Teaching seminar for level 1 doctors(Foundations year 1) and level 2 doctors(SHO/CT1/CT2) regarding the NICE guideline for IVF prescription, and posters of the NICE Guideline to be displayed in the doctor room in the surgical wards.
A re-audit will be conducted after applying the interventions by 1 month to review the effectiveness of proposed interventions.



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118DrMD FAIJULISLAMInternal Medicine trainee year 2 QA Hospital PortsmouthM Noor( Trust SHO )
C Spice (Consultant )		A Quality Improvement Project on Call Bell in Reach in an acute older person medicine ward (age>85 years) 1) Introduction : Call bell within reach of patients is an important part of quality care and standard in the National Inpatient Falls Audit. Initial data collection showed 56% of patients had call bell in reach indicating potential for improvement

2) Understanding the problem: Discussion with stakeholders included: Healthcare support worker, nurses & doctors of all grades, physio, and occupational therapist.

3) Aim : We aimed to improve call bell reach-ability from 56% to 95% or more for patients on the ward Method Data were collected from 2 bays (Total 10 beds) on the ward three times a week for 2 weeks after implementation of each change assuming it should roughly reflect the whole ward		Balancing measure Inpatient falls on the ward (weekly data for the ward).
1st PDSA: Stickers in medical notes as a reminder
2nd PDSA: Teaching session to staff nurses
3rd PDSA: A short video posted in a closed social group of ward
4th PDSA: Make a component in the safety huddle & reminder in daily nursing handover 		Result:
Call bell in reach improved to 93.88 % after 4th PDSA cycle. Inpatient fall did not show any specific correlation with call bell reach-ability and specific fall data for those 10 beds was not available separately
Learning:
•Teaching is effective but it may not be able to involve all the staff especially when staffing is not consistent. Implementation of gained knowledge from the teaching session may not sustain
•Social media can be used to improve patient care provided that it’s closed media & no patient confidentiality is hampered but again may not be a solution
• Reminding the staff of the importance was our most effective change, possibly because of its proximity to patient care immediately being delivered afterward
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119DrSahanaBalakrishnanFY2 Nottingham University Hospitals NHS TrustDr Aayenah Yunus, FY2- Nottingham University Hospitals NHS Trust
Dr Xi Mian Quah, FY1- Lincolnshire Partnership NHS Foundation Trust
Dr Moses Anene, Consultant Psychiatrist- Lincolnshire Partnership NHS Foundation Trust
Improving physical health assessment and documentation in a psychiatric inpatient unit 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, including dyslipidaemia, diabetes, and cardiovascular disease. Acute inpatient psychiatric admission provides an excellent opportunity to screen for physical illnesses and to effectively manage these to reduce morbidity and improve patient outcomes. All inpatients should be offered a physical examination and investigations within 24 hours of admission and where this was not achieved, the reason should be documented clearly. We found that absence of this information hindered our ability to make management decisions.
We aimed to improve assessment and documentation, assess compliance, and implement sustainable interventions. 		We established baselines for physical examination, blood tests, ECG, and documentation by reviewing current inpatients, collecting data from paper and digital patient notes, and blood test reporting system. Target compliance was 100%, with an exception for internal transfers. Cycle 1 focused on raising awareness of guidelines with poster placed clinical areas. We delivered a presentation to all healthcare staff to highlight our findings, collecting feedback regarding potential reasons for the shortcomings in our baseline compliance. In Cycle 2 we sent a further reminder email to all clinical staff to update the new cohort. For Cycle 3 we established regular emails and actively highlighted patients admitted over the past 24 hours with outstanding physical assessments during the daily staff meetings. Through our interventions, physical examination improved from 26.7% to 66.7%. ECGs increased from 13.3% to 55.6%, and blood tests from 23.3% to 55.6%. Documentation rates rose from 18.5% to 50% for ECG and from 20% to 50% for blood tests, with a marginal decline in for physical examination from 34.8% to 33.3%. Our project was limited by small sample sizes and variation of clinical staff between the cycles. We utilised easy to implement and resource effective interventions to provide active reminders to the MDT and produce a sustainable increase in physical health monitoring in a fast-paced ward environment with finite resources. Our long-term aim is that increased compliance translates to reducing strain to the healthcare system and preventing physical complications.
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120DrSarahMersonST5 CardiologyTorbay HospitalMrs Dimitra Nakou 5th Year Medical studentLipid management for secondary prevention of cardiovascular disease in Torquay HospitalThe aim of this project is to improve the care of the patients who are admitted on CCU and CPU In Torbay hospital with acute coronary syndrome (ACS) in line with national guidance for lipid management in secondary prevention of Cardiovascular disease (CVD). This includes initiation of maximum dose statin immediately after the diagnosis, repeating a 3-monthly lipid profile, adding/switching to Ezetimibe if the non-High Density Lipoprotein (HDL) reduced by less than 40%, and considering adding a PCSK9 inhibitor if non-HDL>2.5mmol/L.After literature review and retrospective data collection, a Plan Do Study Act cycle was initiated according to Quality Improvement Principles. Data was collected from patients who were admitted on CCU and CPU at Torbay Hospital between 01/07/2021 and 30/12/2021 with LDL Cholesterol levels 3mmol/L or over. They were 36 patients in total, 4 were excluded. Male to female ratio was 2:1. 62% were initiated on 80mg Atorvastatin. 86% of patients were prescribed a high intensity statin, lower dose statin or ezetemibe with appropriate rational. For 97% no further advice for lipid follow-up or treatment was documented in the discharge letter. 34%(11/32) had a repeat lipid profile 3-months post admission. Of these 45% (5/11) had a non-HDL>40% reduction. For 17% (1/6) with non-HDL-C <40% the GP was advised to consider adding ezetimibe then consider PCSK9i.
We propose a comprehensive follow up scheme that consists of including the lipid profile results in the discharge letter and requesting a repeat in 3 months in the Primary Care with subsequent action according to the national guidelines.
A second cycle will be performed in July 2022
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121DrGeorgiaMathiesonFoundation DoctorEast London NHS TrustLauren King- GPST2Make every encounter count- physical health monitoring in psychiatric inpatients Individuals with serious mental health conditions have a life expectancy on average 17 years shorter than the general population due to the strong association with poor physical health. Tower Hamlets has the 3rd highest rate of first-episode psychosis in London and associated morbidity. Hospital admission provides the oppourtunity to identify and manage physical health problems. Accurate documentation provides information for GPs and longitiunal monitoring.

Physical health monitoring is standard on admission. However, in November 2021 the proportion of documented physical health outcome forms was 30%. Improved monitoring is an imperative step to improving health outcomes.

Aim: to improve the monitoring of full physical examination, bloods including viral screen and ECG of Globe Ward inpatients to 80% by April 2022.		Our measurable outcome is the completion of physical health and investigation monitoring forms. We will measure the number of completed, declined and not done forms. These measures will be compared before and after each intervention.

PDSA1: to establish accurate and consistent use of a centralised spreadsheet with up to date status of patients' physical health, ECG and blood test assessment forms. This spreadsheet should be available to all junior doctors on the ward in order to provide a handover of outstanding tasks.

PDSA2: 'physical health clinic' with a fixed weekly time for physical health monitoring to take place. This will help to ensure that there is available equipment and adequate staffing.

PDSA3: combined nursing clinic proviving lifestyle advise

After implementation of a centralised spreadsheet of outstanding monitoring (PDSA 1), the proportion of documented physical health outcome forms was 67% in December 2021. After the introduction of a weekly physical health clinic (PDSA 2), this increased to 78% in January 2022.

On analysis of the data on a weekly rather than monthly basis, the week-to-week variation in completion was evident ranging between 0-100%. This appears to be impacted by admission day and length of stay. In the weeks where completion was low, often patients were admitted over the weekend and had short stays. It is important that these patients are highlighted prior to discharge by close communication with nursing staff and prioritised.


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123DrAmbreenAli SheikhConsultant Stroke Medicine West Middlesex University Hospital, Chelsea and Westminster Foundation Trust Dr Sanja Zrelec - Consultant Axute Medicine/Stroke Medicine
Dr Athanasius Ishak - Academic Foundation doctor -FY2		In-patient stroke recognition pathway improvement We analysed data of missing stroke cases in 2018-19 and noticed that posterior circulation stroke were not diagnosed in timely manner. Feedback from front line staff mentioned lack of stroke education and training. After reviewing number of screening tools, we introduced BEFAST screening tool with an improved stroke recognition and flow pathway.An initial root cause analysis of missed stroke cases was done followed by introduction of BEFAST screening tool to increase posterior circulation detection. Feedback was received from cross site stroke teams , trainees and emergency medicine staff . Virtual and in -person small group training sessions arranged for nurses and healthcare assistants. One consultant is taking lead in reviewing stroke cases that were either misdiagnosed or have delayed diagnosis. 1- A detailed neurological examination should be documented including eye examination - B stands for balance and E for eye examination.
2- Pan-London stroke pathway was not clearly documented on trust intranet - a clear pathway is now available.
3- Post covid, virtual training and possible simulation scenarios were explored and still working to improve this aspect.
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125DrOluwafisayo CarolineOlabisiFoundation year 2 doctorUniversity Hospital of WalesCharlie Kimberley- Orthopaedic registrar
Josh Nadimi- Orthopaedic registrar
Mr James Lewis- Trauma and orthopaedic consultant		An audit of preoperative fasting times in trauma and orthopaedic patientsPreoperative fasting is widely taught as important to prevent aspiration of stomach contents during anaesthetic induction. The six-two rule is widely taught and known as no solid food six hours before surgery and no water two hours before surgery. However, many studies suggest there may be benefits to preoperative carbohydrate drinks up to two hours pre-induction. Drinking carbohydrate-rich fluids before elective surgery improves subjective well being, reduces thirst and hunger and postoperative insulin resistance.

The aim of this audit is to review how long trauma and orthopaedic (T&O) patients are fasted preoperatively and review current practice relating to preoperative carbohydrate drinks.
A prospective audit was carried out, assessing the first 20 patients identified as admitted to UHW for orthopaedic surgery between the dates of 17/11/2020 and 30/11/20. The theatre lists were used to identify cases at UHW site.
Patients were interviewed briefly within 24 hours of their operation and questioned when they last ate and drank. Data was also collected from patients notes and drug charts using a data collection form. Data documented and analysed in spreadsheet on excel.
The mean age of patients was 68 year old (range 19– 95) with a female to male ratio of 2.3 : 1. All patients met the standards and did not have solid food within 6 hours of induction or any liquids up to two hours before induction.

The average time of last solid food was 16 hours pre-op (range 10-28). All patients fasted for at least 4 hours more than necessary. The average time of last clear fluid was 13 hours pre-op (range 4-28).
Carb loading drinks were not given to ANY patients which shows poor compliance with the standard.

The reasons for the excessive fasting of patients are multifactorial. Suggested changes include targeted staff education and updating clerking proformas.

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128DrJocelynCheukFY2 DoctorRoyal United HospitalAlice Raban
FY2 Doctor		A QiP to Improve the Assessment of Patients >75 years admitted under General Surgery: Focusing on Treatment Escalation and Frailty Scoring Treatment Escalation Plans (TEPs) are used to guide decisions regarding resuscitation and ceilings of care. Appropriate DNACPR decisions can facilitate a natural and more dignified death and avoid unnecessary distress for patients and their families. Barriers to TEP discussions have been identified including insufficient time or training, fears about complaints or causing distress.

The Rockwood Clinical Frailty Scale (CFS) is a holistic clinical measure of function and vulnerability. Identification of frailty can help guide patients' management, as well as help facilitate TEP discussions.

This project aims to increase the rate of completion of TEP and CFS scores to >70% among patients over the age of 75 admitted under General Surgery.
An initial audit was performed to determine the percentage of TEP forms and Rockwood CFS scores completed on admission. The QI Methodology of Plan-Do-Study-Act was incorporated to devise two distinct cycles and completion rates were assessed following the introduction of each intervention. A qualitative survey was also sent out to members of the surgical team to gain a better understanding of their thoughts on current practice for TEP discussions.

The first intervention involved adapting the pre-existing proforma to create an elderly surgical clerking proforma with visual prompts to complete TEP forms and CFS scores.
The second intervention was a teaching session delivered to surgical clerking teams to improve awareness and confidence in TEP discussions.
The initial audit showed 44% and 37% patients had a TEP form and CFS respectively. There was an 18% and 14% increase following the first cycle. However, this was markedly lower after the second intervention, with only 39% of TEPs and 29% CFS scores completed overall.

Results from Cycle 1 were promising and demonstrated that visual aids can be effective prompts. Several limitations were identified following Cycle 2; For example, the sample size was smaller than previous cycles and the time of this intervention coincided with significant changes to the structure of the surgical team. Nonetheless, this has helped guide the next steps of our project, including engaging other members of the MDT and implementing formal teaching.
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130MrsNikki TaylorProgramme ManagerSouth West Academic Health Science NetworkTrevor Jackson, Deputy Manager, Langley House, Wiveliscombe, Taunton, Somerset TA4 2UFSafer Administration of Medicines in Care Homes PilotAim: To reduce severe avoidable medication related harm by 50% by reducing the no. of interruptions on the routine medication round by March 2022 in a Care Home.

A Care Home in Somerset that provides specialist care for upto 12 Individuals with a learning disability, complex needs and challenging behaviour took part in a South West Patient Safety Collaborative Quality improvement pilot which focussed on Reducing the Interruptions on Medicine Rounds in the care home to reduce avoidable harm and increase awareness of safer administration of medicines to all staff.

A Medicine Safety Champion was recruited to develop a intervention to tackle the problem of the demonstrable number of distractions that they had been experiencing during their daily medicine rounds.
The staff used highly visible medicine round aprons with printed wording on e.g. ‘Please do not disturb’. They communicated the key messages, with examples of consequences and scenarios in team meetings to show the importance of the avoidance and prevention of medication errors, and what could happen from an avoidable interruption to the safety of a resident. Medicine Safety Champions engaged with the staff throughout. They completed Safety Attitude questionnaires before the pilot and used meetings with their team to develop ideas and communication channels so that the staff felt consulted and engaged in the test of change. Measurement Plan: 14 data sets of baseline data were collected prior to the intervention, with 14 data sets after the change.The South West Academic Health Science Network provided support to the care homes with peer-to-peer workshops in recruiting and supporting the development of Medicine Safety Champions that would support the medicine administration improvements, and in many cases, take a lead on managing the interventions of the pilots they chose.
The collaborative approach saw many local system experts join our workshops to support their local care homes throughout the journey. We built relationships with the Care Co-ordinators, with attendance from NHS, CCG (Clinical Commissioning Group), and local authorities as well as Compliance and assurance managers from care home groups such as Somerset Care. Langley House was the first pilot to be completed for managing interruptions and showed significant improvement.
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131DrJordanMayerClinical Fellow Univeristy Hospitals Bristol and WestonDr Charlotte Hayden - Respiratory Registrar
Victoria Haile - Physician Associate		Acute Management of Complex Airway Emergencies on a Respiratory High Dependency UnitComplex airway problems are life-threatening emergencies affecting up to 30% of tracheostomy patients(1), where initial management leads to identifiable harm in up to 75% of cases (2). Such situations are increasing in prevalence and recent initiatives stress the importance of guidelines and training (1). However, junior medics working on the respiratory high-dependency unit felt ill-equipped to manage these situations with 44% surveyed never receiving any training throughout their career. This poses significant risk to patient safety, particularly at a time when nurses are stretched.

Aims:
- Improve medic’s self-rated ability to manage complex airway emergencies (primary).
- Improve medic’s self-rated confidence in managing complex airway emergencies (secondary).
- Improve medic’s knowledge of complex airways and associated problems (secondary).

1.PMID:324935802.
2.PMID:20709764
Baseline data were collected via survey to respiratory juniors including self-rated ability and confidence in the management of complex airway emergencies, previous training and teaching received and awareness of resources.

PDSA cycle interventions were as follows:
1. Introductory teaching presentation during the respiratory educational meeting.
2. Simulation complex airway training with the respiratory physiotherapists.
3. Placement of tracheostomy model in the respiratory doctor's office.
4. Addition of information poster's and "test yourself" materials alongside the tracheostomy model (in progress).

Follow-up data collection was carried out throughout the PDSA cycles via random sampling. The participants were asked to rate their ability and confidence from 1 - 10. The mean value was taken for comparison.
By providing teaching, simulation sessions and easy access to educational materials, the junior medical team's ability and confidence in managing complex airway emergencies has improved.

The self-reported ability before any intervention was reported as 2.4/10 throughout the junior medical team. Following each PDSA cycle the self-reported ability improved to:
- Presentation: 3.3/10
- Simulation session: 6.4/10
- Model: 6.3/10

Alongside this, self-reported confidence has also increased from 2.9 to 7 and there is greater awareness of further resources.

This project highlights the value of training and education, particularly regarding a subject that is not consistently taught throughout undergraduate or postgraduate training. By improving the medical team's ability in managing complex airway emergencies, we minimise the risk to patient safety.
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132DrEmma LewinFY2 DoctorKing's College HospitalRuth Evans, IMT3 Doctor
Maitri Shila Tursini, GPST2 Doctor
Harriet Howard, FY2 Doctor		Falls Assessment and Prevention in the Health and Aging Unit (HAU) in a Large Central London Teaching HospitalFalls are a common in the ageing population, with 30% of over 65s and 50% of over 80s suffering with at least one fall a year. A fall can lead to negative physical and psychological sequelae and falls are estimated to cost the NHS in England £435million per year. NICE has produced guidelines advising on the multifactorial assessment that should be carried out in patients presenting to hospital following a fall in the community, in order to prevent subsequent falls in the future and further hospital admissions. We aimed to evaluate how well the department at King's College Hospital was completing the multifactorial falls assessment as described in the NICE guidelines on falls prevention and identify specific areas for improvement. We carried out a retrospective review of 80 inpatients admitted on a randomly chosen week into the Health and Ageing unit at King’s College Hospital and checked our adherence to NICE guidelines. Clinical notes were reviewed for evidence of eight specific assessments, including gait assessment, FRAX score and medications review, and four interventions, including increased package of care and adaptation of home environment. We arranged a teaching session to share our findings and the guidelines with our department and created an electronic proforma and posters to aid with these assessments. We also surveyed staff to identify barriers to completing the assessment. We then re-audited our performance following our interventions and tested for statistical significance change using a chi square test.In HAU, some aspects of the falls assessment are completed thoroughly, while others, such as FRAX scores and lying-standing blood pressures, were not performed consistently. We established interventions to tackle barriers to performing these assessments. For example, where staff did not know how to perform a particular assessment, we provided teaching on this. Following our interventions, we demonstrated a statistically significant improvement in the percentage of patients receiving the full multifactorial risk assessment, particularly an increase in visual assessment (29% to 36%) and FRAX score calculation (21% to 34%). We demonstrated how surveying staff can help us understand why certain aspects of our practice are not being carried out consistently and how continuous education can improve our care for patients.
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133DrSrishtiSarkarFoundation Year 2 DoctorUniversity Hospital SouthamptonDr Jessica Grayston: Foundation Doctor
Dr Hu Chan: Foundation Doctor
Dr Megha Bhandari: Foundation Doctor
Dr Tomilola Adepoju: Foundation Doctor
Dr Ibrahim Bodagh: Consultant MOP
An audit and re-audit of adult venous thromboembolism risk assessment compliance with NICE guidelines in the Medical for Older People department in University Hospital Southampton.Venous thromboembolism (VTE) is the third most common cardiovascular disease in the UK. 60% of VTEs are hospital-associated and cost the NHS £570,000 daily. The COVID-19 pandemic has highlighted the increased risks of VTE and reinforced the need for VTE risk assessment. As per the Department of Health, risk factors for VTE include age over 60, reduced mobility, dehydration and malignancy. All Medicine for Older People (MOP) patients have at least one of the aforementioned risk factors. A correct assessment prevents harm from VTE and also reduces the risk of bleeding from unnecessary pharmacological prophylaxis. The aim of this audit and reaudit was to assess the MOP departments compliance with completing the VTE risk assessment as per NICE guidelines [NG89].The University Hospital Southampton (UHS) Adult VTE assessment is based on the Department of Health VTE assessment and additionally requires input of weight and renal function in order to guide prescribing. 100 consecutive MOP patients across 5 different wards formed the sample population in May 2021 for the audit and then again in December 2021 for the re-audit. Data was collected from the UHS electronic record, CHARTs. Three standards were selected; VTE risk assessed on day of admission, VTE prophylaxis appropriately prescribed for weight and renal function and re-assessment within 24 hours completed. These findings prompted the intervention of teaching sessions on the importance of VTE prophylaxis prescription, delivered to the MOP junior doctor team at a local meeting.44% of patients did not have a risk assessment completed within 24 hours of admission. This decreased to 5% in the re-audit. 4% of patients did not have appropriate prophylaxis prescribed according to renal function and 7% for weight in the audit. In the re-audit, this was 4% and 9% respectively. 94.5% of patients had no re-assessment done within 24 hours in the audit and 99% of patients in the re-audit.

Prescribing according to weight and renal function and re-assessment remain an issue. With this re-audit, we wish to create a 24 hour re-assessment reminder popup on CHARTs and make a VTE assessment sticker which can be placed in patient notes to improve this.
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135DrJvalant NayanParekhCore Surgical TraineeSandwell and West Birmingham NHS TrustSabarinath Vijayakumar
ENT Registrar		ENT Department Compliance with GIRFT Guidelines - a DGH Experience Ear, Nose and Throat (ENT) surgery in many cases is a daycase operation. Patients should be able to attend and leave hospital on the same day. Getting it Right First Time (GIRFT) is a national guidance to promote collaboration and a set standard to enable departments to achieve the highest outcome for patients undergoing surgery.

The aim of this audit was to see if our local ENT department was meeting GIRFT standards in the wake of the COVID-19 pandemic, and if not, how we could improve standards to reduce length of stay (LOS) and streamline the day case pathway in a district general hospital. 		Retrospective data collection over a three month period was performed to review all patients who underwent an operation in the ENT department. Identification of operations which should meet GIRFT standards were recognised and subsequently, an analysis of the inpatient notes was performed to identify which patients were having prolonged admissions and why. Operations of particular interest were (adeno)-tonsillectomy, polypectomy, MUA of the nose but all procedures were considered.
The data was collected from electronic patient records and discharge summaries as well as directly looking at length of stay (>23 hours was identified as prolonged admission unless stated otherwise beforehand).
Data was tabulated on an spreadsheet 		178 operations (65 paediatric and 113 adult cases were recorded).

The day case target was 80% for paediatric tonsillectomies. We identified 69.7% of cases were performed as day-cases, not meeting the required standards. However when compared to the UK average of 55%, the department was above the national average.
In adults, the tonsillectomy day case target was 81% with our department achieving 93% day case rate. The UK average for septal surgery is 78% and we achieved 75%.

Sub-analysis to identify reasons for low day-case rates were reviewed. In particular, monitoring for sleep apnoea was noted as a reason and subsequently, a streamlined pathway has been introduced to reduce LOS adapted by the department.

A reaudit is currently being performed.

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137DrKatherineStylesPaediatric ST8 RegistrarHillingdon Hospital NHS Foundation TrustDr Richa Ajitsaria, Consultant Paediatrician
Ms Nicola Davey, Quality Improvement Clinic Ltd		I need a weight!- a London School of Paediatrics Quality Improvement Change Champions ProjectChildren are not routinely weighed on arrival to our Paediatric Emergency Department which is a lost moment for health promotion. If they need intravenous or complex medications there is delay in prescribing and administering these because this is weight dependent. Even worse some patients are admitted to the ward without an accurate weight leading to drug errors. I aim for our department to weigh 80% of all attenders and 100% of all infants under 6 months of age. I developed High Level Process Maps and Fishbone maps. The recent reconfiguration of the department with the loss of the dedicated triage room meant that triage is happening in the corridor, not an appropriate place to undress and weigh an infant. Baseline measurements demonstrated that some children were being weighed but it was staff-member dependent. My first PDSA was to engage the Matrons and Consultants. These discussions gave me a better understanding of the pressures on triage nurses, some of them new to their role. My second PDSA was to swap the normal triage chair in the corridor for the weighing-chair-scales. My third PDSA encouraged doctors to get infants weighed at the end of their examination when infants were undressed.Overall weight recording increased from 19% to 75%, infant weight recording increased 19% to 78%. In PDSA cycle 2 I discovered that just because children sat on the scales did not mean they got a weight recorded. The nurses actually found it frustrating due to the on/off/tare mechanism in the scales. Cases where weights were available at time of prescribing increased from 30% to 90%. Having a previous weight to refer to has been very useful for a group of children who re-present. Participating in this QI programme has taught me to understand a problem before attempting to implement change and to study the effects of each change idea. I will take these skills forward with me in my career.
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138DrRebeccaAndersonFY2 DoctorLiverpool University Hospital Foundation TrustDr Dhanya Kalathil - Consultant in Diabetes & EndocrineEnsuring Early Involvement of the Diabetic Foot MDT in Management of Diabetic Foot InfectionWith the rising prevalence of diabetes in the UK, diabetic foot infection presents an increasingly significant public health issue. In addition to substantial effects on livelihood, mobility and social participation, diabetic foot disease is associated with an increased risk of mortality. 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. NICE guidance therefore recommends that patients with diabetic foot infection are referred to this service within the first 24 hours of assessment. This audit aims to evaluate whether referral was completed within 24 hours of assessment, and assess the time until first review by a member of the diabetic foot MDT. A business information request identified 165 spells with a primary diagnosis of diabetic foot infection at the Royal Liverpool University Hospital between 1/2/21 and 30/4/21. Spells were excluded if the patient was admitted on an elective basis, if they took their own discharge prior to full assessment, or if ulcers were chronic and non-infected. After patient selection, there were 60 spells, for which information about referral to the diabetic foot MDT was collected from hospital notes, and ICE computer systems. This data was processed within a password-protected Excel spreadsheet.Of the 60 spells analysed, 85% (n=51) were referred to the diabetic foot MDT. Three patients were not referred due to direct discharge from A&E, however there was no obvious explanation for referral not being completed in 10% of spells evaluated. In 8 cases, referral was completed after the 24 hour period recommended by NICE. Although referral to the diabetic foot MDT could be improved, review was timely once a referral was sent with 82% of the 60 spells being reviewed within 48 hours of presentation. To encourage early involvement of the diabetic foot team, educational posters were produced and displayed around the A&E department, highlighting referral as a key part of safe care for patients with diabetic foot infection.
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139DrClemencyBrittonFoundation Year 1 Doctor London North West Healthcare Trust Dr Emily Ching (joint-first author)Improving Paediatric Prescribing in London North West Healthcare Trust 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 pediatric ward to national standards
-Reinforce the prescribing standards we expect from doctors in common practice
-Improve the quality of prescribing through weekly educational emails highlighting areas for improvement


References 1,2,3: full details in bottom submission box

Each week a random selection of 5 drug charts were collected from the paediatric 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 that met national prescribing standards as well as areas of prescribing improvement that week. Following completion of six PDSA cycles, a poster was installed on the Paediatric Ward displaying commonly unmet prescription standards alongside the run chart of results as a permanent educational resource and motivation for change. 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.
The lessons learnt from this QIP include:
-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
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140DrEllenCornish Foundation DoctorPortsmouth Hospitals TrustDr Kirsty Cole - Core Surgical Trainee Improving the Organisation and Accessibility of Essential Equipment on the Surgical Assessment Unit The availability of procedural equipment in ward-based medical emergencies is of upmost importance and leads to the prompt treatment of unwell patients. This quality improvement project aims to decrease the amount of time spent looking for these items in a Surgical Assessment Unit (SAU) by altering the layout of the treatment room and making essential equipment easier to find. In doing so, we aim to improve patient safety by preventing unnecessary delays to patient assessment and treatment. Firstly, to achieve baseline data we asked 15 doctors to identify and collect 11 items from the SAU treatment room. We chose items that were required to gain access, bloods, cultures and a gas from an unwell patient. After timing each participant, we discussed what would have made the process easier for them, enabling us to plan for our first PDSA cycle. The treatment room was then rearranged with the aim of improving the accessibility of this essential equipment, and the equipment trays were given clear labels. The process was then repeated and 15 doctors were again timed to collect the same 11 items. The mean time taken to collect the 11 items prior to intervention was 106 seconds (SE=12.6s). After our intervention, the mean decreased by 25% to 78 seconds (SE:8.9s) (p=0.08).
To allow for more accurate analysis of our intervention, we feel we should have increased our n number, and only tested doctors that work on SAU regularly. For the second PDSA cycle, we aim to standardise the treatment rooms of all four surgical wards. We will then allow doctors working on these wards to acclimatise to the changes, before timing them again. We hope that this project will minimise time spent searching for essential equipment needed to assess acutely unwell patients, and therefore improve the patient safety on our surgical wards.
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141DrAmyMaFY2 DoctorRoyal Bolton HospitalElective paediatric sedation for MR imagingSedation for MRI scans in the paediatric population is common to reduce fear and anxiety and to minimise movement for the procedure. Sedation itself is unpredictable and carries risks including airway obstruction, apnoea, hypoxia and CP arrest.

This process was audited in a north west DGH paediatric department in 2016. However, since then the sedation proforma has been moved online and the local guidance updated in line with the NICE guidelines.

The aim of this project was to evaluate the current practice by re-auditing against local standards with the aim that 90% documentation should be adherent to guidelines. The secondary aim was to identify areas for improvement and implement such changes.		A retrospective audit was carried out of 27 patients sedated for MRI between Jan 2020 and Feb 2021. Paper and electronic notes were reviewed and the process of sedation (15 separate points) was audited against the local guideline.

To gain deeper understanding of the process I observed sedation for an MR scan from start to finish, and had discussions with the senior nursing team running the service.

Results and recommendations were presented at the departmental clinical audit meeting.

A ‘quick guide' for doctors involved in caring for patients having sedation for MR scans was developed. It is currently being reviewed, then will be piloted and feedback sought before implementation in the department.		9/15 points audited reached 90% adherence. There was some evidence of slight improvement from the 2016 audit - however changes in the guideline and the proforma meant that direct comparison could not be drawn. Areas identified for improvement were the need for senior discussion if risk factors present on pre-sedation assessment, observation frequency, patient weight recording, and time of last oral intake recording.

Recommendations included dissemination of a ‘quick guide’ for doctors and a box for exact weight and exact time since last oral intake to be added on the sedation proforma. Sub-standard observation frequency is still an issue and further work with nursing colleagues to explore ways to improve is needed.
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143DrShenthiuiyanTheivendrampillaiSenior House Officer University Hospital Southampton NHS Foundation Trust Francesca New (Urology Registrar)
Bhaskar Somani (Consultant Urologist)		Should pre-operative urine microscopy, culture & sensitivity prior to endoscopic Urological procedures be made mandatory: Results of a clinical audit at a Tertiary centre.Introduction:
Endourological procedures imply the use of special instruments which are introduced into the urinary system and allow antegrade access to the urinary tract. Pre-operative urine microscopy, culture and sensitivity (MC&S) is recommended for all endourological procedures as per European Association of Urology (EAU) guidelines.

Aim:
The audit was conducted to determine the rates of pre-operative MC&S prior to endoscopic urological procedures and its relevance on post-operative urinary infectious complications at University Hospital Southampton NHS Foundation Trust.
Data was collected retrospectively for patients undergoing endourological procedures from November 2019 to March 2020 as a snapshot audit using electronic hospital system (equest) and pre-assessment documentation. We analysed the results of urine MC&S, and whether these were acted upon, endoscopic procedures undertaken, and outcomes related to infectious complications post-operatively. After analysing and presenting the data of the first cycle at the clinical governance meeting, recommendations were proposed to improve patient care, safety and outcome. This was followed by a series of Multi-disciplinary educational sessions and changes to our policy. During the period June-September 2021, a re-audit was undertaken.The first cycle revealed departmental practice did not meet the set standards as per EAU guidelines. 5/54 (9%) patients had pre-operative MC&S at pre-assessment with 11 (20%) patients developing post-operative urinary infection, 2 of which required admission for urosepsis.

Following the interventions, standards of care and safety improved significantly. 39/65 (60%) patients had pre-operative MC&S, of which 8/39 (20%) grew positive cultures and treated for prior to the surgery. A total of 7 (10%) patients had infectious complications post-operatively.

Overall, there was a poor compliance of pre-operative MC&S for endoscopic procedures during the first cycle of the audit, potentially leading to avoidable adverse outcomes. Changes were implemented which led to an overall reduction in post-operative urinary tract infections.
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144DrIshtarRedmanFy1 DoctorSt. Mary's Hospital, Imperial College London NHS TrustDr. Jennie Han, IMT2
Dr. Edward Hoy, SpR (Care of the Elderly)

A Quality Improvement Project aimed at improving catheter documentation in electronic patient notes by implementing an Inpatient Catheter Chart form.Healthcare-associated infections (HCAI’s) are responsible for approximately 300,000 deaths per year in England, costing the NHS an estimated £1 billion annually.
The major predisposing factor for healthcare associated UTI is the presence of a urinary catheter and in the acute setting, the risk of developing bacteriuria increases by 5% each day in catheterised patients.

We recognised that poor catheter documentation led to significant patient safety issues- delayed discharges, CAUTI’S, iatrogenic incontinence and catheter dependence on discharge due to TWOC failure.

SMART OBJECTIVE: To improve catheter documentation in electronic patient notes by implementing an Inpatient Catheter Chart form which will be ICHNT senior clinical leadership sanctioned, hospital wide, mandated and created in accordance with both Trust and national guidelines.
PDSA 1:
Gap analysis of the current catheter documentation as compared to the ICHNT 17 pieces of required upon catheter insertion as per Trust guidance.

PDSA 2:
P/D: Nudge campaign: Poster & Education session(s) targeting FY1/2 doctors and nurses on the first floor.
S/A: Re-audit following implementation of this strategy.

PDSA 3:
P: Convene meeting with high-impact trust stake holders highlighting current issues.
D: Develop automatic text function ‘.cath’, on CERNER which allows a form to be generated with all necessary domains required for catheter documentation- eliminates the need for active recall at the time of documentation.

S/A: Re-audit the above and use results to update the trust wide guidelines on Catheter documentation in conjunction with the Urology team.
Results from gap analysis, PDSA Cycle 1:
N=16, 20% of patient catheters inserted had no indication documented, only 31% of notes indicated if urine was dipped/ MCS sent and 38% indicated that fluid balance monitoring was necessary.

In general, catheter documentation is poor and there is a direct correlation between the quality of catheter documentation and patient outcomes, both quantitative and qualitative.

Building on the work of the nurse led HOUDINI-UC removal protocol which was targeted at reducing at the number of urinary catheters used, we implemented strategies to improve catheter documentation.
To maximise the chances of uniformity and reduce the likelihood that this improvement will be transient, we plan on implementing an inbuilt form onto our electronic charts.
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145MsSianEdwardsAdvanced Nurse PractitionerHywel Dda University Health BoardLouisa Morris General Practitioner/Clinical lead for Quality Improvement, Prince Phillip Hospital, Llanelli.Developing an ANP led scaphoid pathwayIntroduction:
-Prince Phillip hospital (PPH) Minor Injuries Unit (MIU) is led by a team of Emergency Nurse Practitioners (ENP), Advanced Nurse Practitioners (ANP) and General Practitioners (GP)
-Patients with soft tissue injuries (STI) were previously reviewed in STI r/v clinic by visiting ED consultants. COVID restrictions stopped these clinics
-Service evaluation of STI r/v clinics undertaken
-Wide variation noted in management of wrist injuries. Litigation case from missed scaphoid fracture pending
-ANP led STI clinics commenced June 2020

Aims:
-Audit documentation standards for wrist injuries
-Deliver teaching wrist injury/scaphoid fractures
-Improve assessment skills/documentation standards in patients attending with a wrist injury
-Reduce risk of litigation
-Develop ANP led “gold standard” scaphoid pathway
Core working group established: ANP and GP
Commence ANP led STI clinics
Phase 1 - Retrospective analysis of wrist injury documentation standards
PDSA (1) Deliver teaching to ENPs/GPs
Phase 2 - Data collection (documentation standards) post teaching.
PDSA (2) establish local MRI pathway for PPH MIU
Phase 3 - Data collection; MRI referrals and results (inc scaphoid fracture)
PDSA (3) Develop a wrist injury proforma
Data collection to follow
-Phase (1) 42 patient notes analysed. Only 60% of patients had mechanism of injury (MOI) documented. The gold standard triad of scaphoid tenderness was poorly documented: - anatomical snuffbox (67%), scaphoid tuberosity (12%) and positive scaphoid compression test (7%)
-PDSA (1) 67% attendance to teaching session
-Phase (2) 93 patient notes analysed. 75% of patients had MOI documented. The gold standard triad of scaphoid tenderness much improved: - anatomical snuffbox (88%), scaphoid tuberosity (57%) and positive scaphoid compression test (46%)
-PDSA (2) Pilot MRI pathway complete. Awaits HB policy change
-Phase (3) PDSA July 20-Jan 22, 21 MRI Scaphoid requested. 2 positive scaphoid fractures identified
-PDSA (3) Wrist proforma developed. To be piloted April 2022 with data collection to follow
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146DrAmeenaKhanFoundation Year 1 Cardiology DoctorImperial College Healthcare TrustDr Anas Khan (Foundation Year 1 Care of the Elderly Doctor)Investigating how often daily weights are recorded in acute heart failure patientsAcute heart failure (AHF) is a leading cause of hospital admissions and can present as new-onset or decompensated chronic heart failure. Symptoms arise from a build-up of fluid in the lungs or body causing dyspnoea and peripheral oedema respectively. The mainstay of treatment of fluid retention is diuretics. NICE and local guidelines recommend close monitoring of weight whilst on treatment. Daily weights are an objective measure of fluid balance and guide titration of diuretic dose. We noted that within an acute unit in a busy tertiary hospital these body weight measurements were not always recorded consistently.

Aims:
1. Investigate how often daily weights are documented in AHF inpatients
2. Explore whether prescribing daily weights is associated with higher documentation rates
A retrospective analysis of 55 inpatients referred to the AHF specialist team between 1st November and 31st December 2021 was performed. Patients were required to fit stringent inclusion and exclusion criteria. For each patient, we recorded the total length of stay in days and the number of daily weights documented.

As part of the secondary analysis, we hypothesised that patients with “daily weights” written on the drug chart would have higher documentation rates. Therefore, we also recorded if patients had “daily weights” or similar prescribed. Documentation rates were compared, between patients prescribed daily weights on the drug chart and those who were not, with an unpaired T-test.
There were 32 patients who met our criteria. On average, weights were recorded only 46% of days. Prescribing “daily weights” was associated with significantly higher documentation rates (83% vs 46%, p<0.05), however only 25% of patients had these prescribed.

Daily weights may not always be prioritised in busy departments, can be missed in handovers and when patients are moved downstream. Prescribing “daily weights” acts as an automated reminder to healthcare staff to measure and monitor this parameter, with the added benefit of allowing easy comparison of diuretic dose and effect. This audit highlights there is scope for improving weight recording and has identified a novel method for addressing this. These findings will form the basis of our quality improvement project.
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147MsYi-HsuanChiangMedical studentQueen Mary University of LondonLinnuel Joy Pregil - medical student
Liuhao Wu - GP trainee
Optimising and improving the management of patients with abnormal liver function tests in primary careFatty liver disease (NAFLD) is one of the commonest causes of abnormal liver blood tests (LFTs). Majority of patients have good prognosis, however, left unaddressed it can lead to liver damage. The high prevalence, asymptomatic nature and mostly benign progression of NAFLD mean that patients and clinicians are often falsely reassured that it is ‘harmless’. This often leads to poor management of the disease.
We realised the underlying problems are multifactorial, including poor patient education, lack of awareness by clinicians on the appropriate investigation and management of the disease.
This QIP aims to improve patients’ knowledge and physicians’ ability to manage deranged LFTs, as well as implement interventions in the early stages in NAFLD in order to prevent liver fibrosis.
The investigation and management of all patients with abnormal liver function tests
(LFTs) in 2018 were reviewed and cross-referenced with local guidelines to identify systemic issues. A three-pronged approach to service improvement was adopted, focusing on patient awareness, improving management pathways and educating clinicians. Each workstream incorporates a separate PDSA cycle with multiple feedback loops and iterations to fine-tune the interventions. The PDSA cycle involved multiple stakeholder interviews, collecting questionnaires and feedback.
The interventions include designing locally-agreed guidelines, patient infographics/leaflets, text message templates (education/recall/reminder), automated risk stratification calculator and a dedicated liver clinic. A complete re-audit is planned in 3-6 months and the interventions will be shared with other practices/PCN/CCG in the future. 		~5% of NAFLD patients had developed liver fibrosis in our analysis. Areas of improvement were identified regarding management of patients with deranged LFTs in primary care: explaining potential complications of deranged LFTs (~6%), performing risk stratification calculation (~15%), and repeating blood tests (~20%). Following implementation of a dedicated liver clinic, ~20 high-risk patients were recalled and managed appropriately. Our teaching session with GPs along with distribution of locally agreed guidelines was positively received and shared across multiple GP practices. Preliminary analysis, albeit ongoing, demonstrated increased usage of our risk calculator, improved patient education and compliance in tackling deranged LFTs. These interventions will hopefully improve the management of patients with deranged LFTs in primary care and reduce the incidence of fibrosis