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Key
Title of
Audit Lead
Audit/Project
2876 Audit of Acute
Barbara Leach, Senior
Pain Management Acute Pain Nurse,
Nicky Vallance, Pain
Nurse Specialist, Dr
Martyn Ezra, CT1,
Anaesthetics
Brief Description
To ensure that all
staff are complying
with Epidural and
Patient Controlled
Analgesia Trust
guidelines by
reviewing
documentation.
Lead
Division
Surgery and
Critical Care
Date
Status
Started
05/01/2010 Complete
Date
Results and Recommendations
Completed
07/03/2011 Recommendations: Present audit at nurse forums;
review teaching packages; include larger section on
documentation in teaching session; regular snapshot
repeat audit on documentation.
Changes made
The outcome of the audit was
presented at some nurse
forums. Teaching packages
are being reviewed at present
and documentation is being
highlighted more in all pain
sessions. Repeat audit to
review any improvement has
not been carried out but an
improvement has been noticed
during ward rounds. However,
a re-audit will be performed to
assess improvement.
2874 Audit of INR
Control for Acute
Medical
Admissions on
Warfarin (WH)
Dr Oneme Ogona,
FY2, Respiratory
Medicine, WH, Dr
Wathen, Respiratory
Medicine, Consultant
Audit of patients
Medicine
admitted on warfarin
who have INRs
outside the chosen
therapeutic range.
To assess strength of
indictaion for warfarin
treatment and assess
the reasons for poor
INR control.
13/01/2010 Cancelled
02/11/2010 Cancelled
Cancelled - not applicable.
2875 Audit of Use of
Sliding Scales &
Appropriate
Requesting of
HbA1c (SMH)
Dr S Mapara, FYI, Dr R
Lloyd FY1, Dr R Evans
FY1, Dr S Chatterjee,
Consultant, Diabetes
New evidence shows Medicine
that HbA1cs are
useful in diagnosis
and monitoring of
diabetes. The aim of
this audit is to
encourage
appropriate
requesting of HbA1cs
and to ensure sliding
scales are used
appropriately and
reviewed regularly by
the medical team.
14/01/2010 Complete
30/06/2010 > 80% of patients were initiated on a sliding scale for No changes made.
reasons listed in guidelines. Sliding scales are not
being reviewed every six hours as recommended.
Poor documentation of who stops the sliding scale.
Very few teams are requesting HbA1c for diabetic
patients. In many patients with poor BM control,
diabetes referral not made. Recommendations:
Continue to initiate sliding scales for appropriate
reasons. Review sliding scales more frequently.
Clearly document when sliding scale should be
stopped and who has made this decision.
Request HbA1c in any patient with a history of DM or
hyperglycaemia. Contact the diabetes team in the
following circumstances: poor glycaemic control,
recurrent hypoglycaemia, diabetic emergencies,
patients with hyperglycaemia and MI and discharge
planning.
2877 Audit of Pressure Gbonyefa Samani,
Ulcers - A Shared Community Dietitian
Responsibility
Which Starts With
Appropriate
Referral (PCT)
Local policy and
Community
NICE guidance
& Integrated
recommend that
Care
patients on admission
should be screened
immediately to
establish if they are at
risk of developing
pressure ulcers,
using a valid and
reliable assessment
tool and then referred
appropriately.
14/01/2010 Complete
07/07/2010 1. A re-audit to be carried out using a larger sample
size - 10 residents from 5 different care homes. 2.
Presentation on findings to care homes to raise
awareness.
Annual re-education on
pressure ulcers and its
management.
2878 Royal College of
Radiologists
National Audit of
Liver Biopsy
(US/CT Guided)
To assess diagnostic Clinical
adequacy, accuracy Support
and complications of Services
image-guided or
assisted liver biopsy.
19/01/2010 Complete
15/09/2010 Results good, no action required.
None required
An audit to assess
compliance with
NICE Guideline 50 looking after the
acutely ill adult in
hospital. This is
being carried out as
part of a MSc
dissertation.
08/01/2010 Complete
05/01/2011 NICE guideline 50 should be implemented as a
priority: 1. All staff working in acute hospital wards
must use the EWS with every set of observations
recorded. 2. The Graded Response Strategy for
patients identified as being ‘at risk’ of clinical
deterioration, must be followed, especially at night
and out of hours. 3. Matrons and ward managers
should be held accountable for ensuring that the
Trust standard for Physiological Observations of
Adult Non-Obstetric Inpatients (CG 26) is
implemented in their area. 4. The SBAR
communication tool should be rolled out Trust wide to
improve multi-professional communication. 5.
Education needs to be provided for the intensive
care clinical staff to improve the accurate completion
of the ICU discharge paperwork. 6.
The business case for the provision of Outreach and
Follow up services cross site should be revisited. 7.
Provision of ALERT and BEACH courses, which
should be mandatory for all new clinical staff, should
be continued. 8. Re-audit, linked in with the critical
care point prevalence audit in 2011.
Changes are being
implemented as a result of this
audit and also of the Critical
Care Point Prevalence Audit
3212. The CCDG must review
progress with implementation
of this guideline since 2009
and must compile, implement
and audit an action plan to
accomplish full
implementation. Divisional
Lead Nurses and Matrons to
ensure this is done by
outlining expectations to their
ward managers and by
updating job descriptions and
personal specifications.
Develop local audit tool to
monitor compliance with Trust
standard frequently – weekly
suggested – feedback results
to staff. Formal education via
Dr Phil Cadman,
Consultant, Radiology
2879 Audit of
Jenny Ricketts,
Compliance with Outreach Lead Nurse
NICE Guideline 50
- looking after the
acutely ill adult in
hospital
(BHNHST)
Surgery and
Critical Care
ALERT, BEACH, BLS,
induction and preceptor
courses. Explore possibility of
mandatory e-learning module.
Informal teaching in the clinical
area by outreach team,
resuscitation team and other
competent staff members.
2880 H1N1: Local
Descriptive
Epidemiology for
BHNHST
Dr Kathryn Lang, F2,
Microbiology
To analyse each case Clinical
of H1N1 confirmed
Support
and compare with
Services
national and
international finds.
19/01/2010 Complete
25/05/2010 Epidemiological study, no results or
recommendations.
Not required.
2881 Re-Audit of
Compliance with
MRSA Policy
(1.1.1)
Management of
Sporadic Cases
(BHNHST)
Dr Kathryn Lang, F2,
Microbiology
MRSA is a national
Clinical
target. Trust
Support
guidelines clear on
Services
protocol for screening
and then
management once
identified.
19/01/2010 Complete
24/03/2010 Of the 13 cases of MRSA diagnosed in November
No changes forthcoming
2009, 7 fulfilled admission screening criteria and 5
were subsequently screened. The proportion of
cases given suppression treatment once identified as
MRSA carriers was less (10/13) than compared to
our previous audit (22/23) but again we found there
was minimal delay in starting therapy. There was
generally poor documentation in the medical notes
about the patient receiving an MRSA or isolation
leaflet.
2882 Outcome of
Dr RamMohan , Dr
treatment of
Alka Halai, GPVTS,
patients attending SMH
Miss Ashworth's
Infertility Clinic
during 2008-2009.
To review all new
Specialist
referrals to the
Services
Infertility Cllinic during
2008 and 2009 and
review the outcome
of their management.
12/12/2009 Cancelled
30/03/2012 Project cancelled.
2883 Audit of Outpatient
Physiotherapy
Total Knee
Replacement
Class PES (SMH)
To assess the
individual patient's
perceived level of
improvements from
the start of their
physiotherapy rehab
class to the end, a 6
week period.
Clinical
Support
Services
15/01/2010 Complete
07/07/2010 Positive results for TKR rehabillitation. No results or Not required.
recommendations.
To determine whether Clinical
patients believe that Support
the service they are
Services
receiving is meeting
their individual needs.
A patient satisfaction
survey has not been
undertaken for Burns
and Plastic
Physiotherapy for at
least 5 years.
20/01/2010 Complete
01/02/2011 93% of patients were 'very satisfied' with the overall
treatment they received from the Burns and Plastics
Physiotherapy Outpatients Department and 96% of
patients were 'very satisfied' with the overall service.
78% of patients stated it was 'easy' to find the
department and 79% of patients stated they were
provided with written information.
Recommendations: 1) Directions to the Burns and
Plastics Physiotherapy Outpatient Department
should be made clearer. 2) All patients should be
given written information during their period of
treatment.
Tom Barnes,
Physiotherapist,
Rebecca Edwards,
Physiotherapist SMH
2884 Burns and Plastics Jane Leathwood &
Outpatient
Adam Fraser,
Physiotherapy Physiotherapists SMH
PES (SMH)
Project cancelled
Signage round Stoke
Mandeville Hospital is being
updated and Physiotherapy
have been assured that they
are part of this project.
Leaflets and written
information is being continually
updated and handed to
patients.
2886 Audit of Newly
Spinal Cord
Injured, Ventilator
Dependent
Patients Referred
to a SCIC in South
of England
Carrie Gardner, AIAU
Project Co-ordinator,
London Specialised
Commissioning Group
To ascertain numbers Spinal
of ventilator
Injuries
dependent patients
waiting to transfer
and transferring to a
SCIC and to see if
guidelines for
ventilator weaning
are being followed.
21/01/2010 Complete
05/07/2010 There were no recommendations as the audit was
carried out through the South East Commissioning
board. It wasn’t a local audit but encompassed all 3
spinal units in the South. This will be presented at a
National level not at the NSIC audit meeting.
N/A
2885 Side Effects and
Dr Rachel Bate, FY1
Compliance Rates and Dr Chris Durkin,
in Patients
Consultant
Treated with
Dipyridamole and
Aspirin (SMH)
An audit to evaluate
the use of
dipyridamole in
patients after stroke
or TIA, specifically
side effects and
compliance issues.
Medicine
13/01/2010 Complete
07/07/2010 All patients perceived level of function had improved No changes required at this
by a significant amount in 6 weeks and all patients
time.
range of movement had significantly increased in 6
weeks. No shortfalls were identified compared to
the national standards therefore no specific
recommendations are needed at present. This audit
was a small sample size - a larger sample size
should be considered over a longer period of time for
any re-audit undertaken in the future.
2887 Effectiveness of
Sophie Alley, Deputy
Entonox in
Sister, Radiology, SMH
Helping with Acute
Pain in
Interventional
Procedures (SMH)
To ascertain whether Clinical
Etntonox helps
Support
radiology patients
Services
with the acute pain
sometimes
experienced during
procedures.
21/01/2010 Complete
26/02/2010 To have Entonox readily available for use. All staff to Entonox is being used
be trained and competent in use of Entonox. To
occasionally, as required, for
assess patients suitability prior to use.
interventional procedures in
the Radiology Department. It
has not been fully integrated
into the whole department as
yet.
2888 Chemotherapy
Patient
Experience
Survey (BHNHST)
Annie Richards,
Chemotherapy Clinical
Nurse Specialist,
Cancer Services
Obtain patient
Clinical
feedback regarding
Support
the service and
Services
information provided.
18/11/2009 Complete
25/11/2010 Results: Lots of positive comments regarding the
No changes required.
two Units, their staff and the quality of information
provided. However not all patients were aware of the
name of their key worker or the purpose of the key
worker role. Also patients were not always advsied
to bring someone with them to their first consultation
appointment. Recommendations: Review the system
for advising patients to bring someone with them to
their initial appointment. Key worker role needs to
be actively promoted. For subsequent audits
increase the number of questionnaires distributed
and aim for a more equal spread between oncology
and haematology patients. Patients need to be
educated and awareness raised regarding the use
and importance of out of hours contact numbers.
2889 Haematology
Cancer Patient
Experience
Survey (BHNHST)
Asha Mathew and
Marie Pennell,
Haematology Clinical
Nurse Specialists,
Cancer Services
Obtain patient
Clinical
feedback regarding
Support
the service and
Services
information provided.
12/01/2010 Complete
20/01/2011 1. Patients should be given printed information
regarding their diagnosis and details of their key
worker. 2. Patients need to be advised to bring
someone with them for support when the diagnosis is
given. 3. All patients need to be provided with
information on support groups and self-help groups
by CNS. 4. When the re-audit takes place, it should
include a larger sample of patients.
1. All the written information of
diagnosis provided to patients
is reviewed and the CNS is
taking responsibility of making
sure that patients receive
these documents. It is clearly
documented on patients’ notes
(in Key worker document). 2.
Both CNS in the Haematology
Unit have completed an
advanced communication
course. Regular educational
updates are provided for staff
within the
Haematology/chemotherapy
unit and other areas in the
hospital. The Cancer and
Haematology has Practice
development nurse in post to
support with all educational
needs of the staff. 3. All the
changes implemented will be
audited again in 8-12 months
time.
2890 NICE Audit of
Management of
Open Abdomen
(BHNHST)
Mr Hank Schneider,
Locum Emergency
Consultant, SMH
2891 Urology Cancer
Patient
Experience
Survey (BHNHST)
Hilary Baker, Joe
Kearney, Krystyna
Caine, Clinical Nurse
Specialists UroOncology
Concerns have been
raised with the
National Institute for
Health and Clinical
Excellence (NICE)
that there may be a
link between one of
the treatments
currently used on
patients whose
abdomens are left
open after surgery or
injury, called
Negative Pressure
Wound Therapy
(NPWT), and patients
developing intestinal
fistulae, a potentially
serious condition
which can cause
infection and bowel
leaking. NICE have
provided an audit tool
to assist in data
collection.
Obtain patient
feedback regarding
the service and
information provided.
Surgery and
Critical Care
26/01/2010 Cancelled
29/07/2011 Project cancelled as incomplete data submitted
before deadline. Audit Lead left Trust.
Cancelled.
Clinical
Support
Services
25/01/2010 Complete
20/12/2010 Overall the results of the audit were very positive.
The following recommendations were made: Patients
should be advised both verbally and in writing to
have a relative and/or friend accompany them when
receiving their TRUS biopsy results. This advice
should also be included in the written information
given to patients regarding TRUS biopsies. Urology
has three cancer support groups for patients with
prostate, bladder and kidney cancer. Staff should
ensure these are promoted at diagnosis and as
required along the patient’s journey. Develop a
leaflet explaining what a Multidisciplinary Team is
and what its purpose is. Encourage consultants and
associate specialists to attend an advanced
communication course. Key worker documentation
to include information regarding the stage and grade
of disease together with details of the patient’s care
plan.
Patients are advised verbally
and in the patient information
leaflet to have someone with
them when receiving their
TRUS biopsy results. Details
of the three cancer support
groups are given to patients at
diagnosis. A leaflet explaining
the working of MDTs has been
produced and is given to
patients at diagnosis. Key
worker documentation has
been revised to include stage
and grade of disease together
with details of the patient's
care plan.
2892 Breast Cancer
Hilary Hillson, Clinical
Patient
Nurse Specialist,
Experience
Breast Cancer
Survey (BHNHST)
Obtain patient
Clinical
feedback regarding
Support
the service and
Services
information provided.
27/01/2010 Complete
25/11/2010 Overall the results of the survey were very positive
and patients value the service and support provided
by the Breast Care Nurses. Suggestions for
improvement: Ensure all patienst are aware of 'out
of hours' and emergency contact details. Reduce
clinic waiting times by adjusting outpatient
appointment times. Ensure all patients undergoing
surgery receive a post operation telephone call.
2893 Audit of the
Management of
Basal Cell
Carcinomas
(BHNHST)
Dr Katherine Acland,
Consultant, Dr Ben
Esdaile, SpR,
Dermatology
To look specifically at Integrated
diagnostic accuracy, Medicine
documentation,
complete efusions
and clinical and
surgical excision
margins.
29/01/2010 Complete
20/04/2010 The rate of 87% complete excision rate with narrow
margins is unsatisfactory. Reasons for this could be
1) level of operator – large number of juniors
performing procedures due to pressure on system.
Lesions on head/neck not being removed with
sufficient margins. 2) Intent of surgery and triaging of
patients in clinic onto correct surgical list.
Recommendations: More junior training and
supervision. Further dedicated surgical Dermatology
Consultant required. Action plan: Review notes of
incomplete excisions to ascertain intent of procedure,
known diagnosis and then excision. Audit
Recurrence and re-excision. Implement standard
surgical operation sheet proforma with specific
sections for surgical margins etc. Grading and
triaging of surgery to appropriate surgeon – i.e.
consultant supervision for large lesions on
head/neck. Re-audit.
2894 Completion of
EMC X-ray
Request Forms
Amal Fadal, Radiology A substantial number Clinical
of EMC forms are
Support
completed
Services
unsatisfactorily. This
audit is to assess the
size of the problem
and to address it.
15/07/2009 Complete
The clinic template has been
altered so that ward follow up
patients are seen later in the
afternoon to reduce their
waiting time. All breats cancer
patients are phoned post
operatively. All patients are
made aware of out of hours
contact details.
As a result of the audit a
surgical proforma has been
implemented which is currently
in use. This is to attempt to
improve the note taking in the
surgical clinics and to ensure
that clinical margins of
excision are documented and
considered. When the audit
was presented to the
department surgical margins
were also discussed. An audit
is currently in progress which
will show whether the
proformas have improved the
record keeping. It is too soon
to tell whether rates of
complete excision have
improved as the numbers are
not yet sufficient.
17/03/2010 76% forms incorrectly filled or ID information missing. EMC will be moving to
Official memo to be sent to EMC staff asking them to electronic requests soon.
fill in form corretly.
Talks are in progress
regarding the need to repeat
the audit or whether there is
enough information to proceed
with electronic ordering of
forms.
2895 Analysis of
Transfers from
Wycombe and
Aylesbury Birth
Centres to
Delivery Suite
(BHNHST)
Dr Maria ZammitMangion, ST4, Miss
Veronica Miller,
Consultant
Following the recent Women &
closure of WH
Children
Delivery Suite and
conversion to a Birth
Centre, this is an
audit to assess the
cohort of patients
allowed to deliver at
the Birth Centre and
whether they fulfil the
criteria for this. Also,
an analysis will be
made of the reasons
for transfers to SMH
Delivery Suite and
whether management
was appropriate.
29/01/2010 Complete
2896 National Carotid
Mr Patrick Lintott, Mr
Interventions Audit Andy Northeast,
Phase 3
Consultants, General
Surgery, Geraldine
Delacy, Surgical Nurse
Practitioner
National audit of
Surgery and
carotid interventions Critical Care
organised by the
RCP. To enter
details of all
interventions 1st
October 2009 to 29th
October 2010 onto a
web tool. Ongoing
from Round 2 Audit
2640.
01/01/2010 Data
Collection
2897 Airway
Assessment in
Obstetric
Anaesthesia
(SMH)
Assessment of the
Surgery and
patient's airway and Critical Care
documentation of this
are essential
components of
anaesthesia. Failed
intubation rates are
higher in obstetric
patients and a pre-op
prediction of a difficult
airway could reduce
the incidence of failed
intubations. This is a
regional audit
involving 5 hospitals
in the Oxford Region.
08/02/2010 Complete
Dr Michelle Walters,
ST5, Dr M Okolsor, Dr
Willie Sellers,
Consultant,
Anaesthetics
20/04/2010 The audit showed that the reasons for transfers from As no recommendations were
Wycombe or Aylesbury Birth Centre to the Delivery
made as a result of this audit
Suite, were valid. There were fewer transers from
no changes can be recorded.
Wycombe Birth Centre (probably due to proximity).
Pain relief was the major reason for transfer from
Aylesbury Birth Centre. There was a higher
Caesarean Section rate for the patients transferred
from Wycombe Birth Centre (probably reflective of
the differing reasons for transfer).
Results and Recommendations required
Changes required
05/07/2010 This audit of airway assessment and documentation No response from audit lead to
in obstetric anesthesia was performed in five
requests for changes.
hospitals of the Oxford region. In each hospital 200
case notes were examined for evidence of
documentation including assessment of mouth
opening, Mallampati (MP) classification, neck
extension, dentition, jaw subluxation or other tests.
This is the standard recommended by the Obstetric
Anaesthetists' Association (OAA) for airway
assessment. The audit revealed that documentation
of airway assessment is poor in obstetric anesthesia.
Anesthetic charts with specific prompts for airway
assessment improve quality of airway assessment.
The recommendation was to include an airway
proforma on the obstetric anaesthetic chart, to be
completed for all anaesthetic obstetric interventions,
including epidurals.
2898 National Audit of Dr Steve Price,
the Management Consultant Chemical
of Familial
Pathologist
Hypercholesterola
emia
Web based data
Clinical
collection tool
Support
between 1/04/10 and Services
3/09/10. Organised
by Royal College of
Physicians.
08/02/2010 Cancelled
26/01/2011 Didn't take part in audit.
N/A
2899 National CNS
Patient
Experience
Survey (Breast
Screening)
(BHNHST)
Hillary Hillson, CNS,
Breast Cancer, Cancer
Services, Jeanette
Tebutt, Lead Cancer
Nurse
National patient
Clinical
survey developed by Support
the National CoServices
ordination Group for
Nursing in
collaboration with the
West Midlands QA
Reference Centre to
assess the role of the
CNS in breast
screening.
08/02/2010 Complete
02/11/2010 National and individual site results have been
Not applicable
received. No recommendations or action plan have
been formulated. The Trust has carried out it's own
patient experience survey and recommendations and
an action plan will be formulated from this.
2900 Newborn Hearing
Screening
Programme
Satisfaction
Survey
Angela Campbell,
The Newborn
Women &
Newborn Hearing
Hearing Screening
Children
Screening Coordinator Programme has been
running for over 4
years. A satisfaction
survey was
recommended on a
recent visit of the QA.
09/02/2010 Complete
09/09/2010 Screeners should ensure that they follow the format
recommended, by the Programme Centre, for talking
to the parents, which includes: reiterating what is in
the leaflet, so that parents fully understand the need
for the test and timing, and asking if the parents have
any questions.
New Trust Guideline produced
532.1 February 2011. All
screeners have been
shadowed either by Angela
Campbell or the senior
screener to make sure that
everybody is adhering to the
recommended format.
2901 Audit of
Prophylactic
Antibiotic Use in
Orthopaedic
Patients
Lai Ye Cheang,
Pharmacist Band 7
2902 National Survey of Dr David Taylor,
the Impact of
Consultant
Consultant Input
into Acute Medical
Admissions
Management
(BHNHST)
Antibiotic prophylaxis Medicine
in orthopaedic
surgery has changed
in the last few months
and, as infection
rates have been
higher in the last two
years, this audit will
check that antibiotic
prophylaxis is being
given correctly and
that the prophylaxis
regime is being
adhered to.
10/02/2010 Complete
A study aiming to
Medicine
identify correlations
between different
levels of physician
cover for acute
medical admissions
and patient outcomes
such as length of
stay, readmission
rate and hospital
mortality.
25/11/2009 Cancelled
2903 Audit of Electronic Dr Vimal Vyas, GPVTS An audit of
Women &
Fetal Monitoring
and Mr Tunde Dada,
continuous electronic Children
(BHNHST)
Consultant
fetal monitoring,
against current Trust
guidelines.
08/02/2010 Complete
30/09/2010 Results: This audit has demonstrated an
No changes supplied.
improvement in adherence to the Trust’s guideline for
antibiotic prophylaxis in joint replacement surgery
after the introduction of the new regimens around
November 2009. The more straightforward regimen
with teicoplanin and gentamicin led to a greater
degree of compliance than with the previous
flucloxacillin/gentamicin combination.
Recommendations: 1. Improve documentation
surrounding the administration of antibiotic
prophylaxis in order to assess more accurately the
important timing of antibiotics in relation to the start
of surgery. 2. Further improve the actual
administration of prophylactic antibiotics as only 63%
of patients received their peri-operative doses at the
most appropriate time and the timing of postoperative doses also requires attention. 3. Re-audit
in 12 months to look for improvement in prophylactic
antibiotic prescribing, administration and
documentation in elective hip and knee replacement
surgery.
07/07/2011
Cancelled - not applicable
16/03/2010 Areas of non-compiance with the Trust guidelines
were: Recording of signatures after initial starting of
trace; Not recording date of birth on the trace; Not
using Fresh Eyes stickers for interpreting the CTG or
second opinions; Recording signature on the second
sheet, when the CTG paper is changed. Staff
training on correct recording will be provided.
Highlighted at Labour Ward
Forum 09/06/2010. Staff
training on correct recording
being provided.
2904 Audit of
Intermittent Fetal
Monitoring
(BHNHST)
Dr Christina Aye, ST2
and Mr Tunde Dada,
Consultant
An audit of
intermittent fetal
monitoring, against
current Trust
guidelines.
Women &
Children
08/02/2010 Complete
18/03/2010 Presented at academic half day in March 2010. 1st
stage monitoring followed guidelines in 90% of cases
but improvements are needed for use of the
partogram. 2nd stage monitoring followed guidelines
in 100% cases but only 4 cases used a 2nd stage
partogram. Maternal pulse was recorded in 100%
cases at or soon after admission. Maternal pulse
was recorded hourly in 85% cases. Continuous
electronic fetal monitoring was offered appropriately
in all cases. The main recommendation was
improved documentation of auscultation.
No changes forthcoming, but
topic reaudited (2979) and
found Intermittent auscultation
always offered appropriately –
offered in low risk patients and
converted to continuous
monitoring when indicated.
2905 Audit of High
Dependency Care
of Severely Ill
Maternity Patients
(SMH)
Dr Laura Burkimsher,
ST1, Dr Haresh Nagar,
ST1, Miss Miller,
Consultant, Obs &
Gynae. Dr Debosree
Majumdar taking over
Audit of the quality of Women &
high dependency
Children
care received by
severely ill maternity
patients.
12/02/2010 Complete
01/06/2010 Mews charts are being completed. Documentation of Reaudit carried out (3141).
all specialities involved in patient care needs to be
improved. The majority of admissions appear
appropriate (but there was insufficient data to confirm
this). Current guidelines for admission criteria do not
define moderate / severe pre-eclampsia. Admission
criteria should be more specific about patients with
PPH. A re-audit should be carried out in three
months.
2906 Urinary Catheter
Care for Elective
Caesareans
Jackie Dalton, Infection There is concern that Clinical
Control
urinary catheters are Support
not being
Services
inserted/maintained
effectively in patients
undergoing elective
Caesareans. An
observational audit,
using the High Impact
Intervention Tool
used in other
Infection Control
Urinary Catheter
audits, is to be
carried out.
15/02/2010 Complete
03/03/2011 Compliance levels for individual elements of the
Infection Control administer
insertion part of the audit were high; 96% (sterile
the completion of action plans
drainage) -100% for all other elements. Sterile
by individual areas.
drainage was non-compliant on 1 occasion on the
Labour Ward. Compliance levels for individual
elements of the ongoing management part of the
audit were high; 91% (catheter hygiene)-100% for all
other individual elements. Catheter hygiene was
non-compliant on 2 occasions on the Labour Ward.
The area of non participation must produce an action
plan to show how they are addressing these issues
and how they are monitoring compliance.
2907 DVT Prophylaxis
audit
Jane Hegarty, CT2,
Haematology
To audit
thromboprophylaxis
of patients suffering
DVT/PE following
hospital admissions.
To compare current
Trust practice with
recently updated
NICE guidelines.
Clinical
Support
Services
22/02/2010 Complete
17/06/2010 VTE risk assessment NOT done in 78% of cases.
Pharmacological prophylaxis NOT given in 46% of
cases .
No documentation of mechanical prophylaxis in 71%
of cases.
6.5% of cases had a contraindication to
pharmacological prophylaxis. Recommendations:
Implement NICE CG92 guidelines.
Incorporate VTE assessment into admission
proforma across all specialties.
Mandatory junior doctor teaching.
Re-audit (prospectively).
2908 Service Evaluation Mr Aniruddha Pendse,
following Repair of Trust Registrar,
Chronic Achilles
Orthopaedics
Tendon Ruptures
treated with FHL
Biotenodesis
To audit results
Surgery and
following repair of
Critical Care
chronic tendo-achilles
ruptures with FHL
Biotenodesis. To
compare results with
existing studies.
25/02/2010 Awaiting
Report/Ac
tion Plan
Results and Recommendations required
2909 Community
Infection Control
Hand Hygiene
Audit
Hand hygiene tool
completed for various
PCT units. To
analyse and report.
26/02/2010 Complete
14/05/2010 When poor practice is witnessed this must be
challenged by all staff. If appropriate, actions need
to be taken by line managers to ensure compliance
to the hand hygiene policy. Improvements are
needed with the removal of hand and wrist jewellery,
and clinical staff being bare below the elbows,
particularly within our community services.
Facilities in clinical settings that have been identified
as not complying with guidance including HTM 64,
need to be refurbished at the earliest opportunity.
Financial resources need to be provided in order to
achieve these refurbishments. Where this process
needs to be supported by capital bids, these bids
need to be actioned as a priority.
Staff need to be informed that they can order hand
hygiene products for their use, including hand
sanitiser and hand moisturiser, through the supplies
department.
Fiona Simpson,
Infection Control
Nurse, Quality and
Performance Team,
PCT
All DVT/PEs with hospital
admissions and all deaths due
to DVT/PE are now
automatically registered as
SUIs and followed up by
Clinical Governance Incident
reporting
Changes required
The hand hygiene facilities at
Thame and FNH are being
addressed with the ongoing
estates works currently. All
community sites have had a
survey and upgrade of hand
hygiene dispensers
2910 C Diff Infection
Control Policy
Audit
Martina Muscat, FY2,
Microbiology
The guidelines
Clinical
regarding the
Support
management and
Services
documentation of
C.difficile infections
have recently been
amended. This audit
aims to assess
whether these
changes are being
adhered to.
26/02/2010 Complete
26/02/2010 1. Early isolation of patients into side rooms if they
develop diarrhoea. 2. Early submission of stool
samples to the lab (the lab offer a same day result if
the sample arrives before 2pm). 3. Providing
patients or their relatives with leaflets of isolation and
C.difficile infection and documenting this on the
sticker in the notes. 4. Stool chart monitoring with
daily entry, even if there was no bowel movement. 5.
Starting treatment on the day of diagnosis. 6. Filling
in the C.difficile letters and sending them to the GP
and ICT. 7. Indicating on the discharge letter that the
patient had C.difficile and was treated for this in the
hospital.
All recommendations already
in policy, just needed
reminding. Re-audit will be
carried out. It is a requirement
to audit infection control policy.
2911 Community
Infection Control
Urinary Catheter
Audit 2010
Fiona Simpson,
Urinary catheter tool Clinical
Infection Control Nurse completed for various Support
community units. To Services
analyse and report.
Re-audit.
01/03/2010 Complete
26/05/2010 Catheter insertion 100% compliance. Continuing
care 99% inpatient, 100% community. Collection of
specimens 100%. Actions: Obtain stands that
ensure catheter tip does not touch flooring. Although
practice is good, need to continue to observe
practice and ensure infection control training is
updated annually. Staff reminded to check bags
more frequently. Staff member encouraged to wear
apron when emptying catheter bags.
Was previously community so
cannot comment, but I hope
the issues raised from the
action plan were discussed at
ward level following
dissemination of the report as
they were mainly ward
concerns.
We have since repeated this
audit with acute and
community.
15/02/2010 Cancelled
21/03/2011 Project cancelled as doctor has left the Trust and is
not replying to emails.
Project cancelled.
2912 Audit of Doctors'
Dr Tim Brummitt, ST1
Communication
and Dr A Dutta,
and Patient
Consultant
Satisfaction Within
Paediatrics
(BHNHST)
An audit to assess
Women &
communication of
Children
doctors with
paediatric patients
and patient / family
satisfaction,
compared with the
GMC Guidance on
communication for 018 year olds.
2913 Paediatric A&E
Jane Bremnath,
Attendance
Named Nurse for Child
Reports Protection
Information
Documented for
the Purpose of
Paediatric Liaison
(BHNHST)
Working Together to Women &
Safeguard Children
Children
(2006) and the
Climbie
Recommendations
advise that the
relevant GP and
appropriate school
nurse or health visitor
are notified of each
attendance to the
A&E Department by a
child. This is an audit
to identify gaps in
gathering and
recording to enable
and promote more
effective sharing of
information in the
safeguarding
process.
23/02/2010 Complete
28/02/2011 Clinicians are not completing the Paediatric A&E
report forms with as much detail as they are required
to do. At Stoke Mandeville the presenting problems
are generally recorded under generic headings,
whilst at Wycombe this section is completed more
thoroughly, with more detail about the nature,
location and type of injury. This is also the case for
the diagnosis recorded, which the Wycombe forms
describe in more detail than the Stoke forms.
Recommendations: • To ensure that GP and school
attended details are ascertained as correct at each
visit to the A&E/EMC Departments. • To maintain, at
all times, best practice in record keeping and
documentation, using the Remass system of
recording, to document accurate and concise
information for all attendances. • All nursing and
medical personnel should receive training on
Remass, to enable and maintain standards of
documentation.
• To re-audit Paediatric Liaison reports in April 2011.
• To ensure information sharing and record keeping
is an integral part of all child protection training.
However, on both sites, the mechanism of injury,
when given, is almost always a generic description,
using “other injury”, “unwell/non trauma” or “unwell”,
instead of describing the mechanism of injury more
accurately. On six occasions at Wycombe, the
mechanism of injury was described as “unwell/non
trauma” when the diagnosis recorded had, in fact,
been the result of an injury rather than an “unwell”
patient.
Results: As a result of inaccurate or inadequate
recording of the diagnosis and mechanism of injury,
these frequently cannot be considered as being
compatible. Unless clinicians complete these
categories correctly the form is inadequate as a
method of monitoring paediatric attendances at A&E
and for the sharing of accurate and adequate
information. Recommendations: 1. To ensure that
GP and school attended details are ascertained as
correct at each visit to the A&E / EMC Departments.
2. To maintain, at all times, best practice in record
keeping and documentation, using the Remass
system of recording, to document accurate and
concise information for all attendances. 3. All
nursing and medical personnel should receive
training on Remass, to enable and maintain
standards of documentation.
4. To re-audit Paediatric Liaison reports in April 2011.
5. To ensure information sharing and record keeping
is an integral part of all child protection training.
Remass training undertaken.
Child protection training
updated to include
documentation. Re-audit
carried out (3259).
2914 Audit of Fetal
Blood Sampling
(BHNHST)
Dr Lucy Young, SHO
and Mr Tunde Dada,
Consultant
FBS is one of the
Women &
supplementary
Children
investigations to
confirm fetal distress
when CTG is
pathological. The
test should only be
used when indicated
and when facilities
and training are
available. The aim of
this audit is to ensure
that there are
appropriate
indications for taking
FBS and to evaluate
the documentation
after the test.
15/02/2010 Complete
29/03/2010 Presented at academic half day in March 2010. The
results showed that on nearly all occasions FBS
results are documented in the notes in some format
(either handwritten or hard copy). In the majority of
situations where FBS is performed, it is indicated and
is done at the correct time. Plans stating
management following FBS result are always clearly
documented. In the majority of situations the
consultant is informed at the right time. On the
occasions in the sample that they were not it was
because delivery was imminent. The following areas
could be improved: FBS results are not often
recorded on the CTG and rarely recorded on the
partogram. In less than half the sample were fresh
eye stickers used. To consider 2nd FBS if the
delivery is not imminent. To asked for consultant
review if not sure whether FBS is indicated. The
recommendations will be fed back to the Labour
Ward Forum. Future audits on this topic may need to
be expanded to include all patients with a
pathological CTG trace.
2915 Audit of Perineal
Trauma
(BHNHST)
Dr Nadia Aisheh and
Dr Sarah Barker,
SHOs; Mr Tunde
Dada, Consultant
An audit of perineal
trauma against the
current Trust
Guidelines.
15/02/2010 Complete
16/03/2010 The audit was presented at the academic half day in
March 2010. Positive points were: All tears were
classified appropriately; the appropriate technique
was used in all cases documented. The correct
suture material was used for perineal muscles and
skin; all tears were sutured in theatre; in general all
appropriate medications were prescribed; Appendix 1
was filled in correctly; For Wycombe patients all 3
were booked to the perineal clinic and appendix 2
was completed. Areas requiring improvement are:
There is no perineal clinic for Stoke Mandeville
patients; Only 1/11 using 3/0 PDS to IAS + EAS;
Appendix 2 not being used when the patient is seen
in ANC for follow up.
Women &
Children
Results taken to LWF. Reaudit carried out (3154). In
50% of cases review of the
CTG suggested that FBS was
not indicated. This was either
the CTG being classified as
suspicious at the time or when
the trace was reviewed as part
of this audit. Timing of
samples: 53% were correctly
timed. This timing was taken
from the decision to perform
the sample to the sample
being processed. Small
sample size for audit. The
finding that 47% samples were
not indicated was challenged
as some felt there were factors
other than the CTG that
influence the decision to
perform an FBS, although
others felt that this should not
be the case. Re-audit
recommmended.
Re-audit carried out (3152).
2916 Audit of Obstetric
Haemorrhage
(BHNHST)
Dr Rakhi Sehmi, ST1
and Mr Tunde Dada,
Consultant
An audit of obstetric Women &
haemorrhage against Children
current Trust
Guidelines.
15/02/2010 Complete
18/03/2010 Ongoing data collection – an obstetric haemorrhage
proforma should be completed for blood loss greater
than 500ml. An initial audit, detailing the results for
proformas completed between 11th February and 3rd
March 2010, was presented to the department in
March. The main finding was that only 13/67 cases
of blood loss greater than 500ml, had a proforma
completed. Staff were unclear as to the volume of
blood loss at which the proforma needs to be
completed. The proformas which were completed
had poor documentation of timings. The volume of
blood loss at which the profoma needs to be
completed has been reviewed and changed to 1litre.
This will be confirmed with staff. There will be
ongoing staff education regarding the location and
use of the proformas.
The obstetric haemorrhage
proforma has been changed
and has to be completed for
cases of blood loss greater
than 500ml.
2917 Emergency
Caesarean
Section Audit
(BHNHST)
Dr Christine Gan and
Dr Robert Parsons,
SHOs; Mr Tunde
Dada, Consultant
An ongoing audit of
Caesarean Section
against NICE and
CNST standards.
Women &
Children
15/02/2010 Complete
Recommendations referred to
completion of the EMLCS
documentation and the audit
proforma. Ongoing audit, no
changes forthcoming.
2918 Oxytocin Audit
(BHNHST)
Dr Clare Conroy, SHO An audit of the use of Women &
and Mr Tunde Dada,
Oxytocin for induction Children
Consultant
of labour, against
current Trust
Guidelines.
15/02/2010 Cancelled
22/03/2010 Ongoing data collection. An initial audit, detailing the
results for 45 consecutive emergency Caesarean
Sections from 8th February 2010 (when the audit
was initiated) was presented to the department in
March. The main results were: The audit proforma
was completed in 36% notes; 50% had the NICE
grading of CS recorded at the time of the decision;
79% had the reason for CS documented at the time
of the decision; 55% had a delay in decision to
section time (the reason for this was not recorded in
most cases); there was evidence of a post-surgical
discussion of events with the mother prior to
discharge, in 33% cases. Areas of good practice
included antibiotic / thromboprophylaxis, consultant
liaison and antiemetics / antacids. Improvement is
required in completing the EMCS prospective data
collection proforma. A process has been put in place
to raise awareness of the need to complete the form
and complete missing forms retrospectively.
31/03/2010 N/A project cancelled
N/A project cancelled
2919 Management of
Hyperosmolar
Nonketotic
Patients
Dr Alireza
Mohammadi, SpR
(ST3), Endocrinology
2920 Effect of Velcade John Willan, FY1,
on Platelet Counts Haematology
2921 Community
Nutrition and
Dietetic Service
Patient
Satisfaction
Survey
Renu Bansil, Dietetic
Team Lead
To determine if
hospital guideline
relating to HONK is
adhered to.
Medicine
03/03/2010 Cancelled
30/07/2010 Cancelled
Cancelled
Velcade is a
chemotherapy agent
which is known to
suppress platelet
numbers. Currently
given on certain days
of chemotherapy
cycle. Patients must
have platelet levels
measured before
drug given. Audit
aims to understand if
platelets reduce in a
particular way and
thus determine if it is
necessary to
measure platelet
levels before each
dose.
A patient satisfaction
survey to be carried
out to assess the
effectiveness of the
service as part of the
quality improvement
programme.
Clinical
Support
Services
03/03/2010 Complete
15/10/2010 Platelets fall in a very predictable way during
The option detailed was
administration of Velcade.
implemented.
Our results appear to match results from large scale
published studies.
We may be being overly cautious in withholding
Velcade until that days platelet count is available. It
was decided to implement the following option. At
start of each cycle delay day 1 administration of
Velcade until count received. If above 70 then rest of
cycle can be
administered without awaiting counts. Blood should
still be taken pre-Velcade in case patient is in the
<1% who needs a platelet infusion.
Community
& Integrated
Care
03/03/2010 Complete
15/02/2011 The majority of patients are happy with the service
provided. Long waiting times for referral
appointments are being addressed; the integration
into Bucks Healthcare and the hospital dietetic
service may help. RIO may also help with
inequalities in the service. Areas should be identified
in which to extend provision – initially look at more
rural areas e.g. Thame.
Waiting times have been
addressed by providing
additional clinics as and when
required, however additional
clinics in other areas have not
been initiated.
2922 Management of
Empyema in the
Chest Department
(WH)
2923 Annual Hand
Hygiene Report
Dr Lynne Curry, ST4,
Chest Medicine, Dr
Shahidi, Consultant,
Chest Medicine, WH
Empyema is a
serious medical
condition affecting a
number of patients
each year. The
purpose of this audit
is to identify: whether
antibiotics used are in
keeping with local
guidelines, the
proportion of patients
requiring surgery,
whether BTS
guidelines are being
adhered to and
whether there are
certain organisms
grown in our
population of
patients.
Amanda Adkins,
Infection Control have
Infection Control Nurse their own set of Excel
spreadsheets on
which they record all
hand hygiene
observational data
each month by ward.
They want an overall
report, based on this
data, for the period
April 2009/March
2010.
2924 Routine Breast
Gareth Jowett, QMS
Screening Patient Co-ordinator, Breast
Experience
Screening
Survey
Breast screening
patient experience
survey to meet the
requirements of the
NHS Breast
Screening
Programme.
Medicine
05/03/2010 Complete
10/11/2010 On average the respiratory department manages one
patient with empyema per month, and in most cases
diagnostic tap and drain insertion were done
promptly. Our use of ultrasound was low, and
nutritional assessment could also improve. It is worth
noting that part of the audit group predates the
release of both the NPSA and BTS guidance
(published 2008), and we now have a departmental
ultrasound machine for pleural procedures. Surgical
rates within our patient group appear to be
comparable to that found in the literature.
A departmental ultrasound
machine is now available for
pleural procedures, no other
changes made.
Clinical
Support
Services
08/03/2010 Complete
18/05/2010 The overall compliance level has improved from 90%
in 2008/09 to 94%.
‘Bare below the Elbows’ compliance has also
improved from 92% to 95%. There has been a great
increase in the number of observations recorded
from 11999 in 2008/09 to 110213. The hand hygiene
compliance per division ranged from 90% to 99%.
Report issued. Areas with low
compliance required to carry
out extra audits. Audit
ongoing monthly.
Clinical
Support
Services
08/03/2010 Complete
04/10/2010 98% felt they were definitely treated with dignity and
respect. 95% thought the breast screening service
was very good. No-one thought it poor.
RECOMMENDATIONS
Discuss the possibility of longer opening hours once
digital equipment has been installed.
Look into redirecting incoming client calls to a phone
that is not used for any other purpose.
Review the directions to the Wycombe static unit to
see if they can be made clearer.
Review staff attitude.
Research is being conducted
into longer opening hours.
Incoming client calls have
been redirected if phone busy.
New site signage has
improved directions to static
unit. Comments boks have
been introduced and staff
attitude is discussed regularly.
2925 National Maternity Audrey Warren
Survey 2010
(BHNHST)
National Maternity
Survey to be
conducted on all
mothers giving birth
in February 2010.
Women &
Children
08/03/2010 Complete
03/03/2011 Results for antenatal and postnatal care were
considerably worse than in previous years.
Care during labour and birth, although in some areas
it was not as good as in the 2009 survey, was still an
improvement on the 2007 survey.
The CQC
looked at responses from 19 of the survey questions
and scored them. The scores for our Trust were
compared with scores from all 142 acute hospital
trusts that took part in the survey. For all 19
questions our Trust scored in the middle 60% of
trusts, i.e. no better and no worse than other trusts.
Actions taken to ensure as
much as possible that
expectant mothers see the
same midwife or doctor
antenatally, so women are
always involved with their
antenatal care and have
continuity. Developed
literature and improved
website to try to ensure
mothers have choice about
where to have baby. Birth
place options to be discussed
with mother. Launch of DVD
and virtual tour. Review of all
written information given to
mothers. The normal birth
pathway re-launched, focusing
on improved antenatal
education, reducing postnatal
care in the community and
using “drop ins”, ensuring the
community midwife is the first
point of contact. Ensured that
the debriefing and reflections
of childbirth service are fully
available to all women across
the area. Results from the
debriefings are fed back to all
staff. Notice boards in clinical
areas to highlight the
Reflections, PALS and
Complaints services. Steps
taken to ensure all mothers
are sutured within one hour
post-delivery. Remodelled the
organisation of various roles
required during inpatient
admissions. Active birth
classes to inform on pain
relief, labour positions. Many
other changes ongoing.
2926 Is There a Need
for a Bladder
Cancer Support
Group at
BHNHST?
(BHNHST)
Krystyna Caine,
MacMillan Urology
Nurse Specialist
2927 Audit of the Use of Dr Lee Aye, FY1,
the AMT 10
Medicine, Dr C Yau,
Assessment on
Consultant, MFOP
Admission in
Medical Patients
aged over 65
(SMH)
A survey to find out
whether there is a
need for a support
group for patients
(and their families)
who have been
diagnosed with
bladder cancer.
Surgery and
Critical Care
09/03/2010 Complete
National and local
guidelines
recommend that all
older patents should
be screened for
cognitive impairment
on admission to
hospital, using a tool
such as the
Abbreviated Mental
Test - (AMT - 10).
Medicine
11/03/2010 Complete
01/07/2011 1. Currently there is no great need for a support
group for patients with superficial bladder cancer
however further information is required about
patients with invasive disease. 2.We have obtained
some useful information on the possible structure of
a support group, if this is developed in the future. It is
encouraging to know that the structure of our
longstanding Prostate Cancer Support Group is of a
similar nature.
3. Patients are given written information on their
disease and further management when seen in the
Nurse-led Results Clinic. They are also given the
contact details of the Uro-oncology CNS (Keyworker)
if they have any questions/queries. We have
recently amended the Keyworker document (which is
sent to the GP and given to the patient at diagnosis)
and are considering undertaking an audit of the
patient information given out at diagnosis to find out
how useful patients find this. We could also consider
evaluating the support given by the Keyworker during
the patient pathway. 4. We are planning to organise
a meeting with the other cancer support groups in
Urology to discuss merging the three support groups
together.
08/11/2010 Currently not identifying all older patients (over 65
years) with cognitive impairment using the AMT on
admission. Rates of AMT use of admission in the
over 65s can be improved by the modified medical
admissions booklet and continued physician
education. Rates of use were highest in junior
doctors; when the presenting complaint was
confusion; PMHx of dementia; or when the post-take
consultant specialised in elderly care.
Changes required. Emailed
Krystyna Caine for changes
11/1/2012. Reply from KC
4/9/12. Review of support
group structure; regularity of
meetings and suggested
speakers has taken place.
Written information currently
with Patient Education Group
for review. Meeting held –
decision made to keep support
groups as individual groups
but invite/meet up with other
groups as required.
The medical admission
proforma has been
permanently modified to
indicate that the AMT should
be performed in all patients
over 65.
2928 Audit of the use of Gbonyefa Samani,
Oral Supplements Community Dietitian
for patients in care
homes
To measure current
practice of the
management of oral
nutritional
supplements against
standards.
15/02/2010 Cancelled
08/02/2011 Cancelled
Cancelled
2929 Drinks Audit
Liz Evan, Nutrition
Nurse Specialist
To identify how, what Specialist
and when patients
Services
are offered drinks.
Concern that nurses
and housekeepers
provide drinks at WH
and Sodexho at
SMH, to ensure that
patients are not
dehydrated.
02/02/2011 spk to Liz
Evans - she has been
very busy with other
things and will
hopefully get back to
this audit in the next
month.
17/03/2010 Cancelled
10/02/2012 Cancelled
Cancelled
2930 Paediatric
Oncology Patient
Experience
Survey
Jo Davison, Lead
Nurse for Oncology,
Paediatrics
Survey to obtain
patient feedback on
self-assessment in
accordance with
paediatric cancer
measures.
17/03/2010 Complete
01/06/2010 It is recommended that this pilot study be followed up
later in the year with a larger study to include all
oncology families, past and present, under the care
of Buckinghamshire Hospitals NHS Trust. Some of
the questions should be expanded slightly to elicit
more information about the service these families
have received. Action plan: Key worker
documentation needs reviewing and highlighting for
parents who are unclear. Information on the service
provided at Wycombe needs highlighting, as parents
are receiving information from Oxford. Facilities for
teenagers need reviewing in the future (also referral
to TYA in Oxford). A larger questionnaire sample will
be needed later on in the year. This will also be
added to the work plan to take place in Autumn
2010.
We decided not to do our own
expanded survey of all the
oncology patients as they are
already being surveyed by the
John Radcliffe. We intend to
see what we can draw from
their responses rather than
burden parents with a second
questionnaire.
We have improved our key
worker policy and each child is
allocated a key worker.
TYA is not yet established at
Oxford so there is centre to
refer them to, however there is
a TYA MDT at which they
would be discussed. Facilities
for teenagers have not yet
been improved.
Women &
Children
2931 Gynae-Oncology
Patient
Experience
Survey
Francesca Lis, Gynae- A patient experience
Oncology Nurse
survey of patients
Practitioner
receiving care and
treatment for a
gynaecological
cancer.
2932 Bronchoscopy
Dr Helen Davies, SpR,
Patient
Respiratory Medicine
Experience
Survey (BHNHST)
A patient experience
survey of patients
having a
bronchoscopy.
Women &
Children
18/03/2010 Complete
12/04/2011 Overall the results of the survey were very positive.
The following recommendations were made: improve
the communication pathway so all patients are able
to contact their Specialist Nurse; ensure all patients
can discuss their diagnosis, treatment and on-going
care at any time with their Specialist Nurse; offer all
patients copies of correspondence and a summary of
their treatment plan; discuss available national
support groups with patients.
Medicine
18/03/2010 Complete
15/07/2010 Overall feedback was positive. No difference
between hospital sites.
Areas for improvement: Clarity of information given.
Explanation of risks and benefits. Mention dressing
gown, slippers etc. Plan to introduce a new patient
information sheet and provide training for
nursing/medical staff.
Changes made: dedicated
phone line with ansa-phone in
CCHU; patients/relatives ring
Specialist Nurse at any time
for clarification of their
diagnosis, treatment and ongoing care; GPs also contact
Specialist Nurse on work
mobile for similar issues;
patients are offered copies of
correspondence in all of the
clinics: Gynaecology and
Gynae-oncology; national
support groups are discussed
at any time along the patient
pathway, and especially at
diagnosis; we have started
using a Distress Thermometer
in the clinics/Wards and
issues/problems are
highlighted, discussed and an
action plan put into place; a
nurse led clinic is currently in
the process of being set up.
The patient information leaflet
has been revised in line with
the recommendations made
following the audit.
2933 NCEPOD PeriOperative Care
(BHNHST)
Dr Richard Bunsell,
Consultant, John
Abbott, Theatre
Manager
An NCEPOD study
looking at perioperative care.
Surgery and
Critical Care
01/03/2010 Complete
09/12/2011 There is a need to introduce a UK wide system that
allows rapid and easy identification of patients who
are at high risk of postoperative mortality and
morbidity. (Departments of Health in England, Wales
& Northern Ireland). All elective high risk patients
should be seen and fully investigated in preassessment clinics. Arrangements should be in
place to ensure more urgent surgical patients have
the same robust work up. (Clinical Directors and
Consultants). An assessment of mortality risk should
be made explicit to the patient and recorded clearly
on the consent form and in the medical record.
(Consultants). Better intra-operative monitoring for
high risk patients is required (Clinical Directors). The
postoperative care of the high risk surgical patient
needs to be improved. Each Trust must make
provision for sufficient critical care beds or pathways
of care to provide appropriate support in the
postoperative period. (Medical Directors). To aid
planning for provision of facilities for high risk
patients, each Trust should analyse the volume of
work considered to be high risk and quantify the
critical care requirements of this cohort. This
assessment and plan should be reported to the Trust
Board on an annual basis. (Medical Directors)
From the pre-operative
aspects, the Trust currently
falls short on a number of the
recommendations.
Anaesthetic clinics are
available in the preassessment clinic at WH;
there are no current
anaesthetic clincs at SMH.
Consultant anaesthetists see
high risk patients on an ad hoc
basis when required. Urgent
cancer patients are fast
tracked through; there are
some capacity issues
currently. MUST screening is
not currently undertaken in
pre-assessment clinic.
Starvation guidelines are given
in pre-assessment; there is no
cohesive Trust policy re:
carbohydrate pre-op loading.
An assessment of mortality
risk is made for those patients
who are reviewed but not all
high risk patients are seen
currently. Invasive monitoring
is utilised as required during
the peri-operative period; the
availability of esophageal
dopplers / lidco is to be
discussed by the anaesthetic
consultant body. There is no
formal recovery pathway
solely for high risk patients;
however, there is lots of good
practice: pre-op physio
classes for all hip and knee
patients; DM control guidelines
about to be approved; Hb
optimisation in process;
regional anaesthesia utilised.
2934 Audit of
Laparoscopic
Fundoplication
Surgery
(BHNHST)
Dr Hanish Nagar, FY2,
General Surgery, Mr
Farouk, General
Surgery, Consultant
Audit of the follow up Surgery and
of patients post
Critical Care
laparoscopic vissel
fundoplication.
23/03/2010 Complete
(no
changes
reported)
18/04/2011 Recommendations were: generation of database to
log cases of anti-reflux surgery; review long term
outcomes for patients receiving anti-reflux surgery;
identify predictors of success; re-audit.
Changes required
2935 Audit of the Post
Operative
Complication Rate
following Carotid
Endarterectomy
(BHNHST)
Dr Edward Choke,
SpR, Vascular
Surgery, Dr Vimmie
Shriyan, Clinical
Attachment, Mr Lintott,
Consultant, Vascular
Surgery, Dr Patel
To asses the rate and Surgery and
type of post operative Critical Care
complications within
12 to 24 hours of
carotid
endarterectomy.
26/03/2010 Cancelled
30/09/2010 Cancelled
Not applicable project
cancelled
Environment tool
completed for various
PCT units. To
analyse and report.
Re-audit.
27/03/2010 Complete
14/05/2010 Where hand hygiene facilities do not meet the
requirements work needs to be done as a priority to
correct this. Furniture and fixtures that are damaged
or that do not have washable surfaces, need to be
repaired or condemned and replaced as appropriate.
All carpets in clinical areas need to be removed and
replaced with washable floor surface. Cleaning in
some areas was not up to standard on the day of the
audit. Floors that were not clean were identified.
The audit highlighted the need to provide a change
of curtains on a pre-planned programme for clinical
areas. Floors need to be kept clear in order to
enable cleaning staff to clean them effectively.
Storing items on the floor, results in them being
contaminated. No items should be stored on the
floor.
Carpets are being removed
as part of the estates work at
FNH & Thame. All furniture
and equipment has been
assessed during visits and
torn/ripped kit removed and or
replaced
Wing unit and Rayners Hedge
are not inpatient units
anymore
2936 Community
Fiona Simpson,
Infection Control
Infection Control Nurse
Environment Audit
2010
2937 Urology Consent
PES (WH)
Dr T Cibulskas, FY1,
Dr M Lumb, FY1, Mr N
Halder, Consultant
Urologist
Assess whether or
not our consenting
doctors are adhering
to GMC guidelines.
Surgery and
Critical Care
30/03/2010 Complete
25/10/2010 Overall an extremely positive response with excellent Further training has taken
coverage of GMC guidance. Recommendations:
place and a re-audit is being
ensure that side effects have been discussed, and
carried out.
that the patient has taken these on board; clearly
state that the patient always has the option to refuse
treatment; consent patients for the use of their
anonymised images/samples; ensure patients are
given a copy of completed consent form; carry out a
re-audit (see audit 3085).
2938 Audit to Assess
Dr S Hameed, Dr O
the Adequacy of
Duprez, Dr Mike Kazer,
the
Consultant, EMC
Documentation of
Whiplash Patients
in WH EMC (WH)
To assess the
Medicine
adequacy of
documentation in
whiplash patients
presenting at
Wycombe EMC,
highlight areas of
strength and
weakness and
implement guidelines/
checklist for
assessing patients
with neck injury.
01/07/2009 Complete
31/03/2010 C-spine tenderness was well documented, however
there was room for improvement in documenting
neuro findings, GCS and intoxication status. X-rays
were being requested appropriately. A checklist
should be put up in EMU to remind clinicians of the
NEXUS criteria. Re-audit to be carried out in 6
months.
Plans to include audit results
on the departmental document
store so information is easily
accessible and there as a
reference source. The
NEXUS criteria will be
included in this.
2939 Audit of the
Dr Peter Kizito, SHO,
Documentation of Dr Mike Kazer,
Respiratory Rate Consultant, EMC, WH.
at Triage in EMC
(WH)
Audit of patients
presenting to the
EMC at WH with
respiraory related
conditons to see
whether their
respiratory rate was
documented.
01/07/2009 Complete
31/03/2010 Respiratory rate is an important tool for monitoring
and assessing patients in a clinical setting and
should be recorded at triage and every time other
observations (e.g. pulse, BP, etc) are monitored and
recorded. Clinical staff need to be reminded of the
importance of monitoring and recording respiratory
rate. Will be re-audited when the CEM vital signs
audit is carried out.
Though not directly as a result
of this audit, vital signs
documentation for acutely ill
patients - 'modified early
warning score' (MEWS) has
been introduced which
incorporates measurement of
respiratory rate. The Trust is
also taking part in the CEM
vital signs audit.
Medicine
2940 Audit
Rehabilitation
Referrals (SMH)
Dr Yesa Yang, FY1,
MFOP, Dr Rachel
Fisken, FY1,
Haematology, Dr Yau,
Consultant MFOP
There is no formal
Medicine
handover of patients
to the rehab team
which has led to
delay in
investigations and
loss of outpatient
follow up which could
compromise patient
sfaety.
01/04/2010 Complete
30/09/2010 Audit showed that there is often a lack of a formal
structured medical handover when patients,
especially the elderly, transfers from Acute care to
Rehab. Patients are being transferred without proper
physio and OT review and some with outstanding
acute medical problems. Propose the introduction of
a medical handover proforma to address these
problems.
A new handover proforma was
designed and introduced for
use on the Rehabilitation
Ward. This did lead to better
handover of follow up plans,
however the Rehabilitation
Ward has since closed.
2941 Medical
Readmissions
Audit (BHNHST)
Dr Graz Luzzi on
behalf of the
Healthcare
Governance
Committee; Dr Mitra
Shahidi, Respiratory
Consultant
A review of medical
readmissions,
requested by the
Healthcare
Governance
Committee.
Medicine
01/04/2010 Complete
28/01/2011 A significant proportion of `re-admissions` are due to
planned follow up appointments i.e. DVT Clinic,
cystoscopy, colonoscopy. Of those `legitimate`
medical admissions, 11% were due to acopia
following discharge (equal to our misdiagnosis,
COPD & LRTI re-admission rates). Re-admissions
at the end of life (known terminal disease) is the
single largest contributor at 15%. Clarify the CRS
search criteria to select only `legitimate` readmissions. Repeat the audit with a larger sample.
coded DVT re-attenders
differently so they are no
longer showing as
readmissions. Faith Button to
comment on additional
changes.
2942 January 2010
Mortality Review
(BHNHST)
Dr Graz Luzzi on
behalf of the
Healthcare
Governance
Committee
A review of January
2010 deaths,
requested by the
Healthcare
Governance
Committee following
an increase in
mortality rate for this
period.
Trustwide
01/04/2010 Complete
19/11/2010 Recommendations were to: continue to improve the
recognition of the deteriorating patient - the use of
Early Warning Scores should be an integral part of
this process; redesign the Emergency Care pathway
for medicine to ensure early review by a senior
clinician; implement the action plan resulting from the
NCEPOD report into Acute Kidney Injury; continued
scrutiny of hospital deaths at all levels of the
organisation, including committee review of clinical
outcome data, Service Delivery Unit review of every
death and involvement in a review of 50 case notes
every 6 months as part of the South Central Patient
Safety Federation ‘Reducing Needless Deaths’
workstream.
Increased scrutiny of deaths in
the organisation; assurance
provided to the Board with
regard to clinical care of
patients prior to death; links
with the Mortality Task Force
work around reducing HSMR.
2943 Day Hospitals
Service Patient
Experience
Survey (Pilot)
(BHNHST)
Todd Kaye,
Physiotherapist,
MFOP, Dr Simmie
Manchanda,
Consultant, MFOP
To investigate
patients' overall
satisfaction with the
service provided by
the Day Hospitals
and including their
reactions to and
experiences of using
the Nintendo Wii as
part of their
treatment.
Medicine
07/04/2010 Complete
23/09/2010 Pilot showed that questionnaire is too long and
complicated for elderly patients to complete. A new
method of collecting data is to be devised together
with physiotherapy staff and a re-audit carried out.
Pilot, no changes required.
2944 Investigation of
Iron Deficiency
Anaemia in Men
Under the Age of
50 (BHNHST)
Dr Kapil Sahnan, FY1,
General Surgery, WH,
Dr McIntyre,
Consultant
Gastroenterologist, WH
Currently the national Medicine
guidelines indicate
'top & tail' scopes for
all men under the age
of 50 with iron
deficiency anaemia.
The question is do
these cases really
warrant endoscopy?
01/04/2010 Complete
(no
changes
reported)
19/05/2011 Microcytic anaemia is uncommon in men less than
Changes required
50 & GI malignancy is rarely a cause especially in
those less than 45. Chronic disease &
haematological causes, usually apparent from the
clinical picture and simple tests, accounted for more
than half of the abnormal FBCs when one was
identified. Not investigating these patients further
would seem appropriate and would not miss GI
malignancy. We would suggest that in men under 45
GI investigation with endoscopy and colonoscopy
should generally be considered only after obvious
disease (haematological, chronic disease, coeliac,
etc) has been excluded or in those whose anaemia
worsens or fails to respond to treatment of known
disease.
2945 DIEP Breast
Reconstruction
Dr Jonathan Cubitt,
SHO, Plastics
To analyse all DIEP Surgery and
breast
Critical Care
reconstructions
performed and
compare outcomes
from 2003 to 2010.
Focusing on length of
operation,
complications, postop analgesia and
length of stay.
Aiming to publish
results.
07/04/2010 Complete
05/08/2011 This was a retrospective analysis of all DIEP breast No recommendations for
reconstructions performed within the Trust from 2003 change were made.
to 2010. There are many publications about
preoperative perforator mapping using CT or MRI
scans and the benefit on outcomes. This series of
159 flaps, with no flap loss, only had Duplex
ultrasound for perforator mapping. This technique is
cheap and readily available. It gives a real time
image of the perforators and the route through the
muscle and also allows visualization of the internal
mammary vessels. In response to 3 pulmonary
emboli DVT prophylaxis was revised to LWMH and
there were no further Pes. Our partial flap necrosis
rates were much higher at the beginning of the series
when the flap was shaped on the abdomen. Now
that the shaping occurs on the chest the rates are
significantly lower. There is not much written about
perioperative analgesia in the literature. Our
combination of intrapleural block and post operative
morphine PCA gives an acceptable analgeisa. As
with any new technique there is a learning curve.
Several factors were compared through the series:
the length of operation, the ischaemic time, the post
operative haemoglobin and the incidence of
complications. The most significant changes
observed were in the increase in post operative
haemoglobin and the reduction in number of
complications as the series progressed.
2946 Excision of
Cutaneous
Squamous Cell
Carcinoma
Dr Sameer Gujral,
CT2, Plastics DrAadil
Khan, ST3, Plastics
Dr Jonathan Cubitt,
CT2, Plastics
To determine clinical Surgery and
and histological
Critical Care
findings of excisions
for squamous cell
carcinomas, 20082009. To evaluate
findings to determine
outcomes, need for
re-excisions and
whether there is a
need for change in
practice.
2947 NSIC Orthotics
Dot Tussler, Kirsten
To review those
Clinical
Hart, Physiotherapists, patients provided with Support
NSIC
orthotics, which
Services
orthotics cointinue to
be used, which are
abandoned. Review
all patients not seen
for over a year to
identify reasons why,
in particular which
orthotics are most
likely to continue to
be used.
07/04/2010 Complete
31/12/2010 This was a regional audit involving the Oxford and
Wessex Training Region. It was the largest
European study of SCC excisions and involved larger
and deeper tumours. It was presented at BAPRAS in
London in December 2010. Results: Overall, the
incomplete excision rate (8%) was higher than
predicted; national guidelines for radial excision
margins were exceeded; radial incomplete excision
rate was 2.5%; deep margin involved in 92% of
incomplete excisions.
The audit was a regional audit
and compared practice at
Stoke Mandeville Hospital with
that at other hospitals. Overall
our practice was good and no
changes were needed. Other
hospitals needed to make
changes.
13/04/2010 Complete
09/02/2011 Results: 49% orthoses are still being used regularly Follow up audit being
and another 20% are used, but not used as often as designed.
they should be. 31% orthoses are no longer used.
Reasons for not using the orthosis or not using it
often enough were most commonly discomfort
(29%), ineffectiveness (19%) and impracticality
(18%). 13% of orthoses were no longer needed. Of
those orthoses no longer used, 39% were no longer
used within 6 months of receiving them. 32% feel
they need a review of their orthotics provision.
Recommendations: It is recommended that a
prospective audit through follow up questionnaires is
initiated 6 months after the provision or completion of
any orthotic intervention, in association with
dissemination of the NSIC Orthotic service user
information.
2948 Management of
Meconium Liquor
(BHNHST)
Dr Ralph Robertson,
ST1 and Dr Cathy
Noone, Consultant
Women &
Children
14/04/2010 Complete
01/04/2011 Only one baby had meconium aspiration syndrome. No changes will be
This baby was immediately recognised as being
forthcoming for this audit. No
unwell and taken directly from Labour Ward to NICU. recommendations were made.
Seven babies had abnormal meconium observations
and had paediatric review. Of these, three were
managed conservatively and four were started on
IVABx. All were discharged home with negative
cultures at 48 hours. Can we safely discharge
babies who have had meconium stained liquor, but
are clinically well, without 12 hrs of Meconium
Observations?
2949 Review of the use Miss Deborah Sumner,
of HPV testing in Consultant (Tunde
Colposcopy Clinic Solebo)
(BHNHST)
HPV testing has been Women &
introduced to try and Children
help the management
of colposcopy
patients and hopefully
allow discharge of
patients from clinic.
This is an audit to
determine whether
HPV testing has
helped management
and whether patients
have been
discharged from
clinic.
19/04/2010 Complete
13/01/2011 Results: 54% of patients tested were HPV positive.
(95% of these with a HR-HPV). 11 HPV negative
patients were discharged back to their GP. 13 more
HPV negative patients theoretically could have been
sent back to their GPs . Of these 11 had low grade
smears.
The majority of patients over 40 with HR-HPV were
not Types 16 or 18.
The majority of the older women positive for HR-HPV
had low grade smears (61%). Department
continuing to use HPV testing to try and aid in
management of difficult cases.
There were no
recommendations made as a
result of this audit and
therefore no changes are
forthcoming.
2950 Audit of Isolation
Precautions
Signs outside side
Clinical
rooms are sometimes Support
not maintained
Services
correctly which can
lead to confusion.
This audit is to
confirm whether side
rooms are maintained
according to hospital
guidelines.
27/03/2010 Complete
02/08/2010 Results: Maintenance of isolation notices generally
poor.
Availability of PPE & usable sharps bins in each side
room generally good. Inconsistent maintenance of
isolation notices may lead to confusion and perhaps
reduction in compliance to barrier nursing
precautions by staff. Some patients unaware of why
in isolation. Recommendations: Proposed
intervention – alert infection control link nurses on
each ward; notice in email bulletins; consider putting
up posters in hospital temporarily to increase
awareness. Re-audit.
Doesn't look as though any
changes made or
recommendations actioned. It
will be re-audited.
Yesa Yang, Rachel
Fisken, FY1, Gen
Medicine,
Haematology
An audit to assess
whether we are
following the
standards for
meconium
observations in
neonates, outlined in
the NICE Guideline
on Intrapartum Care.
2951 Gonorrhoea
Treatment Audit
(WH)
Dr Amanda Roberts,
Associate Specialist,
GU Medicine, Dr G
Luzzi, Consultant GU
Medicine
Ascertain current
resistance levels of
GC and assess
whether current
BASHH guidelines
are being met.
Medicine
22/04/2010 Complete
05/07/2010 Using ceftriaxone as first line treatment for
gonorrhoea infections follows national guidelines and
has a 100% success rate. More patients are seeing
a health advisor, but more care needs to be taken to
ensure patients are receiving written information and
that this is documented. Consider providing patients
with details of links to relevant websites as well as
written information. Consider changing responsibility
for administrating ceftriaxone to health advisors to
ensure all gonorrhoea positive patients are seen by a
health advisor. Consider a reduction in ‘test of cure’
appointments for symptomatic male patients who
have been given ceftriaxone, they would be advised
to return only if their symptoms did not settle.
Greater care is now taken to
ensure all patients receive
written information about their
diagnosis and treatment.
Health advisors are
administering ceftriaxone
injections, when time and
staffing levels allow, thus
ensuring the patients see a
health advisor. There has
been no change yet in seeing
male patients for test of cure
as national guidelines indicate
there may be some
ceftriaxone resistance
emerging. For this reason we
continue to see all patients for
test of cure.
2952 Colorectal Cancer
Patient
Experience
Survey (BHNHST)
Robin Radley, Clinical
Nurse Specialist
Colorectal Cancer,
Jeanette Tebbutt, Lead
Cancer Nurse
Obtain patient
Clinical
feedback regarding
Support
the service and
Services
information provided.
19/04/2010 Complete
31/08/2010 On the whole this is a very favourable report and for
the most consistently high scoring. There are a few
areas where some improvement could be made such
as information about Multidisciplinary Teams. We
also appreciate that some of the written post
operative information is not always up to standard,
but this should improve when we implement the
Enhanced Recovery Programme (ERP).
Recommendations: Ensure it is explained to all
patients that their treatment will be co-ordinated by a
Multidisciplinary Team (MDT) and that they receive
written information explaining what an MDT is.
Improve the quality of the post operative information
which is provided to patients.
There has been an initial
change in the literature to
include reference to MDT
working. A completed review
of all literature is taking place
with a view to producing a
comprehensive information
pack for all patients. Which
will include a leaflet explaining
MDT working.
2953 National Sentinel
Audit of Stroke Organisational
Audit 2010
Dr M Burn and Dr C
Durkin, Consultant
To measure the rate Medicine
of changes in stroke
service organisation
within BHNHST, with
benchmarking
against National
provision.
19/04/2010 Complete
05/10/2011 The report produced by the RCP has been reviewed No changes required
and discussed. Since this audit was completed there
has been a complete review of stroke services within
the Trust and a Hyper Acute Stroke Unit has been
established at Wycombe Hospital.
2954 National Sentinel
Audit of Stroke
2010 - Clinical
Audit (BHNHST)
Dr M Burn and Dr C
Durkin, Consultant,
Stroke Leads
To measure the
Medicine
quality of care for
stroke patients,
including National
benchmarking, and
the extent to which
the recommendations
made in the 2008
audit have been
implemented within
BHNHST.
19/04/2010 Complete
05/10/2011 The report produced by the RCP has been reviewed No changes required
and discussed. Since this audit was completed there
has been a complete review of stroke services within
the Trust and a Hyper Acute Stroke Unit has been
established at Wycombe Hospital.
2955 WHO Surgical
Safety Checklist
(BHNHST)
John Abbott,
Operations Manager,
Critical Care, Jo
Eldridge, Acting
Matron, Wycombe
Theatres, Jackie
Benson, Debra
Panikkar, Theatres
Stoke Mandeville
To monitor
Surgery and
compliance with the Critical Care
WHO Surgical Safety
Checklist, which must
be completed for all
surgical procedures,
and that a record has
been kept of the prebrief for theatre
teams' listings on a
daily basis.
22/04/2010 Complete
01/04/2011 1. Redesign of day surgery booklet to include WHO
Time Out checklist. 2. Standard intra-operative
booklet to be used in all admission areas. 3. All
integrated care pathway (ICP) booklets to include
WHO Time Out checklist. 4. Clinicians encourage
junior doctors to fully complete all sections of the
WHO surgical checklist. 5. Surgeon/scrub nurse to
lead Time Out just prior to knife to skin with all team
present and paused.
1. Booklet was redesigned
and has been put out in all
admission areas i.e.
Mandeville Wing at SMH,
A&E, Day Ward at Wycombe
etc. 2. Standardised in-patient
booklet containing WHO timeout checklist already in all
admission areas. 3. Only
applies to Fractured Neck of
Femur pathway. 4. This will
be included as part of
team/audit/governance
meetings as well as training
sessions so that all grades of
doctors receive
‘training’/reminder. As
evidence, we will be asking
the SDU lead to send us
copies of agendas/minutes
demonstrating this was
discussed. 5. Rachel Young
met with all SDU leads to
confirm that this means the
surgeon and scrub nurse need
to vocalise the WHO Time out
so that all staff present in the
theatre pause and are aware it
is taking place so that they
can hear the questions and
the respondent’s reply.
Rachel Young will follow this
up with observational audits as
part of on-going TPOT work.
Any non-compliance will be
reported to both the theatre
matron and SDU lead for that
speciality.
2956 Audit of
Mr Geoffrey Taylor,
submissions to the Consultant, Dr Sameer
National Joint
Gujral, CT2, Plastics
Registry
To look at which
Surgery and
patients undergoing Critical Care
hip, knee and ankle
replacements have
been submitted to the
National Joint
Registry and to check
that the BHNHST
coding, used by HES
to calculate
compliance, is
correct.
22/04/2010 Complete
04/04/2011 Discrepancies exist between the compliance rates
the NJR quote for BHNHST against those calculated
by the Trust. Improve compliance rates.
Recommendations: 1. Ensure all trainees are NJR
registered and trained. 2. Ensure surgeons are
logging procedures at corrected hospitals. 3. Further
analysis of figure so far by consultant. 4. More
regular review of our stats – re-audit. Ensure
accurate data consent rates: 1. Provide a form in the
POD to consent for data at same time as procedural
consent. Alternatively patient completes form in clinic
or via post prior to op.
Not much has changed so far.
The issure of one surgeon
logging the wrong hospital has
been corrected. All trainees
are asked to register with the
NJR but this always takes time
and not all do this.
2957 Audit of
Indications for
Hartmann's
Procedure
Ashley Ridout, CT2,
General Surgery
To assess the
Surgery and
indications for
Critical Care
Hartmann's
procedure, including
reason for procedure,
grade of surgeon,
outcome and
reversal.
26/04/2010 Cancelled
30/09/2010 Project cancelled
NA - project cancelled.
2958 Child Death
Management
Protocol
(BHNHST)
Dr Shailendra Rajput,
ST5 and Dr A Dutta,
Consultant
There is no current
Women &
Trust guideline for the Children
management of child
death. National
guidelines have been
published by the
Royal College. This
audit is being
undertaken to review
whether we are
managing child death
in line with national
standards and to
propose a guideline
for use locally.
20/04/2010 Complete
06/12/2010 Results: The guideline is not being followed. There
is poor documentation of procedures around child
death. There is poor note keeping, no uniformity in
collecting investigations and no explanation of why
the investigations were not done. No consistency in
recording the involvement of other agencies.
Recommendations: Need for a robust local trust
guideline – has been prepared. Detailed action
checklist - has been prepared. Documentation of
Post mortem reports and results of multiagency
discussions. Documentation of final outcome. Reaudit in 2 years.
A new Trust Guideline (Policy
in the event of a sudden
unexpected death of a child or
young person 773.1) was
uploaded onto the intranet in
June 2011.
2959 National
Donna Beckford-Smith, To start in June 2010. Clinical
Comparative Audit Transfusion Specialist
Support
of the Use of
Services
Group O Negative
RhD Red Blood
Cells
01/06/2010 Complete
25/08/2010 National audit, data submitted. National report
received.
No changes required.
2960 Shoulder Dystocia Miss Veronica Miller
Audit (continuous) and Mr Tunde Dada
(BHNHST)
01/02/2010 Complete
10/01/2011 Results of audit April 2008-April 2009 (six months
either side of merger of midwifery services
19/10/2009). 1. 7/37 (19%) of the women had no
antenatal risk for shoulder dystocia. The most
common risk was BMI>30 (30% ). Only one patient
had previous shoulder dystocia. 2. 20/37(54%) of
the women had no intrapartum risk. The most
common risk was augmentation of labour 27%. 3.
Times, and whether staff were already present or
called, were poorly documented. Where times were
recorded staff arrived very quickly after diagnosis. 4.
18/37 (49%) of patients required only Macrobert’s to
resolve shoulder dystocia. 5. The mean time
between head and body delivery was 2 minutes. 6.
50% of shoulder dystocia sheets were fully
completed after merge compared to 35% before. 7.
86% of babies went straight to postnatal ward after
delivery (90% after merge compared to 82% before).
8. No baby had either brachial plexus injury or
another complication that required follow up after
delivery. Recommendations: 1. Documentation
sheets need to be fully completed. 2. Details of
timings need to be well documented.
CNST requirement to
complete continuous audit of
all cases. Audit proformas
and Datix forms should be
completed in all cases and this
will be raised at each 8 a.m.
safety briefing. New
procedures have come into
place since this audit and in
the six months following this
compliance is now 78%.
A continuous audit of Women &
the management of
Children
shoulder dystocia.
Required for CNST.
2961 Audit of Operative Miss Veronica Miller
Vaginal Delivery
and Mr Tunde Dada.
(continuous)
(BHNHST)
A continuous audit of Women &
operative vaginal
Children
deliveries. Required
for CNST.
01/02/2010 Complete
18/08/2010 47 patient notes audited. Results of first audit
showed lack of documentation. Indication was
appropriate for all 47 patients. 89% patients had
documented consent. On 2 occasions there were 4
pulls but all delivered. 2 patients did not have
analgesia. Recommendations included improving
documentation; always administer analgesia; debrief
on post-op care by obstetrician; always record cord
gases.
CNST requirement to
complete continuous audit of
all cases, year on year report
written with no changes.
21/2/13 CP
2962 Audit of Obstetric
Haemorrhage
(continuous)
(BHNHST)
Miss Veronica Miller
and Mr Tunde Dada
A continuous audit of Women &
the management of
Children
obstetric
haemorrhage.
Required for CNST.
01/02/2010 Complete
28/02/2011 Interim results of ongoing audit. More than 70% of
transfusions are based on low Hb or clinical signs.
Pre-transfusion Hb in 85% patients is less than
8gms/dl. Consent was documented in only 25% of
patients.
CNST requirement to
complete continuous audit of
all cases, year on year report
written with no changes.
21/2/13 CP
2963 Audit of Severe
Pre-Eclampsia /
Eclampsia
(continuous)
(BHNHST)
Miss Veronica Miller
and Mr Tunde Dada
A continuous audit of Women &
the management of
Children
severe pre-eclampsia
/ eclampsia.
Required for CNST.
01/02/2010 Complete
10/01/2011 During March 2010, 47% of patients with preeclampsia were not examined for clonus, therefore
potentially missed out on optimum management for
severe pre-eclampsia. MEWS recorded 80%; urine
output recorded 60%; fluid balance recorded 60%;
fluid restriction 30%; corticosteroids 2 out of 3.
Recommendations: Improved documentation to
enable monitoring of compliance with protocol;
magnesium sulphate prophylaxis; improved
monitoring of fluid balance and restriction.
2964 Maternity Record
Keeping Audit
(BHNHST)
Miss Veronica Miller
and Mr Tunde Dada
2965 A Comparison of Justine Osborne,
Detection Rates
Sonographer
for Urinary Tract
Calcification in
Patients with a
Spinal Cord Injury
An audit of maternity Women &
record keeping,
Children
carried out by
supervisors of
midwives and senior
midwives. Required
for CNST.
01/06/2010 Complete
A Comparison of
Specialist
Detection Rates for
Services
Urinary Tract
Calcification in
Patients with a Spinal
Cord Injury. Project
being carried out for
MSc dissertation;
registration only.
27/04/2010 Complete
(no
changes
reported)
07/05/2010 1. Results to be circulated to all midwives requesting
they examine their own practice against the audited
standards. 2. Audit report to be covered during SoM
session on mandatory day B, session to include
discussion of problems and solutions associated with
record keeping to increase compliance. 3. Liaise
with consultant audit leads to plan their involvement
and revise monitoring section of guideline to reflect
this when finalised. 4. On-call SoM and band 7
midwives co-ordinating shifts to conduct ad-hoc quick
reviews of records pertinent to their area, offering
advice and pointing out good and bad practice. 5.
Workplace teaching sessions regarding risk
assessments at booking and throughout pregnancy.
6. Introduction of detailed sticker to gather this
information. 7. New format should lead to more
organised notes; introduced to midwives on
mandatory training during SoM session and support
staff using these in practice. 8. Revision of these
documents to complement other components of the
maternity records and encourage compliance with
specific areas. 9. Informal canvassing of midwives
comments regarding use of the tool in conjunction
with Audit Department. 10. Remind midwives of the
correct use and completion of CTGs, MEWS, VTE
assessment, prescription chart, epidural and suturing
records in relevant training sessions. 11. Previous
audit two years ago soon after introduction; to be
repeated to monitor compliance and highlight
deficiencies.
01/09/2011 The conclusions of the study were that UTUS is a
significantly superior imaging tool for UTC than AXR.
Also thatassessment by AXR did not seem justified in
the routine urological assessment of SCI patients
with the ability to fill their bladder for UTUS. Based
on the results of this study alone, it is hard to justify
the exposure to ionising radiation by AXR to this
group of SCI patient. Furthermore, the continued
follow-up by routine AXR would appear to be
inappropriate.
1. Email sent with audit tool
and audit results attached. 2.
Initiated 26/05/2011 - ongoing.
More SoM volunteers needed
for Day B sessions. 3. All new
medical staff to complete 2
audits. This plan now agreed
and written into maternity
record keeping guideline. 4.
Quick audit tools now devised
"TIFIs" and in use on the
wards. 5. On-going but
progress slow at present as
MPDT awaiting new team
member. 7. New notes
demonstrated during record
keeping session on Day B.
Work being developed with
FA. 8. Work 50% completed.
Dischrge form out to midwives
for consultation. 11. MEWS
chart is now audited monthly
by productive ward team and
senior midwives on
Rothchilds. Charts that
"trigger" to be audited by
MPDT when identified by
above audit or during notes
reviews. This plan now written
into Observations guideline.
Changes required
2966 National Audit of Dr Syed Hasan,
Falls and Bone
MFOP, Consultant
Health in Older
People (BHNHST)
Clinical audit
Medicine
component of
National Falls & Bone
Health inOlder
People Audit.
01/05/2010 Complete
10/11/2011 Recommendations: Multifactorial falls risk
Changes required
assessment clinical proforma to include
osteoporosis, vision and routine ECG. Develop a
measure so inpatient falls rate and injurious falls rate
can be presented at board level. Appoint a specialist
pharmacist in falls & bone health. Consider adopting
and priorities the key indicators. Consider ways of
identifying patients for whom OT assessment for
potential hazards at home would beneficial. For non
hip fracture patients ensure lying/standing BP,
exercise programme after fall and osteoporosis
treatment happen. Document that written falls
prevention information has been given to patients.
2967 Retrospective
Audit of
Pharmacist
Intervention
Reports
As part of a regional Clinical
intervention reporting Support
scheme, pharmacists Services
record interventions
over a fixed time
period once a year.
The investigator
audited the
intervention reports
for trends.
31/03/2010 Complete
31/03/2010 1. The audit findings should facilitate continuous
medical education, CME activities and training
programmes to address gaps in medication-related
issues. 2. These CME activities and training
programmes must be extended to the other
healthcare providers, i.e., physicians, nurses and
pharmacists. 3. To successfully address medication
error incidents, pharmacists require sufficient clinical
knowledge, adequate set of skills and the suitable
technicalities to negotiate with other clinicians. 4.
Documenting and analysing interventions should be
performed routinely. 5. Feedback reports about the
medication errors detected, and the proper methods
to eradicate, them should be sent to the other
healthcare providers on a monthly basis. This will
increase the level of awareness amongst all
healthcare providers.
.
Roisin Kavanagh,
Pharmacy
Data on medication errors
received more recently has
superceded the intervention
data from this audit and
therefore is used to inform
medicines management
training. Nurses were already
receiving medicines
management training and
medication incidents are
discussed via this training.
We already have training and
assessment programmes in
place to ensure pharmacists
have appropriate skills and
knowledge. We have just
repeated the intervention
study at the beginning of
December and now need to
analyse the data.
Mechanisms already exist for
discussing error reports within
SDUs, Trust governance and
DTC. There are no plans to
change the current system.
2968 Outpatient
Roisin Kavanagh,
Parenteral
Pharmacy
Antibiotic Therapy
Retrospective audit of
OPAT service
examining infections
managed, antibiotics
used and the cost in
comparison to
inpatient
management of those
infections.
31/03/2010 Complete
31/03/2010 The OPAT service in BHNHST has shown a
favourable clinical and safety outcome in the study
population with significant cost-savings generated in
the OPAT management of bone and joint infections.
2969 A Study of
Roisin Kavanagh,
Patients'
Pharmacy
Information Needs
Regarding
Discharge
Medicines
Study of Patients'
Information Needs
Regarding Discharge
Medicines
31/03/2010 Complete
31/03/2010 Patients greatly valued information on their discharge No funding to carry out this
medicines and it is important to make sure all
research at the moment.
relevant information is communicated to patients.
However, it is not possible to generalise information
needs for individual patients and ways to assess
individual patients’ needs should be investigated.
Further research is needed to uncover the reasons
for nurses’ low preference as the source of
information.
2970 Availability of
MRSA
Suppression Kits
on Wards
Prospective study of
use and availability of
newly designed
MRSA suppression
kits at ward level to
identify if problems
around timely supply
and use have been
resolved by provision
of the kits as ward
stock.
31/03/2010 Complete
31/03/2010 There has been a significant improvement in the
speed of provision of MRSA suppression therapy.
Although the standard of 100% of patients receiving
suppression therapy was not attained on the day of
the results, this could be related to the timing of the
results being made available. The recommendation
of this audit is to encourage clinical staff to prioritise
the treatment of patients identified as MRSA positive
to minimise the transmission of MRSA to other
patients.
Breda Cronnolly,
Pharmacy
No changes required.
There is no problem with
patients receiving the MRSA
suppression packs in a timely
manner.
2971 Maternity Record
Keeping Audit
Pilot (BHNHST)
Hannah Hunter and
Lucy Duncan
A pilot of the
Women &
maternity notes
Children
record keeping audit
tool. 42 audit tools
received in total of
notes audited by
Band 7 midwives and
supervisors of
midwives. Report to
be done every 6
months.
Complete
26/05/2010 1. General improvement in record keeping standards
throughout the maternity unit. 2. Raise awareness
of current areas of particular problem with record
keeping. 3. Correct completion of pregnancy
booklet. 4. Correct completion of Waterlow score.
5. Full documentation on CTG as per NICE and
CNST. 6. Completion of VTE assessment. 7.
Correct completion and interpretation of MEWS
charts.
2972 CEFM Electronic
Fetal Monitoring
Dr L Hawxwell, ST1
A reaudit of
continuous electonic
fetal monitoring,
against the current
Trust Guidelines.
Women &
Children
13/05/2010 Complete
30/09/2010 30 sets of notes were audited for
February/March/April 2010. Results showed that
indications for CEFM were documented in 96%
cases. Documentation of date and time had
improved from 63% in last audit to 80%. The
standard overall was similar to thre previous audit,
but none of the CTGs met all requirements. Re-audit
recommendations (September 2010) 1. Improve the
use of fresh eyes stickers hourly, through education
of staff. 2. Senior midwives and doctors to
remember to sign the CTG and use a fresh eyes
sticker when the trace is reviewed by them. 3.
Introduction of checklist for things to be documented
on a CTG to be put on each monitor.
2973 Perineal Trauma
Dr Nighat Arif, ST1
Reaudit of the
classification and
treatment of perineal
trauma, against the
current Trust
Guidelines.
Women &
Children
13/05/2010 Complete
10/10/2010 1. Equity in service provision between SMH and WH
with the introduction of a midwife-led perineal clinic
on the SMH site (there is no funding for this so this
recommendation will remain just that). 2.
Introduction of a leaflet on perineal trauma. 3.
Greater awareness of the guideline and the need to
complete Appendix 2 when the patient is reviewed
and that it is available in the clinic setting.
All band 7 midwives to audit 3
sets of notes in one year.
Individual record keeping
booklets circulated. Circulated
results of the audit to all
midwives via email to identify
points of concern regarding
record keeping. Meet with the
community midwives on both
sites to discuss minimum
requirements. Raise
awareness and outline
requirements in baseline
newsletter. Design a poster to
publicise minimum
requirements. Discuss at
annual supervisory review.
Continue to include in
mandatory training. Continue
to cover in mandatory training.
Hannah Hunter has created
the checklist referred to in
point 3 of the
recommendations. Staff
education is being carried out
at morning meetings.
2974 Audit of Screening Dr Olufemi Dina,
Test for Diabetes Registrar
in Pregnancy
Re-audit of guidelines Women &
on screening test for Children
diabetes in
pregnancy.
13/05/2010 Complete
10/10/2010 1. Ensure that all women have a RBS at booking CMW education. 2. Documentation of results and
hard copy filing. 3. Documentation of the need for
GTT at 28/40 when risk factors are identified and
documentation of the reason if omitted.
To Audrey Warren for
discussion with Diabetes
Specialist Nurse.
2975 Analysis of Axillary
Clearances Comparing
Sentinel Node
Biopsy and
Primary Clearance
(WH)
Dr Vimmie Shriyan, F1,
Surgery, Mr Cunnick,
General Surgery,
Consultant
Audit to compare
Surgery and
primary clearances
Critical Care
and clearances after
sentinel node biopsy.
17/05/2010 Cancelled
30/09/2010 Cancelled due to lack of activity.
Cancelled - not required.
2976 Audit of Oxygen
Prescribing in
Acute General
Medical Wards
(SMH)
Dr Senthil
Rajasekaran, SpR, Dr
Stephen Gardner,
Consultant
An audit to evaluate
current practice at
SMH with regards to
oxygen prescribing
and monitoring.
18/05/2010 Cancelled
25/10/2010 Cancelled - Doctor left the Trust without completing
the audit.
Cancelled - not required.
Medicine
2977 Audit of Venous
Thromboembolism
Prophylaxis in
Medical Inpatients
(SMH)
Dr Senthil
Rajasekaran, SpR, Dr
Stephen Gardner,
Consultant
An observational
study to assess
current practice with
regards to VTE
prophylaxis in
medical inpatients.
2978 The
Implementation of
a Single
Assessment
Process in Day
Hospitals (WH)
Patricia Gettings, Staff
Nurse, Dr Simmie
Manchanda,
Consultant
2979 Intermittent Fetal
Monitoring (SMH)
Dr Alice Bristow, ST1,
Miss Veronica Miller
and Mr Tunde Dada,
Consultants
Medicine
18/05/2010 Cancelled
25/10/2010 Cancelled - Doctor left the Trust without completing
the audit.
Cancelled - not required.
Project being
Integrated
completed for
Medicine
Master's Dissertation.
Aim to implement a
single assessment
process in the Day
Hospital, in line with
NSF
recommendations.
19/05/2010 Cancelled
16/09/2011 Not applicable
Changes required
A reaudit of
intermittent fetal
monitoring, against
the current Trust
Guidelines.
19/05/2010 Complete
18/08/2010 Intermittent auscultation always offered appropriately No changes forthcoming.
– offered in low risk patients and converted to
continuous monitoring when indicated.
Recommendations were: 1. Clear guidance needed
on when monitoring should be commenced. 2.
Partogram could be used instead of notes to prevent
duplication and help pattern recognition. 3.
Importance of recording FHR as single figure to be
emphasised. 4. Inclusion of knowledge of local
guidelines in birth plan (including intention to
auscultate immediately after a contraction for 60
seconds).
Women &
Children
2980 Audit of Paediatric Dr Wendy Bailey, ST4
Diabetes Care
and Dr Dutta,
Following the
Consultant
Introduction of a
Paediatric
Diabetes
Specialist Nurse
(BHNHST)
An audit of paediatric Women &
diabetes care
Children
(frequency of hospital
admission and length
of stay, glycaemic
control and follow up)
pre and post
introduction of a
diabetes specialist
nurse.
19/05/2010 Cancelled
16/09/2010 Cancelled.
Audit cancelled - never
started.
2981 Fetal Fibronectin
Audit (SMH)
Dr Francisco Garcia,
Dr Lorna Lamb and Dr
Hamdulay, SHOs.
Miss Veronica Miller
and Mr Tunde Dada,
Consultants
An audit of
adherence to the
hospital protocol for
fetal fibronectin
testing and
documentation of
this.
01/01/2010 Complete
20/04/2010 A sample of 20 patients undergoing fetal fibronectin
tests between August 2009 and February 2010 were
included in the audit. The main results were:
admissions were high in negative test results (57%);
28% of those with negative results were given
steroids; 75% of PV bleeds had negative results, all
were discharged with no steroids. In 3 cases tests
were performed outside the gestational age marked
by guideline. There was no record of intercourse
prior to the test in any of the 20 cases.
No recommendations were
made and thus no changes
are forthcoming. Audit of New
Clinical Procedure.
2982 Peri-operative
Paediatric
Temperature
Control (WH)
Dr Bianca Tingle, CT1,
Tessa, Greenslade,
Anaesthetics, WH, Dr
S Snyders, Consultant
Anaesthetist, SMH
Children are more
Surgery and
prone to heat loss
Critical Care
during surgery due to
the large body
surface area to
volume ratio.
Therefore RCOA
guidelines
recommend a strict
post op temperature
of 36 to 37oC. The
aim of this audit is to
assess whether all
children have a post
op temperature in this
range and to evaluate
what warming
techniques are used
intraoperatively.
19/05/2010 Cancelled
13/01/2011 NA - audit was not carried out.
NA - audit was not carried out.
Women &
Children
2983 Infection Control
Kitchen Audit
2010
Niamh Whittome,
Kitchen tool
Clinical
Infection Control Nurse completed for various Support
community health
Services
units and BHT areas.
To analyse and
report. Re-audit.
19/05/2010 Complete
28/07/2010 Overall compliance 90%. The elements least likely to
be complied with were: 1) No fabric tea towels or
dish cloths in use (community only) 57%. 2) The
cleaning schedule for the kitchen is displayed
(community only) 57%. 3) Inaccessible areas
(edges, corners and around furniture) free of dust
and dirt 62%. 4) Waste bins clean (community &
acute) and labelled "for general waste"? (acute) 72%.
5) Shelves, cupboards and drawers clean inside and
out, free from damage, dust, litter or stains and in a
good state of repair 74%.
Applicable wards informed of
results and the need to
improve. Relevant wards
have produced action plans.
For re-audit next year.
2984 Infection Control
Niamh Whittome,
Patient equipment
Clinical
Patient Equipment Infection Control Nurse tool completed for
Support
Audit 2010
various community
Services
health units and BHT
areas. To analyse
and report. Re-audit.
19/05/2010 Complete
28/07/2010 Overall compliance 97%. Areas with lowest
compliance were: 1) Daily/weekly department
schedule available for equipment such as blood
pressure machines, drugs trolleys etc. (84%). 2) “I
am clean” stickers being used appropriately (88%).
3) Washers/disinfectors tested according to HTM
2030 standards (86%).
Applicable wards informed of
results and that they must
improve. Relevant wards
have produced action plans.
For re-audit next year.
2985 Interventional
Maggie Rees,
Radiology Nursing Radiology Sister
Documentation
27/04/2010 Complete
01/06/2010 Action plan drawn up by Maggie Rees. 1. Ensure
relevant staff are aware of results of 2010 audit. 2.
Ensure line manager is supporting action plan. 3.
Re-audit to check for improvements.
Changes required. Emailed
Maggie Rees 20/10/11.
Emailed again 11/1/2012. No
longer on global. May have left
Trust, so unable to chase.
Audit of nursing
Clinical
documentation for
Support
interventional
Services
radiology. Aim to
improve or change as
necessary.
2986 Intravesical
Hilary Baker, UroChemotherapy
oncology CNS
Patient
Experience
Survey (BHNHST)
A survey to assess
patient satisfaction
with the intra-vesical
chemotherapy
service at Stoke
Mandeville and
Wycombe Hospitals.
Surgery and
Critical Care
12/05/2010 Complete
12/03/2012 This is the first audit of patient experience of
Intravesical Chemotherapy. The findings were that
overall the patients were very satisfied with the care
and treatment they received. 1. The audit does show
that the nursing team do need to emphasise to
patients who are undergoing maintenance treatment,
or a second course of treatment, that they may suffer
more side effects than their first course of BCG. 2.
Consent forms must be signed prior to treatment and
a copy of the consent given to the patient for them to
refer to prior to treatment. 3. The nursing team need
to examine cross cover and flexibility in the service
when staff are away on annual leave etc. so that
patients can be treated within six weeks of
commencing treatment. In general, a good report
with some interesting findings where objectives have
been set with review dates.
1) New patient information
sheets produced by the Trust
are now available for patients
at the time of their treatment.
2) All trained Nurses who give
IVC chemotherapy are
competent at consenting
patient and obtain consent on
starting treatment. 3) The
introduction of Mito in is still
ongoing.
2987 Nurse-led
Hilary Baker, UroSurveillance
oncology CNS
Flexible
Cystoscopy Patient
Experience
Survey (BHNHST)
A survey to assess
patient satisfaction
with the nurse-led
surveillance (flexible
cystoscopy) service.
Surgery and
Critical Care
12/05/2010 Complete
01/06/2011 1. To try and offer appointments at either Wycombe
or Stoke Mandeville hospitals. 2. To consider
whether same gender patients could be grouped
together for flexi appointments. 3. To enquire as to
whether the department can obtain gowns in larger
sizes.
1. The urology teams discuss
with patients their choice of
hospital when booking
investigations. 2. The clinic is
booked in blocks for female
and male patients or there are
all female/male lists. 3. Larger
sized gowns are now available
in the clinic.
2988 Speech And
Language
Therapy Survey
A survey amongst
Clinical
consultants and other Support
healthcare
Services
professionals to
assess the service
provided by the
Speech & Language
Therapy Department.
24/05/2010 Complete
21/09/2010 Generally the respondents’ feedback was positive
with the acute SLT team at Wycombe viewed as
reliable and professional. The service provided was
seen as valuable and helpful. The issue which was
commented on most was that of weekend cover.
Recommendations: Design a decision making tool to
support nursing staff with weekend admissions
requiring swallowing assessment.
SLT to carry out a proactive ward round on Friday
afternoons to identify inpatients requiring swallowing
assessment before the weekend.
For patients on restricted amounts for safety a
member of the SLT team will ensure the relevant
medical team has been contacted prior to the
weekend to explain the assessment process and
rationale for this decision.
For palliative patients who may be made nil by mouth
over the weekend SLT team will ensure the ‘At Risk’
feeding sign has been agreed and explained to the
nurse in charge of the ward.
SLT Team to complete regular Monday morning
audits to identify the number of weekend admissions
Tool has been designed for
weekend working and will be
presented soon. SLT are
carrying out proactive Friday
afternoon ward rounds. SLT
team are aware they need to
discuss patients on limited oral
intake over weekend. An "at
risk" feeding sign is now in use
and has been agreed with
Nutrition Committee. An audit
has been designed for
identifying relevant weekend
admissions - it is dependent
on decision making tool being
actioned. DTN programme
awaiting agreement from
Midwifery Board.
Debbie Begent, Adult
Speech & language
Therapy Service
manager
that could not be managed by using the decision
making tool.
New Dysphagia Trained Nurse (DTN) guidelines
have been developed and a further programme of
training will be planned to enable DTNs to cover out
of hours and weekends.
2989 Audit of the Use of
Imipenem on the
General Medicine,
Haematology and
Spinal Wards at
BHNST
Breda Connolly, Senior
Pharmacist, Dr David
Waghorn, Consultant
Microbiologist
The prescribing of
imipenem has
increased over the
last year. The
purpose of this audit
is to ensure that
prescriptions for
imipenem are
appropriate and are
used for an
appropriate duration
of therapy.
Clinical
Support
Services
2990 Pressure Ulcer
Audit (BHNHST)
Janine Ashton and
Julie Sturgess, Tissue
Viability Nurses
An audit of pressure Trustwide
ulcers to be carried
out on 28th and 29th
April 2010, to
determine the level of
reporting.
26/05/2010 Complete
01/09/2010 No action required.
No changes required.
15/04/2010 Complete
31/05/2010 In October 2009 it was agreed by the Trust that all
pressure ulcers Category 2 and above would be
reported as a clinical incident via the DATIX System.
This includes both patients admitted into the hospital
with pressure ulcers and pressure ulcers that have
developed whilst the patient is in hospital.
A pressure ulcer prevalence audit conducted in
October 2009 identified that of the 72 patients found
to have pressure ulcers, only 11 had been reported
via DATIX, a percentage of 15%.
Following heightened awareness by both Tissue
Viability and Risk Management it was thought that
the level of reporting had significantly increased. An
audit was performed on 28th & 29th April 2010 to
establish if this was the case. The results are far from
optimistic, of the 53 patients found with ulcers only
16 had been reported via DATIX, a percentage of
30%. The information from the DATIX records will be
used to prepare reports for the commissioners, the
Strategic Health Authority and the High Impact
Actions. The quality of reporting at present is not
adequate to provide a true reflection of the numbers
We are auditing every 2 weeks
in the acute trust to still try and
increase reporting levels.
There is now a pressure ulcer
group which is chaired by
Celina Eaves and involves
divisional leads, matrons,
nutrition etc and also involves
acute and community.
of pressure ulcers in our Trust. We have been set
targets to reduce our pressure ulcers by 25% and
30% but we are still unable to establish a baseline
and consequently demonstrate a reduction. The
percentage of reporting would need to improve to a
minimum of 80% for this to be achieved.
We feel as a team that we are constantly promoting
the reporting system, but believe that in order to
meet this target, direction needs to be provided from
top management to ensure that all pressure ulcers
are reported.
2991 Postural
Hypotension
Measurement in
Orthogeriatric
Patients (SMH)
Rachel Thompson,
FY1, General
Medicine, Dr Syed
Hasan, Consultant,
Medicine for Older
People
Audit of the
Medicine
measurement of lying
and standing blood
pressure to diagnose
postural hypertension
in elderly patients,
with a fracture,
following a fall.
04/06/2010 Complete
16/08/2010 Orthogeriatric rehab ward compares favourably with
national average for postural bp measurements.
However, still a way off achieving ideal target of
100%. Hip fracture proforma extremely
comprehensive and never fully completed. Proposed
changes: Introduce teaching sessions for rehab
nurses, stickers on obs charts, reminders written on
obs charts, posters displayed on rehab ward.
Results of re-audit carried out following these
changes. 57% patients had lying and standing bp
measured after intervention (compared with 28%
previously). Postural hypotension picked up in 14%
patients (compared with 5% previously).
Teaching sessions for rehab
nurses, stickers on obs charts,
reminders written on obs
charts, posters displayed on
rehab ward.
2992 Audit to Assess
the Need for an
Outpatient
Parenteral
Antibiotic Delivery
Service
Jesuloba Abiola, FY1,
General Medicine, Dr
Cann, Consultant,
Microbiology
To assess current
adhoc parenteral
antibiotic provision
and compare how
this compares to
standards set by
OPAT.
09/06/2010 Cancelled
18/07/2011 Not aplicable - cancelled.
Not applicable
Integrated
Medicine
2993 Audit of the Use of Dr Jackie Moncur,
Emergency
Specialty Doctor, GU
Contraception
Medicine
(EC)
Audit of the use of EC Medicine
to ascertain whether
this, especially the
IUD, is being use
appropriately,
whether women are
being offered a
choice of EC and to
determine how many
women present for
EC within 72 to 120
hours.
03/06/2010 Complete
03/06/2011 1.All women should be offered all available methods
of EC. 2.Notes need to document that all methods,
i.e. Levonelle, Ella One and IUD, have been offered.
3.Notes need to document reasons behind
recommended method of EC. 4.Notes need to
document the woman’s decline/acceptance of each
method and subsequent action taken.
5. The introduction information leaflet ‘Advice for
Patients taking the EC’ (Levonelle) needs to include
a section on drug history detailing if the patient is on
any enzyme-inducer drugs and should include the
‘effective rates’ of each EC in more detail. 6. Reaudit notes to ensure full and accurate records are
being kept.
Emailed Jackie Moncur
11/1/2012 also asked if she
was currently re-auditing as
we need to register the reaudit if she is. Changes
reported - Proforma for
emergency contraception has
been changed a year ago to
prompt staff to ask and
document all the
options/decisions/actions. A
re-audit has taken place and
report drafted - much better
record keeping this time.
2994 Paediatric Early
Warning Score
A new EWS form was Women &
introduced in
Children
September 2009. The
audit will assess
whether it is being
used properly by
wards and by A&E. A
staff questionnaire
will also be used to
see what they think of
the form.
09/06/2010 Cancelled
06/12/2010 Cancelled.
Project cancelled.
Record keeping audit Women &
of SEND discharge
Children
letters used by the
NICU at SMH.
Compare the
information in the
SEND discharge
letters with the
information in the
notes to see how up
to date/complete the
information in the
SEND discharge
letter is.
14/06/2010 Complete
18/01/2011 Training for juniors to update SEND weekly. Use in
notes instead of weekly sheets. All SEND letters
need to be counter signed by registrar. Notes for
babies that are discharged to postnatal wards need
to come back to unit for letter to be completed.
Paediatric Department has
confirmed that these changes
have been implemented.
Jo Davison, Practice
development nurse,
Paeds
2995 Are SEND
Dr Sumedha Bird, ST4,
Discharge
Paeds
Summaries Being
Completed
Appropriately?
(SMH)
2996 An Investigation
into Patient
Satisfaction and
Preferred
Appointment
Times for
Outpatient
Physiotherapy in
BHT.
Ian Springall,
Physiotherapy, WH
a patient satisfaction Clinical
survey which includes Support
asking patients when Services
they would like to be
treated. This
coincides with the
move to 7 day
working, which is
currently under
consultation.
09/06/2010 Complete
2997 Audit of
Effectiveness of
Paediatric
Admission
Proformas
Dr Meena
Shamuganathan, ST2
GP VT2, Paediatrics
To look at the
Women &
effectiveness of
Children
current paediatric
admission proformas.
As they are legal,
medical documents,
we would like to see if
they are filled out
appropriately and if
they are designed to
meet the needs of
doctors and nurses in
an on-call setting.
15/06/2010 Cancelled
28/07/2010 Overall there is a very high patient satisfaction in all
areas with the physiotherapy service across all three
sites. Patient satisfaction with the quality of written
information whilst still high is not as high as verbal
communication. Written information may be an area
to improve in the future. Patient satisfaction with
reception staff is very high in terms of speed of
service and attitude although WGH suffered from
poor response when there was no receptionist
present. Patients are very satisfied with the comfort
and cleanliness of the departments. 15%-25% of
patients found direction to AGH or SMH physio
departments (respectively) poor or fair. This may be
an area that needs to be improved. Car parking is
considered fair or poor by 53% of patients across all
three sites. Overall approx 10% of all patients would
prefer to be seen at some time other than what is
currently offered. The same people asked for sat am,
or very early weekday am, or late pm. This does not
support opening at weekends but may support more
flexible weekday hours to meet demand. The most
popular time for appointments was weekdays
between 8am and 12pm.
23/05/2011 Project cancelled as doctor has left Trust without
completing audit.
As a result of this audit some
patient handouts for common
conditions have been updated
or are in the process of being
updated. There are also plans
to print patient information in
conjunction with the
nationwide exercise referral
scheme to give patients
information as to where they
can go to exercise post
discharge from physiotherapy.
As for the flexible working,
physiotherapy has now started
7 day working on the wards.
This has reduced the number
of staff working during the
week, but we have managed
to maintain our 8am-5pm
opening times. There is not
capacity to run the service any
earlier or later at this time.
Project cancelled.
2998 FIM / FAM
Karen Earp, Advanced
(Functional
Physiotherapist
Independence
Measure) Reaudit
A re-audit of
Clinical
FIM/FAM (functional Support
independence
Services
measure) to evaluate
stroke outcome.
21/06/2010 Complete
14/02/2011 1. To encourage use of this outcome tool in the new
Neuro-Rehabilitation Unit for use in acquired brain
injury. 2. Train and update new staff in its use. 3. To
use tool to develop skills in outcome prediction,
treatment planning and to facilitate team working. 4.
Resurrect the idea that consultants in neuro-rehab
consider its use in their outpatients clinics.
Changes required. Emailed
Karen Earp 7/11/2011. Karen
has emailed about re-auditing
FIMFAM. Will need to get
changes first.
2999 Allergies
Documentation
Dr Rebecca Evans,
FY2 and Dr Yau,
Consultant
An audit of the
documentation of
allergies in patient
notes.
14/06/2010 Complete
03/09/2010 Conclusion: record keeping standards are not being
met. Recommendations: introduce mandatory
teaching, stickers on clerking sheets, allergy section
on PMS and an, allergy section on TTOs (pharmacy
will not dispense drugs unless section is filled out).
Teaching on therapeutics and
safe prescribing is now
included as part of the
medicine teaching
programme.
3000 Obstetrics and
Gynaecology
Presentations at
the Emergency
Department
Dr Sonali Dassanaike,
ST1, Mr Tunde Dada,
Consultant
An audit of the
Women &
assessment /
Children
admission of obstetric
patients attending the
emergency
department.
14/06/2010 Complete
18/08/2010 70 sets of patient notes were audited. 29% of
patients were seen and managed by A&E with no
discussion or referral. Is it appropriate and practical
for all cases to be discussed with the oncall Gynae
SpR? As EPAU is a valuable resource is it
acceptable for an A&E SHO to see and discharge a
patient without discussing with Gynae team or A&E
SpR. In terms of patients being admitted under other
specialities, it is imperative that the O&G team are
made aware of this admission. Recommendations: 1)
To discuss with other specialties that although
patient may not present with O&G problem that it is
important that they let the oncall Cons/SpR know that
there is a pregnant patient in the hospital and to
devise a central list of these patients which should be
regularly updated. 2) A&E doctors should do
speculums where needed and when patient is not
going to be referred to O&G team therefore, increase
education and training for the A&E juniors on
speculum examination and swabs. 3) Establish a
proper pathway for patients going to Ward 9 for
review. 4) Revise the guidelines for pregnant women
Guideline being reviewed by
consultants; will be amended
to introduce more robust
practices.
Medicine
(<20/40) presenting to A&E. 5) Need to split the
audit up into mini audits looking specifically into
trauma and pregnancy/Acute medicine and
pregnancy. 6) Re audit to assess if changes
implemented have made a difference.
3001 Oxytocin Audit
Dr Misbah Ali, ST1, Mr An audit of the use of Women &
Tunde Dada,
Oxytocin, against
Children
Consultant
current Trust
guidelines.
3002 Laparoscopic
Dr Alex Tzivanakis,
Hartmann's
CT3, General Surgery
Procedure for
Bowel Evacuatory
Disorders in
Spinal Injury
Patients
A case series report Surgery and
to describe the
Critical Care
Trust's experience of
Laparoscopic
Hartmann's
procedure for bowel
dysmotility disorder in
spinal injury patients.
14/06/2010 Cancelled
18/08/2010 30 sets of notes were audited for the 3 month period
March to May 2010. 97% women assessed before
monitoring commenced. 80% women did not have
an individual management plan when oxytocin
commenced. It was not documented when oxytocin
should be stopped for any of the women. The main
recommendation was for an improvement in
documentation, with individual management plans
and the time that oxytocin should be stopped being a
priority.
A study is in progress looking
at how women are managed.
Education has been given on
carrying out a VE before
starting oxytocin. Veronica
Miller and Audrey Warren
taking to STAG.
22/06/2010 Complete
29/07/2011 Results: Laparoscopic Hartmann’s procedure is an
No changes to practice
effective option for spinal cord injury patients with
required.
bowel dysfunction where conservative methods of
bowel care have failed. It has an acceptably low
incidence of post-operative complications and it has
a reduced incidence of diversion proctitis compared
to similar published series where stoma formation
alone was performed. These findings were
presented to the Association of Surgeons in Training
in 2011.
3003 HQIP Inpatient
Audit of Children
with Diabetes
Dr A Dutta, Consultant,
SMH, Dr M RussellTaylor, Consultant,
WH, Diabetes &
Endocrinology
3004 Evaluation of the Lynn Bath, Clinical
Physiotherapy Led Specialist,
Back Group
Physiotherapy
A regional multiIntegrated
centre audit of
Medicine
inpatient care for
children with
diabetes. This audit,
which has been
approved and funded
by HQIP, is in 3 parts:
organisational data
collection, clinical
data collection,
including patient
feedback, and
implementation of the
action plans based on
the findings of the
audit.
22/06/2010 Complete
An evidence based
back group is run at
all 3 hospitals. The
audit will obtain
patients' views on
how it has affected
their perceived
disability, timing and
content, in order to
improve the service.
23/06/2010 Complete
Specialist
Services
28/09/2012 National results showed that over 85% of all infants,
children and young people diagnosed before 2011
had their HbA1c measured, however only 16.4% of
males and 15.1% of females achieved the NICE
recommended HbA1C target of <7.5% this has
increased from 14.5% in 2009/10 to 15.8% in
2010/11. There has been an increase in the
incidence of diabetic ketoacidosis emergency
admissions from 2005-6 to 2010-11. Stoke
Mandeville patients had 6.3% of missing HbA1C
results with 29.1% of those surveyd having all key
care processes missing. Wycombe patients had
2.4% of missing HbA1C results with 30.7% having all
key care processes missing. Conclusions - The
development of regional networks and the
inroduction of the best practice tariff in England
should help deliver high quality service. Further
analysis is taking place concerning diabetic
ketoacidosis but this should also be addressed at
local level.
10/06/2011 Results: The Back group was designed to address
patients’ fears of exercising and taking part in
physical activity and to improve their confidence and
fitness when they have back pain. The responses to
the questionnaire indicate that the back group is
achieving this aim with 67% reporting improved
fitness and 60% increasing the range of activities
they could do, which often exceeded their
expectations.
The area where some people were disappointed was
in the continuation of their pain, although 47%
reported a reduction in pain and 68% reported the
effect on pain was about what they expected or
better.
Using the Roland Morris questionnaire as an
outcome measure we can see that 38% of patients
had a statistically significant reduction in their level of
back related disability. All patients rated the Back
Group as very good or good. Patients particularly
praised the physiotherapists that ran the groups.
Recommendations: Explore in more detail those that
increased their RM score. Look at how we influence
psychosocial yellow flags by using a suitable
outcome measure. We have not collected data on
how many patients did not complete the 6 sessions
and we should explore how many drop out and their
reasons for doing so.
The results of this audit should be presented to the
musculoskeletal physio service and those referring
patients to the physio departments.
National report for 2010/11 further audits have
superceeded any action plans.
Results presented to Pain
Consultants and their teams
where it was well received and
has resulted in them referring
patients for this type of
approach. The Rheumatology
department were also very
enthusiastic about it and agree
that this is a useful way of
dealing with people with
chronic pain. Has been
presented to physio
departments and has boosted
morale.
The other recommendations
will require a further audit
which has not yet been done.
3005 Care of Ventilated Amanda Adkins,
To evaluate results of Clinical
Patients May 2010 Infection Control Nurse High Impact
Support
Intervention (HII) 4
Services
tool used in Saving
Lives Infection
Control programme.
25/06/2010 Complete
30/07/2010 Overall compliance for all applicable elements
performed was 69%. This is considerably worse
than in 2009. However, different wards have taken
part so overall compliance is not directly comparable.
3006 Urinary Catheter
Care May 2010
25/06/2010 Complete
15/10/2010 Compliance levels for individual elements in the
All recommendations actioned.
insertion part of the audit was of a consistently high To be re-audited.
standard. With the exception of the personal
protective equipment element (99% compliance), all
other elements achieved 100%. Compliance levels
for the individual elements in the continuing care part
of the audit ranged from 94% to 100%. The
compliance level for the hand hygiene element was
100%. The other results were catheter hygiene
(98%), aseptic sampling (95%), drainage bag
position (98%), catheter manipulation (94%) and
catheter needed (94%). A review of the continuing
need for a catheter should be an integral part of
catheter management. As there is a significant
increase in the number of observations from the
2008/2009 audits, direct comparisons can not be
made. However the overall compliance level for all
applicable elements for the on going care of
catheters has dropped from 100% in 2009 to 88%. It
is not possible to tell from the audit whether the
individuals being audited are Doctors or Nurses.
Future audits should record the staff group of the
individual carrying out the urinary catheter insertion.
Amanda Adkins,
To evaluate results of Trustwide
Infection Control Nurse High Impact
Intervention (HII) 5
tool used in Saving
Lives Infection
Control programme.
Applicable wards informed of
results and that they must
improve, particularly with
regard to hand hygiene prior to
ventilation. For re-audit next
year.
3007 Epilepsy 12
Kamal Sawhney, C G
Rastogi
Specialist
Services
01/05/2011 Complete
3008 CMACE Head
Injury in Children
Study
Dr Rastogi, SDU Lead, A CEMACE study
Women &
Dr Subramanian,
into head injury in
Children
Associate Specialist
children. The aim of
the head injury in
children study is to
build up the evidence
base concerning how
early management of
head injury in children
affects health
outcomes and to
identify avoidable
factors associated
with adverse
outcomes.
01/09/2009 Cancelled
3009 Re-Audit of CSSD John Abbott, Critical
and Trays
Care Operations
returned to CSSD Manager, Jill
Hathaway, CSSD
Manager
A national audit
looking at the quality
and delivery of care
for children and
young people with
suspected and
diagnosed epilepsy.
Re-audit of 2008
Surgery and
audit to record
Critical Care
problems with
cleanliness of
equipment/instrument
s cleaned by CSSD
and also to re-audit
incorrect and
incomplete
paperwork being
returned to CSSD by
theatres.
25/06/2010 Complete
16/10/2012 24 eligible patients included in audit. Investigations Changes required
obtained at the audit unit were 12 lead ECG; 'awake
MRI'; MRI with sedation; MRI with GA. 6/24 children
(25%) had a diagnosis of epilepsy (two or more
episodes of epileptic seizures) by the first paediatric
assessment and 10/24 children (41.7%) at 12
months after the first paediatric assessment. 9
children commenced on AEDs. Of 10 children with
epilepsy, there were 5 children with input by a
‘consultant paediatrician with expertise in epilepsies’
or a paediatric neurologist by 1 year (50%). Of all 24
children, there were 12 children with evidence of
appropriate first paediatric clinical assessment
(50%). Of 10 children diagnosed with epilepsy, there
were 10 children who still had that diagnosis at 1
year (100%). Of 2 children meeting defined criteria
for paediatric neurology referral, there was 1 child
who had input of tertiary care by 1 year (50%). Of all
24 children, there were 12 children with evidence of
appropriate first paediatric clinical assessment
(50%).
Audit suspended.
Cancelled
07/11/2011 1. Storage in theatre area to be reviewed to help limit
damage to trays. Theatre Matrons to assess all
equipment no longer used. Storage is still a huge
issue in New Wing and Loakes. Still to be
addressed.
2. Knowledge of job roles between units. Visits to be
arranged between Sterile Services and Theatres to
allow staff the opportunity to understand each others
roles. April 2012.
Theatre Storage - New Wing
has been addressed with new
racking being purchased.
Concerns over handling in
WGH addressed and all
theatre sets are now returned
directly to Theatres. Faulty/old
equipment - Where possible
new instruments/sets have
been purchased and
repair/replacement is an
ongoing issue monitored from
Sterile Services.
3010 Audit of
Comprehensivene
ss of Consenting
for Dynamic Hip
Screws
Dr Bradley Porter, FY1,
Orthopaedics, Mr
Alistair Graham,
Consultant, T&O
To compare
comprehensiveness
of consenting for
dynamic hip screws
with the
recommendations of
the British
Orthopaedic
Association.
Surgery and
Critical Care
3011 National Diabetes
Audit 2009 to
2010 Paeds
(BHNHST)
Dr Atanu Dutta,
Consultant, SMH, Dr M
Russell-Taylor,
Consultant, WH
A national system for Medicine
routine data
collection, analysis
and feedback of
diabetes related data.
24/06/2010 Complete
22/08/2011 Recommendations included: meeting with Registrars
and Senior House Officers; handout demonstrating
BOA recommendations and results from the 1st
audit cycle; referred to Orthoconsent.com; re-audit in
3 months.
01/03/2010 Complete
28/01/2013 SMH summary results - based on 111 children with No changes received as now
type 1 diabetes. Percentage of patients receiving
working on 2011- 2012 audit.
care processes - national framework is that all
children should ahve HbA1c measured every year
and all children aged 12 and above should receive all
care processes - completion rate for HbA1C was
89.2%, percentage receiving all care processes was
35.3%. NICE target for HbA1c is 7.5% or less,
percentage of patients achieving the set treatment
target (N= 99) was 9.1%.Incidents of patients
admitted for ketoacidosis was 8.8 per 100 patients (9
patients excluded due to diagnosis within the audit
year)
WH summary results - based on 166 children with
type 1 diabetes. Percentage of patients receiving
care processes - national framework is that all
children should have HbA1c measured every year
and all children aged 12 and above should receive all
care processes - completion rate for HbA1C was
98.8%, percentage receiving all care processes was
4.2%. NICE target for HbA1c is 7.5% or less,
percentage of patients achieving the set treatment
target (N= 164) was 9.8%.Incidents of patients
admitted for ketoacidosis was 16.7 per 100 patients
(10 patients excluded due to diagnosis within the
audit year)
A re-audit has been carried
out and it is planned to
produce guidance for inclusion
in the SHO Truama and
Orthopaedic induction pack.
3012 National Diabetes Dr Stephen Gardener,
Audit 2009 to
Consultant, SMH and
2010 (BHNHST)
Dr Ian Gallen,
Consultant, WH
A national system for Medicine
routine data
collection, analysis
and feedback of
diabetes related data.
28/06/2010 Complete
Ongoing educational support to improve the quality
of diabetes management within Primary Care.
Data collected relates to GP
practices and Primary Care,
so no changes to be made.
3013 Stroke
Improvement
National Audit
Programme
(BHNHST)
Dr M Burn, Stroke
Consultant, WH
A national stroke
Integrated
audit which focuses
Medicine
on the first 72 hours
of stroke care and
requires every stroke
patient to be entered
onto an audit tool.
11/06/2010 Not yet
started
Results and Recommendations required
Changes required
3014 Use of Faecal
Occult Blood
Testing in an
Acute General
Hospital (WH)
Dr Victoria Morrell,
FY1, Gastroenterology,
WH. Dr Fisken taken
over audit in August
2010.
To investigate the
Medicine
use of FOB testing in
acute hospitals - is its
use appropriate, if
inappropriate what is
the impact of
inappropriate testing?
Should FOB testing
be available in an
acute hospital.
17/06/2010 Cancelled
14/06/2011 Cancelled doctors failed to complete theis audit.
Not applicable
3015 Timing to First
Dr Vishalli Ghai, FY1,
Dose of Antibiotics Anaesthetics
in Sepsis
An audit of antibiotic
prescription for
patients with sepsis.
Looking at mortality
and timing of
antibiotics from
presentation.
Surgery and
Critical Care
06/07/2010 Cancelled
30/09/2011 Project cancelled.
Project cancelled.
3016 UK National IBD
Audit 3rd Round
2010
Dr Sue Cullen,
Consultant
Gastroenterologist WH,
Dr R Sekhar,
Consultant
Gastroeneterologist
SMH
A national audit to
examine the
organisation and
structure of IBD
services and clinical
care throughout the
UK.
Integrated
Medicine
07/07/2010 Complete
21/02/2012 Key recommendations from national report: Sites
Changes required
should work to establish an identifiable IBD team with
a named clinical lead. Clinical pharmacy support for
the IBD team should be strengthened given the high
cost and complexity of the drug regimes that are
often used. Colorectal surgeons should be
encouraged to enter the data on pouch operations
onto the ACPGBI Ileal Pouch Registry:
tp://www.acpgbi.org.uk/research/ileal
Sites should work to engage psychology and
counselling services. IBD Team meetings and
multidisciplinary working should remain a focus of the
IBD team in the face of opposing pressures. Any
opportunity to improve the bed to toilet ratio should
be grasped and IBD teams should seek to create
solutions within a defined timescale.
3017 Complications
Following
Laparoscopic
Cholecystectomy
Kapil Sahnan, FY1,
General Surgery,
Project Sponsor Mr
Wasantha
Hiddalachchi, Trust
Registrar
Follow up audit on
Surgery and
elective laparoscopic Critical Care
cholecystectomy.
Compare post op
complications
between the two
audits. (We don't
seem to have
previous audit
registered) Audit
2515?
07/07/2010 Cancelled
08/12/2010 Project cancelled - audit was not carried out.
Project cancelled.
3018 Audit Grade 4
Pressure Ulcers
(BHNHST)
Alison Brandon,
Audit of all grade 4
Divisional Lead Nurse, pressure ulcers
Division of Medicine
reported via Datix
between 1/10/2009
and 31/103/2010.
Medicine
08/07/2010 Cancelled
28/02/2011 Cancelled
Cancelled
3019 An Audit of
Inpatient
Endoscopy
Referrals (SMH)
Dr Helen Cordey, FY1,
Gastroenterology, Dr
Ravi Sekhar,
Consultant
Gastroenterologist,
SMH
Medicine
09/07/2010 Complete
22/10/2010 Conclusion: Referral forms are still not being
correctly used and completed. Recommendations:
Clinicians can to help improve the service provided
by endoscopy by: using the correct form, filling in all
sections of the forms, checking the pt is happy to
have the procedure prior to booking it and letting
Endoscopy know if pt is to be discharged or is
otherwise unable to have their booked endoscopy.
During departmental induction
junior doctors are educated in
the correct way to complete
endoscopy referral forms and
reminded of the need to
submit them in a timley
manner. This is also
discussed during medical
meetings.
3020 Peripheral Line
Insertion and
Continuing Care
Audit June 2010
Amanda Adkins,
Patients with Iv
Clinical
Infection Control, SMH cannula device in situ Support
should have VIP form Services
properly completed.
28/07/2010 Complete
04/11/2010 Results: Insertion: Overall compliance for the
All recommendations actioned.
different elements of the tool were as follows:
To be re-audited.
Insertion using aseptic technique 98%. Skin
preparation performed 99%. Dressing in situ 100%.
Insertion of device documented 93%. All applicable
elements complied with 91%. If theatres are
excluded compliances for all divisions are worse than
in 2009. Continuing care: VIP forms were
completed for 84% patients with IV lines, a
considerable reduction on the 2009 compliance of
95%.
Insertion documentation is particularly badly
completed, particularly the name of the person
inserting the IV device and the date/time of insertion.
Aseptic access is performed in 99% cases.
Compliances for presence of a VIP form, insertion
documentation and continuing clinical indication are
worse than in 2009. Compliances for removal
documentation, access documentation, aseptic
access and labelling of admin sets have improved.
To audit how
adequate and
appropriate inpatient
endoscopy referrals
are and how soon
after referral
endoscopies are
carried out.
3021 Surgical Site
Infection Audit
Plastics June
2010
Amanda Adkins,
High Impact
Infection Control, SMH Intervention
preventing surgical
site infection for
Plastics only.
3022 To Establish the
Kara Hoskins, Sara
Long-term
Edmondson, Physios
Compliance of AIS
A SCI Individuals
with Standing Post
Discharge from
NSIC
Clinical
Support
Services
Questionnaire to
Specialist
patients discharged
Services
1998-2008 to
establish compliance
with standing.
28/07/2010 Complete
13/09/2010 Pre-operative component. Only 57% screened for
All recommendations actioned.
MRSA. None tested positive so further action cannot To be re-audited.
be audited. Peri-operative component. Only 54%
received prophylactic antibacterial 60 minutes prior to
incision. Normothermia monitored and maintained
for 94% patients. All applicable elements complied
with in 55% cases.
28/07/2010 Complete
03/01/2012 Results: 74% patients’ standing devices were
available when they were discharged from hospital.
4 patients waited more than 6 months for their
standing device to be available. 1 patient never
received their device. Whilst waiting for their devices
4 patients did not use an alternative to standing. 4
patients used stretches, either by themselves or with
assistance from a carer. 69% of patients were
recommended the Oswestry standing frame by their
treating physiotherapist.
30% patients stated that they no longer stand on a
regular basis.
10/12 patients stated that they stopped standing over
one year ago.
Patients reported that they stopped standing for a
number of reasons; the most common were ‘lack of
time’ and ‘no one available to assist’.
9/14 patients still have their standing device, but do
not stand.
78% patients were still using their original standing
device.
22% of those who still stand do not stand for the
recommended length of time. Recommendations:
Patient advice leaflet/ patient education
Re-audit in SPOP – larger sample, shorter
questionnaire. Provide contact details in e-shot for
those unhappy with current standing provision.
Standing promotion day. Increased number and
variety of standing frames in unit. Search of
alternative frames on the market
Demonstrations of various products to staff. Some
trialled with patients.
‘Problem solving sessions’ with current suppliers.
1. Various different Reps have
provided staff with in-service
training on new standing
devices. 2. Different frames
have been loned to the unit for
trial with patients. 3.
Therapists have been
encouraged to inform patients
regarding the reasons for
standing. 4. A database has
been compiled of people to
approach in commissioning at
various PCTs throughout the
country.
3023 Endoscopy Staff
Satisfaction
Survey 2010
(BHNHST)
Sue Kenny, Sister,
Endoscopy Unit SMH,
Deborah DobreeCarey, Sister,
Endoscopy Unit WH
To asses levels of
Medicine
staff satisfaction and
identify any areas for
improvement.
14/07/2010 Complete
19/11/2010 Recommendations: Improve staffing levels (both
sites). Greater opportunities for staff training,
including specialist training (both sites). More visible
input from Trust management (SMH). Review of the
facilities and layout of Unit given the recent increase
in activity (both site). Ensure staff appraisal are
carried out on an annual basis (WH). Discuss future
plans for the Unit (both sites).
New staff have been
appointed at WH. A working
party was set up but
suggested changes to
facilities/ layout were vetooed
by management because of
lack of funds. More training
with specialist outside
agancies is being undertaken.
Staff appraisals are up to date.
A re-audit is planned for
September 2011.
3024 Community Head
Injury Service Audit of Initial
Assessment
Process
Dr Andy Tyerman,
Consultant Clinical
Neuropsychologist,
Head of Service CHIS
The initial
assessment process
used by the
Community Head
Injury Service is
essential to the
effective provision of
the service. This
audit will check
whether the initial
assessment process
provides the
background
information required
in order to provide an
effective service, and
check how well the
process operates
from a
clinical/administrative
perspective.
A manual handling
assessment should
be carried out before
physiotherapy and
updated regularly.
Audit to see if this is
being carried out..
Audit repeated
monthly until
sufficient compliance.
Integrated
Medicine
29/06/2010 Complete
24/08/2011 Draft revisions to be made to the; Initial Assessment
Checklists, Background Interview Schedule, Head
Injury, Problem Schedule & Relatives Screening
Interview for discussion at CHIS Service
Management Group (12/09/11) Final amendments
to be made to forms by 30/09/11 with a view to
revised forms being ready for implementation from
01/10/11. Changes to be outlined to all staff at next
staff meeting on 13/10/11. Revised form to be
reviewed at Service Management Meeting in April
2012.
Changes required
Clinical
Support
Services
01/07/2010 Complete
30/07/2010 Recommend that re-audit is completed monthly until Re-audited.
a completion rate of over 90% is obtained. Manual
handling forms present (July 75%, August 90%,
October 100%, November 90%), manual handling
forms completed (July 65%, August 85%, October
80%, November 90%), risk assessment form present
(July 65%, August 45%, October 80%, November
60%), risk assessment form completed (July 25%,
August 45%, October 50%, November 45%)
3025 Audit of Manual
Dot Tussler,
handling
Superintendent
Documentation in Physiotherapist, NSIC
Therapy Notes of
Spinal Patients
July 2010 onwards
3026 Audit of Manual
handling
Documentation in
Therapy Notes of
Spinal Patients Oct 2010
Dot Tussler,
Superintendent
Physiotherapist, NSIC
A manual handling
Clinical
assessment should
Support
be carried out before Services
physiotherapy and
updated regularly.
Audit to see if this is
being carried out.
Also done in July
2010 and August
2010. August results
presented in this
audit.
3027 Laparoscopic
Surgery Information,
Counselling and
Consent
Dr Hooman Soleymani, An audit to assess
Women &
Dr Dawn Brittain, ST1 the performance of
Children
the gynaecology
department against
the RCOG greentop
guidelines for consent
for operative
laparoscopy.
01/10/2010 Complete
25/10/2010 Results: Now 20/20 (100%) had manual handling
forms present. 16/20 completed, 14/16 updated
once. 16/20 risk assessment forms present. 10/20
completed. Improvement on August and July but still
not good enough. Recommendations: Completed risk
assessment and manual handling forms to be kept at
front or rear of notes. Re-audit monthly until 90%
achieved for each form. Consideration of manual
handling and risk assessment documentation with
implementation of IMS needs to be considered.
Now have electronic record
keeping (IMS), paperforms no
longer required. Too early to
assess IMS documentation.
Re-audit will be done.
01/10/2010 Complete
16/11/2010 Results: Documentation of discussion, major and
common complications was well completed.
However, the common minor complications such as
wound bruising 4%, shoulder- tip pain 10%, & wound
gaping 0% were not well documented. Also the
RCOG recommend that women who are obese, have
significant pathology, previous surgery or pre-existing
medical conditions are informed that they are at
increased risk of complications. The verbal
information given to patients was supplemented by a
leaflet in only 60% of cases. 18% were consented in
clinic prior to admission and the remainder on the
day of surgery. Recommendations: information
should be given, preferably in a written format, in the
clinic prior to admission, but consent should be
gained on the day of surgery by the surgeon. The
use of a sticker to make the general consent form
specific to the procedure, and therefore act as a
memory aid, was considered a positive suggestion,
along with the suggestion for those at greater risks.
A dedicated laparoscopic
surgery patient information
leaflet was ratified Mr Dada
has been distributing this. He
has also completed a ‘ post
laparoscopic surgery’ pt info
leaflet which is going through
the system (August 2011) and
will be available in due course
for further info sharing and
good practice. Consent is also
currently being addressed for
all gynaecological surgery. No
junior should consent for an
operation that he/she cannot
carry out. We are meeting as
a consultant body to consider
if we agree templates for
minor ops and standard ones
ie TAH etc. Laparoscopic
surgery consent will probably
remain the domain of the
surgeon.
3028 Laparoscopic
Surgery Techniques and
Outcomes
Dr Laura Creasy,
GPST1, Mr Tunde
Dada
An audit of
gynaecological
laparoscopic surgery
against national
guidelines: to ensure
the guidellines are
being adhered to; to
compare the
performance of
different operating
surgeons; to
determine length of
stay.
Women &
Children
01/10/2010 Complete
01/11/2010 As complications with laparoscopic surgery are
relatively rare the small sample size limited the
information that could be collected with this audit. It
was felt that a larger sample over a longer period
would be a greater benefit. It was also felt that an
audit which focuses on one reason for the
laparoscopy rather than the range sampled in this
audit would give more useful data.
No changes will be provided
as the results were not
conclusive. Re-audit
suggested with larger sample
over a longer period and
focusing on only one reason
for laparoscopy.
3029 Audit of Fast
Track
Physiotherapy
Service for Staff
referred from
Occupational
Health
Kate Glover,
Physiotherapist
An audit of staff
Specialist
members referred by Services
Occupational Health
to the Fast Track
Physiotherapy
Service to assess the
speed of service,
number of days on
sick leave and
outcome of treatment.
Survey being carried
out as part of
compliance with
recommendations in
the Boorman Report
published 2009.
01/12/2010 Complete
25/05/2012 Figures were used to support bid for further funding
of fast track service so not really an audit as such.
No recommendations or action plan or report.
Not applicable
01/11/2010 Complete
01/11/2010 The audit found that there was better compliance
with the guideline in elective patients, but in general
documentation was poor and that Fragmin was being
under prescribed. Recommendations and discussion:
1. Fragmin should be initiated as part of the WHO
check list in theatre. 2. Responsibility for prescribing
or recording the reason for omitting should sit with
the surgeon. 3. Reformatting the operation record to
have a check box for Fragmin. 4. VTE form should
be completed as part of the clerking procedure. 5.
Training to increase awareness of the guideline. 6.
Re-format the prescription chart to have fragmin preprinted on it requiring only the dosage and signature
to be added. 7. To design a Gynae admission
proforma with VTE/Fragmin check boxes. NICE
guidance advises that all Gynae patients should
have TED stockings. It was felt that there is a need
for a change in practice to ensure that best practice
becomes the normal culture. While flowtron boots
are used in the Gynae theatres, when the patient
returns to the ward they are not used because the
ward doesn’t have the required pumps. Action issue
Discussed at the Academic
Half Day. Will also be
discussed at Risk Monitoring
meeting - part of the ongoing
raising of awareness.
3030 Thromboprophylax Mayurika Wimalaranta, Audit against Trust
is in Gynaecology Memoona Kan
guideline 539.1.
Women &
Children
to be raised at O&G business meeting. The use of
the VTE form in A&E this should be included in the
emergency paperwork. Action Audrey Warren to
ensure that there is a supply available.
3031 Thromboprophylax Vishalli Ghai, Lorna
is in Obstetrics
Evans
Audit against Trust
guideline 646.2.
Women &
Children
01/11/2010 Complete
3032 Vaginal Birth with
Uterine Scar
Audit against Trust
guideline 443.3.
Women &
Children
01/11/2010 Complete
Sangeetha Pelly,
Naomi Jeffery
01/11/2010 Results: Risk assessment is not being correctly
New VTE forms introduced.
performed, and treatment is not being correctly
prescribed. Postnatally, 100% of LSCS patients
received prophylaxis but other patients sometimes
had multiple risk factors that had been identified.
Recommendations: There is a need for greater
awareness of this guideline and training for staff. The
booking assessment should be performed by the
community midwife but after this point any
practitioner seeing the patient should check that it
has been completed and complete it as required. As
part of this discussion the possibility of changing the
colour of the form so that it is more easily identifiable
in the notes was raised. The form will be changing
format when the new guideline is published. Staff
should remember that mechanical methods of
prophylaxis are indicated for some patients. The
need for an assessment to be completed in the
postnatal period should be stressed.
01/11/2010 Recommendations and discussion: Documentation Documentation and use of the
of the audit requirements in the antenatal period
sticker has improved.
were found in a variety of places which made the
audit more difficult. Wider use of the sticker
introduced in the VBAC clinic will make this easier for
future audits and should increase compliance with
the guideline. Regarding review of the requirement
for all VBAC patients to be seen at 36 weeks: could
the guideline be amended to remove this
requirement for those women who have already
made a decision about proceeding with a VBAC?
When these patients are reviewed at 20 weeks could
the GP letter be tailored to fulfil the audit
requirements? Ensure that women who miss the 36
week appointment are followed up.
3033 LMA and ETT
Intracuff
Pressures Audit
Dr Bartosz Swiech,
FY2, Anaesthetics
To measure the
Surgery and
intracuff pressures of Critical Care
Laryngeal mask
airways (LMAs) and
Endotracheal tubes
(ETTs) in theatre. To
assess the
relationship between
intracuff pressures
and post operative
sore throats.
01/11/2010 Complete
3034 Monthly Survey of Sue Ball, Patient
PALS Clients
Experience Manager,
Nick Bigwood, Head of
PALS
To regularly survey a Trustwide
random selection of
PALS clients to
measure satisfaction
in the service and
identify any areas for
improvement.
05/08/2010 On-going
3035 Audit of the
Dr Nihal Fernando,
Incidence of VTE Associate Specialist,
in Stroke Patients MfOP, WH
Audit to investigate
Integrated
the incidence of VTE Medicine
(PE) in stroke
patients and the
effectiveness of
prevention strategies.
Have there been any
changes since the
CLOTTS trial?
05/08/2010 Cancelled
12/11/2009 LMAs: Out of 109 patients, 30 (27.5%) reported
Appropriate size of LMA cuff is
having a sore throat post operatively. Out of these
now being chosen.
30 patients, 93% of patients had an intracuff
pressure greater than 60cmH2O. ETTs: Out of 60
patients 39 (65%) reported a sore throat. Out of
these patients, 59% had an intracuff pressure greater
than 32cmH2O. In both the LMA and ETT groups it
was found that the intensity of sore throat
experienced by a patient was directly linked to
increased intracuff pressure. Recommendations:
Handheld intracuff manometers should be available
in all anaesthetic rooms. Intracuff pressures should
be routinely monitored during surgery. The correct
size of LMA should be used based on weight as this
may cause an increase in cuff pressure for adequate
seal.
Results and Recommendations required
14/11/2011 Not applicable
Changes required
Not applicable.
3036 Audit of
Cutaneous
Squamous Cell
Cancer Excisions
Dr Rubeta Matin, SpR,
Dr Katharine Acland,
Consultant,
Dermatology, AH
Squamous cell
carcinoma is the
second commonest
form of nonmelanoma skin
cancer diagnosed.
Recent guidelines
have been drawn
regarding the
management of
patients with SCC
and this audit will
determine whether
these are being
adhered to.
Integrated
Medicine
05/08/2010 Complete
18/03/2011 Results: Documentation at time of diagnosis is poor. A surgical proforma has been
Recommendations: Design and implement use of a introduced.
proforma for skin lesions presenting at the Triage
Clinic. Need to document the size and site of the
lesion so an appropriately skilled surgeon and
appropriate time-slot can be allocated.
3037 Audit of
Methotrexate
prescribing in
Dermatology
Dr Rubeta Matin, SpR,
Dr Sophie
Grabczynska,
Consultant,
Dermatology, AH
Integrated
Medicine
05/08/2010 Complete
04/07/2011 This re audit highlights that we need to continue
assessing the F/U patients for risk factors to MTX
such as alcohol intake and drug interactions.
Contraceptive advice must be improved in F/U
patients. To continue to improve our blood
monitoring including P3NP levels (which will partly
involve the GPs). Ensure all patients have
documented co prescription of folic acid with MTX.
A check list has now been
introduced for use at all clinics.
Agreed at the Dermatology
Clinical Governance Meeting.
3038 Measuring the
Surgical
Management of
Otitis Media with
Effusion in
Children against
NICE Guidelines
Jane Lambie, Lead
Research Nurse,
Genetics of Otitis
Media Study, Nuffield
Department Surgical
Sciences, Mr Ian
Bottrill, Consultant,
ENT, SMH
An audit was
undertaken in
November 2007 to
determine prescribing
of methotrexate in the
Dermatology
Department.
Suggestions were
made and the audit
increased awareness
of the prescribing
guidelines. The reaudit is therefore
being undertaken to
determine if these
standards are being
met and to close the
audit loop. (Original
audit 2027)
The NICE guideline
for the surgical
management of Otitis
Media with Effusion in
children, introduced
in February 2008,
places a 3-month
period of active
observation at the
centre of the care
pathway and provides
guidance on when
surgery is most
appropriate. This
audit aims to
measure the degree
of compliance with
NICE guideline
CG60.
Surgery and
Critical Care
06/08/2010 Cancelled
10/08/2011 Project never started.
Not applicable - project
cancelled.
3039 National
Comparative ReAudit of the Use of
Platelets 2010
Donna Beckford,
Transfusion Nurse,
Terry Perry,
Transfusion Nurse
Audit to examine the
use of platelets in a
haematology setting.
Clinical
Support
Services
09/08/2010 Complete
01/08/2011 Platelet usage is within normal range. Nothing
unusual.
Main points circulated to
haematology consultants.
3040 Baseline Audit of
Putting Feet First
Erin Lee, Band 7,
Podiatry, Jane Coles,
Band 7, Podiatry
A one-day audit of all Medicine
diabetic inpatients,
looking at the number
of patients, their risk
rating according to
NICE guidelines and
the current inpatient
care. The audit aims
to draw up
specifications for the
proper management
of the diabetic foot in
secondary care. Left
message 3/12/2010
on answerphone - no
response. Sent
emails on 7/1/2011
with list of questions
and also asking for a
meeting. 18/1/2011,
24/1/2011, 2/2/2011
emails sent
requesting a meeting
to discuss data as
cannot proceed
without their input.
11/08/2010 Complete
20/06/2011 Results: Only 14% of patients over the 3 hospital
This audit has now been
sites had their feet screened on admission.
superceded by audit number
However, only 6% of these screened patients had
3349.
been referred to the specialist team. When
screening all diabetic inpatients on 9th November
2010, we actually identified that - 32% patients were
low risk; 45% were increased risk; 12% were high
risk and 12% were ulcerated. This would indicate
24% of these patients should have been referred to
the specialist team. This demonstrates that putting
feet first report and NICE clinical guideline 119
(2011) key priorities are not being met.
Recommendations: 1) Develop a programme of
education, awareness and practical training for
healthcare professionals to highlight the risk of
complications of the diabetic foot. 2) Standardize a
foot screening tool. 3) Referral pathway. 4) re-Audit
Inpatient foot screening. 5) More time and staff.
3041 Audit of
Investigations &
Outcomes for
Patients with
Presumed Lower
GI Bleed (SMH)
Dr Ben Wildblood,
FY1, Dr Ben McNeillis,
Dr Wei Liong,
Consultant, Radiology,
SMH
Audit to assess
Medicine
whether SIGN & BSG
guidelines are being
followed and whether
CT angios are being
requested
appropriately. How
do the different
investigations
compare regarding
diagnosis and
outcomes?
17/08/2010 Cancelled
07/10/2010 Not applicable project cancelled
3042 Evaluation of MCU
Antibody Testing
as Serological
Marker in Early
Diagnosis of
Rheumatoid
Arthritis
Aleksandra SryntarJarocka, Biomedical
Scientist, Jacqui
Wozniack, Lead
Biological Scientist,
Virology & Immunolgy
Use of results of
MCU Antibody
Testing to improve
diagnosis and
monitoring of
treatment for
rheumatoid arthritis.
25/08/2010 Complete
27/04/2011 When considering the diagnosis and monitoring,
None indicated.
statistical analysis proved that the MCV test can and
should be used as a screening test. This was more of
a research project than an audit and there were no
recommendations relating to the Trust.
3043 Evaluation of New
In-house PCR
Method for
Diagnosis of
Herpes Simplex
Virus
Tate Watson, Trainee
Biomedical Scientist,
Jacqui Wozniack, Lead
Biological Scientist,
Virology & Immunolgy
Samples for PCR
Clinical
diagnosis for herpes Support
simplex virus had
Services
previously been sent
to a referral
laboratory but are
now dealt with inhouse. This audit will
compare the two
methods.
25/08/2010 Complete
15/02/2012 This is almost certainly research. Report very very
technical.
Specialist
Services
Not applicable
Not applicable
3044 Personal
Protective
Equipment audit
July 2010
Amanda Adkins,
Use of personal
Clinical
Infection Control Nurse protective equipment Support
tool in all wards to
Services
evaluate if infection
control guidelines are
being followed.
24/08/2010 Complete
29/11/2010 To achieve the target compliance level the score
Infection Control administer
must be 85% or above as set by the Infection
the completion of action plans
Prevention Society. The overall score for all areas of by individual areas.
this audit was 97%. 48 areas achieved a compliance
level of 100%. 4 areas were below the 85%, with
scores ranging from 62% to 78%. Scores by question
varied from 90% to 100%.
3045 National Inpatient
Survey 2010
Medical Director, Chief National Inpatient
Trustwide
Nurse
Survey to 850
inpatients discharged
from hospital in July
2010.
25/08/2010 Complete
03/06/2011 Improvement of >=5% in following areas since 2009:
Were offered a choice of hospital, cleanliness of
ward and bathrooms, hospital food, help to eat, hand
hygiene, confidence in nurses, enough nurses,
patient involvement in decisions, pain control,
answering call button, discharge information,
medication information, copies of GP letters, treated
with respect and dignity, very good or excellent care.
There was a decline of at least 5% in explanations of
procedures. We were amongst the 20% worst
performing trusts for wait to be admitted, sharing a
sleeping area with patients of the opposite sex, time
to answer call button, explanation of operations,
information on discharge medication, clarity of letters
to GPs, asking for patient views, info on how to
complain. We were in best performing 20% trusts for
offering a choice of food.
3046 Gentamicin
Prescribing
Denys Gibbons,
Pharmacist
25/08/2010 Complete
Re-audit to compare Clinical
the results with those Support
of a previous audit
Services
and to assess the
implementation and
use of a new
gentamicin chart.
Medicine Division are:
Monitoring waiting lists.
Urgent care pathway being
implemented. Single sex
policy implemented. Auditing
patient experience through
Matron's walkabouts.
Attendance at medicines
management training being
monitored. Patient
representative on service
redesign group. All wards
have a sign stating how
patients/famililies can access
doctors and when ward rounds
are. Ensuring all areas have
discharge leaflets.
Community Hospitals have
implemented inpatient referral
management system to enable
improved access to
community beds.
25/08/2010 Reason for initiating recorded in only 37% cases. Of Ensured that the new chart
those where indication recorded, all were prescribed was in use on every ward as
in line with Trust guidelines (75% in last audit).
great deal of the old charts
Weight recorded in 33% cases (10% improvement on were still in use in the trust
last audit). If weight recorded improvement of 5% in and the supplier was using up
correct dose prescribed. Only 1 made checks on
old stock.
renal function before prescribing. Improvement of
1% in gentamicin level monitoring. Charts should be
monitored by pharmacists but only 16% were. 90%
used gentamicin chart but old charts still being used
at WH. Recommend awareness and education
campaign, revision of chart to include pharmacist's
signature.
3047 Seretide
Prescribing
Shu Yi Tan, Pre-reg
Pharmacist
Audit to identify
Seretide prescribing
trends (used for
asthma and COPD).
Medicine
25/08/2010 Complete
25/08/2010 Only 73% prescriptions written according to licensed
doses and frequencies (most rectified by ward
pharmacist). 51% used off license, cost savings if
switched to equivalent medication. Recommend
education sessions, cost comparisons, re-audit.
3048 Audit of 'Place of
Death' Outcome
from Palliative
Care Team
Caseload
Carol Hobson,
To reassess current Specialist
Palliative Care Cancer practice with regard
Services
Nurse Specialist
to recording patient's
preferred place of
death and exploring
reasons for
discrepancies
between actual place
of death and
recorded place of
death.
26/08/2010 Complete
20/10/2011 1.The results of this audit should be presented at the Re-Audit took place in 2012
EOLC steering group. 2.The results should be
after introduction of new EOLC
presented at the Palliative Care Management
pathway in February 2012.
Meeting. 3.Re-audit should take place in 2012.
3049 BTS National
Pleural
Procedures Audit
2010
Dr Rachel Ayers, SHO,
General Medicine, Dr
Charlotte Campbell,
Consultant,
Respiratory Medicine,
WH
03/09/2010 Awaiting
Report/Ac
tion Plan
National audit looking Medicine
at pleural procedures
- diagnosis, treatment
and outcomes.
Results and Recommendations required
Pharmacists assist new
doctors to review so inhalers
are reviewed. Inhaler
technique review partially
achieved. Prescribers
constantly reminded by
pharmacists of different dosing
regimes. Seretide 500
Accuhaler now on Trust's
formulary. A new clinical
guideline for COPD has been
created which uses most costeffective inhalers. This has
been circulated Trustwide
including PCTs. Pharmacists
aware and intervene where
appropriate. No future audits
carried out as yet.
Changes required
3050 Health Visitors
Client Experience
Survey
Rosemarie
Finley/Jenny
Chapman, Clinical
Manager/Head of
Children & Young
People's Community
Services
A client experience
survey of the Health
Visitors service.
Women &
Children
3051 Seasonal and
Swine Flu
Vaccination
Survey
Dr Kathryn Campion,
Consultant
Occupational Health
Physician
Survey of doctors'
Community
and nurses'
& Integrated
perceptions of flu
Care
vaccination to identify
why uptake is low.
3052 Cardiac Day Unit
PES (WH)
Ghazala Yasin, Sister, Survey to ensure a
Medicine
Nicola Bowers, Sister, high quality service is
Cardiology, WH
being provided to
patients within the
Cardiac Day Unit and
to highlight any areas
for improvement.
16/08/2010 Cancelled
19/10/2011 Failed to supply recommendations and action plan
report still in draft format
Not applicable
10/09/2010 Complete
04/05/2011 The results of the audit were well received and it is
Not applicable
hoped that some of the observations may shape this
year's flu campaign e.g. highlighting the benefits of
the flu vaccine both from a work and a personal
perspective.
20/09/2010 Complete
18/05/2011 1. Ensure an appointment letter is always sent to the
patient with clear instructions showing how to get to
the hospital from the centre of High Wycombe town
and also how to get to the Unit from within the
hospital.
2. Ensure information sheets explain fully what will
happen during the patients time in the Unit, e.g.
include the fact that procedure could take place
through the wrist and what this means in terms of
being able to drive and work etc, likely waiting times,
items of clothing to bring, drugs lists to bring and
likely recovery times. 3. Ensure patients are met as
they arrive at the Unit and all staff introduce
themselves. 4. Maintain the patients privacy at all
times and keep them informed of progress through
the procedure. 5. Avoid situations where patients in
recovery have to move from their bed to a chair to
free up their bed for another patient.
6. Continue to improve standards of cleanliness in
the Department, particularly toilets.
1. Staff are making a
conscious effort to introduce
themselves to all patients and
are also wearing name
badges, clearly showing name
and position. 2. Deputy Sister
Abbey is working on uploading
information about the cardiac
day unit on the new Swan
website. 3. Chairs at the end
of the unit have been clearly
labeled as recovery chairs for
patients to sit in whilst
recovering from angiograms.
4. Staff have been informed
that the coordinator of each
shift needs to inform patients
of likely waiting times and cath
lab activities, which is being
undertaken on each shift. 5.
Cleaners have been asked to
check the toilets at around
lunch time everyday, which is
being monitored and has been
accomplished. 6. Planning to
work on the letters with the
secretary and hoping to do
that when the website is active
and uploaded, as we can put a
lot of information about the
procedure on the website and
patients are able to access
this information from home.
3053 Comparison of
Tahmina Islam,
Long Term
Registrar,
Results of Bilateral Ophthalmology
Congenital
Cataract Treated
with Early
Cataract Surgery,
Aphakic Glasses
and Secondary
Intraocular Lens
Implantation
To evaluate the long Surgery and
term visual outcome Critical Care
after early surgery of
bilateral dense
congenital cataracts,
aphakic correction
with glasses and
secondary intraocular
lens (IOL)
implantation.
01/10/2010 Complete
21/02/2011 Presentation received, contained a discussion
Changes not required
section but no recommendations. Numbers were
small (22) despite collection over 12 year time
period. Very difficult to draw conclusions but enabled
a discussion of current practice.
3054 Diagnosis &
Dr Zac Etheridge, F2,
Treatment of UTIs Microbiology, Dr K
Cann, Consultant
Microbiologist, SMH
UTI may be over
Clinical
diagnosed in SMH
Support
with the result that
Services
antibiotics are
unnecessarily
prescribed or there is
a delay in reaching
the correct diagnosis.
21/09/2010 Complete
22/11/2010 Urinary tract infection is poorly diagnosed at SMH,
and the current guidelines may not be applicable to
older people. In this audit, only 6% of patients were
treated appropriately according to current guidelines.
In an era of increasingly resistant bacteria and
Clostridium difficile associated diarrhoea, accurate
diagnosis and avoidance of unnecessary courses of
antibiotics is essential, and UTI should not be used
as an easy “get out” diagnosis when presented with
a non-specifically unwell older adult.
Recommendations: i) Establish a consensus
between MFoP physicians and microbiologists at
SMH for correct diagnosis of UTI. ii) Consider
recommending an in-out catheter for obtaining a
urine specimen in patients who are unable to provide
one. iii) Educate doctors as to the correct use and
interpretation of urine dipstick testing. iv) Educate
nursing staff regarding the correct procedures for
dipstick testing via infection control study days. v)
Produce an updated clinical guideline for
assessment of UTI.
The Trust guideline regarding
Urinary Tract Infections has
been up dated to include the
suggestions made. The
results of this audit were
presented to nurses at the
Infection Control Study Days
at WH & SMH in November
2010. Junior doctors are
continually reminded regarding
the correct procedure for
interpretation of dipsticks.
3055 Audit of Renal
Dr Claire Atkins, FY1,
Growth in Children General Surgery, Dr
with SCI (SMH)
Alison Graham,
Consultant, NSIC
Children with SCI are Spinal
at risk of renal
Injuries
disease due to loss of
bladder function as a
result of their inury.
These children
require regular
assessment of upper
tract anatomy and
renal growth for
optimal urological
management.
21/09/2010 Complete
26/04/2011 This study has shown preliminary evidence that
spinal cord injury in childhood impacts on renal
growth. The study has also shown that renal growth
patterns differ in children with spinal cord injury
compared to uninjured children and renal growth
charts used need to be specific to this patient
population. Regular renal length measurement has
an important role in identifying early, a child who is at
increased risk of developing renal disease. The NSIC
should be performing renal ultrasounds on their
paediatric population. By using some small
measures, improvements in care for children with
spinal cord injuries can be achieved.
Renal growth and size will
continue to be measured and
recorded as both are useful
clinical indicators of healthy
development.
3056 Audit of Outcome
of Outpatient
Hysteroscopy in
comparison with
national data
Dr Gemma Brierley,
ST2, Gynaecology, Dr
Shalmali Karnard, ST1,
Mr Tunde Dada,
Consultant
To audit the outcome Women &
of outpatient
Children
hysteroscopy in
comparison with
national data and
Trust guideline 644.2.
21/09/2010 Complete
The management of the
inadvertent finding of a
thickened endometrial lining in
postmenopausal women who
have not had any bleeding is
contentious. There is no
national or indeed international
agreement on what should be
done in these circumstances –
a reason for initiating the audit
in the first place. Now that we
have our own data however
we are able to counsell our
patients as to what we have
found in our own unit, which is
invaluable
3057 Radical
Cystectomy Audit
Mr John Kelleher,
Consultant, Urology
To compare
Surgery and
complications and
Critical Care
outcome of radical
cystectomy over 3
periods during last 15
years.
27/09/2010 Complete
17/03/2011 Results: Hysteroscopy is an easy, relatively safe
method for investigating women with a thickened
endometrium. Hysteroscopy with the indication as
raised endometrial thickness alone appears justified
as it identifies 48.5% benign pathology and 9.5%
potentially sinister pathology. Incomplete
documentation may be skewing analysis of data.
Hysteroscopists are now going to enter data directly
onto database at time of procedure. Do rates of
identification of pathology differ between OPH and
inpatient/ DSU hysteroscopy? Is it any different
using TVUS rather than abdominal USS? Discussion
around performing hysteroscopy for raised
endometrial thickness found on USS in the absence
of other symptoms, audit showed the majority were
found to have benign pathology. Recommendations:
It was felt that there was a need for a guideline on
the treatment of women found to have raised
endometrial thickness on USS. Possible randomised
controlled trial on conservative management
/hysteroscopy.
07/10/2010 Lessons learned: reduction in LOS over the years;
enhanced recovery programme; extraperitoneal
cystectomy; combined approach to neobladder
surgery; radical prostatectomy experience invaluable
especially for nerve sparing; cystectomy for G3pT3B
and G3pT4 cancer is palliative.
No response from audit lead to
requests for changes.
3058 A Survey of
Patient
Satisfaction
following
Outpatient
Endometrial
Ablation
Dr Sarah Martin,
GPST1, Mr Chris
Wayne, Consultant,
Obs & Gynae
A survey to assess
Specialist
patient satisfaction
Services
following outpatient
endometrial ablation
through written
patient feedback, and
to assess adherence
to NICE guideline
TA78 for the
management of
menorrhagia.
28/09/2010 Complete
3059 BTS Emergency
Use of Oxygen
2010
Jennifer Ricketts, ICU
Outreach Lead Nurse,
Dr Simon Barnes, SpR,
Respiratory Medicine,
Dr Chris Wathen,
Consultant Respiratory
Medicine
National British
Medicine
Thoracic Society
(BTS) audit to
establish the practice
of oxygen presribing
and delivery
throughout the Trust.
16/10/2010 Complete
3060 VTE Prophylaxis
in Orthopaedic
Patients Post TKR
and THR
Dr Siobhan Williams,
FY2, Orthopaedics, Nik
Bakti, CT1, Surgery,
Project Sponsor, Mr
Biring, Consultant,
Orthopaedics
An audit of VTE
Surgery and
prophylaxis in
Critical Care
elective TKR and
THR patients pre and
post introduction of
dabigatran, a new
oral anti-coagulant.
30/09/2010 Complete
05/04/2011 Results and Recommendations for menorraghia
component of audit: Investigations completed as
part of patient assessment: FBC (71%); USS (94%);
Swabs (52%); Hysteroscopy/biopsy (94%). 52% of
patients presented to clinic without any prior
treatment from their GP.
Of the treatment options discussed with patients,
most commonly discussed were medical and ablative
therapies. The most common treatments offered
were the Mirena coil and ablation. 68% of patients
were discharged with no further follow up. There is a
need for documentation to be more thorough, and
further conclusions can not be made until the second
part of the audit is completed. It was felt that the
small sample size and the multitude of variables
made this a difficult audit to complete and obtain
useful data. There are different pathways on the twin
sites. However, it was a positive finding that
hysterectomy is no longer the first line of treatment.
14/06/2011 Recommendations: Further training required
regarding the requirements of the British Thoracic
Society (BTS) Guideline for Emergency Oxygen Use
in Adult Patients, particularly: need for a written
prescription with a stated target saturation range,
signing for oxygen on the drug chart at each drug
round, adjusting delivery devices and/or flow rates
when the oxygen saturation falls outside the target
range, recording details of the oxygen delivery
system on the observation chart. Re-audit to be
carried out - participation in the BTS Emergency
Oxygen Audit 2011.
Second part of the audit
should be carried out, i.e.
follow-up, in order to complete
the cycle before changes can
be made.
28/09/2011 The outcome of the study was not conclusive. It will
be followed up with a possible audit with the
Haematology Department to correlate dabigatran
levels and post op wound oozing.
The outcome of the study was
not conclusive. It will be
followed up with a possible
audit with the Haematology
Department to correlate
dabigatran levels and post op
wound oozing.
F1s & F2s receive training in
oxygen prescribing. The
correct procedure for oxygen
prescribing is taught on staff
induction days, BEACH course
and the ALERT course.
Pharmacy & Radiology have
received training and are
helping with prescribing issues
on the ward. The Trust
Oxygen Policy has been
updated and is available on
the intranet. Working is being
done on an e-learning
programme.
3061 Medications and
Fasting: Up To
What Point Can
Oral Medication
Be Given
Dr Jonathan
Chambers, FY1,
General Surgery, Mr
Akinwale, Consultant,
General Surgery
To assess whether
Surgery and
there is a need to
Critical Care
clarify the guidelines
on oral medication
when patients are nil
by mouth. Is
confusion regarding
which oral
medications can be
given and up to what
point, when patients
are nil by mouth,
leading to significant
incidences of omitted
medications?
04/10/2010 Complete
3062 Audit of Delirium
in ICU Patients
Dr Joyee Basu, FY1,
Anaesthetics/ITU,
Project sponsor Paul
Wong, Consultant,
Anaesthetics/ITU
Delirium contributes Surgery and
to prolonged mortality Critical Care
and morbidity and
has been shown to
be common on ICU.
It is often poorly
recorded and
assessed. This audit
aims to determine if
every patient is being
assessed daily and to
look at the risk and
management of
delirium.
05/10/2010 Complete
15/04/2011 Results: This audit set out to assess how frequently
doses of oral medications are being omitted whilst
patients were ‘nil by mouth’ for theatre. It found that
17% of doses prescribed were omitted due to
patients being ‘nil by mouth’. However, of this
percentage, only 3% of these were clearly not contraindicated by the underlying disorder and surgical
indication and should have been administrated
unless two hours prior to the operation. Therefore,
the majority of omissions documented as ‘nil by
mouth’ were justified. This audit concludes in finding
that when oral medications were being omitted, this
was done so appropriately. It has not shown any
objective evidence to suggest that confusion exists
on the wards regarding fasting guidelines and so
causing significant amounts of unnecessary
omission.
Recommendations: introduce and display posters on
specific pre-operative fasting guidelines for ward
staff; encourage clearer documentation by doctors
regarding their requirements for fasting e.g. “Nil by
Mouth from 0000, but clear fluids and regular oral
medications up to 2 hours before theatre"; consider
introducing a ‘Six is Safe’ scheme, ensuring early
morning doses of regular medications are
administered; consider providing theatre lists by 0200
hrs for nursing staff of patients on the General
Surgical theatre list for later in the day.
12/01/2011 Results: Patients admitted to ICU have multiple risk
factors for the development of delirium; assessment
of delirium is not routinely performed and/or
recorded; treatment is often not administered to CAM
ICU positive patients. Recommendations: Education
programmes, incorporation of a flow sheet onto ICU
charts and clear clinical guidelines may help to
improve detection, documentation and management
of delirium.
Following the report, the
following action has been
taken: a) Several copies of the
same poster have been
distributed around the General
Surgical Ward (6) in SMH
which presents the Trust
Guidelines for Pre-operative
Fasting, both for elective and
emergency surgical cases; b)
The audit was presented to
the General Surgical
Academic Half Day, with
points made to encourage
clearer documentation by
doctors regarding their
requirements for fasting
(included explanation for why
this was necessary) and
discussion on the ‘Six is Safe’
scheme and provision of
theatre lists.
The RASS scale assessment
tool has been incorporated on
to the ITU chart. The SMH
ITU Acting Matron set up
teaching sessions for the
nurses to raise awareness and
assess the delirium on a daily
basis. The Confusion
Assessment Method (CAM)
ITU tool is now attached at the
bedsides to facilitate the
assessment process which will
be on a daily basis. These
actions will be cross site.
Work is in progress on the ICU
daily assessment chart for
doctors incorporating delirium
check. The treatment will
depend on the findings and
patient’s clinical state.
3063 Audit of Process
of Discharging
MGUS patients to
Primary Care
Dr Robin Aitchison,
Consultant
Haematologist,
Timothy Lim, F1
Haematology
Assess compliance
Specialist
with BCSH MGUS
Services
guideline on issue of
information given to
patients and GP
when patients
discharged to primary
care.
05/10/2010 Complete
3064 Audit of the Daily
Checking of
Defibrillators WH
Dr Anne Beh, FY2,
General Medicine, WH,
Jenny Wright,
Resuscitation Manager
Trust policy says all
Surgery and
defibrillators should
Critical Care
be checked daily by a
clinical member of
staff. This audit will
look at whether
checks have been
made daily, who by,
any problems
identified and any
action taken.
08/10/2010 Cancelled
3065 Audit of
Adherence to the
Guideline for
Management of
Reduced Fetal
Movements in
Pregnancy (SMH)
Dr Gemma Brierley,
ST2, Obs & Gynae,
Miss A Reddy,
Consultant
Audit of adherence to Specialist
Trust Guideline 419.3 Services
Management of
Reduced Fetal
Movements.
17/10/2010 Complete
02/09/2011 All 10 GPs surveyed had received written information
of some sort, whereas this figure was only 2 out of 10
in the patient group. Recommendations: Create a
template clinic letter/leaflet for our clinic to send to
GPs and patients on MGUS, including all relevant
information.
Ensure copies of GP letters are sent to patients.
Ensure leaflets on MGUS are readily available in our
clinic.
Emphasise the importance of follow-up.
Encourage patients to have a reminder system for
themselves to pursue follow-up.
Action Plan
MGUS information leaflets designed with the BCSH
guidelines in mind will be given to newly-diagnosed
MGUS patients in our CCHU from now onwards,
prior to being discharged to primary care. Related
leaflets will also be sent out to their respective GPs.
The importance of follow-up will also be emphasised
more heavily to patients with a new diagnosis of
MGUS.
05/05/2011 Project cancelled - no information provided.
Patient information booklets
have been produced and
agreed.
NA - Project cancelled
01/06/2011 Audit 111 patients 86 sets of notes obtained and
No changes required - re-audit
reviewed (77%). These patients had 118 encounters taking place January 2012.
between them. Appropriate decisions were made but
13 scans were not performed when indicated. 100%
of scans detected appropriate findings. 7 incidences
of detected IUGR. 7 incidences of unexpected birth
of baby <10th customised centile. A re-audit was
suggested.
3066 An Audit to
Review the
Effectiveness and
Accuracy of
Discharge
Documentation in
Communication
with GP's
Dr Jessica Gale, FY2,
Rheumatology, Dr
Samantha Scammell,
FY1, Rheumatology,
Dr Stevens,
Consultant,
Rheumatology
An audit to see
whether discharge
documentation is
being accurately
completed.
Medicine
06/10/2010 Complete
(no
changes
reported)
04/02/2011 The following criteria all with a 90% standard were
measured by this audit, details of the standard
achieved are included after each criteria: all
summaries should detail diagnosis or presenting
symptoms 100%, all summaries should be clearly
legible 35.7%, associated medical conditions should
be accurately completed 50%, discontinued
medication should be clearly documented 75% and
follow up plans should be clearly stated 60.7%.
Conclusion: Current handwritten discharge
documentation is significantly below the standard
expected. Recommendations: Typed summaries
should be implemented and considered mandatory.
A structured format for completing electronic
discharges should be made available to all juniors.
Importance of correct completion of discharge
summaries should be reinforced at Trust induction
meetings. Re-audit in 6 months.
No changes have been made.
3067 IV Antibiotics
Missed Doses
Audit
Dr Zac Etheridge, F2 ,
Microbiology, Dr Xin
Hui Chan, F1,
Diabetes, Dr K Cann,
Consultant
Microbiologist
It is important
Clinical
patients with serious Support
infections do not miss Services
iv antibiotic doses, as
this can lead to a
prolonged hospital
stay and a poorer
outcome. This audit
looks at why doses of
iv antibiotics are
missed.
19/10/2010 Complete
31/05/2011 Results: This audit demonstrates that not all doses of
intravenous antibiotics prescribed are administered.
The reason for omission was unknown in 48.8% of
cases despite the existence of medicines not
administered codes. The next most common reasons
– 7% each – were the patient being off the ward, lack
of intravenous access and medicines not being on
the ward. Recommendations: Appropriate training
and support should be provided to doctors, nurses,
pharmacists and patients to improve prescription,
supply, administration, compliance and
documentation. This should include encouraging the
use of medicines not administered codes. Also
suggest changes to the Buckinghamshire Healthcare
Trust prescription chart. Re-audit in 3 months.
Training for doctors, nurses,
pharmacists and patients to
improve prescription, supply,
administration, compliance
and documentation has taken
place. Changes have been
made to the Buckinghamshire
Healthcare Prescription chart.
A re-audit is being carried out.
3068 Audit of
Malnutrition in
Surgical Patients
Dr Claire Atkins, FY1,
Dr Nisha Sriram, FY1,
General Surgery, Mr
Schneider, Consultant,
General Surgery, SMH
Nutrition is known to Surgery and
affect surgical
Critical Care
outcomes and length
of stay in hospital.
This audit is based on
a NICE guideline
published in 2006 on
the implications and
assessment of
malnutrition in
hospital.
19/10/2010 Cancelled
28/11/2011 Not applicable - cancelled.
Not applicable - cancelled.
3069 Is the
Management of
Early Inflammatory
Arthritis in Line
with EULAR/ACR
Guidance? (SMH)
Dr Ben Wildblood,
FY1, Rheumatology,
Dr Sally Edmonds,
Consultant
Rheumatologist, SMH
Audit to investigate
Medicine
whether current
practice is in line with
the new criteria
published by the
EULAR/ACR and
suggest areas for
improvement.
19/10/2010 Complete
31/12/2010 Results of the audit compared favourably to the new
criteria introduced by the EULAR/ACR. The audit
helped to introduce clinicians to the new guidelines
and highlighted the need for faster referral from
primary care to the Rheumatology Dept.
No changes required - results
of the audit show the guideline
is already being followed.
3070 NCEPOD Cardiac Dr Graz Luzzi, Medical
Arrest Procedures Director, Jackie Smith,
Study
NCEPOD Reporter,
Jenny Wright,
Resuscitation Services
Manager
The aim of the
NCEPOD study is to
identify areas where
the care for adult
patients who receive
resuscitation in an
inpatient setting may
be improved.
Surgery and
Critical Care
12/10/2010 Complete
01/07/2012 NCEPOD report published June 2012.
http://www.ncepod.org.uk/2012report1/downloads/C
AP_fullreport.pdf
Changes required
3071 Audit of
Dr C A Thiyagarajan,
Urodynamic
Associate Specialist,
Practices in Spinal Spinal
Unit
Audit of current
practice of filling
cystometry. Filling
cystometry is started
as a baseline
investigation to all
newly injured spinal
patients since Jan
2009. To compare
current practice
against ICS "Good
Urodynamic
Practices" report.
Specialist
Services
25/10/2010 Complete
09/09/2011 Recommendations: Referrer’s feed back on the
value of baseline filling cysometry and report system.
Integrate Urodynamic report to Patient’s e-record.
“PILL” need to be issued prior to the urodynamic.
We have successfully
integrated the urodynamic
report to patient’s e-record.
Patient information leaflet is
designed and waiting for
approval. Referrer’s feedback
is collected and waiting to be
analysed.
3072 An Audit into Bed
Positioning of
Spinal Patients at
Night
Hannah Proctor,
Michelle Clarke,
Physios
3073 Long line Venous
Catheter October
2010
Amanda Adkins,
To evaluate the
Clinical
Infection Control, SMH results of the High
Support
Impact Intervention
Services
(HII) Central Venous
Catheter tool used in
the Saving Lives
Infection Control
programme. ITU and
St Andrews only.
3074 Audit of Service
Debbie Begent,
User Opinion of
Service Manager,
Speech &
S&LT
Language
Therapy
Outpatient Service
To identify how
patients positioned,
what equipment
used, identify if
nursing staff adhere
to positioning charts.
A "24 hour
positioning" working
party has been set
up.
Specialist
Services
One to one
Clinical
questionnaire with 12 Support
users.
Services
25/10/2010 Complete
18/05/2011 Results: Patients are asked how they want to be
positioned BUT – patients not always educated in all
options, which best meets their clinical needs.
Positioning charts were not being used. Pressure
requirements not always met. No postural
requirements met. Not always access to water/ECU
Recommendations: Need to consider patients
positioning at all times (24hrs!) when back in bed not
just when going to sleep. Review & Utilise 24 hour
positioning charts already in place with nursing staff.
Incorporate education to patients on postural needs
in bed as well as skin – patient education lecture.
Ensure access to ECU & water at all times. Ensure
increased involvement of nursing staff in 24 hr
positioning – on the ward and in working party. Reaudit in 4 months – consider evening positioning and
night positioning.
We are continuing to do 24hr
posture assessments in gym
and ward for rehab patients.
We carried out our first ever
MDT assessment on a patient
and are due to do another.
The actual awareness of 24 hr
positioning is increasing.
Discussed patient talk with the
Patient information officer.
25/10/2010 Complete
10/01/2011 Results: There was 100% compliance for hand
hygiene, catheter site inspection, catheter injection
ports and catheter access. Overall compliances for
dressing, admin set replacement and avoid routine
catheter replacement varied from 95% to 99%. All
applicable elements were complied with for 93%
observations. There were 12 non-compliant
elements in total from the 160 observations. Action
Plan: All areas with non participation must produce
an action plan on how they are monitoring their
compliance with this audit. Areas who did not
produce an action plan and return an action plan at
the time of completing the audit must produce an
action plan to show how areas of non-compliance
have been addressed.
All areas with ‘No’ answers are required to sign off
this action plan to confirm all actions have been
completed and then return to the IPC.
Infection Control administer
the completion of action plans
by individual areas.
26/10/2010 Cancelled
12/04/2011 Cancelled
Cancelled
3075 Oncology/Haemat
ology Research
Patient
Experience
Survey (SMH)
Tracey Stammers,
Cancer & Haematology
Research Nurse,
CCHU, SMH
The research team
Specialist
has been through
Services
many changes over
the last 18 months
and now that they
have achieved
stability they want to
review and optimise
their practice
regarding recruitment
of patients into
clinical trials.
27/10/2010 Complete
22/12/2011 Results: 76% patients stated they had heard the
term 'clinical trials'. 65% patients stated they found
the explanation given to them about clinical trials
'very easy' to understand. 94% patients were
provided with written information. 98% stated the
written information was clear. 96% patients stated
they were given enough time to consider whether
they wanted to participate in a trial. All patients felt
that their dignity and privacy was respected at all
times. 80% patients decided to participate in a trial.
31% stated they were aware that Buckinghamshire
Healthcare NHS Trust particpates in clinical trials.
Recommendations: 1) Promote trial awareness for
professional colleagues. 2) Promote trial awareness
for the public, potential trial participants and their
carers. 3) Ensure that the correct patient groups are
selected for participation in the Patient Experience
Survey to obtain clearer results.
An Abstract from the result of
the audit was submitted to the
National Cancer Research
Institute ‘NCRI’ .Cancer
Conference 2012. The
Abstract title: Enhancing
recruitment into clinical trials
by promoting understanding
and awareness of a
comprehensive portfolio of
research studies available in a
local NHS Trust was selected
for inclusion in a poster
session at the Conference. A
piece relating the clinical trials
has been incorporated on the
Trust website.
3076 Acuity/Dependenc Celina Eves, Lynn
Dependency level
Trustwide
y Scores
Swiatczak, Chief Nurse recorded for each
patient on each ward
for 20 days every 6
months. Used to
calculate nursing
requirement.
27/10/2010 Complete
28/07/2011 No action plan
No action plan
3077 Do Not Attempt
Resuscitation
(DNAR) Re-Audit
08/10/2010 Not yet
started
Graz Luzzi, Medical
Director & Jeanette
Tebbutt??
Audit of DNAR
process/paperwork
against Trust
guidelines. This is a
re-audit from 2008.
Trustwide
Results and Recommendations required
Changes required
3078 Outpatient
Hysteroscopy
Patient
Experience
Survey
Tunde Dada,
Consultant, Obs &
Gynae
01/10/2010 Complete
14/03/2012 1. Patients should be reviewed by the consultant if
possible in recovery after the procedure. 2.
Analgesia should be offered in the form of NSAID or
PCM. (Both disseminated through staff at
hysteroscopy meeting). 3. The post-hysteroscopy
information sheet should be revised and always
given to the patient after the procedure. 4. Ensure
written communication of histopathology results to
appropriate patients.(To be passed through
hysteroscopy guidelines).
3079 Lymphadenectom Miss Sally Jay ST5,
Following a recent
Surgery and
y Audit
Audit Lead, Consultant change in guidelines Critical Care
Sudip J Ghosh
as to who can
perform
lymphadenectomies,
this audit aims to
review clinical and
histological outcomes
pre and post the
change in the
guidelines.
03/11/2010 Complete
23/05/2011 In this audit of practice at Stoke Mandeville, Oxford
No recommendations for
and Salisbury Hospitals, compliance with the
change were made.
guidelines as to who can perform
lymphadenectomies made no significant difference to
the outcome of the operation in terms of
complications and recurrence. Oxford data (bigger
cohort) suggests significant reduction in regional
recurrence. Indirect effect of guideline is that all
patients get discussed/treated in MDT.
3080 Neonatal Heart
Murmur Audit
03/11/2010 Complete
01/03/2011 Overall the current protocol was followed in its
Re-audit taking place.
entirety in only 2 cases. An apparently high
proportion of pansystolic murmurs was found on first
assessment, which were later felt to be innocent;
although we were unable to find any published data
on the comparative incidences of ejection and
pansysolic murmurs, intuitively this would seem to be
unlikely to be a correct representation. The likeliest
cause would be misunderstanding of the descriptors
used for murmurs by the staff performing the
newborn examinations. Solutions would include
either more training of junior staff, or insistence upon
middle grade review of all of these babies. Senior
review is required by the current protocol, but did not
occur in a quarter of cases. All these cases had been
initially described as pansystolic murmurs potentially pathological and so review should have
been mandatory. Currently re-auditing to check
whether the new proforma started after the March
Audit has improved our practice. The new audit was
started in August using exactly the same audit
proforma as the one in March, and aiming to
Peter Sidgewick, ST1,
Paediatrics
Patient experience
survey of outpatient
hysteroscopy for
service review and
development.
Specialist
Services
Compare practice
Women &
with neonatal heart
Children
murmurs against
guidelines with aim of
updating local
guideline.
Mr Dada now reviews patient
in Recovery after the
procedure.
compare the results.
3081 Audit of
Percutaneous
Biliary Drainage
and Stent
Insertion
Dr Zishan Sheikh, CT2, Audit against British
Gastroenterology, Dr
Institue of Radiology
Sekhar, Consultant
standard.
Gastroenterologist,
SMH
3082 Retrospective
Audit of Neonatal
Chest X-rays
Michelle Sugrue,
Radiography Student,
Pam Sangster,
Radiology Manager
Integrated
Medicine
Retrospective audit of Clinical
neonatal chest
Support
radiographs
Services
performed with
respect to image
quality and
evaluation, with a
view to making
recommendations for
improvement in
radiographic
technique.
03/11/2010 Cancelled
17/06/2011 Cancelled
Not applicable cancelled.
03/11/2010 Cancelled
01/08/2011 Not carried out
Not carried out
3083 Monitoring of
Jane Eastman, Jenny
Length of Stay for Grievson, Senior
Primary Elective
Physiotherapists
THR & TKR 2010
(BHNHST)
3084 Specialist Clinic
for Diabetes and
Sport Patient
Experience
Survey
3085 Re-audit of
Urology Consent
PES (WH)
Dr Alistair Lumb, SpR,
Diabetes
To monitor length of
stay for THR and
TKR and to identify
reasons for delays in
discharge.
The Trust has been
running a specialist
clinic for the
management of
diabetes for sport and
exercise for 3 years.
Before that,
appointments were
offered on a more ad
hoc basis. The aim
of this audit is to
examine the
effectiveness of the
clinic in terms of its
effectiveness in
improving blood
glucose control and
to assess the patient
experience of the
clinic.
Rebecca Nicholas,
Following audit 2937,
FY1, Urology, Tom
this is a re-audit to
Rees, FY1, Urology,
assess whether or
Mr Haldar , Consultant, not our consenting
Urology
doctors are adhering
to GMC guidelines.
Surgery and
Critical Care
12/11/2010 Cancelled
12/04/2011 Not applicable - cancelled.
Not applicable - cancelled.
Integrated
Medicine
12/11/2010 Complete
(no
changes
reported)
03/04/2012 Recommendations were to: improve follow-up
Changes required
access; provide information sheet to patients prior to
clinic visit.
Surgery and
Critical Care
12/11/2010 Complete
28/07/2011 Results: Overall: positive responses, good coverage
of GMC guidance; improvement in explaining
possible side effects since original audit but re-audit
highlighted need for clearer discussion of potential
complications including patient wishes.
Recommendations: clearly state that the patient
always has the option to refuse treatment +/statement in leaflet; consent patients for use of their
anonymised images/samples; offer patients copy of
completed consent form.
The results were presented to
us at one of our departmental
monthly audit meetings and
we agreed to make changes to
offer patients a copy of the
consent and request their
consent for use of their
images. By definition by
requesting consent the patient
is made aware that they have
the option to refuse consent
and decline treatment.
3086 Audit on the
Management of
Respiratory
Distress in
Children under
One Year of Age
(WH)
Dr Anne Beh, FY2
Respiratory distress Integrated
in children under one Medicine
is generally poorly
managed by nonpaediatric staff and it
is thought that the
protocol is not
followed, with
patients often
receiving
unnecessary
treatment. Audit will
contribute to changes
in practice which will
improve compliance
with the protocol.
15/11/2010 Cancelled
01/12/2011 Project cancelled as doctor has left Trust and did not Project cancelled.
have time to do the audit.
3087 Management of
Dr Howell Williams, Dr
Hyperglycaemia in Henrietta Brain,
Patients admitted Consultant, Diabetes
with MI
To compare
Medicine
management of
diabetic patients with
MI with Bucks
protocol.
16/11/2010 Complete
3088 DVT/PEs with
Jonathan Pattinson,
Hospital
Consultant
Admission in
Haematologist
previous 100 days
Every 3 months we
Specialist
produce list of
Services
DVT/PES with
previous hospital
admission using
information from DVT
clinics and cause of
death lists received
from the ONS. Dr
Pattinson needs to
examine notes of
these patients.
These must now be
reported as a SUI.
17/11/2010 On-going
20/05/2011 Results: Lab glucose measured in most but not all
patients. Sliding scales not used in the majority of
cases. BM control the same, and within safe range.
Most patients not referred to DM team. S/c insulin
not commenced in anyone. Recommendations:
Guideline change: Hypoglycaemia and
hyperglycaemia should be avoided. Aim for BM 5 –
11 mmol/l. Sliding scale is not necessary in all
cases. Consider using sliding scale to control
hyperglycaemia at BM = 10 – 11. Start sliding scale
if BM > 11. Treat for hypoglycaemia if BM < 5.
Other recommendations: It is essential to measure
admission lab glucose in patients with confirmed or
suspected MI. Capillary BM monitoring – 4 or more
in first 24hrs. All patients should be referred to DM
team (diabetic specialist nurses) DM team will
commence s/c insulin in suitable patients. Publicise
recommendations by presentation at Academic halfday and presentation to cardiology / medical juniors.
Not required. Just used to check notes to ensure
incident reported.
Draft guidelines incorporating
the new recommendations
have been circulated to
cardiology consultants. We
were holding off finalising
guidelines as we were
awaiting NICE guidance which
was published last month. The
new NICE guidance is very
similar to our new
recommendations so we are in
the process of combining the 2
into a new guideline. The new
guideline will be highlighted at
the next F1 and F2 teaching
given by a Diabetologist.
Howell Williams plans to reaudit in the new year.
Changes required
3089 Questionnaire for
Dysphagia
Trained Nurses
Elizabeth Fraser,
Speech & language
Therapy Clinical Lead
3090 Venous
Jonathan Pattinson,
Thromboembolism Consultant
Prophylaxis
Haematologist
Medicine
S&LT are planning to Specialist
introduce new
Services
guidelines and
training for dysphagia
trained nurses
(DTNs). Initially need
to identify current
practice and numbers
of nurses requiring
training so can design
training effectively.
22/11/2010 Complete
As a follow up to
Clinical
audit 2907 which
Support
showed patients were Services
not being assessed
for DVT and to
comply with NICE
guideline 92, a rolling
audit of venous
thromboembolism
prophylaxis. Each
division audited once
a year (about one
division every 2
months). 50 sets of
notes audited (notes
from ward) and
proforma completed
and sent to CA&E for
analysis and report.
First audit for
22/11/2010 Complete
10/05/2011 Results: It was clear from respondents that their
initial 1:1 contact with SLT for training / refreshing
training varied dramatically with some staff having
received 1:1 SLT training over 7 years ago. Despite
this there is a large number of swallow screens being
undertaken by DTNs across the Trust. The majority
of respondents reported they were completing
documentation in the medical notes for all swallow
screens however this cannot be confirmed.
Recommendations: In order to maintain
competencies by carrying out regular swallow
screens – use of DTNs should be restricted to a
smaller number of wards most likely to receive
Stroke patients – Stroke Wards, MAU & AMU and
A&E/EMC.
All DTNs that responded and currently work on the
above target wards will require refresher training
delivered by an SLT and where appropriate 1:1
supervision to ensure that competencies are up-todate.
All DTNs will be trained using the guidelines
compiled by the SLT team and invited to annual
refresher sessions. These refresher sessions will be
mandatory in order to continue carrying out
swallowing screens.
DTNs will need to complete swallow screen flow
chart for all screens and return to the SLT dept so
that the team can monitor and audit the efficacy of
the DTN programme. There was a suggestion made
that SLT could provide a drop-box on the ward where
staff could leave screens to be collected by a
member of the SLT team on a weekly basis.
A list of all current DTNs can now be kept and DTNs
will be asked to keep the SLT team informed if they
move wards or leave the Trust. This will be updated
on an annual basis.
DTNs that did not respond to the questionnaire and
those not working in the above target wards will be
informed in writing that they are no longer able to
carry out swallow screens.
10/01/2011 Patients should be assessed using the appropriate
BHNHST VTE assessment tool and appropriate
prophylaxis should be given if necessary. SMH
Medicine Jan/Feb 11: 80% fully compliant and
another 10% were given the appropriate prophylaxis
although the assessment form was not completed. 5
patients (10%) were not given appropriate
prophylaxis. WH Medicine Dec 2010: 47% were
fully compliant and another 44% were given the
appropriate prophylaxis although the assessment
form was not completed. 9 patients (9%) were not
given appropriate prophylaxis.
Swallow screening has now
been limited to the Stroke Unit
only. Staff have been
identified for update training
and this commenced last
week. Annual refresher will
be initiated by SLTs and
completed on the wards with a
ward based practical. Part of
the update training includes
requesting that staff complete
a handover sheet listing any
screening assessments
completed, which is kept on
the stroke unit, so that SLT
can track screening
assessments. The Training
and Development Department
will be keeping an updated list
of those trained to screen
swallowing. SLT have
requested that senior nurses
write to nurses who are not on
the stroke unit and have not
had updated training, this has
not been completed.
Results reported back to
divisions. To be re-audited
next year.
Medicine Division.
3092 Physiotherapy
Staff Survey
regarding 7 Day
Working
Charlotte Moss,
Service manager,
Physiotherapy
Weekend working for Specialist
physio and OT staff
Services
introduced in
September 2010.
Survey to assess
staff views and
suggestions.
22/11/2010 Complete
01/09/2011 Recommendations: A training update for respiratory
skills will be continued on an annual basis.
Training updates/refreshers for equipment and
focusing on orthopaedics will be established for both
sites.
The rota to continue as present rota with the ability to
exchange dates. Bank holidays and weekend days
associated with bank holidays to become
volunteered rota. All staff must volunteer for the
appropriate quota per year.
Taking NWD time back – to extend the time period to
a maximum of 6 weeks within which NWD should be
taken.
Recording of working hours and NWD time taken
back to be changed to assist in better logging and
recording at the end of the month.
Working hours to be adjusted (OT 9.00 – 2.00; CSW
9.30 – 1.30; PT 8.30 start for resp PT’s, 8.30 or 9.00
start for cat 2/3 PT’s) - the impact of this change will
be monitored for adverse effects.
Working sheets to be modified for Physio to enable
more consistent data collection.
A training update for
respiratory skills is continued
on an annual basis.
Training updates/refreshers for
equipment and focusing on
orthopaedics in progress.
The rota continued as present
rota with the ability to
exchange dates. Bank
holidays and weekend days
associated with bank holidays
have become volunteered
rota. All staff must volunteer
for the appropriate quota per
year.
Taking NWD time back – time
period extended.
Recording of working hours
and NWD time taken back
changed to assist in better
logging and recording at the
end of the month.
Working hours adjusted - the
impact of this change will be
monitored for adverse effects.
Working sheets modified for
Physio to enable more
consistent data collection.
3093 Mortality Review
April - September
2010
Dr Graz Luzzi on
behalf of the
Healthcare
Governance
Committee
A review of 50 deaths Trustwide
requested by the
Healthcare
Governance
Committee as part of
an ongoing review of
mortality within the
Trust.
24/11/2010 Complete
(no
changes
reported)
21/04/2011 Recommendations were: Medical Director and
Associate Director Healthcare Governance (ADHG)
to review the 3 potentially avoidable deaths;
independent consultant to confirm the assessment
that death was probably avoidable in the cases
identified - if the final assessment is probably
avoidable then these should be investigated as
Serious Incidents; Medical Director to remind all
consultants about appropriate supervision of junior
doctors and documentation; Associate Director
Healthcare Governance to discuss with Associate
Directors of Nursing (ADNs) what actions are being
put in place to improve the use of the Early Warning
Score and fluid balance management; continued
focus on reducing harm from falls and pressure
ulcers as part of the Safety Express programme.
The 3 potentially avoidable
deaths were reviewed and the
final assessment was that
death was not avoidable.
3094 The Quality of
Speech &
Language
Therapy Case
Notes
Michelle Holmes,
Deputy Manager,
S&LT
Audit undertaken
Clinical
each quarter to
Support
identify quality of
Services
S&LT notes, some
quarters
concentrating on
quality, some on
organisation etc.
Each Clinical Team
Leader accesses
random sets of case
notes and assess
using checklists for a
range of criteria.
Comparisons made
with previous
quarters to assess
improvement.
24/11/2010 Complete
Emailed staff re areas
requiring immediate attention
and have provided training at
a recent departmental
meeting. Will be reauditing the
casenotes in December.
3095 Assessment &
Management of
Wheeze in
Children Under 1
Year Presenting at
A&E/PDU
Dr Liza Waldegrave,
FY2, Paediatrics, Dr
Michelle RussellTaylor, Consultant
Paediatrics
During the winter
Specialist
months bronchiolitis Services
is the commonest
cause of wheeze in
under 1s presenting
at hospital. This audit
aims to see if these
children are
appropriately
assessed on
admission and
treated in line with
Trust guidelines.
25/11/2010 Complete
17/01/2011 Oct-Dec 2010. 25% of standards were achieved in
more than 96% of case notes. 16% of the identified
standards were adhered to in 86% to 95% of case
notes. 50% of standards were not followed in 85% or
less of the case notes. Six standards were achieved
with 100% adherence. Comparisons will be made
when the areas specifically targeted in this audit are
reviewed in the same quarter next year.
Recommendations:
Summary of the casenote audit be emailed to staff
where the following areas would be identified as
requiring immediate attention: Statistical front sheet
filed. Appointment time and time session started.
Written information re Service given. Preferred
name and title noted. Client’s name, ID
number/date of birth on each sheet of notes. Long
term aims recorded. Short term aims recorded.
Record of outcome given. Date of discharge and
code used noted. Copy of discharge report included
if appropriate. All entries signed.
21/06/2011 Maintain the current good clinical standards by
including awareness of this guideline in the induction
day for new A&E and PDU doctors. Other measures
to increase awareness of the guideline; posters in
both departments, ensuring doctors know where to
access guidelines and presenting the results of this
audit to both departments.
Changes required
3096 Prolonged SROM Dr Radha Karnad,
(SMH)
ST1, Dr Bindu
Annamraju, ST4, Dr
Shalimali Karnad
Audit of the
management of
patients with
prolonged
spontaneous rupture
of membranes,
September and
October 2010.
3097 Audit on
Vimmi Shriyan, FY2,
Completion of the Spinal
ISCOS
Neurocheck Chart
in NCIS
3098 Audit on use of
Sally Painter, ST4,
antirhinitis
Ophthalmology
treatment in the
management of
pseudonasolacrim
al duct obstruction
Specialist
Services
02/11/2010 Complete
17/05/2011 Looked at 90 sets of notes - Gestation at SROM;
No recommendations given,
Method of diagnosis; Onset of labour; Mode of
junior Doctor audit unable to
delivery. Discussion around diagnosis of SROM
contact CP 21/2/13
which can be very difficult, use of syntocinon versus
prostin for an unfavourable cervix. Evidence currently
does not support the use of prostin as method to
improve outcome. The diagnosis of intact forewaters
is important. The discussion also covered whether
evidence suggested it was best to perform induction
immediately SROM is diagnosed or delay for 24
hours.
Neurocheck charts
Spinal
are normally
Injuries
completed on the first
admission of a patient
to NSIC. This audit
looks at whether all
elements of the chart
are completed.
30/11/2010 Complete
30/11/2010 Of 30 patients the following elements were
completed. Patient identity 14/30, sensory check
22/30, sensory total 17/30, motor check 24/30, motor
total 9/30, AIS score 11/30, date examination 16/30,
ward 22/30. To be re-audited in 6 months.
Computerised system now in
place so some of the issues
are prefilled. The
recommendations were to
improve and recheck and the
use of the ims system should
help this. Should be able to
re-audit by using data on
systems.
To review the notes
of the patients who
have been treated
with steroid
medication and to
assess the success
of the treatment.
01/12/2010 Complete
29/02/2012 This small study showed that use of topical steroids
and nasal decongestants can treat patients with
patent nasolacrimal systems. Patients can be
maintained symptom free on beclometasone nasal
spray alone. This treatment regime is recommended
as first line management for these patients. An
abstract of this audit has been accepted for
publication at the Royal College of Ophthalmologists
Annual Congress and Oxford Ophthalmology
Congress.
The use of topical steroids and
nasal decongestants to treat
patients with patent
nasolacrimal systems is now
routine practice.
Surgery and
Critical Care
3099 On-call
Commitments
have no Effect on
BMI
3100 National Audit of
Heavy Menstrual
Bleeding
Lorna Lamb, ST1
On-call commitments
(GPVTS), Tunde Dada, predispose to
Obs & Gynae
sedentary behaviour
and increased calorie
intake through
unsocial hours,
altered food
consumption and
preference for
unhealthy snacks.
Conversely activity
may be limited by
request to stay on
site. To assess
whether on-call duties
affect calorie intake.
To assess whether
on-call duties
predispose to
sedentary behaviour.
Are on-call duties
unhealthy activities?
Tunde Dada, Obs &
An audit of patient
Gynae
outcomes and
experience of
treatment for women
with heavy menstrual
bleeding. Joint
project with RCOG,
London School of
Hygiene & Tropical
Medicine, and Ipsos
MORI. Two part
audit: 1. to evaluate
current referral
patterns, protocols
and practice in the
management of HMB.
(May to September
2010) and 2. A study
of symptoms and
health-related quality
of life among women
who attend outpatient
gynaecology clinics
with complaints of
HMB.
Specialist
Services
01/08/2010 Cancelled
Specialist
Services
01/02/2011 Data
Collection
31/05/2011 Project cancelled.
Results and Recommendations required
Project cancelled.
Changes required
3101 Antibiotic
Prophylaxis &
Post-operative
Infection following
Spinal Surgery
Dr Vimmi Shriyan,
SpR, Spinal, Dr
Jamous, Consultant,
Spinal
To assess
compliance within
Trust guidleines
regarding the use of
prophylaxis
antiobiotics in spinal
surgery. Assess the
post-operative rates
of wound infection in
spinal surgery.
Spinal
Injuries
3102 National Audit of
NICE Public
Health Guidance
Relevant to the
Workplace
Dr Kathryn Campion,
Consultant
Organisational audit Trustwide
of the implementation
of NICE public health
guidance relevant to
the workplace.
30/11/2010 Complete
04/05/2011 This audit has highlighted that in spite of not
complying with the Trust Guidance Protocol
regarding antibiotic prophylaxis, there has not been
any evidence of post-operative wound infection
following spinal surgery in spinal cord injured
patients.
No recommendations
01/10/2010 Complete
09/04/2012 Trust does prioritise some health promotion topics for
staff. Valuing staff days, health awareness no
smoking, national stress day. Stress workshops don’t
meet the requirements of action 43 as workshops not
mandatory. More managers need to be targeted.
Need to review the health and well being strategy
and update this and ensure it includes obesity.
Action plan put into place.
Service review of workplace
health is currently taking
place. Out of this reivew there
will be a rolling programme of
effective preventative
measures which will be
developed and promoted
across the organisation.
Stress workshops have been
provided for 65 managers so
far. New intranet due to be
launched in May 2012 will give
easier access to all health and
well being and the proposal is
to have well being at work as
the main umbrella to all
Occupational health services
etc. Awareness events
incorporated into existing
training programme for
managers and supervisors core module on engagement
and wellbeing to recognise the
link between engagement and
health and wellbeing and
performance/productivity.
3103 Breast Cancer
Service Pledge
Hilary Hillson, Breast
Cancer Nurse
The Trust are taking
part in a patient
survey organised by
Breakthrough Breast
Cancer to review
existing service,
identify areas for
improvement and
publish a local
Service Pledge for
Breast Cancer. This
is happening at
several breast care
units across the
country and also
involves interviews
with patients.
Specialist
Services
06/12/2010 Complete
01/06/2012 Things that work well: communication from staff,
waiting times, ward areas. Things that could be
improved: décor of the waiting areas, information
provision.
A pledge in the form of a
patiemnt leaflet was produced
but after months of waiting for
it to be agreed by
Communications it has still not
been so will likely be
abandoned as now out of
date.
3104 Outcomes of
Patients
presenting with
ST-elevation
Myocardial
Infarction
Dr Tiimothy Williams,
FY1, Cardiology, Dr P
Clifford, Consultant
Cardiologist
Since June 2010
Integrated
primary PCI has been Medicine
offered for patients
presenting with ST
elevation myocardial
infarction. This audit
will look at the
outcomes for these
patients.
06/12/2010 Complete
15/07/2011 Recommendations: Continue early alert of the pPCI
service in High Wycombe hospital. Ensure record
keeping standards are maintained in particular in
relation to timing of intervention. This audit will form
part of the Unit’s clinical governance strategy and
become an ongoing analysis to continue monitoring
performance in a formalised manner.
Changes required
3105 Pre-operative
Fasting and
Regular
Medications
Dr Amy Thomson,
CT1, Anaesthetics
A clinical survey of
Surgery and
opinion regarding
Critical Care
administration of
routine medication in
patients who are nilby-mouth. There are
concerns that
patients are missing
essential medications
due to ambiguous
Trust guidelines on
nil-by-mouth. The
aim is to obtain a
consensus of opinion
from Anaesthetists
regarding routine
medication and to
educate staff
accordingly.
07/12/2010 Awaiting
Report/Ac
tion Plan
Results and Recommendations required
Changes required
3106 Emergency
Laparotomy
Dr Jessamy Bagenal,
FY1, General Surgery
To investigate
Surgery and
process of care when Critical Care
taking patients for
emergency
laparotomy.
10/12/2010 Complete
3107 Hand Hygiene
Observational
Audit
Amanda Adkins,
Infection Control
Observations of hand Specialist
hygiene. Carried out Services
in all wards each
month. Annual report
produced by Clinical
Audit. (Audit 2923 for
2009/10)
01/04/2009 On-going
Observational audit
Clinical
general theatres only. Support
Services
01/09/2010 Complete
3108 Surgical Site
Amanda Adkins,
Infection Pre-op
Infection Control
and Peri-op Audit General Theatres
23/09/2011 Educating juniors regarding evidence for preoperative investigations empowers them to
incorporate them into their practice and hence
improves documentation of lactate and base excess
prior to laparotomy. Further improvement could be
achieved through the development of a proforma for
pre-operative care prior to emergency laparotomy.
Simple educational measures
were used to improve
performance. A workshop for
junior staff in surgery and
anaesthetics was held and
during the four week period
following the teaching session
80% (8/10) of patients arriving
in theatre for emergency
laparotomy had a documented
lactate and base excess.
Ongoing audit
07/03/2011 Pre-Op 93% screened of which one found to be
positive and treated appropriately. Peri-Op 40
patients audited, 5% some data not recorded, 33%
non-compliant in at least one area. Action plans to
be produced and carried out in all cases of noncompliance.
Infection Control monitor
completion of action plans and
re-audits.
3109 Surgical Site
Amanda Adkins,
Infection Pre-op
Infection Control
and Peri-op Audit T&O Theatres
Observational audit
T&O theatres only.
Clinical
Support
Services
01/10/2010 Complete
07/03/2011 Pre-Op 96% screened for MRSA, 4% not. 1 patient
found positive but not clear if treated appropriately.
Peri-Op 6% not given prophylactic antimicrobial
when should. Hair removal and monitoring of
normothermia 100% compliance. Glucose control
not maintained for 1 of 4 diabetic patients. Action
plans to be produced and carried out in all cases of
non-compliance.
3110 Hand hygiene
Practice and
Facilities
Amanda Adkins,
Infection Control
Audit of hand hygiene Clinical
facilities and practice. Support
Services
01/01/2011 Complete
04/03/2011 Results: The overall compliance for all areas of this Infection Control monitor
audit was 95%. Only 16 areas achieved a
completion of action plans and
compliance level of 100%. 5 of the 59 wards/areas
re-audits.
who completed the audit achieved compliances of
less than 85%. 34 wards/areas did not participate in
the audit. Recommendations: All areas with non
participation must produce an action plan on how
they are monitoring the compliance with this audit.
Areas who did not produce an action plan and return
an action plan at the time of completing the audit
must produce an action plan to show how areas of
non- compliance have been addressed. All areas
with ‘No’ answers are required to sign off this action
plan to confirm all actions have been completed and
then return to the IPC.
3111 Sharps
Management
Amanda Adkins,
Infection Control
Audit of sharps
management.
01/02/2011 Complete
27/05/2011 Results: 83 wards/areas returned audit tools. Overall
compliance was 93%. Scores varied by unit from
73% “Yes” responses to 100%. 13 wards/areas had
overall compliance less than 85%. Some units did
not answer some of the questions. Compliance for
each question varied from 56% to 100%. A total of
52 areas across the trust did not participate in this
audit. 42 of the 83 units (51%) returned either no
action plan or an incomplete action plan, where there
was no action for at least one of the “No” responses.
Recommendations: The Divisional Associate
Director of Nursing to complete an action plan to
address the issues highlighted. All the action must
be signed off by the Divisional Associate Director of
Nursing as completed. Increased input is required to
educate staff. In addition to the current input at Trust
induction sessions, the sharps management policy
needs to be included in staff induction at department
level. Education on sharps management should
continue to be re-enforced in the mandatory annual
update for all clinical staff by the infection control
team. Department Managers need to monitor
Clinical
Support
Services
Infection Control monitor
completion of action plans and
re-audits.
Each division is monitoring the
completion and signing off of
action plans. Education
continues in mandatory
training. Discussion of points
raised continues at IPCC
meetings.
compliance to policy within their area and promote
correct practice at all times. Adequate supplies of
sharps trays must be available for staff to use.
3112 Transfer Audit
Form
Amanda Adkins,
Infection Control
3113 Surgical Site
Amanda Adkins,
Infection Pre-op
Infection Control
and Peri-op Audit Urology
Audit of transfers.
Clinical
Support
Services
01/02/2011 Complete
Observational audit
urology only.
Clinical
Support
Services
01/12/2010 Complete
03/06/2011 Results: Inter-healthcare transfer form often not
used. For a
number of patients transferred with known or
potential infections, this information was absent.
Recommendations: Matrons/Sisters are responsible
for implementing the use of the Inter-Healthcare
Transfer Form within their areas and monitoring
compliance. If discharge/ transfers packs are
available then the Inter-Healthcare Transfer Form
must be included within the pack. The Transfer
Policy is currently being drafted and includes the
Inter-Health Transfer Form. Once this policy has
been finalised it should be disseminated to all staff to
ensure they are aware of its content. Further
development of the Care Records System (CRS)
must include the Inter-Health Transfer Form which
will have to be completed on each transfer.An action
plan must be completed to address the issue of low
compliance.
07/03/2011 Pre-Op 1 patient not screened for MRSA. Peri-Op 1
patient (4%) not given prophylactic antimicrobial
when should. 1 patient normothermia not monitored
when should. Glucose control not maintained for the
only diabetic patient. Action plans to be produced
and carried out in all cases of non-compliance.
Infection Control monitor
completion of action plans and
re-audits.
Infection Control monitor
completion of action plans and
re-audits.
3115 Outbreak Policy
Audit
Amanda Adkins,
Infection Control
Specialist
Services
01/03/2011 Cancelled
01/05/2011 Cancelled as no outbreaks
Cancelled
Trustwide
06/12/2010 Complete
18/05/2011 N/a - No report drawn up - just quantative data of %
of each division complying with legal requirements
regarding workplace health and safety. This is
annually re-audited.
This audit is to be annually reaudited. Re-audit commenced
15/11/11.
Dr Anthony Crosse, Dr An audit to assess
Specialist
May Yoshida,
the type of
Services
(GPST1), SMH
hysterectomy,
complications and
correlation of
pathological staging
and MRI staging in
endometrial cancer.
To assess the criteria
for laparoscopic
hysterectomy vs open
hysterectomy and
accuracy of MRI in
guiding this decision.
08/12/2010 Complete
01/02/2011 Laparoscopic hysterectomy is a suitable alternative No recommendations were
to TAH. It is consistently associated with longer
made and thus no changes
theatre time and shorter hospital stay. Major
are forthcoming.
complication rates/ readmissions seem to be higher
in TAH. TAH was associated with increased BMI.
MRI only accurate in just over 50%, tends to be lower
staged than final histology report. Compared to the
previous year: more laparoscopic surgery was
undertaken (50% to 68%); reduced conversion rate
(23 to 8%), possibly leading to improved outcome in
terms of complications and hospital stay.
3116 Workplace Health Marion Carnell, Health
& Safety Audit
& Safety Facilitator,
Stoke Mandeville
Hospital.
3117 Audit of
Hysterectomy in
Endometrial
Cancer
Audit of compliance
with legal
requirements
regarding workplace
health and safety.
3118 Management of
Women with
Raised BMI in
Pregnancy and
Labour (SMH)
3119 Long Term Effect
of MRI on SARS
Implant in SCI
Patients
Dr Lamiese Ismail,
ST4, Mr Tunde Dada
Prevalence of obesity
is increasing with
ensuing risks for
mothers, babies and
staff. Raised BMI
confers higher
morbidity and
mortality risks. Early
identification, good
communication,
referral and ongoing
surveillance are
required to reduce
risk. To ensure that
the department is
meeting the needs of
women with raised
BMI by appropriate
information sharing,
referral and
intrapartum
management.
Guideline 446.3.
Luis Lopez de Heredia, Patients with SCI
Research Scientist,
usually have disruped
Radiology
bladder emptying due
to disruption of
normal reflex
pathways. This can
be circumvented by
use of a SARS
(Sacral Anterior Root
Stimulator) implant
which stimulates the
detrusor muscle and
relaxes the sphincter.
SCI patients often
undergo MRI scans
which use magnetic
fields and
radiofrequency which
might damage the
implant. Audit to
identify spinal
patients with SARS
who have had MRI
scans to identify
SARS complications.
Specialist
Services
14/12/2010 Cancelled
13/12/2011 Project cancelled, report not forthcoming.
Cancelled
Clinical
Support
Services
16/12/2010 Complete
26/04/2011 Long-term follow-up showed no adverse effects
attributed to more recent MRI examinations at 1.5
Tesla in patients with SARS.
None required. Audit showed
no adverse effects.
3120 CEM Vital Signs
National Audit
2010-11
Dr Mike Kazer, Staff
Grade, EMC, WH
College of
Medicine
Emergency Medicine
national audit based
on the clinical
standards for
recording vital signs,
developed by
concensus from
representatives of the
CEM Clinical
Effectiveness
Committee, ENCA,
FEN & RCN
Emergency Care
Association.
08/12/2010 Complete
09/06/2011 Actions
CEM Guidance & Reports available on the Trust
intranet within the Document Store/Emergency
Medicine/Audit/CEM 2010 folder so that these are
readily available for reference and as feedback.
Training to be concentrated on the following areas
which the CEM audit identified as areas for
improvement. Recording of respiratory rate and,
repeating observations within 60 minutes where
initial obs are abnormal. A repeat audit will be
performed later this year.
3121 CEM Feverish
Children National
Audit 2010 -11
Dr Mike Kazer, Staff
Grade, EMC, WH
College of
Medicine
Emergency Medicine
national audit based
on the clinical
standards for
managing feverish
children. Standards
taken from NICE
CG47.
08/12/2010 Complete
06/06/2011 CEM Guidance & Reports available on the Trust
Changes required
intranet within the Document Store/Emergency
Medicine/Audit/CEM 2010 folder so that these are
readily available for reference and as feedback. A
repeat audit will be performed later this year. Training
to be concentrated on the following areas which the
CEM audit has identified as areas for improvement;
recording of temperature, recording of capillary refill
time and promptness of recording of observations.
3122 Efficiency of Hand Mr Mike Tyler,
Clinic
Consultant, Plastic
Surgery
An audit to examine Surgery and
whether patients are Critical Care
being brought back to
the Hand Clinic
unnecessarily and
whether they could
be managed in PDC
or by
physio/GP/consultant
clinic.
Cancelled
31/12/2010 Cancelled as no information provided, doctor left
Trust Feb 2010.
Changes required
Project cancelled.
3123 Audit of
Readmission of
Babies within the
First Ten Days of
Life
Dr Cathy Noone,
Consultant, Paediatrics
(Dr Madhu
Gangadhara, ST5)
A reaudit of the
Specialist
reasons for
Services
readmission of
healthy, term
neonates discharged
from the postnatal
ward.
04/01/2011 Complete
31/10/2011 Results: Poor documentation of weight at birth, on
No changes received 21/2/13
day 5, and on readmission (15% of babies had poor (CP)
weight documentation). Poor record of readmissions from community. Patients still get
readmitted due to feeding problems ( numbers
slightly improved but still high). Most of readmissions
are from primi mothers. 70% of babies still get
discharged the first or second day.
Recommendations: Review feeding before
discharge. Weight check on day5 and review.
Bilicheck availability in community. Biliblanket
provision in community. More breast feeding support
for mothers. Regular midwife/community follow-up
(clinics). Parental awareness sessions re: problems
and to seek advice early. Document D0 and D5
weight at re-admission. Re-audit.
3124 Intra-operative
Surgical
Timekeeping
Dr Angus McKnight,
CT2, Anaesthetics,
Project sponsor, Dr
Sara McNeillis,
Consultant,
Anaesthetics
To determine how
Surgery and
accurately surgeons Critical Care
are able to estimate
when 5 minutes of
operating time
remains. To help
determine whether
the turnaround time
between patients can
be shortened.
06/01/2011 Cancelled
15/08/2011 Project cancelled by clinician, unable to collect
enough data.
3125 Extubation
Practice
Dr Angus McKnight,
CT2, Anaesthetics,
Project sponsor, Dr
Sara McNeillis,
Consultant,
Anaesthetics
The practice of
Surgery and
tracheal extubation is Critical Care
changing in the UK,
moving from leftlateral, head-down
position at a deep
level of anaesthesia
towards supine,
head-up extubation of
the awake patient.
Auditing current
practice in the Trust
will inform
departmental
discussion on the
training of Junior
Doctors and on risk
management at
extubation.
06/01/2011 Complete
18/07/2011 Results: UK tracheal extubation practice is changing No changes to practice were
from left-lateral, head down position, at a deep level required.
of anaesthesia towards supine, head-up extubation
of the awake patient. The results of this audit
confirm suspected national trends regarding position
at extubation (79% supine, head up). Depth of
anaesthesia at extubation is similar to the published
1998 study (20% deep). This audit aimed to allow
informed discussion of departmental practice
surrounding extubation of adult patients. The
summary of discussions was that although practice
was not 'classical' teaching, there were several
reasons why it was clinically justified, and additionally
there was no evidence that it was better or worse
than traditional practice.
Not applicable, project
cancelled by clinician.
3126 Audit of
Unplanned
Obsteric
Admissions to ICU
Post Merger
Dr Prabir Patel, ST4,
Anaesthetics, Dr
Ankers, Consultant
Anaesthetics
To review all
Surgery and
obstetric critical care Critical Care
admissions since the
merger of maternity
units at SMH and WH
looking at reasons for
admission, outcomes,
and potentially
avoidable cases to
determine if the
number of
admissions could be
reduced.
3127 Audit of Patients
on Anti TNF's
Jane McVea, Asst Dir Bucks PCT are
Specialist
Quality Bucks PCT via working with BHT on Services
John Quinn
drugs excluded from
contract (through
John Quinn) and
need to do an audit of
50 patients who are
on anti TNFs.
24/01/2011 Cancelled
3128 Regional Audit of
Emergency ENT
Admissions
Hamish Thomson,
Consultant, ENT
01/03/2010 Complete
An audit looking at
Surgery and
the workload involved Critical Care
in emergency ENT
admissions with a
view to determining
the feasibility of
merging ENT centres
across the region.
23/11/2010 Complete
23/09/2011 There has been a reduction in critical care
admissions post merger, however, a greater
proportion of admissions need higher level of care
and longer stay - potentially due to a single larger
unit now managing higher risk obstetric patients;
creation of 4 bed close observation unit, increased
consultant presence and 24 hour obstetric
anaesthetic cover has resulted in this group that
would otherwise have needed HDU bed being
managed in a high dependency environment within
labour ward; close observation bay also a step down
area; increased use of IABP and appropriate staff
training may potentially further reduce admissions to
ICU - > ?cost implications.
Readmissions after discharge: a need for focus on
post partum sepsis and ‘surviving sepsis’ guidelines;
failure to recognise severity of illness, delay in
commencing appropriate therapy / intervention may
cause longer stays and more support.
05/11/2012 cancelled
The Obstetric unit now uses
the CEMACH inspired
MEOWS early warning system
for detecting sick mothers.
This was a recommendation of
this audit but was introduced
as a CNST requirement.
Obstetric HDUs are nationally
thought in theory to be a good
idea, but practically
recognised nationally to be
undeliverable. There are a
myriad of reasons for this
including cost, skill
maintenance, midwives no
longer training in nursing,
safety, etc.
24/12/2010 If the Swindon numbers are accurate then the
emergency admission workload is not excessive.
Combination of emergency centres is probably
feasible but has bed implications. We only looked at
admissions. How much work is involved in advice,
A&E referrals etc?
Partly as a result of the audit,
emergency ENT admissions
are now amalgamated
between Wexham and
Reading and ENT
emergencies at Wycombe are
now going to Oxford.
cancelled
3129 Cataract Surgery
under Topical
Anaesthesia
Kanmin Xue, ST1,
Ophthalmology,
Zuzana Sipkova, FY1,
Ophthalmology, Project
sponsor, Mr
Manuchehri,
Consultant,
Ophthalmology
Local anaesthesia for Surgery and
cataract surgery can Critical Care
be provided by either
sub-tenon block or
topical anaesthesia.
This audit aims to
assess the
complication rates of
cataract surgery
under topical
anaesthesia.
10/01/2011 Complete
23/03/2011 Results: Overall 11.1% patients developed
complications post-op (national rate 14.4%). Higher
CMO rate most likely associated with higher rate of
pre-op ocular co-morbidities (e.g. diabetic
retinopathy, ERM). In patients without ocular comorbidities, post-op complication rate and VA
outcome very similar to UK national rate.
Recommendations: Cataract surgery using topical
anaesthesia, supplemented with intracameral
anaesthesia, in skilled hands could achieve good
operative outcomes comparable to the national
standard.
Specialist
Services
01/01/2011 Ongoing
data
Collection
Results and Recommendations required
3131 Neonatal intensive Dr Sanjay Salgia,
Audit of neonatal
Specialist
and special care
Consultant, Paediatrics intensive and special Services
(NNAP)
care. Part of the
National Neonatal
Audit Programme run
by RCPCH.
01/01/2011 Ongoing
data
Collection
2011 National report available on line:
Changes required
http://www.rcpch.ac.uk/system/files/protected/page/R
CPCHNNAPAnnuaReport2012.pdf
3130 Perinatal mortality Dr Sanjay Salgia,
National Audit of
(NPEU) (ongoing) Consultant, Paediatrics Perinatal Mortality
(ongoing).
Cataract surgery is continuing
under topical anaesthetic as
the complication rates were
non existent.
Changes required
3132 Emergency LSCS Dr Mohammed
& P/N Analgesia
Yousafzai, Dr Abigail
Blumenthal
3133 Audit of
Management of
Benign Vulval
Disease
Dr Mark Olavesen
FY1, Dr Charlotte
Benson, GPST1
CNST Audit as per
Women &
EMCLSCS guideline Children
463.3. In addition,
audit of analgesia
used peri and post
caesarean section as
per local and NICE
guidelines.
Audit of current
practice, compared to
RCOG
recommendations, for
management of
Vaginal Intraepithelial
Neoplasia and
Extramammary
Paget's Disease.
Specifically to:
identify a cohort of
patients diagnosed
with VIN and EMPD;
identify date of
diagnosis and grade;
identify
interventions/treatme
nts and followup/recurrence;
identify
complications.
3134 Infection Control
Amanda Adkins,
Use of tool to audit
Environment Audit Infection Control, SMH the cleanliness of the
November 2010
environment in all
Trust areas.
01/01/2011 Complete
Women &
Children
01/01/2011 Complete
Clinical
Support
Services
01/12/2010 Complete
17/03/2011 Results: Audit proforma completion 64% same as
2010. NICE grading at time of LSCS 97%, up from
50% in 2010. However of those completed 11% had
differences in NICE category between the
contemporaneous notes, operating note and audit
note. Reason for LSCS 92% up from from 78.6% in
2010. Decision to delivery interval: Category 1 =
100% average being 13mins. Category 2 = 20%
average being 45 mins. Category 3 = 27% average
being 122 mins. Antibiotic prophylaxis 100%.
LMWH 100%. Consultant informed 83%. Discussion
with patients 50%. Recommendations: The audit
showed that the dose of diclofenac that is given in
theatre is not being written on the prescription chart.
80% of patients receiving BD diclofenac on the ward
had already received 100mg in theatre. Codeine is
not being given; 50% of patients received no codeine
in the first 24hours and there is poor compliance with
administration of the regular paracetamol, only 28%
patients receiving it QDS as prescribed.
17/03/2011 Recommendations: Need for a comprehensive local
guideline for all practitioners. To include: 1.
Information leaflets and referral to appropriate
websites to be given to all women with new
diagnosis. 2. All patients to be referred to Clinical
Nurse Specialist. 3. All patients offered access to
psychosexual counselling [poll]. 4. MDT and audit
meetings should occur at least annually to review
guidelines and outcomes (including patient
feedback). MDT to include Gynaecology,
Dermatology, Pathology, CNS. A diagnostic protocol
regarding when to biopsy/ observe. A treatment
protocol advising when to excise/monitor/ offer
topical treatments. Guidelines on how often to followup: Patient feedback questionnaire to be sent to all
patients one year following initial diagnosis.
Understanding of condition, management of
symptoms, psychological support.
Junior doctor audit completed
in 2011, changes chased but
never received 21/2/13 (CP)
Changes required
01/02/2011 Results: 75 wards/areas took part in the audit. To
Infection Control administer
achieve the target compliance level the score must
the completion of action plans
be 85% or above as set by the Infection Prevention by individual areas.
Society. The overall compliance for all areas of this
audit was 91%. Only 5 areas achieved a compliance
level of 100%. 27 of the 136 audit questions (20%)
achieved compliances of less than 85%. 18 of the
75 wards/areas (24%) achieved compliances of less
than 85%. 27 areas did not return a completed
action plan. 40 wards/areas did not participate in the
audit. Recommendations: All areas below the
compliance level must complete a re-audit to check if
actions have been rectified and compliance level
met. All areas which didn’t participate in the audit
must complete the action plan to state how they are
monitoring issues within their ward/areas.
3135 Audit of the use of Jessica Phillips,
MUST on
Macmillan Specialist
Chemotherapy
Dietitian (BHT)
Outpatients Unit
12/1/2011- MUST
Specialist
has been launched
Services
on the Chemotherapy
units at Wycombe
and Stoke Mandeville
Hospital. NICE
guidelines for
nutritional support in
Adults (2006) states
that all outpatients
should be nutritionally
screened.
12/01/2011 Complete
3136 Radical
Prostatectomy
Data
Mr Neil Haldar,
Consultant, Urology
(Krystyna Caine,
Clinical Nurse
Specialist, Urology)
To record and
monitor outcomes
following Radical
Prostatectomy.
13/01/2011 Data
Collection
Results and Recommendations required
Changes required
3137 Audit of Adult
Community
Acquired
Pneumonia (BTS)
Dr N Numbere, SpR,
Respiratory Medicine,
Dr M Shahidi,
Consultant,
Respiratory Medicine
To assess adherence Integrated
to local and BTS
Medicine
guidelines regarding
the management of
pneumonia and to
identify any areas for
improvement.
14/01/2011 Awaiting
Report/Ac
tion Plan
Results and Recommendations required
Changes required
Surgery and
Critical Care
18/07/2011 53% patients at Stoke Mandeville Hospital and 44% Changes required
at Wycombe Hospital had a Preliminary Nutritional
Screening questionnaire present in their notes.
Recommendations: 1. To discuss with nursing staff
possible reasons for the lack of nutritional screening
and strategies for improving compliance. 2.
Additional training to reinforce the importance of the
full completion of the Preliminary Nutritional
Screening questionniare/MUST and accurate
recording.
3138 Trustwide Consent
Audit 2010/11
3139 Renal Nurse-Led
Clinic
To assess the extent Trustwide
to which appropriate
consent is obtained
from patients within
the Trust. To assess
the quality of consent
obtained from
patients within the
Trust. To educate
clinicians in the
standards of consent
expected by the
Trust.
Sue Foster, Diabetes
To assess
Integrated
Specialist Nurse,
effectiveness of a
Medicine
Louise Meakes, Senior nurse-led renal clinic.
Diabetes Specialist
Nurse
3140 Insulin Pump
Viv Sandford, Diabetes To assess whether
Integrated
Therapy for Type Specialist Nurse
patients with Type 1 Medicine
1 Diabetes (SMH)
Diabetes given insulin
pump therapy benefit
from reduced
frequency of severe
hypoglycaemia and
restoration of early
hypoglycaemia
warning symptoms;
improved glycaemic
control; and improved
quality of life.
10/01/2011 Analysis/
Report
Results and Recommendations required
Changes required
14/01/2011 Data
Collection
Results and Recommendations required
Changes required
14/01/2011 Ongoing
Results and Recommendations required
Changes required
3141 Admissions to
Observation Bay
on Labour Ward
Christina Aye, ST3,
Obs & Gynae
A review of
Specialist
admissions to the
Services
Observation Bay on
the Labour Ward are the patients
appropriate or do
they require HDU/ITU
care? Does the bay
decrease HDU/ITU
admissions?
22/03/2011 Complete
04/08/2011 Results: Combined with results from audit for
No change forthcoming.
HDU/ITU admissions, we found that there was a
Further audit recommended.
reduction in critical care admissions with a greater
proportion of admissions needing a higher leverl of
care and a longer stay. This could potentially be
partly due to the creation of the four bed close
observation unit, which means that some women
who would have needed an HDU bed being
managed in a high dependency environment within
the labour ward. Recommendations: Could further
use of invasive monitoring in the observation bay
further reduce admission to ITU? There would be
issues regarding training and equipment costs.
However, if HDU/ITU admissions could be avoided
the cost of this may be offset. In addtition there
would be psychological benefits for the mother and
she would have more appropriate access to obstetric
care. Further audit recommended.
3142 Audit into
Consultant Clinic
DNAs following
Referral from
Hand Clinic
Dr Adam Sykes, CT2,
Plastics, Mr M Tyler,
Consultant, Plastics
Patients referred to
consultant clinics
from hand clinics
have anecdotally
been shown to DNA
more frequently than
elective referrals.
18/01/2011 Complete
10/03/2011 This audit was useful as a preliminary audit to hone
methodology but the small data set means it was
difficult to draw solid conclusions from.
Recommendations: DNA letters to have more
information to allow easier data collection (or a DNA
proforma to be filled in and sent to GPs instead);
suggest repeating data collection from ALL
consultants over a longer period before further
decisions made regarding changes to follow up.
This audit was useful as a
preliminary audit to hone
methodology but the small
data set means it was difficult
to draw solid conclusions from.
To be reaudited with larger
data set.
21/01/2011 Complete
11/05/2011 Results from the questionnaire confirmed that
patients/carers/relatives have a positive experience
when visiting the Cancer Care and Haematology
Unit. It confirmed that parking is an ongoing problem
for patients attending the hospital site.
Recommendations: Questionnaires will be used as
evidence for the MQEM on the 15th April 2011.
Adapt questionnaire to use again annually. Drop off
point outside the CCHU will remain ‘coned off’ to
prevent unauthorised parking, blocking the drop off
point and disabled bays.
All the recommendations have
been actioned.
Questionnaires were used as
evidence for the MQEM. Drop
off point outside CCHU
remains coned off.
3143 Macmillan Quality Sandy Barnett, Lead
Environment Mark Cancer Nurse
Audit
Surgery and
Critical Care
Patient questionnaire Clinical
produced by
Support
Macmillan to reflect
Services
the key aspects in
providing a quality
care environment. To
evaluate
questionnaires and
use as evidence
when applying for
Macmillan Quality
Environment Mark.
3144 Audit of CTPA (CT Sam Healy, Medical
Pulmonary
student, Tom Meagher,
Angiogram) of
Radiology Consultant
Suspected
Pulmonary
Embolism in
Spinal Cord
Injured Patients
VTE has high
Clinical
prevalence in SCI
Support
patients. Imaging
Services
with CTPA needs
caution because of
radiation. Identify
positive outcomes of
CTPA and evaluate
clinical indications for
it.
21/01/2011 Complete
22/02/2011 Results: 65 CTPA scans were performed in 59
patients. 12 (18.5%) of patients in the cohort had
positive imaging for pulmonary embolus. This falls
slightly short of the audit standard. 4 (6%) of studies
were non-diagnostic, meeting the audit standard.
Recommendations: Data sub analysis – prevalence
of emboli in patients already on prophylactic anticoagulation. Identifying neurological levels.
Differentiating acute from readmission patients.
Presentation of results with discussion at monthly
Spinal cord injury audit meeting. Drafting consensus
guidance for imaging suspected PE in SCI patients.
Submission of Scientific paper for publication in
Spinal Cord.
Results presented. TM is
meeting up with a specialist
from Oxford Brookes in
December 2011 to discuss the
results. The numbers are
small and there may need to
be a clinical trial before the
drafting of consensus
guidance for imaging
suspected PE in SCI patients
or submission of Scientific
paper for publication in Spinal
Cord is considered.
3146 VTE Prophylaxis
for Hip & Knee
Primary
Arthroplasties
Peter Reilly, Trainee
Operations manager,
Orthopaedics, Liz
Hollman
PCT has asked us to Surgery and
audit VTE prophylaxis Critical Care
in hip & knee
arthroplasties for
National Improving
Quality Programme.
Proforma provided.
21/01/2011 Complete
31/03/2012 Cancelled
Cancelled
3145 Audit of Invasive
Perinatal
Screening Cycle in
Down's Syndrome
(SMH)
Miss Aparna Reddy,
Consultant, Obs &
Gynae (Dr S
Palaniappan, ST4, Obs
& Gynae)
An audit to determine Specialist
whether the current
Services
Down's Syndrome
screening cycle
meets national
screening and local
standards. The
sample is initially
processed at SMH
and then sent to
Oxford. The results
of PCR of
amniocentesis should
be communicated
within 72 hours.
01/02/2011 Complete
01/09/2011 Overall Bucks health care doesn’t meet the NSC
No changes received and
standards. Results from Wycombe site don't meet
maternity re-configuration now
the standards - 80% of serum reports issued within 3 completed 21/2/13 (CP)
days of the specimen at local lab (Standard - 97%).
Results from SMH site meet NSC standards
marginally (97.4% against standard of 97%). This is
mainly due to delay in specimen reaching Oxford
more than 1 working day (at both sites but more at
Wycombe 84% and SMH 54%). 10% took 3 days.
Also due to different dates for NT scan and bloods
and dating and NT scan. Recommendations:
Improve the standards at Wycombe site - booking
midwife to advise women to get bloods done on the
same day of the scan. Improve facilities for dating
and NT scan on the same day. Improve quick
appointments for NT scans as 18% more than 13+6.
Improve the facilities so that all specimens reach
Oxford within 1 working day.
3147 Myocardial
Ischaemia
National Audit
Programme
(MINAP)
Cardiac Specialist
Nurse, SMH, Dr Piers
Clifford, Consultant
Cardiologist
3148 Audit of Outcomes Barbara Reynolds,
for Voice Therapy Michelle Holmes,
Speech Therapists
The Myocardial
Integrated
Ischaemia National
Medicine
Audit Project
(MINAP) was
established in 1999,
in response to the
national service
framework (NSF) for
coronary heart
disease, to examine
the quality of
management of heart
attacks (myocardial
infarction) in hospitals
in England and
Wales.
01/01/2010 Ongoing
Audit of therapy
Clinical
outcomes for patients Support
with voice disorders Services
using Kent outcome
measures and patient
self-evaluation using
Voice Handicap Index
(VHI).
01/10/2010 Complete
Total number of admissions recorded = 18. Onset to Changes required
needle time <120 mins - 36.6%. Call to needle time
<60 mins - 49.1%.
25/01/2011 Outcome measures recorded for 12 patients. 9
achieved 100% objectives, 2 75/80%, 1 65%.
Objectives achieved in less than 4 treatment
sessions. VHI scores showed significant
improvement. GRBAS (voice therapist perceptual
voice evaluation) scores also improved.
Recommend to continue using same outcome
measures format for every patient. Ensure VHI
implemented pre and post therapy. Continue team
training in GRBAS. Repeat audit Jan 2012.
Outcome measure sheets to be recorded in patient
casenotes.
All voice patients have an
outcome measure sheet
completed instead of the audit
only taking account of patients
seen during a selected quarter
of the year. This means that
the audit will measure
progress for people attending
a longer term course of
therapy and not just those who
complete their therapy within a
specified quarter.
Therapists now routinely
implement VHI pre and post
therapy.
The voice therapists hone their
skills in GRBAS during a
practical session scheduled for
each of their team meetings.
Outcome measure sheets are
filed in the patient’s notes and
will be accessed from the
discharge cabinet at the time
of the audit in January.
Previously, outcome sheets
were sent to the team lead for
voice by therapists.
3149 CEM - Renal Colic Dr Mike Kazer, Staff
National Audit Grade, EMC, WH
2010-11
Purpose of the audit Medicine
is to compare current
practice in
Emergency
Departments against
CEM clinical
standards. Audit
criteria are based on
the clinical standards
for managing renal
colic developed by
the CEM Clinical
Effectiveness
Committee.
01/09/2010 Complete
07/06/2011 The CEM Guidance & Reports have been published
on the Trust intranet within the Document
Store/Emergency Medicine/Audit/CEM 2010 folder
so that these are readily available for reference and
as feedback of our status. We will concentrate on
improving the following areas; recording of pain
score, promptness of provision of analgesia and reevaluation of pain response to analgesia. A repeat
audit will be performed later this year.
Changes required
3150 Elective Surgery
Patients requiring
HDU
Jo Eldridge, Acting
Matron, Surgery
Patients identified as Surgery and
requiring HDU bed
Critical Care
but bed may not be
available. Patient
either cancelled or
goes ahead without
available bed.
Decision to do this
often delays theatre.
Want to identify
number of cases and
delays/cancellations
involved.
26/01/2011 Cancelled
27/07/2011 Cancelled
Cancelled
3151 Wycombe and
Aylesbury Birth
Centres Patient
Experience
Survey
Carole Beetham, Lead
Midwife, Aylesbury and
Wycombe Birth
Centres, Mr Tunde
Dada, Consultant
Patient experience
survey to assess the
service provided by
the Birth Centres at
Wycombe and
Aylesbury.
27/01/2011 Cancelled
03/05/2011 Audit cancelled.
Audit cancelled as survey
covered by annual Maternity
Survey in February.
Specialist
Services
3152 Audit of Third
Degree Tear
Following
Spontaneous and
Normal Vaginal
Deliveries (WH)
Carole Beetham, Lead
Midwife, Aylesbury and
Wycombe Birth
Centres, Mr Tunde
Dada, Consultant
An audit of third
degree tears
following
spontaneous and
normal vaginal
deliveries at
Wycombe and
Aylesbury Birth
Centres.
Specialist
Services
01/03/2011 Cancelled
13/12/2011 Audit cancelled.
Audit cancelled
3153 Audit of External
Cephalic Version
(SMH)
Miss Nutan Mishra,
Consultant, (Dr Dahlia
Sikafi, Reg) Obs &
Gynae
An audit of the
Specialist
success of ECVs and Services
their outcome and to
compare the success
rate of SMH to
national figures.
01/02/2011 Complete
30/01/2012 1. Comparable success rates to national rates and
No changes received, Dr has
previous rates. 2. Reduction in number of
now left Trust 21/2/2013 (CP)
Emergency Caesarean Sections for successful ECVs
(although numbers are small). 3. Place to offer more
vaginal breech deliveries especially for multips.
Recommendations: To further improve our success
rates particularly with primips (this review success
rate 34.5%). To continue to encourage community
midwives to refer patients with suspected breech
presentation to DAU or ANC.
To increase awareness regarding benefits of ECV
particularly to community midwives.
3154 Audit of Fetal
Blood Sampling
(SMH, WH)
Dr Kawther Al-Shahib, Audit of practice
Women &
ST1, Dr Doria
against Trust
Children
Bouzebra, FY2
guidelines 425.3 on
fetal blood sampling:
if FBS taken when
contraindicated;
documentation of
results; paired cord
samples taken
appropriately; referral
and consultant
review.
02/02/2011 Complete
17/03/2011 Results: In almost half of the cases the FBS were
done when not indicated (after a suspicious CTG).
Significant delays in performing FBS when indicated.
FBS documentation needs to be improved
(hardcopies to be stuck in the right place near to the
handwritten plan). Timing of the FBS rarely
documented on the CTG. In the majority of cases a
plan post FBS was documented. Better recording of
paired cord gases results is needed. Paired arterial
and venous cord samples not always taken.
Consultant advice was sought when appropriate.
No changes required as small
sample size for audit and
results disputed at academic
half day.
3155 Audit of the Use of Dr Anu Ram Mohan,
Propess for
ST5, Obs & Gynae
Induction of
Labour in
Primipari women
(SMH)
3156 Audit of Neonatal
Referrals for
Paediatric
Orthopaedics
An audit to assess
Specialist
the effectiveness of
Services
Propess (vaginal
pessary containing
dinoprostone,
prostaglandin E2) for
IOL, introduced in
November 2011 at
SMH, and to compare
the results with the
use of Prostin E2 in
primipari women.
Guideline 415.
Rachel Babajee, Sarah Neonatal referrals of
Evans, FY1s, T&O
"clicky hips" to
paediatric
orthopaedics to
identify congenital
abnormalities of hips
and treat
appropriately.
Identify how many
require further
intervention; are
these a particular
subgroup, if so
should guidelines be
implemented for
"clicky hip" referrals
rather than referring
all?
3157 Management of
Angus Goodson, ST3,
Neonates with
Neonatology
Suspected
Hypoxic Ischaemic
Encephalopathy
Surgery and
Critical Care
Current optimal
Specialist
treatment for
Services
neonates born with
HIE is therapeutic
whole body cooling,
most effective when
started within 6 hours
of birth. No facilities
for this at SMH so
early referral to
tertiary centre and
passive cooling is
required. To
compare babies born
at SMH who meet
cooling criteria
against neonatal unit
protocol and identify
any problems with
achieving best
practice.
02/02/2011 Complete
08/08/2011 The aim of the audit was to evaluate the use of
No changes received, Doctor
Dinoprostone vaginal pessary (Propess) for induction now not with Trust 21/2/13
of labour in primigravida, which was introduced at
(CP)
SMH in 2010. 26 cases identified 1/2 - 10/3 2011.
The audit showed that Propess is well tolerated by
women; there were no major complications.
Recommendation is that there should be clear
guidelines on management when the Propess
pessary is expelled prematurely. Further audit should
look at effectiveness, maternal satisfaction and
acceptability of various regimens of prostaglandins,
and different management policies for failed
prostaglandin induction.
02/02/2011 Cancelled
27/06/2011 Project not completed.
02/02/2011 Complete
30/12/2011 There was a lack of documentation in some areas.
Junior doctor audit, no
Delays in commencement of passive cooling contact changes recevied and doctor
with cooling centre. No babies had rectal
has left Trust 21/2/13 (CP)
temperatures documented. Recommend education
of clinical staff, a checklist for doctors and a policy of
obtaining signed consent from parents.
Project cancelled.
3158 Ventilatory
Management of
H1N1 Positive
Patients on ITU
Carly Grandidge, FY1,
Anaesthetics,
Samantha Scammell.
Project sponsor Dr
Patrick Strube.
To determine whether Surgery and
Acute Respiratory
Critical Care
Distress Syndrome
protocols are followed
for H1N1 positive
patients on ITU and if
not, does this result in
worse mortality?
02/02/2011 Complete
(no
changes
reported)
23/05/2011 This audit showed that no patients had predicted
body weight calculated, and as such the first step of
the ARDSNet protocol was not used. The high use
of non-invasive ventilation on the ICU was
highlighted. Recommendations included early
intubation; the calculation of predicted body weight
(to enable tidal volume calculation) for H1N1
suspected patients; and having copies of the
ARDSNet protocol visible on the ICU.
Changes required
3159 Epidural
Joyee Basu, FY1,
Effectiveness
Surgery
Following
Colorectal Surgery
Epidural analgesia
Surgery and
forms part of the
Critical Care
ERAS programme
following bowel
surgery. This audit
aims to identify the
success rate of
epidurals, the
possible reasons for
failure, ways to
reduce the failure rate
and the effect of
failure on patient
outcome.
02/02/2011 Cancelled
01/10/2012 Audit report not received, cancelled by audit &
effectiveness lead.
Project cancelled
3160 Evaluation of
Effectiveness of
Physiotherapy for
Shoulder Pain
Use of validated
Specialist
outcome measure to Services
look at whether
physiotherapy helps
patients with shoulder
pain. Also patient
satisfaction
questionnaire.
03/02/2011 Complete
02/08/2012 •Results: 83% (40/48) patients achieved a reduction Changes required
in their SPADI score of 10% or more, i.e. a significant
improvement in symptoms. 82% patients rated the
physiotherapy as very good and 16% rated it as
good.
74% patients had less pain after the physiotherapy,
89% had improved flexibility and 74% had increased
the range of activities they could do. Action Plan :
Physiotherapy staff to be guided by the mean
number of physiotherapy appointments (7) as
maximum number of appointments.
Reinforce to physiotherapy staff to discuss with
senior staff members after 3-4 sessions if patient not
progressing to meet this objective.
Physiotherapy staff at each site to meet and discuss
management of each shoulder condition and decide
some consensus for management and how
efficiencies can be made, e.g. patient attends for 1:1
and then be progressed to shoulder class.
Vicky Russell,
Specialist
Physiotherapist
3161 Smoking
Prevalence
Survey
Alyson Moss, Smoking
Cessation Coordinator, Respiratory
Medicine
The no smokiing
Integrated
policy enforced by the Medicine
Trust means that
patients who smoke
require NRT whilst
they are an inpatient
of this Trust. The
purpose of this audit
is to establish the
number of inpatients
who smoke requiring
NRT in order to
estimate the potential
cost of providing
NRT.
04/02/2011 Complete
26/08/2011 As part of a drive to improve the Nicotine
Replacement Therapy (NRT) available to inpatients
of Buckinghamshire Healthcare NHS Trust, a
prevalence survey of smokers amongst inpatients
was commissioned to establish the possible need for,
and uptake of, NRT throughout the Trust and the
subsequent cost implications. 363/398 patients who
were asked whether they smoked or not answered
this question. 56/363 patients responded yes they
did smoke. This represents 15.4% of the total patient
population. Higher proportion of NSIC patients were
smokers - 24/101(24%) patients sampled said they
smoked. The Clinical Audit and Effectiveness
Department highlighted the possible inaccuracy of
answers given by patients, due to the sensitive
nature of the survey. It was also noted that some
patients gave their status as non smoker as they had
not smoked since their admission to hospital.
Improvement of Nicotine
Replacement Therapy (NRT)
available to inpatients of
Buckinghamshire Healthcare
Trust.
3162 Heart Failure
Follow-up Project
Emma Parry, Service
Innovation Manager,
AH
The South Central
Integrated
Cardiac Network
Medicine
(SCCN) has identified
outpatient follow up of
patients with LVSD
as an area of clinical
activity where there
may be potential to
improve quality and
reduce costs. A
service evaluation to
review the curent
services provided.
07/02/2011 Complete
Changes required
Re-audit - an
Integrated
experience survey of Medicine
patients attending for
endoscopy. The
questionnaire has
been designed in line
with global rating
scales for excellence.
08/02/2011 Complete
06/09/2011 Following the report the recommended model of
care is: Following discharge from hospital
appropriate patients with LVSD will be referred to
community heart failure specialist nurses. Patients
may return to secondary care outpatient for their first
appointments and subsequent appointments will be
made only if deemed necessary. Patients with heart
failure not caused by LVSD should be seen as
required by secondary care. Multidisciplinary support
in the community for those with established heart
failure should be available comprising of specialist
nurses, GP’s, community nurses/matrons, palliative
care teams and cardiac rehabilitation. Access to
heart failure clinics for follow-up based in either
primary (mainly subsequent appointments for those
with LVSD) or secondary care (mainly initial
appointments or those with heart failure due to other
causes) should be available for those with confirmed
heart failure. Access to diagnostics should be
available based on clinical need in either primary or
secondary care as per NICE guidelines (2010).
15/09/2011 Recommendations: Improve signage to the Units.
Ensure patients are given a realistic idea of waiting
times. (WH) Consider the layout of the waiting area.
(WH) Ensure staff at all entrances/receptions are
able to provide accurate directions to the Endoscopy
Unit (SMH) Consider the feasibility of holding single
sex sessions. (SMH) Ensure the Unit reception is
manned at all times. (SMH)
3163 Endoscopy Patient Sue Kenny, Sister,
Experience
Endoscopy Unit, SMH
Survey 2011
& Deborah DobreeCarey, Sister,
Endoscopy Unit, WH
Estates have improved the
signage at both sites.
Appointment letter explains
there may be a 2 to 4 hour
wait. (WH) A flow chart has
been put in the waiting area
explaining the pathway. (WH)
Staff to keep patients up dated
on their progress. (WH) Re
design of the waiting area at
WH is not possible at present
due to financial constraints.
Sodexho staff have been
reminder of the need to give
patients accurate directions.
(SMH) Feasibility of single
sex sessions being explored.
(SMH)
3164 IV in the
Community
Patient Survey
Emma Parry, Service
Development
Some patients having Integrated
IV are discharged
Medicine
and continued at
home with visits from
nurse. New service
recently started.
Questionnaire to
evaluate.
08/02/2010 Complete
17/05/2011 Results: The results demonstrate that the service has
been very positively endorsed by the patients and
the level of satisfaction is generally very high with all
aspects of the service provision. 95% of the
respondents stated the service was very good.
Recommendations: We continue to monitor the
patient experience to this service by on-going
evaluation. We consider alternative community
venues for patient so they can access the service at
more convenient locations – this already is
underway. A robust and formal training programme
is already in place but we need to ensure it is
reaching all the nursing teams so they feel they are
appropriate prepared to manage the nursing tasks
required of them. OPAT team will offer more
targeted support to community nursing teams if
required.
We now send patients home
with a questionnaire on
discharge from hospital. This
way the experience is fresher
in their mind and we are in a
position to prompt them to
return them when we
discharge them from the
community care. Two
questionnaires have been
developed – one for early
supported discharges and one
for our admission avoidance
patients.
We now have a variety of
alternative venues including
clinics in SMH, WGH,
Amersham Hospital.
However, in general most
patients continue to be treated
at home.
The IV service train and
educate all staff on a regular
basis via an ad hoc on the
ward process or in a more
formal setting. The IV team
have established a full training
programme with the education
department. The team now
deliver Venepuncture training,
Community IV therapy full day
& Community IV therapy
update sessions commencing
in January 2012. We have
also been providing IV
calculation sessions
separately to the trust
sessions to get the community
hospital & community staff up
to date with requirements of
the trust.
To date we have facilitated 61
staff through the calculation
tests and are providing
another 5 sessions over the
next few months to ensure
staff are trained.
We also support the training
department on the trust
Central Venous Catheter days
and other IV specific training
as required.There have been
difficulties with achieving the
appropriate training needs of
the community staff as there
are different needs for the
services that we are trying to
establish pathways for.
3165 Evaluation of
Meals in NSIC
Samford Wong,
Dietitian, NSIC
Questionnaire to
Spinal
patients re meals
Injuries
provided. Similar
questionnaire to staff.
Also food intake to be
measured for every
patient in NSIC for 1
day to determine
nutrition and food
wastage.
02/02/2010 Complete
03/08/2011 Morning, afternoon and evening snacks were rarely
offered and were mostly consumed by those that had
eaten all their meals.
29 (48%) patients ate 3 full meals a day. 52 (85%)
patients ate the equivalent of at least 2 full meals.
27% patients are satisfied with the meals. 47% are
not. Recommendations: Ensure nutrition screening
on admission is implemented effectively. Raise
awareness. Arrange education sessions for catering
staff, nursing staff, medical staff. Review the
quality/choice of dishes on the hospital menu. To
involve volunteer help in meal ordering; to make sure
food is cut up and placed within reach. Ensure menu
available to all patients. Create Breakfast / Lunch /
Supper club – to give patient company and
encouragement while they eat.
Nutrition sreening week held
to increase awareness.
Nutrition care plan updated.
Audit findings disseminated.
Nutrition education session
held Jan 12 for all ward staff.
Now included in NSIC
induction and SHO training.
New menu in May 2011 which
is available to all patients.
Facility to review hospital food
is ongoing. Introduction of
breakfast/lunch/supper clubs
ongoing.
3166 An Audit into the Dr Itopa Fidelis Abedo, Review success of
Integrated
Use of Exenatide ST5, Diabetes
Exenatide treatment. Medicine
in Type 2 Diabetes
Review whether
patients receiving this
treatment meet
criteria drawn up by
NICE. Find out how
many patients have
dropped out.
11/02/2010 Complete
04/08/2011 Results: 17 out of 40 patients achieved NICE weight
and HbA1C targets at 6 months. The same number
met the above targets in the group treated with oral
hypoglycaemic (17/29 patients). These results are
comparable to the Association of British Clinical
Diabetologist’s Nationwide exenatide audit. No one
in the Insulin group achieved both targets. An audit
of the exenatide treated patients should be done at
12 months to see whether the gains are sustained.
A separate audit into insulin treated groups is
advised once we have a substantial number of
patients.
Changes required
3167 Audit of Radiology Libby James,
Request Forms
Radiology
01/01/2011 Complete
15/02/2011 8% forms were not fully completed. Data sent to
Medical exposure Committee for comment and
recommendation. Inadequately completed requests
to be rejected, minimum data set required, referrer's
identity required.
We are moving towards
ordercomms – electronic
requesting – this does not
allow the requestor to request
using an inadequately
completed form.
As to the paper requests we
are continuing to reject
inadequately completed forms
– our goal is for all requests to
be 100% fully completed, but
due to the rapid introduction of
ordercomms we will not repeat
this audit. Review 2012.
Radiology request
Clinical
forms should be fully Support
completed to avoid
Services
mistakes and to
increase value of
radiology report. 476
radiology request
forms audited.
3168 Audit to Check
Compliance with
Request Form
Scanning
Libby James,
Radiology
Radiology request
forms should be
scanned. 1975
radiology request
forms audited.
Clinical
Support
Services
01/01/2011 Complete
15/02/2011 94% compliance.
We would wish for 100%
compliance but will not be
reauditing as ordercomms
negate the need to scan in a
request form. We will review
this in 2012.
3169 Audit to Check
Libby James,
Radiology Reports Radiology
sent to MDT When
Necessary
397 scans audited to
see if sent to MDT
when necessary.
Clinical
Support
Services
01/01/2011 Complete
15/02/2011 14 cases referred properly and promptly. 7 referrals
from GPs which should have needed referral were
sent back to GP without referral. 6 cases from OP
clinics should have been faxed or highlighted but
weren't. Imaging capacity is adequate.
Recommendations: Maintain adequate number of
skills and staff in each clinic. All acute/unexpected
cases with positive findings from GP clinics should
be referred to hospital clinics. Acute/unexpected
results from OP clinics should be faxed promptly to
referrer. Keep to maximum capacity of clinics.
The sonography staff were
instructed to record how the
patients are managed on the
report. The modality lead for
U/S has been tasked with
finding a way of auditing this,
Practice Educator to follow this
up in 3 months.
3170 Audit to Check All Libby James,
Radiology Results Radiology
are Reported
All radiology results in Clinical
March 2009 checked Support
to see if reported.
Services
01/01/2011 Complete
15/02/2011 Over 99% reported after 4 weeks (X Ray 99.6%, MR Ongoing departmental audit of
99.3%, CT 99%, US 98.8%).
unreported specials is now
part of general housekeeping.
3171 National Care of
the Dying Audit
Jeanette Tebbutt,
Cancer Services
Audit run by Marie
Specialist
Curie Palliative Care Services
Institute. Registered
for organisational and
clinical parts of audit data collection AprilJuly 2011.
17/02/2011 Complete
30/04/2012 Results: Access to information regarding death bottom 25% trusts. Access to specialist support for
end of life care - top 25% trusts. Continuous
education, training & audit - top 25% trusts. Clinical
protocols regarding dignity & respect - middle 50%
trusts. Anticipatory prescribing for key symptoms
which may develop - bottom 25% trusts.
Communication with relatives & carers regarding
plan of care - middle 50% (SMH), top 25% (WH).
Ongoing routine assessment - top 25% (SMH),
bottom 25% (WH). Compliance with completion of
LCP - middle 50% of trusts. Action Plan: Review
existing information leaflets (ICP for the Dying Adult
– Supporting care in the last days – CISS 64, Place
of care options for patients with palliative care needs
- CISS 57, Hospital Palliative Care Team - CISS 1).
Through the educational roll out raise the importance
of discussion and decisions with the patient/carer.
Review the need for an educational roll out Trustwide
on communication skills. Continue to recognise
importance of palliative care service and produce off
duty accordingly. Review present structure of acute
palliative care nurses and through current WTE
create a LCP facilitator 4 days a week (30 hours).
An established educational programme is in place,
but does need to be reviewed this year to capture all
the audit recommendations. Bring to discussion at
the Nursing and Midwifery Board for agreement that
it becomes mandatory for all staff to attend training
regarding caring for dying patients and their families,
on induction, and update annually. Develop
elearning tool for yearly update for all clinical staff.
To produce information leaflet on the process of ICP
for healthcare professionals. To review allocation of
ICP files to ensure each clinical area holds an up to
date copy of the folder with training material and is
ensure that this is updated by the palliative care link
nurses and the acute palliative care CNS team
leader/facilitator.
To review roles and responsibilities of the link nurses
and increase numbers on each clinical area following
the possible reconfiguration.
ICP on existing intranet, and will be placed on the
new intranet.
Raise awareness of spiritual care to be available for
end of life care and carers support. Chaplains to
audit uptake of spiritual care provision following
notification of patient being placed on ICP. One of
the chaplains will be identified as the lead for acute
end of life care with the potential to be become a
Macmillan postholder. Through the education
programme raise the awareness and importance of
clinicians prescribing medication for the five key
symptoms. Through the education programme raise
the importance of communication both verbally and
in written format to carers and relatives regarding the
plan of care. To raise awareness through education
of the ward nursing team on the importance to hand
out the leaflet Help for the Bereaved CISS 23, prior
to relatives and carers leaving the ward. Carry out
A robust teaching plan was
developed and has been
delivered. This is not yet
mandatory but an e learning
package has been written and
once this is in operation it
should be easier to access
end of life training. The
training incorporates training in
spiritual care and the
chaplains have received
additional training. A recent
audit showed that the
prescription of suitable drugs
had improved. Information
has been added to the ICP
paperwork re information
given to health professionals
so this should now improve.
After the recent news reporting
on the ICP an assurance
paper has been written and
will be delivered to the Trust
board in December 12.
another audit on the compliance of the wards
handing out of the Help for the Bereaved leaflet, and
compare to previous audit. Review leaflet in March
2013. Part of the education programme will include
encouraging the clinical staff to communication with
the GP/primary health care teams on the initial
assessment and ringing once the patient has died in
order for the GP to support relatives/carers. The
educational programme will include encouraging the
clinical staff to assess and formally document the
care delivered. Each division to run audits on the
compliance of good documentation which should be
reported at their divisional board on their balance
scorecard. An established end of life steering group,
however further commitment is required from each
division for attendance. Issue to be raised at each
divisional board.
3172 Audit of Use of
SBAR approach to
patient handover
and ward rounds
Mr Tunde Dada,
Consultant, Obs &
Gynae (Dr Fiona
Legge, ST3)
An audit of clinical
Specialist
sheets used by the
Services
coordinator on
delivery suite
incorporating gynae
handover, in order to
ensure that patients
are being handed
over using the SBAR
approach (Situation,
background,
assessment,
recommendation).
Against RCOG Good
Practice Guideline 12
Improving Patient
Handover and Trust
Handover Guideline
BHT 43.1.
07/03/2011 Complete
13/07/2011 Results: 1. Attendance of ‘the big 5’ (consultant
No changes reported as junior
obstetrician, anaesthetist, labour ward coordinator,
doctor now not with Trust
obstetric registrar and obstetric SHO) at the morning 21/2/13 (CP)
handover meeting was 94%. The Consultant
Anaesthetist was absent on 2 occasions. (I was not
able to ascertain if s/he was busy). On average they
signed in when they were present only 51% of the
time. 2. 28 patients (1 not seen on the ward round
and therefore not included). Of the 27 remaining
patients, 17 (63%) had all appropriate information
regarding their risk factors recorded on the smart
board. 9 (33%) patients had risk factors or
background information that should have been
recorded on the smart board but was not. Some of
these patient had 2 factors that should have been
recorded. 3. The plan from the ward round should be
followed (unless clinical indication to alter). The Plan
was followed 86% of the time
4 cases where the plan was not fully followed…i. No
CSU sent (and the catheter bag was changed!) ii. No
Teds applied. Iii. Bloods not chased. Iv. Plan
changed by Reg. Recommendations: We should
include BMI on the smart board. We need to be
diligent about updating the smart board
We need to ensure the technology can keep up with
what we are asking of it. Good at attending meetings
but there are often too many people there (average
25).
3173 Audit of Massive
PPH, pre and post
merge of WH and
SMH
Dr Helen Jefferis, ST3,
Mr Tunde Dada,
Consultant, Obs &
Gynae
A review of PPH of
Specialist
>1500 ml pre and
Services
post merge,
focussing on the
management of 3rd
stage, and
management of PPH
according to Trust
Guideline 550.1 and
RCOG Greentop
guideline 52.
14/02/2011 Complete
04/08/2011 Only the post merge part of this audit was completed. Post merger audit, no changes
Recommendations: 1). Risk factors for PPH to be
given 21/2/13 (CP)
highlighted in antenatal notes and on labour
Admission. 2). Reminders to staff that hospital policy
is to use Syntocinon IM for lower risk women but if
higher risk for Syntometrine. 3). Senior obstetric and
anaesthetic staff to be involved in all cases of
massive PPH. 4). Remember the risk of bleeding
with a retained placenta increases with time –
consider whether earlier transfer to theatre possible.
5). Re-audit with larger sample size.
3174 Resuscitation
Trolley Audit
Jenny Wright,
Resuscitation Service
Manager
To monitor
compliance of
wards/departments
checking of
resuscitation trolleys
in accordance with
the Trust
Resuscitation Policy
(BHT Pol 098). To
ensure all
resuscitation trolleys
are stocked with the
approved equipment
as listed in the Trust
Resuscitation Policy
and approved
checklist.
01/12/2010 Complete
21/02/2011 Matrons/Ward Sisters to ensure staff are aware of
need to check resuscitation trolley and actually carry
out the check; improve documentation of checks;
wards to contact the Resuscitation Service if unsure
how to check trolley and trolley awareness sessions
will be arranged; staff to familiarise themselves with
the trolley information folders as most information
required can be found within; Resuscitation Service
to carry out repeat audit in 6 months to ensure better
compliance with procedures and policy.
Surgery and
Critical Care
The trolleys were re-audited
during July this year to ensure
compliance with checking had
improved. Following the initial
audit in February 2011,
trolleys that had been
highlighted as having too
much equipment on them
were checked by one of the
Resuscitation Team and extra
equipment removed; staff
were also familiarised with the
checking process. At re-audit
there was a marked
improvement in checking
procedures and trolleys no
longer had the large amounts
of excess equipment on them.
Areas that still had poor
compliance were put on a spot
check list and since the audit
their compliance has also
improved. Compliance will
probably deteriorate over time
but the trolleys will be reaudited on an annual basis to
try to ensure this is not the
case. The next audit will take
place over the summer
months of 2012.
3175 Unerupted
Maxillary Central
Incisors
Helen Veeroo, SpR, Dr
Helen Travess,
Consultant
Orthodontics
To investigate the
management of
children referred to
the department with
unerupted maxillary
central incisor teeth.
To look at the
orthodontic and
surgical
management, the
treatment methods
and the outcomes
against the Royal
College of Surgeons
Guidelines for
Unerupted Central
Incisors.
3176 Audit of Inpatient
Deaths of Patients
Admitted From
Care Homes
Elizabeth Hollman,
Associate Director
Healthcare
Governance
3177 Enhanced
Recovery Audit
Emily Hubbard, CT1,
Anaesthetics
Surgery and
Critical Care
28/02/2011 Complete
18/01/2012 Ensure all patients who are referred directly to Oral
Maxillofacial Surgery are assessed by an
orthodontist. Management decisions to be made on
a case by case basis depending on the child’s level
of dental development rather than the chronological
age suggested in the guidelines.
Changes required
Mortality Task Force Trustwide
request to review the
records of all patients
from nursing homes
who died in our care
in the month of
February 2011. The
audit will contact the
Nursing Home for
each patient to find
out whether the
patient had an
advanced care plan,
and conduct a review
of the clinical record,
paying particular
attention to end of life
care.
01/03/2011 Complete
01/12/2011 Results and Recommendations required
Changes required
Audit of intra-op care Surgery and
during colorectal
Critical Care
resections compared
to evidence-based
enhanced recovery
protocols.
02/03/2011 Cancelled
24/10/2011 Project cancelled as Doctor left Trust before
completion.
Not applicable - project
cancelled.
3178 Implementation
and Delivery of
Nutrition in ICU
Dr George
Hadjipavlou, CT1,
Anaesthetics
An audit to assess
Surgery and
whether SMH
Critical Care
delivers nutritional
care to its intensive
care patients in
accordance with
guidelines, focussing
on initiation and safe
delivery of nutrition.
03/03/2011 Complete
3181 Reaudit of WHO
Surgical Safety
Checklist
John Abbott,
Operations Manager
Reaudit of 2955 to
assess
implementation of
Safer Surgery
Checklist. This audit
will include
documentation audit
and observation
audit.
03/03/2011 Complete
Surgery and
Critical Care
26/07/2011 Results: Oral and enteral feeding predominate; more
than half of patients have an established feeding
route early (0-8 hrs); despite this, only approximately
half of people are fed within 24hrs; few people had
some form of dietician assessment within 24hrs;
those on oral feeding had little / no recording of
nutritional intake. Tthere was no data collection on
the following: 1) feeding delayed by >24hrs, 2) mean
level of nutrition over 7 days, 3) number of feeding
holds, 4) Nursing at 30-45 degrees, 5) Use of
prokinetics, and use of chlorhexidine mouthwash.
Recommendations: everyone should have a
nutritional assessment on admission to ITU;
everyone should have documented the NICE
recommended feeding route; aim that everyone
should have nutrition started within 24hrs; those on
oral feeding should have feeding documented and
not just sips; suggest a simple A4 form to be
completed on admission.
10/08/2011 1. The Day Surgery booklet should be redesigned to
follow a similar format to the Intra-Operative booklet,
incorporating the WHO Checklist.
2. The Intra-Operative booklet should become the
standard documentation for all patients irrespective
of whether they are elective (planned) or
emergency/trauma patients. 3. Where there are
specific Integrated Care Pathway documents for
patients e.g. Fractured Neck of Femur, these should
have the Time Out checklist incorporated into the
document. 4.Clinicians who have already taken up
the use of the checklist should be requested to
encourage others, especially more junior doctors, to
use it in their own procedures. Given that the
introduction of the checklist in the two hospitals was
in February 2010, a strategy for increasing its use
should be found (see Appendix 1). 5. The Time Out
section of the checklist should be read by the
surgeon or scrub nurse just prior to putting knife to
skin, when all theatre staff must pause and respond
verbally to the questions asked. Just prior to knife to
skin means that all patient preparation and draping
etc. is complete so staff will be able to pause to listen
and respond to the Time Out.
After discussion with
Nutritional ITU lead a form has
been drafted and is currently
under review before
implementation.
1. New Day Surgery booklet,
incorporating checklist will be
put out in all admission areas
e.g. Mandeville Wing at SMH,
A&E, Day Ward at Wycombe
etc. in November. 2.
Standardised in-patient
booklet containing WHO timeout checklist already in all
admission areas. 3. Only
applies to the fractured neck of
femur ICP. 4. Celina Eves
and Rachel Young have
agreed that Rachel will meet
individually with each SDU
lead to talk through when this
will be included as part of
team/audit/governance
meetings, as well as training
sessions, so that all grades of
doctors receive
‘training’/reminder. As
evidence, the SDU leads will
be asked to send copies of
agendas/minutes
demonstrating this was
discussed.
5. Rachel has met with all
SDU leads to confirm that this
means the surgeon and scrub
nurse need to vocalise the
WHO Time Out, so that all
staff present in the theatre
pause and are aware it is
taking place and they can hear
the questions and the
respondent’s reply. RachelI
will follow this up with
observational audits as part of
the on-going TPOT work. Any
non-compliance will be
reported to both the theatre
matron and SDU lead for that
speciality.
3179 Delivery and
Administration of
Medication on
Medical Wards
Dr Claire Greszczuk,
FY1, Dr Mariam Abbas
Syed, FY1, Gastro, Dr
R Sekhar, Consultant
Gastroenterologist
An audit of
Integrated
administration of
Medicine
prescribed medicines
on 3 medical wards at
SMH. This will look
at which drugs were
not administered, the
timing and dose, and
whether reasons for
not administering
drug are recorded.
25/01/2011 Cancelled
18/01/2012 Not applicable - project cancelled.
Changes required
3180 Nursing Record
Keeping with
Regard to Child
Protection
Pauline Collins, Child
Protection Liaison
Sister, Jane Bramnath,
Named Nurse for Child
Protection
A review of nursing
records to include
parental interaction
sheet with regard to
child protection
issues. To ensure
effective information
gathering and
communication with
other agencies.
22/03/2011 Complete
06/06/2011 1. To ensure that personal details are recorded for all
parents of babies admitted to the Neonatal Unit and
that they are easily identifiable and accessible in the
notes. 2. To ensure that the name, professional role
and contact details for other professionals working
with the family are documented and easily
accessible. 3. To maintain, at all times, best practice
in record keeping as per Trust policy (27.3 Record
Keeping Policy for Registered Nurses and Midwives)
to enable clear and accurate documentation,
effective information sharing within the Neonatal unit
and other professionals working with the family, to
ensure that, where there are concerns, babies are
safeguarded from harm. 4. To review the Parental
Interaction Sheet and develop a more
comprehensive record keeping tool to enable a more
effective record keeping process for babies where
there are child protection concerns. A standardised
system of recording information should be adopted
by all medical and nursing staff working within the
Unit.
New proforma for Child
Protection Record Keeping
designed and presented to
Clinical Governance meeting
in November 2011.
Specialist
Services
3182 Orthotic Clinic
Patient Survey
Dot Tussler,
Follow up of patients Specialist
Physiotherapist, Spinal 6 months after having Services
Audit Lead
been given orthosis
to see if still using
and if not, why not,
and also to ask if they
were satisfied with
the service.
28/02/2011 Cancelled
02/01/2013 cancelled
3184 Audit of Patient
Readmissions
within 28 days
following
Discharge from
Medicine
Robert MacKenzieRoss, SpR,
Respiratory Medicine,
Dr Mitra Shahidi,
Respiratory Consultant
Audit to look at the
Integrated
reasons for
Medicine
readmission of
patients within 28
days following
discharge from
Medicine. Results
will be compared with
those of the previous
audit, 2941.
07/03/2011 Complete
01/11/2011 Distinguishing between a readmission for the
Changes required
same/related complaint, readmission for a new
complaint and planned hospital attendance for
clinic/day case procedures is difficult to perform
without the use of the hospital notes. Malignancy
and respiratory problems make up the largest
proportion of readmissions to hospital within 28 days.
Episodes of continuous care ‘divided’ between WGH
and SMH or the trust and John Radcliffe hospital
would be classed as a re-admission using the
parameters of this audit.
3185 COPD Discharge
Support Service
Evaluation
Jo Hockley,
Programme Director
for Change
Early supported
discharge service for
COPD patients was
introduced in
November 2010.
This audit is to
evaluate the service
from the patient's
perspective.
07/03/2011 Complete
17/05/2011 Results: Overall, the patients were satisfied or very
satisfied with the discharge support service, they felt
it was safe and effective, and no major issues were
identified. All liked having their COPD flare up
managed at home, and most felt they had a better
understanding of their COPD as a result of contact
with the specialist nurses. In particular, they were all
confident that they understood their medications.
Patients felt well supported and would all use the
service again if asked. Recommendations: Ensure
all patients are aware of the content and location of
the patient leaflet before discharge and again when
at home.
Medicine
cancelled
Patients are all now made
aware of the leaflet and are
given the phone number of the
specialist nurse.
3186 Audit of Nutritional Jo Birrell, Matron,
Assessment,
Medicine for Older
Falls, Depression People
Screening and
Dementia
Screening in Older
People
Audit to assess
Integrated
whether or not
Medicine
appropriate
assessment of older
people takes place
when they are
admitted to hospital.
This audit includes
nutritional
assessment, falls,
depression screening
and dementia
screening.
02/03/2011 Complete
31/01/2012 The Trust must ensure that the revised nursing
documentation is in place. Ward staff should be
made aware that they accountable for completion of
required documentation. Dementia awareness
training to be cascaded to all nursing staff.
Changes required
3187 European COPD
Audit (BTS)
Dr Mitra Shahidi,
It is the intention of
Medicine
Respiratory Consultant this COPD audit to
develop a core data
set that can be used
to audit COPD in
acute hospital
admissions across
Europe, with a view
to raising the
standards of care to a
level consistent with
the European
management
guidelines.
02/03/2011 Not yet
started
Results and Recommendations required
Changes required
3188 National Cardiac
Arrest Audit
(NCAA)
None
08/03/2011 Not yet
started
Results and Recommendations required
Changes required
The National Cardiac Surgery and
Arrest Audit (NCAA) Critical Care
is an ongoing,
national, comparative
outcome audit of inhospital cardiac
arrests. It is a joint
initiative between
Resuscitation Council
(UK) and ICNARC
(Intensive Care
National Audit &
Research Centre)
and is open to all
acute hospitals in the
UK and Ireland.
3189 Clopidogrel and
Trauma Patients
Mr Harish Karup,
Consultant, T&O (Dr
Anan Ramasamy, FY1,
T&O)
To assess the delay
and complications of
trauma patients on
clopidogrel. Do we
need to wait 7 days
before operating?
British Orthopaedic
Association
standards.
Surgery and
Critical Care
09/03/2011 Complete
3190 Ankle Fractures:
Screws or Tight
Rope?
Mr Harish Karup,
Consultant, T&O (Nik
Bakti, CT1, Surgery)
To compare any
Surgery and
differences/benefits
Critical Care
of 2 different surgical
techniques in
managing ankle
fractures.
09/03/2011 Complete
3191 Pre-op
Haemoglobin and
Joint
Replacement:
Impact on Blood
Transfusion
Dr Sara McNeillis,
Consultant,
Anaesthetics (Tamsin
McAllister, CT1,
Anaesthetics)
Audit against NATA
Surgery and
guidelines Jan 2011. Critical Care
What level of
haemoglobin are we
accepting prior to
joint replacement
surgery and what are
we doing to optimise
it? How is this
impacting on need for
post-op transfusion?
10/03/2011 Complete
18/07/2011 Results: 37% (n=8) patients were operated within the
48 hours of admission as per the BOA guidelines.
The drop in haemoglobin post-operatively in those
who were operated within 48 hours, 3-7 days and
more than 8 days were statistically significant;
p=0.0022, p=0.0360, p=0.0381 respectively.
Therefore, delaying the surgery because of
clopidogrel does not reduce the haemoglobin drop
during operation. Half of the patients (n=11) required
blood transfusion but there was no correlation
between the different groups. None of the patients
required platelet transfusion. Patients who waited
longer for operation had more complications
(myocardial infarction, pneumonia, stroke and death).
Recommendations: educational meetings suggesting
a) early surgery for patients on clopidogrel rather
than waiting days/weeks and b) use of general
anaesthetic rather than spinal in patients on
clopidogrel; ensure cross-match is available; ensure
clopidogrel is restarted post-surgery; liaise with
haematologist re: Buckinghamshire Trust policy on
patients on clopidogrel requiring surgery.
27/07/2011 Results of this audit indicate that tightropes achieve
radiologically similar reduction of syndesmosis as
screws without any significant difference in
complications. The need for a second operation is
significantly lower with tightrope fixation.
Education meetings were
organised to educate
surgeons and advocate early
surgery for patients on
clopidogrel. Junior staffs were
reminded to ensure cross
match is available for patients
before operation. We liaised
with the haematologist to
devise a local trust guideline
for patients admitted on
clopidogrel requiring trauma
surgery.
28/10/2011 Recommendations included: improve % patients with
pre-op Hb close to 28 days prior to operation;
patients with low Hb - investigation and optimisation;
raising awareness - pre-op / juniors; clear guidelines
for acceptable pre-operative Hb; guidelines for
referral / investigating low pre-op Hb; re-audit.
A guideline incorporating a
flowchart for pre-operative
anaemia management has
been developed by Dr Tamsin
McAllister. It has not yet been
implemented.
Recommendations for change
were not made as numbers for
tightrope were too small.
3192 Audit of
Community
Acquired
Pneumonia Q4
2010/11
Dr Mitra Shahidi,
Respiratory Consultant
and Liz Hollman,
Associate Director
Healthcare
Governance
IQP audit to assess
patients with
community acquired
pneumonia.
Integrated
Medicine
3193 NJR Hip Mortality
Review
Mr Alastair Graham, Dr Mortality review of
Surgery and
Graz Luzzi
THR deaths following Critical Care
alert from National
Joint Registry.
11/03/2011 Draft
Report
with
Clinician
3194 Effectiveness of
TemporoMandibular Joint
Arthrocentesis
Mr Bahattin Bagdadi,
Specialty Doctor
14/03/2011 Complete
To determine the
Surgery and
effectiveness of the
Critical Care
TMJ arthrocentesis
procedure and to
determine which
patients would benefit
from the procedure.
11/03/2011 Complete
31/03/2012 Results and Recommendations required
Changes required
Results and Recommendations required
Changes required
26/10/2011 The audit showed that the procedure can benefit
patients but no demonstrable link to the Wilkes
classification was found.
No changes to current practice
required.
3195 End of Life Care in C Graham, Consultant Comparing end of life Surgery and
ITU
(Dr Makris, ST5
care in a 1 year
Critical Care
Anaesthetics)
period in Wycombe
ICU with standards
set by DoH and the
Liverpool Care
Pathway for the
Dying Adult.
16/03/2011 Awaiting
Report/Ac
tion Plan
Results and Recommendations required
3196 Survey of Patients
having
Orthodontic
Treatment and
Facial Surgery
15/03/2011 Complete
27/06/2011 Overall patients appear to be very satisfied with the
treatment they have received. However, it appears
that patients could be better informed about what to
expect in the immediate post operative period.
Patients would also benefit from more information
regarding retainer wear and the importance of good
compliance. Recommendations: A detailed verbal
explanation of pre-surgical orthodontic treatment,
proposed surgery and post-surgical orthodontics
including retention should be given to all; the risks
and benefits of all aspects of treatment should be
discussed and this should be documented in the
notes; all patients must receive relevant orthodontic
and surgical information leaflets pre-operatively; all
patients should be given the option of watching the
BOS DVD on orthognathic surgery; consider the
benefits of meeting patients who have previously had
orthognathic surgery; all patients should be given the
leaflet on post-operative care following orthognathic
surgery; all patients should be seen by a dietician
prior to discharge; the audit cycle should be repeated
in 12-18 months to review compliance with current
recommendations.
Miss Helen Travess,
Consultant (Dr Helen
Veeroo, Specialty
Registrar)
Part of a regional
Surgery and
audit being organised Critical Care
by Oxford to look at
satisfaction and
outcomes following
orthognathic
treatment using a
nationally approved
survey form.
Changes required
A detailed verbal explanation
of pre-surgical orthodontic
treatment, proposed surgery
and post-surgical orthodontics
including retention is given in
our combined clinics by both
orthodontists and surgeons;
the risks and benefits of all
aspects of treatment are
discussed and documented in
the notes in our combined
clinics by both orthodontists
and surgeons; all patients are
given national leaflets at initial
appointments and/or
combined clinic; DVDs are
loaned out at no charge and
we ask patients to return them
to the department - we have
very good feedback from their
use; meeting patients who
have previously had
orthognathic surgery is offered
on a case by case basis, and
is not something many
patients ask for. The leaflet on
post-operative care following
orthognathic surgery was
designed in Oxford where the
patients have their in patient
episode, so this is not under
the control of this Trust; all
patients should be seen by a
dietician prior to discharge
from their inpatient episode in
Oxford so this is not under the
control of this Trust.
3197 Management of
children and
young people 0 18 years with
decreased
conscious level
C G Rastogi,
This audit aims to
Specialist
Consultant, Dr Abhijit
assess whether
Services
Mazumdar, Paediatrics children presenting to
emergency
departments and
acute paediatric
assessment units,
with a decreased
conscious level, are
receiving the
appropriate
assessments,
investigations and
management in line
with guidance issued
by the Paediatric
Accident and
Emergency Research
Group, 2005.
01/03/2011 Complete
3198 Neonatal
Abstinence
Syndrome
Dr Rupjani Banerjee,
ST4, Paediatrics
20/03/2011 Cancelled
To determine the
Specialist
number of newborns Services
being scored for
neonatal abstinence
syndrome; the
number of babies
needing admission;
criteria for admission;
recovery time,
admission and plan of
management.
28/02/2012 The key challenge of this audit in Buckinghamshire
No changes as not sufficient
Healthcare NHS Trust was the identification of
number of eligible cases (2).
eligible cases which was particularly problematic
perhaps due to the following factors: 1. Genuinely
low numbers of eligible cases; 2. Possible difficulty
in systematically identifying these patients because
they fall into a multitude of diagnostic categories; and
3. Possible difficulty in managing the audit's data
collection across two specialties (paediatrics and
emergency medicine) which may have hampered
engagement with the audit. Trust had only two cases,
therefore no definitive statements on the
management of children presenting with a decreased
conscious level can be made. The Trust should
consider a limited re-audit (six months after
the dissemination of the audit's findings) of the
management of children presenting with a decreased
conscious level focusing on the following key areas:
1. documentation of the clinical history features; 2.
documentation of the observations of heart rate,
respiratory rate, blood pressure and temperature on
presentation to hospital; 3. documentation of GCS
measurements within the recommended frequency;
and
4. documentation of capillary blood glucose taken
within 15 minutes of presentation to hospital.
09/04/2012 Audit cancelled. Doctor left Trust without completing Changes required
audit.
3199 Audit of
Hyponatraemia
Dr Ian Gallen,
Consultant (Dr Alice
Davenport)
Audit of the
recognition,
investigation and
management of
hyponatraemia. Are
clinicians following
the Trust guideline?
Integrated
Medicine
18/03/2011 Complete
15/07/2011 The current hospital guideline gives advice regarding Changes required
how to approach and further investigate
hyponatraemia however the guideline lacks practical
advice regarding the management of these results. It
is possible that a management plan which included
practical advice may have a greater uptake.
Suggest revising the present guideline. In order for a
greater uptake of current guidelines we would
recommend incorporating teaching about the
importance of recognition and further investigation of
abnormal Sodium results into Junior Doctor teaching
syllabuses and to widen knowledge of the existence
of hospital guidelines through bulletins on
biochemistry review systems and hospital
communication systems (e.g. PMS).
3200 National
Dr Sue Cullen,
Colonoscopy Audit Consultant & Dr Ravi
Sekhar, Consultant
This project aims to
Integrated
assess and record
Medicine
the quality of current
colonoscopy practice
in the United
Kingdom. It is
supported by the
British Society of
Gastroenterology and
the Association of
Coloproctologists of
Great Britain and
Ireland.
22/03/2011 Awaiting
Report/Ac
tion Plan
Results and Recommendations required
3201 Hand Hygiene
Amanda Adkins,
Observational
Infection Control, SMH
Audit April 2010 to
March 2011
Hand hygiene audits Specialist
carried out on all
Services
wards monthly (audit
3107) and recorded
in spreadsheet. To
analyse spreadsheets
to produce annual
summary.
01/04/2011 Complete
06/06/2011 Results: Overall, hand hygiene was carried out in
97% cases, an increase of three percentage points
on the 2009/10 compliance of 94%. Compliance had
increased for all staff groups since 2009/10.
Compliance had increased for all situations since
2009/10. Compliance by ward/area varied from 79%
to 100%. Recommendations: If the month‟ s
compliance level is below the recommended level
then weekly audits must be completed along with an
action plan. This must show how low compliance is
being addressed. Areas of non participation
throughout the year (not highlighted in this audit)
should be addressed on a monthly basis. All hand
hygiene results must be displayed at ward level for
public information.
Changes required
All recommendations have
been completed and ongoing
re-audit each month to ensure
compliance remains high.
3202 Junior Doctors'
Record Keeping
Audit February
2011
3203 National
Outpatient Survey
2011
Dr Graz Luzzi, Medical Junior Doctors'
Trustwide
Director
Record Keeping Audit
carried out by
February 2011 intake.
National Outpatient
Survey of sample of
850 patients seen in
April 2011.
Trustwide
07/03/2011 Complete
30/06/2011 Results and Recommendations required
Changes required
20/05/2011 Complete
16/08/2012 Scores similar to other Trusts. Several
Changes required
improvements since 2009. Not so many worse
results. Actions: Access to the organisation has
been assessed and the next steps will include
implementing standardised processes, improving
clinic utilisation and ensuring the best pathway for
the patients. The surgical division have reviewed the
slot utilisation and have increased capacity at
Amersham hospital to provide additional
ophthalmology clinics and have added an additional
plastics clinic to assist with the increased demands
on the service. The nursing staff are to work closely
with the reception staff to ensure that any delays are
communicated to the patient early and that patients
are informed at each step of the process what the
waiting time will be. The matron is to ensure that the
cleaning plan is reviewed on a weekly basis and the
department or shift leader is to escalate any
concerns as soon as they become apparent. Medical
Staffing to address improved explanation of tests and
treatment at doctors induction. This will be picked up
on induction of staff and the service standards cover
staff being courteous to patients and ensuring that
the patient knows who they are talking to and their
role within the organisation.
A quality check for patients leaving the outpatient
department is to be introduced in order to ensure that
patients leave the department feeling that they have
all the information that they need and their visit has
me their expectations. Medical team to explain to
patients in clinic any changes in medication and the
nursing staff to ensure that the patient understands
before leaving clinic. Pharmacy team will ensure that
patients that are attending the pharmacy to pick up
their medication are provided with both a verbal and
a written explanation about their new medication.
ADO to review with admin staff to ensure patients
receive copies of GP letters. Medical and Nursing
staff to ensure that the patients are informed verbally
and in writing for possible issues or complications
that may arise from their condition in clinic. Nursing
Staff to ensure that the patient is assured that they
have all the information that they need prior to
leaving the clinic by asking quality check questions.
Matron and the department manager to ensure that
staff are engaged in supporting patients with dignity
and respect and that dignity champions are
encouraged in the OPD area. Therapies are to take
part in the patient experience feedback questionnaire
in order to get live feedback to address any issues.
3205 Prolonged VTE
J Pattinson,
Prophylaxis in
Consultant,
High Risk Surgery Haematology (Kabir
Ahluwalia FY1,
Surgery)
Audit to determine
Specialist
whether prescribing
Services
for DVT prophylaxis
is meeting NICE
recommendations for
patients undergoing
surgery for cancer, as
well as orthopaedic
(hip/knee
replacement, major
trauma and fractured
neck of femur). This
is part of rolling audit
which is repeated
each year.
25/03/2011 Complete
21/06/2011 Results: Patients were being given appropriate in
hospital prophylaxis whilst in hospital. The results for
prolonged prophylaxis are disappointing with only 2
patients out of the 48 being provided with the
appropriate therapy. There are a significant number
of patients being given Aspirin as prolonged
prophylaxis which is not within the recommendations
as stated by NICE. There is a 4% risk of
development of either Deep Vein Thrombosis or
Pulmonary Embolism following the procedures
audited.
Recommendations: To speak to members of the
Trauma and Orthopaedics team, including nurses
and senior doctors to highlight the guidance
suggested by NICE and advise on prolonged
prophylaxis to be prescribed in future practice. Reaudit of April 2011.
Dr Pattinson spoke to
members of the Trauma and
Orthopaedics team, including
nurses and senior doctors to
highlight the guidance
suggested by NICE and
advised on prolonged
prophylaxis to be prescribed in
future practice. Re-audit of
April 2011commenced.
3206 Audit of the Use of Dr Alister McIntyre,
Flumazenil
Consultant
(BHNHST)
Gastroenterologist
The original audit was Integrated
carried outfolllowing Medicine
an NPSA alert
regarding reducing
the risk of over
sedation in adults.
Use of the reversing
agent flumazenil was
audited. Since the
original audit new
procedures have
been implemented
and this audit is to
monitor their
effectiveness.
18/03/2011 Cancelled
04/08/2011 Cancelled - not applicable
Changes required
3207 Iatrogenic Errors
Associated With
ICU Admission
J Graniewski, ITU
Consultant (Dr Kumar
Panikkar, ITU
Consultant, Dr
Olusegun Olusanya,
ST4 Anaesthetics)
3208 Re-audit of MUST Liz Pryke, Chief
(BHNHST)
Dietitian
Six month study of
Surgery and
iatrogenic events that Critical Care
have led to ITU
admission at SMH.
30/03/2011 Complete
MUST was last
Specialist
audited at the end of Services
2008. As a trust we
should be aiming to
nutritionally screen all
our inpatients and
this is required to be
reported as part of
CQC standard
'Meeting Nutritional
Needs'.
30/03/2011 Complete
16/01/2012 Results: This was a comprehensive review to
ascertain the incidence, type, severity and
preventability of iatrogenic events leading to ICU
admission in six UK hospitals: Royal Berkshire; John
Radcliffe; Wexham Park; Stoke Mandeville; Milton
Keynes; and Lewisham Hospital. The Stoke
Mandeville arm of the audit showed that 26 out of 49
ICU admissions were associated with an iatrogenic
event (53%). The average across all six ICUs was
29%, suggesting that Stoke Mandeville experiences
a much higher incidence of iatrogenic events prior to
ICU than other hospitals. There is a suggestion of
increased mortality in the event group versus the
non-event group. These findings are significant, and
have been escalated to the Medical Director for
further action.
Recommendations: It is difficult to define a set of
recommendations that will remedy this multifactorial
issue. This audit demonstrates challenges to be
faced across the board, from nursing staff to medical
consultants. Education in the recognition of the
critically unwell patient, adequate staffing numbers,
timely consultant reviews, the use of a Medical
Emergency Response Team (MERT), improved
handover- especially when discussing seriously ill
patients on the ward, and improved communication
between professional groups may all go some way
towards remedying the situation. One of the highest
recommendations is the implementation of some
form of ICU Outreach service. This already exists in
High Wycombe and has proved popular and
effective. It may be that having a similar “track and
trigger” system may lead to a reduction in the
number of events, with a corresponding effect on
patient mortality. A repeat of this study to
encompass High Wycombe and Stoke Mandeville
has been recommended by the Medical Director
31/01/2012 Results: Improved compliance still needs to be
achieved regarding the completion of the Waterlow
Pressure Ulcer Risk Assessment Form as this is
required to initially identify patients at risk of
malnutrition. 19% cases at Stoke Mandeville
Hospital and 36% at Wycombe Hospital did not have
Waterlow Tool completed with 48 hours of
admission. Where a Waterlow Tool has been
completed, not all 3 trigger questions indicating
whether a patient is at risk of malnutrition had been
completed. However the question regarding BMI
was answered in 77% of cases at Stoke Mandeville
and Wycombe Hospital. Where indicated MUST
forms are being completed in the majority of cases,
however not all sections on the MUST form are being
completed fully. The MUST action plan is not being
recorded in the patients’ notes; only 3% cases at
Stoke Mandeville and 3% cases at Wycombe
Hospital stated that the MUST action plan had been
recorded. Comparing results to 2009 MUST audit
these results show some improvement in specific
areas e.g. initial screening at SMH has improved
from 72 to 81%, and weights recorded on MUST
Critical Care Outreach was
started on Aug 13th 2012.
Adequate staffing numbers are
an issue especially with the
current reconfiguration.
Intensive Care is consultant
led as it is. All the other
recommendations are the
remit of the divisions of
Medicine and Surgery.
Reauditing will occur as part of
the outreach data collection
which has begun.
Monthly traning sessions
arranged. MUST scores
reported at AND's and
Nutrition Committee. Shift
leaders check MUST and
Waterlow charts to ensure
compliance. Results of audit
discussed with ward staff.
Areas of good practice shared
at monthly ward meeting.
Sisters to ensure nutrition
folders are kept up to date.
forms have improved on all sites. However in many
areas this re-audit appears to have shown that little
improvement has been accomplished since 2009,
and also there is huge variation between wards.
Recommendations: 1) To disseminate audit results
to nursing management to enable Associate
Directors of Nursing to produce divisional action
plans to address issues specific to their wards. 2)
To continue with monthly training sessions for trained
nurses, and also to target specific wards that may
need further support.
3) To monitor MUST
scores on an ongoing basis, results to be reported to
Associate Directors of Nursing and the Trust Nutrition
Committee on a quarterly basis.
3209 Out of Hours Calls Mr Belei, Spinal
in Spinal Unit
Consultant (Dr Malik,
FY2)
To plan medical
Specialist
workforce and on call Services
rotas and assess
compliance with
European work time
directives.
05/03/2011 Complete
10/06/2011 75% nights required intervention from junior doctor
with average 87 mins/night. Junior doctors should be
supervised and able to liaise with middle grade oncall doctor. Hospital at night team should be involved
and develop close co-operation with ITU because
many interventions related to ventilators. Workload
increased by 20% since previous audit.
Recommendations: Increase no. of junior doctors.
Change rota to full shift. Negotiate with ITU to
explore combined on-call cover.
All the recommendations have
been discussed at the Acute
quality improvement group
NSIC, Medical staff committee
meeting NSIC, Divisional
board NSIC.
Further discussion with the
ITU CD at the NSIC medical
staff committee will take place
this month in order to finalize
the rota & define the level of
out of hours collaboration with
the ITU. 2 new posts for
Physician Assistants were
created and are being
interviewed.
3210 Audit of Third
Degree Tear
Following
Spontaneous and
Normal Vaginal
Deliveries (SMH)
A retrospective and
prospective audit of
the incidence of third
degree tears
following
spontaneous and
normal vaginal
deliveries at Stoke
Mandeville
September 2010 February 2011.
07/04/2011 Complete
13/07/2011 Results: Incidence of perineal tears in SVD 44/1801 = 2.4%. 63.7% Midwives had less than 5
years experience. 29.5% babies weiged more than
4Kg. Difficulty using risk factors to predict or prevent
obstetric anal sphincter tears.
No recommendations made.
Small sample and difficulty in
using risk factors to predict or
prevent obstetric anal
sphincter tears.
Mr Tunde Dada,
Consultant, Obs &
Gynae (Dr Han Wing
Cheung, SpR)
Specialist
Services
3211 DNACPR Use in
Surgery
Mr Arnold Goede,
Locum Consultant,
Surgery (Dr Chiraush
Patel, FY1, Surgery)
To assess the quality Surgery and
of uptake and
Critical Care
implementation of
DNACPR orders on
surgical/T&O wards
and nursing attitude
towards it.
08/04/2011 Complete
26/07/2011 Recommendations: resuscitation status should be
considered and documented on ALL patients on
admission to the hospital; add DNACPR section to
the PTWR sheet; decision made by consultant on the
PTWR; communicate decision to other healthcare
members, patient and family; educational sessions
on resuscitations; re-audit.
The recommendations have
been followed. The
presentation and the audit are
on our server to be available
to future incoming trainees,
and are part of the induction
process.
3212 Critical Care Point Jenny Ricketts,
Prevalence Audit Outreach Lead Nurse,
2011
Deputy Matron, Critical
Care
Re-audit of point
Trustwide
prevalence Trust
wide, taking place on
11th and 12th April
2011.
11/04/2011 Complete
01/06/2011 1. The Critical Care Delivery Group must implement
all elements of NICE Guideline 50 as a priority. 2.
Trained nurses and Ward Managers to be
accountable for implementation of Trust standard for
observations (clinical guideline 26). 3. Improve
compliance with completion of EWS for all patients
through mandatory training. 4. Complete critical care
bed modelling work. 5. Amend audit tool to include
audit of fluid balance chart accuracy, respiratory rate
and oxygen administration, in addition to audit of
observation compliance against Trust standard. 6.
Develop a Trust wide strategy to ensure patients who
trigger EWS of 4 or more are assessed by personnel
with core competencies to manage acute illness as
recommended by NCEPOD 2005.
The BEACH course is well
attended. Productive Ward
carries out observations audits
on all wards and shows that
there is a slow improvement.
Oxygen training is underway.
The business case for
Outreach at Stoke Mandeville
is again going out for approval.
Audit of Iatrogenic Errors
associated with ICU admission
shortly to be reported. Reaudit of point prevalence is
scheduled for April 2012.
3213 Appropriateness
of Red Cell
Transfusion at
Wycombe Hospital
December 2010 February 2011
To assess whether
red cell transfusions
given between
December 2010 and
February 2011 were
compliant with
hospital and national
guidelines.
12/04/2011 Complete
28/09/2011 90% of transfusions were justified.
Recommendations: improve education to junior
doctors to ensure that they a) re-check haemoglobin
values in patients who have an aberrantly low
haemoglobin with no cause and b) check a post
transfusion haemoglobin at intervals throughout the
transfusion to avoid over-transfusing stable patients
receiving multiple units of red cells; clarify
Buckinghamshire Healthcare NHS Trust guidelines
of when to transfuse the bleeding patient, who is not
compromised and is sustaining their haemoglobin.
In terms of education to junior
doctors, a presentation was
made at a grand round on 29
September 2011 to inform the
junior doctors of the results of
the audit and the transfusion
protocol that should be
adhered to. Dr Watson,
Consultant Haematologist
incorporated audit findings into
the transfusion department
annual report.
Mr Andrew Huang,
Consultant, General
Surgery (Catherine
McGlennan, FY1,
Surgery)
Surgery and
Critical Care
3214 Trial of an SLT
Elizabeth Fraser, Acute Acute SLT teams
Specialist
Outcome Measure Clinical Lead, SLT
used Functional Oral Services
for Stroke Patients
Intake Scale (FOIS)
with stroke patients
over 2 month period
to identify
improvements in oral
intake.
01/11/2010 Complete
3215 Assessment of
Visual Impairment
in Patients
Admitted with
Falls
12/04/2011 Complete
Dr C Yau, Consultant,
MFOP (Dr Zuzanna
Sipkova, FY1, General
Medicine)
Multifactorial
Integrated
assessment of
Medicine
patients admitted to
hospital with falls
should include visual
impairment
assessment. Vision
assessment and
referral is an
important component
of a successful falls
prevention
programme.
11/04/2011 FOIS suitable for stroke patients. To be
implemented on stoke units at WH and SMH. SLT
team to investigate alternative outcome measures for
other medical conditions. Acute clinical lead to
implement guidelines for Dysphagia Trained Nurses
and to develop outcome paperwork for them to
complete.
FOIS is now part of an Acute
Stroke Pathway Outcome
measure that SLTs are
completing for Stroke patients
across both sites.
The team identified
Malcolmess Care Aims as a
potential outcome measure for
the general medical patients
on the SLT caseload. This
was trialled over the summer
and agreed at the most recent
team meeting in October to be
effective and useful. The
acute team are now
completing these care aims as
an outcome measure for all
other patients.
Dysphagia Trained Nurse
(DTN) guidelines were
developed and submitted to
the Nursing and Midwifery
Board for approval.
Unfortunately these were not
approved so at the moment
there is no further progress
with establishing DTNs with up
to date training and guidelines.
We are continuing to reveiw
this situation.
27/07/2011 Updating the examination part of the medical clerking A new Trust guideline 683.1
proforma to include a section on testing visual acuity. How to Measure Visual Acuity
Improving availability of Snellen charts on the wards (VA) using the Snellen Chart
and A&E, especially hand-held Snellen charts that
has been introduced. This has
could be brought to the bedside for testing visual
improved the availability of
acuity in elderly patients with mobility issues.
Snellen charts on the wards.
Development of Buckinghamshire Hospitals “Falls
Trust policy 197.2 Prevention
Guidelines” for patients admitted with a fall aimed at & Management of Patient
doctors. The currently used “Falls Care Plan” is
Slips, Trips and Falls includes
aimed mainly at nursing staff and it is written for
a section on vision.
prevention and management of falls in hospital.
3216 An Audit of
Operation Notes:
Time to Change to
a Computerised
Form?
Mr G Biring,
Consultant, T&O (Dr
Anantharaman
Ramasamy, FY1,
General Surgery)
To ascertain our
Surgery and
clinical practice
Critical Care
regarding writing
operation notes.
Legible, complete
and
contemporaneous
operation notes are a
professional and legal
requirement.
12/04/2011 Complete
(no
changes
reported)
15/07/2011 Surgeon education through meetings. Problems
Changes required
identified: omission of important information, illegible
hand written notes. Recommendations: Use of a
proforma - computer generated template, aidememoire - check list for surgeons and encourage
computer typed operation notes. Re-audit.
3217 Intraoperative and
Post Operative
Complications of
Tension Free
Vaginal Tape
Insertion
Mr Ian Currie,
Consultant, Obs &
Gynae (Dr Han Wing
Cheung, SpR)
To assess the
Specialist
intraoperative and
Services
postoperative
complications of
tension-free vaginal
tape insertion, and
length of hospital
stay. To assess the
feasibility of carrying
out this procedure as
a day case.
28/04/2011 Cancelled
01/05/2012 Audit cancelled. Doctor left Trust without submitting
report.
3218 Audit of
Discharges
Resulting in
Complaints
Elizabeth Hollman,
Associate Director
Healthcare
Governance
To assess the
Trustwide
discharges of patients
that subsequently
resulted in
complaints. To
ascertain whether
improvements can be
made to the
discharge process.
15/04/2011 Complete
Results and Recommendations required
Cancelled.
Changes required
3219 Mortality Review
October 2010 March 2011
Dr Graz Luzzi on
behalf of the
Healthcare
Governance
Committee
A review of 50 deaths Trustwide
requested by the
Healthcare
Governance
Committee as part of
an ongoing review of
mortality within the
Trust.
21/04/2011 Complete
3220 Paediatric
Occupational
Therapy Resource
Pack
Emma Parry, Service
Innovation Manager;
Catriona Johnstone,
Team Lead for
Wycombe Paediatric
Occupational
Therapists
A survey carried out Specialist
on a random sample Services
of parents to get their
views on a newly
introduced resource
pack for use with
children prior to their
first OT assessment,
in order to make
amendments before
continuing with
another print run.
14/04/2011 Complete
12/10/2011 Medical Director and Associate Director Healthcare
Governance (ADHG) to review the 1 potentially
avoidable death and 4 deaths which were not
expected. Iindependent consultant to confirm the
assessment that death was potentially avoidable or
not expected in the cases identified. If the final
assessment is death was probably avoidable then
these should be investigated as Serious Incidents.
Medical Director to remind all consultants about the
timely review of patients, the need to obtain
investigations without delay, appropriate supervision
of junior doctors and documentation. Director of
Infection Prevention & Control to remind all staff
about the need to use VIP charts. Associate
Directors of Nursing (ADNs) to review the actions put
in place to improve the use of the Early Warning
Score and fluid balance management. Continued
focus on reducing harm from falls and pressure
ulcers as part of the Safety Express programme. To
continue the 6-monthly mortality reviews and submit
the audit reports to the Risk Monitoring Group for
monitoring and action.
04/11/2011 Only 17/100 questionnaires were returned. Many of
the comments related to the fact that although the
resource pack could possibly be useful it was no
substitute for being able to see an OT specialist who
could give specific advice on their child. The
Occupational Therapy service has reduced the
length of the time waiting from referral from 2 ½
years to 18 weeks. Some children were sent a
Resource Pack following having waiting for an
assessment for 2 plus years. Therefore initial
problems with parents being dissatisfied with
receiving a Resource Pack in place of an
assessment is no longer an issue. No complaints
are received now as Resource Pack are sent out in
timely manner following referral. Recommendations:
Occupational Therapist to deliver training sessions
on how to use and implement activities from
Resource Pack to cluster of schools. All schools to
have a named therapist who visits 2 hours termly to
discuss any issues school have and offer advice. A
second Resource Pack will be introduced aimed at
children over 10 years old. To amend Occupational
Therapy terminology within Resource Pack.
The review of the 1 potentially
avoidable death and 4 deaths
which were not expected
concluded that no deaths were
avoidable. Ongoing 6-monthly
mortality reviews are being
carried out.
All mainstream school in
Bucks have received
invitations to the Universal
Training on the Resource
pack. We have delivered 9
talks since September which
have been well attended. All
mainstream schools in Bucks
have been offered School
Advice Clinics, there has been
a significant take up and all
interested schools have
received termly visits from
their link therapist. There have
been many compliments about
these. The Resource pack for
Older Kids has been compiled
and is awaiting printing. It will
then be distributed in response
to appropriate referrals
received. Amendments to
Resource Pack have been
completed.
3221 NCEPOD Bariatric TBA
Surgery Study
A NCEPOD study
looking at Bariatric
Surgery (e.g. gastric
bands, gastric
bypass).
3222 BTS Non Invasive Dr A Prasad,
Ventilation (Adult) Consultant,
Audit 2011
Respiratory Medicine
(Dr Shivani Kochhar,
FY1, Medicine)
A national audit by
Integrated
the Britsh Thorasic
Medicine
Society (BTS) looking
at patients treated
with non invasive
ventilatioon outside
ICU. Comparing care
received with the
standards of care set
by the BTS.
03/05/2011 Awaiting
Report/Ac
tion Plan
3223 VTE Prophylaxis
in the Urology
Patient
To audit adherence to Surgery and
clinical guidelines on Critical Care
VTE prophylaxis risk
assessment and
prescription.
05/05/2011 Complete
Neil Haldar,
Consultant, Urology
(Dr Natalia White, FY1,
Urology), Jonathan
Pattinson, Consultant
Haematologist
Surgery and
Critical Care
01/04/2011 Complete
18/10/2012 Report published:
http://www.ncepod.org.uk/2012bs.htm
Results and Recommendations required
05/09/2011 Initial audit results: 50 patients’ case notes were
reviewed. Only 12% of inpatients were treated in a
way that was fully compliant with NICE guidance.
Recommendations: Deliver verbal and written
teaching & guidance to the current clinical team.
Devise a useful clerking tool that prompts VTE risk
assessment, incorporates a VTE risk assessment
form, and prompts the prescription of prophylaxis.
Reaudit Sep 2011.
Changes required
Changes required
Presentation of audit at M&M
meeting (June). Induction
presentation given to new
FY1s (August).
Informal guidance given on the
wards (August) Creation of
guidance sheet on ‘routine’
prophylaxis for urological
conditions and procedures
according to typical VTE and
bleeding risks.
Audit data, recommendations
and reminders emailed to
nursing staff, junior and senior
doctors (August).
Creation of induction material
for use by FY1 doctors when
new to urology. Creation and
distribution of an integrated
urology emergency
admissions clerking proforma
containing a VTE form.
3224 Traumatic Limp in Dr Atanu Dutta,
Children/Transient Consultant,
Synovitis
Paediatrics, (Katherina
Kastrissianakis, ST1)
A retrospective
Specialist
review of case notes Services
of children presenting
with a traumatic limp,
looking at
assessment and
management of this
and presenting
complaint, and how it
compares with
recommendations
found in the literature.
05/05/2011 Complete
3225 Cardiovascular
Morbidity in
Rheumatoid
Arthritis
Jane Reeback,
Consultant
Rheumatologist (Dr
Kuljeet Bhamra, SpR,
Rheumatlogy)
To assess whether
patients with RA are
being assessed for
CVD and whether
they are treated
appropriately as per
EULAR guidelines.
Integrated
Medicine
08/05/2011 Analysis/
Report
3226 Audit of End of
Life Care in the
Division of
Surgery
Karen Brown,
Divisional Manager
Surgery. Celina Eves,
Associate Director of
Nursing Surgery.
To assess patients
who died as
inpatients under the
Division of Surgery
between 01/11/2010
and 30/04/2011
against the EOL
template.
Surgery and
Critical Care
13/05/2011 Complete
17/11/2011 The main recommendation is that a guideline should
be produced for the management of children
presenting with a non-traumatic limp. 1. Pelvic Xrays should be used more selectively in children
presenting to our unit with non-traumatic limp (e.g. to
rule out SUFE in >9 years of age, to rule out NAI in
children < 3years, if there is bony tenderness on
examination, to rule out Perthes if the history is
prolonged). 2. If concerned about a hip effusion (i.e.
septic arthritis or transient synovitis), a hip ultrasound
should be the first line investigation and not a pelvic
X-ray. 3. Improvements could be made in the
documentation of examination findings such as gait,
hip examination, and abdominal examination.
4. Normal inflammatory markers do not rule out
septic arthritis.
5. Should we follow-up all children presenting with
non-traumatic limp? What is the best timing and
pathway for follow-up? 6. Should we send an ESR in
addition to CRP and FBC when checking
inflammatory markers
Results and Recommendations required
No changes recevied as
Junior doctor now not with the
Trust 21/3/13 (CP)
03/05/2012 1. For all surgical patients identified as requiring end
of life care that they are commenced on the Trust’s
ICP as soon as possible to ensure the care is
appropriate and individualised. 2. Once the ICP has
commenced all aspects of the goals are reviewed
and actioned by the medical and nursing teams. 3.
Excellent communication with the patient and their
family is continued and assessed to ensure the
correct care planning is in place. Action Plan:
Training in the introduction and use of the Integrated
Care Pathway for end of life care to ensure that
medical and nursing staff have update sessions to
access throughout the year. Repeat audit planned
for early 2013.
Emailed to John Clark, new
interim Associate Director of
Nursing, Surgery as Celina
and Karen have both left.
7/2/13 (LS). John Clark
emailed back 22/2/13 to say
he has passed matter on to
new Associate Director of
Nursing Surgery Carolyn
Morrice as he has now left the
interim post. (LS).
Changes required
3227 Management of
Miss Hall, Consultant,
Shoulder Dystocia Obs & Gynae (Zoe
(continuous)
Barber, FY1 and
Rhiannon Darcy FY1)
To follow up previous Specialist
audit and compare
Services
performance to NICE
and Trust guidelines.
(Previous numbers
2270, 2354, 2960).
16/04/2011 Complete
01/06/2011 Results - 60 patients audited. 13 did not have a
On going CNST audit now
shoulder dystocia proforma filled in. 18 patients had under 3524 20/2/13 (CP)
a shoulder dystocia proforma completed but did not
have shoulder dystocia listed as a delivery
complication in the delivery book. Delay between
head delivery and shoulder delivery documented in
100% cases. 2.91 minutes average time delay (range
1 - 11 mins). Recommendations - All patients with
shoulder dystocia must have a proforma filled out
and listed as a complication in the delivery book.
The whole of the proforma must be completed
accurately, particularly suspected fetal injury, incident
reporting and discussion with parents.
3228 Management of
Nutan Mishra,
Hypertension in
Consultant, (Lisa
Pregnancy against Procter) Obs & Gynae
NICE and Trust
Guidelines
An audit of the
management of
hypertension in
pregnant patients.
Prospective audit of
about 50 patients
between April and
June 2011.
Specialist
Services
01/04/2011 Complete
01/06/2011 Audit results showed improvement since last audit in On going CNST audit
use of MEWS chart; discussion with obs consultant repeated in 2012 CP 21/2/13
and in involving paediatricians in delivery decisions.
It found room for improvement in documentation use of proforma to identify severe criteria and
management; fluid balance and restriction; checking
for reflexes and clonus; use of MgSO4 prophylaxis.
3229 Audit of Operative Veronica Miller,
Vaginal Delivery
Consultant, Obs &
(continuous)
Gynae (Heather
Counsell, ST1)
A continuous audit of Specialist
operative vaginal
Services
deliveries. Required
for CNST. (Previous
numbers 2749/50,
2961)
01/05/2011 Complete
01/06/2011 Results June 2011: Strong preference for Neville
CNST requirement to
Barnes forceps, operator dependent. Little evidence complete continuous audit of
of adequacy of analgesia. Episiotomy 79%. The rate all cases 21/2/13 CP
of instrumental deliveries is above national levels.
Documentation is a key area for improvement requires accurate and full completion. Proforma
requires updating to meet audit criteria.
3230 Audit of the
S.A. Akinsola,
Management of
Consultant, Obs &
Ectopic Pregnancy Gynae (M. Sadik
Haleem, SpR)
An audit to measure Specialist
the proportion of tubal Services
pregnancy cases
managed
laparoscopically,
January to December
2010. (Previous audit
numbers 2131,
2133).
31/05/2011 Cancelled
07/09/2011 Cancelled. Dr has left Trust and audit never started. Project cancelled.
3231 Copying of Letters Dr G Luzzi, Medical
to Patients Survey Director
A survey of practice
in relation to copying
patients into clinical
letters.
Trustwide
10/05/2011 Complete
20/05/2011 Dr Luzzi to use the results to inform discussions on
copying letters to patients.
3232 Audit of
Management of
Pelvic
Inflammatory
Disease
Audit of Management Specialist
of PID against RCOG Services
guidelines (Greentop
Guidelines 32).
30/05/2011 Complete
13/07/2011 18 cases over a period of seven months Dec 2010 - No chnages forthcoming, to be
June 2011. 14 admitted for PID. 4 attendances at
reaudited in 2013 by another
AE from May to June 2011. All seen by gynaecology junior 21/2/13 (CP)
team. 2 were initially referred to surgical team from
A&E for appendicitis. All had abdominal
pain/tenderness. Under diagnosed/Missed cases or
low rate of PID. Poor documentation in majority of
the cases. Incomplete clinical examinations. Not
aware of/not following the guidelines. Five
admissions could have been avoided.
Recommendations: Juniors to be more aware of PID
and the relevant guidelines. Suggest including this
topic in the induction programme. Use of a proforma
for clerking patients with PID. Re-audit once above
implemented.
Tunde Dada,
Consultant, Obs &
Gynae (Arass Ahmed
FY1, Louise Cripps,
FY1)
Changes required
3233 Post Take Ward
Round
Documentation
Dr Syed Hasan,
Consultant MFOP (Dr
Anthony Dimarco, CT2,
Medicine)
To asses the
Integrated
completeness of
Medicine
documentation of
information on the
post take ward round
proforma
19/05/2011 Complete
27/07/2011 Areas of strength and weakness have been
Changes required
indentified through this audit. Although
documentation of patient data met the standards, the
time of the encounter was not well documented.
Considering there are government targets linked to
this then this is an area which needs to be improved.
Other areas for improvement are investigation
findings and completion of tick boxes to assist the
team that take over the care of the patient. Following
feedback at the Medical Grand Round it was decided
to make a concerted effort to improve
documentation. If this approach fails then
modifications to the proforma may be required.
3234 Intrathecal Opioids Dr Hans Mathew,
Associate Specialist,
Anaesthetics, Mary
Miller, Lead Nurse Pain
Management (Dr Dana
Kelly, ST5,
Anaesthetics)
To determine current Surgery and
practice relating to
Critical Care
the timing of
administration of
systemic opioids after
intrathecal opioid with
the aim of producing
formal guidance.
19/05/2011 Complete
25/07/2011 Recommendations:all patients who have received
Intrathecal (Spinal) Opioid
intrathecal opioids should have naloxone prescribed Guidelines for Adults are being
on drug chart (if not already prescribed on a PCA
developed.
chart); consider formal published guidance relating to
the use of intrathecal/ epidural opioids (to be
available on the hospital intranet); consider reducing
dose of opioids and increasing frequency of
monitoring in high risk groups - this could be altered
on the new sticker easily (i.e. writing half hourly
instead of hourly observations); suggest a review of
current IT opioid stickers.
3235 National
Parkinson's Audit
2011
This is a national
audit designed to
help Trusts evaluate
their Parkinson's
service against the
NICE Guideline and
National Service
Framework for Long
Term Neurological
Conditions, compare
their Parkinson's
service to others
around the UK,
highlight strengths
and weaknesses in
current service and
develop an action
plan to improve
services.
20/05/2011 Awaiting
Report/Ac
tion Plan
Dr Syed Hasan,
Consultant MFOP
Integrated
Medicine
Results and Recommendations required
Changes required
3236 Audit on the
Management of
Hyperglycaemia in
ACS Patients
Dr Firoozan,
Cardiology Consultant
(Dr Catherine Hildyard,
FY2, Medicine)
Assessment of the
Integrated
proportion of patients Medicine
with ACS, with
documented
hyperglycaemia, that
are started on an
insulin sliding scale,
in accordance with
guidelines.
20/05/2011 Complete
14/11/2011 It was felt that poor performance in commencing lipid
and glucose lowering therapy are likely to be due to
lack of awareness of guidelines. In particular, lipid
lowering therapy was previously not felt to be an
important part of in hospital management, and was
therefore left to the patient's GP to start; however
there is increasing evidence to suggest the benefits
of starting a stain immediately afar an ACS event.
Recommendations: Draft a new ACS clerking
proforma, with
a management pathway advising initiation of lipid
and glucose lowering therapy. This will also allow
specific areas of weakness to be highlighted in
teaching sessions.
A new ACS clerking proforma
has been introduced which
includes a management
pathway advising initiation of
lipids and glucose lowering
therapy.
3237 Distal Finger Tip
Mr Heywood,
Injuries in Children Consultant, Plastic
Surgery (Roman
Mykula, SpR, Plastic
Surgery)
Retrospective survey Surgery and
of surgical treatment Critical Care
and outcomes of
distal fingertip injuries
in children aged 12
and under from
January to June
2010.
24/05/2011 Complete
12/01/2012 This survey included 52 injured digits in 50 children
aged 12 and under. Data was collected on the
mechanism and nature of the injury, the operative
details and the outcome of surgery. The data was
presented in the June 2011 Plastic Surgery RITA
Day and was combined with data from Oxford,
Salisbury, and Plymouth. No recommendations for
change were recorded.
No recommendations for
change were recorded.
3238 Skin Cancer
Patient
Experience
Survey
To determine the
Specialist
effect of the
Services
introduction of the
CNS Skin Cancer
Clinic on patient
experience regarding
being given a
diagnosis of SCC or
Melanoma. Survey of
all patients seen in
the Skin Cancer
Clinic from 1 Jan to
30 June 2011.
17/05/2011 Complete
06/02/2012 Recommendations: all SCCs, melanoma and high
risk lesions should continue to be flagged for
histology as urgent; all patients should be advised
that histology results can take 4-6 weeks before
patients will be informed – this has been amended
on the patient information leaflet; specimens sent to
another Institute for a second opinion can result in a
delay which can increase anxiety – this needs to be
detailed in the patient information leaflet; a clear plan
should be in place so that patients receive their result
/ appointment in a timely manner; all patients with
biopsy results outstanding will be advised that they
will receive an appointment to be given the
diagnosis. This ensures that patients with a
diagnosis of a cancer will be seen face-to-face. If the
lesion is benign/BCC a letter will be sent; patients
must be given appropriate preparation at the time of
first referral and/or time of surgery so that their
expectations can be managed; there are times when
it is still appropriate, however, to give a diagnosis of
a low risk skin cancer (including BCCs) by post or
over the telephone providing that this is followed up
Managing patient expectation:
Patient leaflet has been
amended. Repeat survey has
been completed - except for
action plan.
Breeches: 2 trackers have
been employed to investigate.
Rescheduling of
appointments: When skin
patients are seen by
dermatology and have their
lesions removed they are
automatically given an appt for
follow up usually for 6 weeks.
If the lesion proves positive
then this appt will be altered
i.e. brought forward.
Patient Information: Along with
the network we currently issue
the Macmillan information
booklets - we are waiting for
the go ahead with Skin
Rubeta Matin,
Specialist Registrar,
Dermatology, Fiona
Briggs, Skin Cancer
Clinical Nurse
Specialist, Dr
Katharine Acland (MDT
Lead)
with written information and an offer to discuss the
diagnosis face-to-face; patients should be given a
telephone contact number (Cancer Nurse Specialist)
as a point of contact once a skin cancer is diagnosed
or at the discretion of the doctor at the point of initial
referral; all patients should be clear when given the
diagnosis what the ongoing plan for care involves
and this may require additional written information;
consider review of the cause of breech in individuals
when this occurs; rescheduling of appointments due
to hospital factors e.g. absence / leave / cancellation
of clinics need to be discussed with management
regarding the possible options to reduce this.
3239 Prescription of
A Goede, Consultant,
Intravenous Fluid Surgery (Robin Spacie,
and Electrolytes in FY1, General Surgery)
Emergency
Surgery
Prospective audit of
fluid prescription and
administration in
emergency surgery,
based on British
Association for
Parenteral and
Enteral Nutrition
(BAPEN) guidelines:
British Consensus
Guidelines on
Intravenous Fluid
Therapy for Adult
Surgical Patients.
Surgery and
Critical Care
23/05/2011 Complete
information prescriptions.
Histology 2nd opinion:
Tracking system is in place; a
report issued immediately
stating that lesion is possibly
malignant and has been sent
for second opinion; case
added to next MDT list so that
MDT can monitor.
12/09/2011 Results: The audit shows a clear need for better fluid Teaching sessions have taken
prescribing for adult emergency surgery patients as place and a re-audit is
no audit standard was met. The audit did show
planned.
some improvement in prescribing following teaching
but the difference was lower than expected. Possible
reasons for this are that the session was fairly short
and was delivered near the end of the FY1 year
when it may be difficult to change prescribing habits
amongst doctors. Also, whilst a handout was
provided there was no post teaching assessment of
knowledge to ensure that knowledge had improved
and hence provide extra help as needed.
Recommendations: Fluid prescribing by junior
doctors needs to be improved, and this can be done
through teaching sessions. In future, doctors starting
their surgery rotation should be taught best practice
fluid prescription based on the national guidance.
The ideal time for this would be before they start
working in the department so should form part of
their departmental induction, or occur during
induction week in August prior to starting work. Once
this recommendation is implemented it will be
necessary to re-audit practice to ensure prescribing
is improving.
3240 Management of
Multiple
Pregnancies
Aparna Reddy,
Consultant, Obs &
Gynae (Anne Beh,
FY2)
Review of notes to
Specialist
audit the
Services
management of
multiple pregnancies
- antenatal,
intrapartum, second
and third stage care,
to assess compliance
with Trust and CNST
guidelines.
09/05/2011 Cancelled
03/08/2011 Cancelled, audit never carried out. Doctor now left
the Trust.
Project cancelled
3241 Staff
Questionnaire to
Evaluate HPV
Information
Sheets
Cathie Hansen,
Colposcopy Nurse
Smear test from
January 2012 will
incorporate HPV test
to identify whether
any HPV infection is
high or low risk for
cervical cancer.
Results will affect
necessity for recall.
Specialist
Services
24/05/2011 Complete
06/10/2011 Action Plan: Rewrite leaflet to give clearer
explanation of what a positive HPV test means to an
individual patient. Avoid repetitive statements.
Include a flow chart to simplify the new protocols
The National Guidelines have
been withdrawn as they have
changed from the original
concept.
The information leaflet would
not now be correct and new
guidelines are not yet agreed.
Observational audit
spinal only.
Clinical
Support
Services
01/12/2010 Complete
31/05/2011 3/10 patients were not screened for MRSA pre-op
Infection Control monitor
when they should have been. Peri-op: The WHO
completion of action plans and
surgical checklist was undertaken in 100% of cases. re-audits.
Within New Wing Theatres prophylactic
antimicrobials were administered in line with Trust
antibiotic guidelines. However on discussing the
regime with the cystoscopy unit, it was clear that they
are not following the guidelines correctly.
Ciprofloxacin is being given on induction. 1 patient
had hair removed by shaving. All hair must be
removed using clippers not shaving. It is unclear if
the glucose monitoring and normothermia should
have been maintained or if it was
‘not applicable’. Staff should be reminded to
complete the form correctly by ticking the appropriate
column. All areas with non participation must
produce an action plan on how they are monitoring
the
compliance with this audit. Areas who did not
produce an action plan must produce an action plan
to show how areas of non- compliance have been
addressed. All areas with ‘No’ answers are required
3114 Surgical Site
Amanda Adkins,
Infection Pre-op
Infection Control
and Peri-op Audit Spinal
to sign off this action plan to confirm all actions have
been completed and then return to the IPC.
3242 Audit of
Management of
Alcohol
Withdrawal (WH)
Dr David Goddard,
Consultant
Gastroenterologist (Dr
Michael Pavlides, SpR,
Gastroenterology)
Are patients being
Integrated
assessed and treated Medicine
in line with Trust
guidelines.
03/06/2011 Complete
20/10/2011 Recommendations: Poor adherence to guidelines for Changes required
treatment of alcohol withdrawal. Patients discharged
too soon without completing their detox. Vernicke’s
encephalopathy not sought and only 50% of at risk
patients receive pabrinex. Coding not accurate.
Recommendations: Educate medical and nursing
staff. Make guidelines more easily available via
posters, printed CIWA sheets in clinical areas,
reminder on clerking proforma. Alcohol assessment
team need to identify Themselves to medical and
nursing staff. Annual re-audit
3243 NAPA Guidelines
Assessment:
Airway and
Aspiration
Dr J Drake, Dr
Ramaswamy,
Consultants,
Anaesthetics (Dr J
Hughes, SHO,
Anaesthetics)
Assessment of
Surgery and
whether or not a
Critical Care
formal complete
airway assessment
and aspiration
assessment has been
completed.
03/06/2011 Complete
18/10/2011 Recommendations: Training of the juniors.
Emphasis on the importance of pre-assessment and
subsequent documentation. Improve the anaesthetic
chart. Re-audit.
An academic morning in May
was devoted to a department
airway teaching for all
anaesthetists.
We already carry out training
for novice anaesthetists in the
Trust and are aiming to
include something regarding
airway training in their
induction programme.
Regarding documentation,
there is a new anaesthetic
chart in the pipe line, a specific
one for obstetrics is already in
circulation, with a formalised
airway assessment to be
completed by the anaesthetist.
Re auditing will take place
once this chart is in circulation
3244 Antenatal blood
screening against
CNST, NICE and
Trust Guidelines
Miss Aparna Reddy,
Consultant, Obs &
Gynae, (Kirstie
Kinross, FY1)
An audit of antenatal Specialist
screening for
Services
infections, i.e. HepB,
C, HIV, rubella,
syphilis. To check
whether all women
are offered screening
and, if found positive,
were they correctly
managed.
Retrospective audit
for March 2011.
06/06/2011 Complete
13/07/2011 Results: 1. HepB - 346 births, 1 positive HepB,
correctly managed. Random sample of 52 patients
checked and no other cases identified. 2. No record
of any HIV positive patients found in birth register,
none identified in random sample of 52 patients. 3.
No record of any negative rubella immunity status
patients in register and none identified in random
sample. 100% women/babies being offered
screening within 13 weeks. Recommendations:
Patients with rubella susceptibly have been identified
by ante-natal blood test. Unfortunately, no result to
cross reference with the lab. No clear documentation
if MMR being offered post-natally, refused or advice
sent to GP. Recommend rubella ante-natal audit and
evidence of regular training on screening for staff.
No changes forthcoming as
junior doctor now left. Audit to
be repeated in 2013 21/2/13
(CP)
Audit of approx 20
patients to ascertain
whether NICE
initiation and
continuation criteria
are met.
Specialist
Services
06/06/2011 Cancelled
05/11/2012 Cancelled
Cancelled
3246 Care of Ventilated Amanda Adkins,
To evaluate results of Specialist
Patients May 2011 Infection Control Nurse High Impact
Services
Intervention (HII) 4
tool used in Saving
Lives Infection
Control programme.
01/05/2011 Complete
10/08/2011 There was one instance in St George’s Ward where No changes required. Rehand hygiene was not performed prior to the
audit next year.
procedure. In all other cases there was 100%
compliance. This equates to an overall compliance
for all applicable elements performed of 99%. This is
better than in all previous years.
3245 Audit of Exenatide Dr Henrietta Brain,
NICE Compliance Consultant, Diabetes &
Endocrinology (Maire
Stapleton, Formulatory
Manager)
3247 Urinary Catheter
Care May 2011
Amanda Adkins,
To evaluate results of Specialist
Infection Control Nurse High Impact
Services
Intervention (HII) 5
tool used in Saving
Lives Infection
Control programme.
01/05/2011 Complete
3248 Environment,
Kitchens, Patient
Equipment
Infection Control
May-Jul 2011
Amanda Adkins,
To audit cleanliness, Specialist
Infection Control Nurse infection control etc in Services
all environments and
equipment in all
areas of the Trust.
01/05/2011 Cancelled
28/11/2011 Results: 99% compliance for all elements for urinary
catheter insertion. 94% compliance for urinary
catheter continuing care. Recommendations:
Ensure all areas with non participation complete the
audit within their area and address any issues
highlighted by producing an action plan detailing how
they are monitoring the compliance with this audit.
Ensure that all areas who did not produce and return
an action plan at the time of completing the audit
now produce an action plan to show how areas of
non- compliance have been addressed.
Ensure all areas with ‘No’ answers sign off this action
plan to confirm all actions have been completed and
then return it to the IPCT.
Adapt audit tool to make it clearer how to respond.
Future audits should record the staff group of the
individual carrying out the urinary catheter insertion.
This should be added to the audit tool.
The Urinary Catheter Assessment and Monitoring
Form tool has successfully been piloted in specific
areas and will be introduced across the Trust
following ratification. The form acts as a prompt to
inform practice and should be integrated into
individual staff group training sessions and updates
including Infection Control Link Practitioner days,
HCA Induction and Nurse Development and update
days.
06/03/2012 Cancelled
All actions have been
addressed and the audit form
has been updated.
Cancelled
3249 National
Paediatric
Diabetes Audit
2010 to 2011
Dr A Dutta, Paediatric
Consultant, SMH, Dr M
Russell-Taylor,
Paediatric Consultant,
WH
A national system for Specialist
routine data
Services
collection, analysis
and feedback of
diabetes related data.
08/06/2011 Complete
28/09/2012 To be added. File on website damaged, cannot
read.
Changes required
3250 Perioperative
Management of
Diabetes Mellitus
in Elective Day
Surgery Patients
Dr P Strube,
Consultant
Anaesthetist (Dr
Matthew Brown, FY1,
Anaesthetics)
An audit to
Surgery and
investigate
Critical Care
perioperative
optimisation of blood
sugar and adherence
to perioperative
measures in diabetic
patients.
08/06/2011 Complete
31/10/2011 None of the audit standards were met.
Changes required
Recommendations: Raise awareness of local
protocol and national guidance with regard to
perioperative management of diabetes. Check
HbA1c on all preoperative diabetic patients to assess
stability of disease. Perform urinalysis on all diabetic
patients admitted for day case surgery. Prioritise
diabetic patients on the operating list to limit
starvation times. Ensure regular perioperative blood
glucose measurements as per guidance, to enable
identification and treatment of hypo or
hyperglycaemia.
3251 Audit of
management of
incomplete/missed
miscarriage
Chris Wayne,
Consultant, Obs &
Gynae (Dr Will Gray,
FY1)
An audit of
Specialist
management of
Services
patients who present
to EPAU with
miscarriage. Are
ultrasounds
requested
appropriately and
what proportion of
patients subsequently
have confirmed,
incomplete or missed
miscarriage? Against
EPAU and RCOG
Greentop guidelines.
24/05/2011 Complete
13/07/2011 Results: On the whole the Unit functions very
Re audit completed in Nov
effectively for such a busy unit. Record keeping is on 2012 21/2/13 (CP)
the whole excellent, and information readily
available. Referral criteria by and large are met.
Recommendations: 1. To discourage patients being
permitted to self refer, as many could perhaps be
filtered by Primary Care. 2. To be stricter on meeting
criteria for scans, especially those with a hx of
recurrent miscarriages. 3. To re-audit in the future, ?
a prospective audit looking at the management of
missed miscarriage and what percentage of those
receiving conservative tx go on to have heavy PV
loss -> ERPC.
3252 National
OesophagoGastric Cancer
Audit (NOGCA)
Maureen Kiely, Clinical This national audit
Nurse Specialist, GI
has now been
Cancer
reopened collecting
data on all patients
diagnosed from the
1st April
2011onwards.
3253 NSIC FamilyDr Alison Graham,
Centred Care Staff Consultant, NSIC
Survey
Integrated
Medicine
10/06/2011 Data
Collection
Results and Recommendations required
A survey to assess
Specialist
staff understanding of Services
the NSIC as providing
"family-centred" care.
13/06/2011 Complete
26/09/2011 Organisational change: 1. Develop action plans to
advance the practice of patient- and family-centred
care and create sustained organisational and cultural
change. 2. Apply patient- and family-centred
principles to policies, programmes, environmental
changes, staff practices, and professional education.
3. Facilitate and enhance collaboration with patients
and families across disciplines and settings. 4.
Develop or revise methods for gathering information
about patients’ and families' perceptions of care.
Staff development and professional education: 5.
Conduct training programmes on best practices and
innovations in patient- and family-centered care. 6.
Create partnerships for quality and safety. 7. Develop
peer support and family-to-family support. 8.
Integrate patient- and family-centred concepts in staff
education. Environmental review: 9. Review projects
for consistency with patient- and family-centred
principles and strategies. 10. Involve patients and
families in planning processes. 11. Review planning
documents, plans, concepts for interior finishes,
furnishings, and decor to meet the overall goals and
needs of all users.
Changes required
1. A multidisciplinary quality
improvement group has been
set up to review patient and
family centred care for both
the paediatric and the adult
service. This meets monthly
and reports to the Quality
Improvement Group overal,l
as identified by our CARF
recommendations which
reports to Divisional Board. 2.
Ongoing- family room and
quiet room have been
changed to enable more
families to access them. We
are reviewing the PFCC
agenda as part of the Kings
Fund initiative to improve
family invovlement in the ward
round process. Family
education is being supported
by the development of an
education channel. 3. Pilot of
family involvement in structurd
format for Dr Graham adult
and paed ward rounds. 4. Use
exisitng experience - dataproductive ward, relatives' day
and patient experience data
needs to be reviewed by more
members than current rehab
lead. Family Counsellor to
establish coffee mornings for
informal review. 5. Training
programmes being introduced
on a bedside model around 1
consulatnt ward round to pilot
invovlement. 6.Partnership
still needs further
development- need more
input- plan is to start with work
3254 Management of
Soft Tissue
Infections
Mike Tyler, Consultant, An audit to assess
Surgery and
Plastics (Sophie Dann, the time lapse
Critical Care
ST3, Plastics)
between prescription
and administration of
IV antibiotics for soft
tissue infection.
3255 Compliance of
Dr Rowena Warwick,
Rate of Reporting Consultant Radiologist
by Non-Radiology
Clinicians
Non radiology
Specialist
clinicians are required Services
by the IR(ME)
regulations to provide
an interpretation of
radiology images in
patient records in
certain clinical areas
where there is an
agreement with the
radiology department.
This audit measures
compliance with this.
14/06/2011 Awaiting
Report/Ac
tion Plan
16/06/2011 Complete
Results and Recommendations required
around medication and then
review use. Paediatric
medication sharing knowledge
in first instance but will use
this with adult population. 7.
Family coffee mornings,
sibling workshops and spin
group for networking and
suggestion sharing with
clinical staff. Family week
activities for social events. 8.
Work with practice
development nurse and also
with medical education to
ensure family considered in all
areas of work- sample audit. 9.
Education channel is to be
used as a major scheme for
family involvement.
Changes required
05/09/2011 Results: 35 (73%) patient notes contained a report of Results fed back to Trauma
the X-ray either in the clinical notes or in the GP
and Orthopaedics and Oral
letter. 13/48 (27%) patient notes contained no report Surgery and Orthodontics.
of the X-ray. Recommendations: Results to be fed
back to Trauma and Orthopaedics and Oral Surgery
and Orthodontics.
Re-audit October 2012.
3256 Prolonged VTE
Prophylaxis in
High Risk Surgery
Re-audit
J Pattinson,
Consultant,
Haematology (Kabir
Ahluwalia FY1,
Surgery)
Audit to determine
Specialist
whether prescribing
Services
for DVT prophylaxis
is meeting NICE
recommendations for
patients undergoing
surgery for cancer, as
well as orthopaedic
(hip/knee
replacement, major
trauma and fractured
neck of femur). Reaudit of 3205 based
on April 2011 data.
21/06/2011 Complete
01/08/2011 Re-audit of 3205 after discussing results with T&O
Results have been reported to
team. The number of patients being prescribed
T&O.
prolonged prophylaxis has increased to 98%,
representing that implementations made have been
successful. The number of patients being prescribed
Aspirin has also reduced to 0.
There continues to be good medical prophylaxis for
inpatients during the perioperative period.
Unfortunately, prescriptions for TEDS stockings
actually were decreased compared to the data
collected in January
The number of VTE assessments is decreased
compared to those in January. However, it appears
that the correct form of prophylaxis is being
prescribed despite this.
There was 0 PE’s or DVT’s for the patients audited
during the month of April, possibly representing the
benefit of providing prolonged prophylaxis.
3257 Outcomes of
Back/Lower Limb
Exercise Classes
Sharine Ballicanta,
Physio WH
An audit to determine Specialist
effectiveness of
Services
back/lower limb
exercise classes.
23/06/2011 Complete
20/09/2011 Results: The class discharges an average of 7.7
patients per month. The majority of patients drop out
before completing the course; with only 37%
completing the full course. Of the 17 completing the
class, 13 had the LEFS outcome measure recorded
before and after the class.
Of these 13, 12 had an improved outcome, 9 of them
significantly improved. This shows that the class is
effective in improving the patient’s functional abilities.
Recommendations: Ensure that every one referred
to the class has pre-class LEFS scores. Present
results of audit to the Wycombe Physiotherapy
Department. In future, record LEFS scores after 4
sessions and at the end of the course.
We have implemented the
recommendations for the LL
class based on the results of
audit. i.e. everyone referred to
the class has pre-class LEFS
scores. LEFS scores
recorded after 4 sessions and
at the end of the course. The
future plan is to audit the LL
classes across sites and follow
up patients who have dropped
out. There is no immediate
plan to do this at the moment.
However, we are continuing to
collate this information.
3258 Community
Nursing Team for
Children with a
Learning Disability
Client Experience
Survey
Anne Poll, Clinical
Nurse Specialist
Children with Learning
Disabilities
Client experience
Specialist
survey to obtain
Services
feedback on the
service provided by
the community
nursing team for
children/young
people with a learning
disability.
27/06/2011 Complete
12/01/2012 Action plan: Make information about services
available for children with a learning disability more
ease for healthcare professionals to access. Make
parents more aware of the contents of their child’s
care plan. Reduce the waiting time following referral.
Identify which families require written information in a
language other than English. Investigate the
feasibility of assisting parents with the transporting of
children to appointments.
Intranet updated to improve
accessibility of information to
professionals. Training
updated to ensure Community
Staff Nurses are making
parents more aware of the
contents of the child's care
plan. Recruitment for an
additional member of staff is
currently being implemented.
Written information provided in
another language is in-hand.
The final action regarding
assisting parents with the
transporting of children to
appointments is proving to be
challenging and a solutions is
yet to be found.
Specialist
Services
27/06/2011 Complete
31/10/2011 The new ‘First Net’ CRS system for both emergency See audit 3424.
departments will improve the recording of patient
information. Diagnosis and school will be mandatory
fields; address and GP details will be taken from the
NHS spine. An audit of the free text fields should be
carried out in 2012 to see if adequate information is
being provided.
Debbie Begent,
Service Manager
Summary of clinical
Specialist
activity data and
Services
referral data 2010 to
ensure collecting right
info and to identify
trends.
01/05/2011 Complete
28/06/2011 Results: The distribution of Acute staff, from
statistics shown appears to be at the correct level.
The number breached waiting times is stabilising.
We are receiving more referrals from ENT
Consultants and the hub for Head and Neck Cancer
care is moving more patient care to local services.
The Voice team have done much to improve their
efficiency with introduction of a telephone screening
system. Recommendations: Monitor statistics and
re-distribute staff as required in response to changes
in the Trust. To continue to develop the care
pathway for patients with Long Term Conditions.
Also to make ongoing improvements in the Waiting
List management ensuring we have enough
designated initial appointments each week.
Continued collection of statistics in order to monitor
referral and response rates so that we can be flexible
in an organisation that is changing and developing.
Jill Mowforth, Hayley
Adams, Lung Cancer
Specialist Nurses
To explore patient
Specialist
experience for those Services
patients with lung
cancer and
mesothelioma who
are admitted to
hospital. To identify
the role of the CNS in
supporting the patient
during an admission.
30/06/2011 Cancelled
10/07/2012 Project cancelled due to insufficient numbers.
Patients either die while still inpatient or go home or
to hospice to die post admission.
3259 Paediatric A&E
Reports Re-audit
Sydnella Terry,
A re-audit of 2913.
Paediatric Liaison
Nurse, Jane Bremnath,
Named Nurse for Child
Protection
3260 Speech &
Language
Therapy Annual
Statistical report
3261 Lung Cancer
Inpatient
Experience
Survey 2011
1. Continue to monitor
statistics and are redistributing staff as the Trust
re-organises e.g. to Stroke
Unit based at WGH.
2. There is a delay on the start
of ESD Speech Therapy due
to recruitment problems and
this post commences 12.3.12.
Reviewing the pathway for
people with long term aphasia
and working with the Stroke
Association to develop a new
pathway in better partnership.
3. Keeping a referral datbase
which indicates if a patient is
referred with Head and Neck
cancer
4. Continue to collect stats.
Project cancelled
3262 Local Enhanced
Service: Below
Knee Wounds
Sarah Mobsby,
Specialist Vascular
Nurse
Evaluation of training Integrated
for practice nurses on Medicine
how to perform
doppler assessment
and compression
bandaging.
01/07/2011 Complete
10/07/2012 No recommendations or action plan received. No
plans to continue the service at present.
3263 Gestational
Diabetes Dietetic
Clinic Patient
Experience
Survey
Anna Martin, Dietitian
Survey of gestational Specialist
diabetes dietetic clinic Services
patients.
28/06/2011 Complete
05/11/2012 Looking at the results, all participants were satisfied None required
with the dietetic service in question. All patients were
given consistent advice post their diagnosis of
Gestational Diabetes. Although advice was given by
a number of health professional including midvives,
consultants and dietitians, patients were not given
conflicting or confusing advice.
Most patients made positive changes to their diet in
accordance with the most up to date evidence based
advice for Gestational Diabetes after their
consultation with the Dietitian, but some had made
changes prior to their consultation.
3264 Spinal Trauma
Audit
Mr Belci, Consultant,
Spinal, Temi Ayorinde
Review clinical notes Specialist
of spinal injury
Services
patients to design
and plan spinal
trauma pathways.
Auditing against
National Spinal
Injuries Pathways
International
Guidelines.
04/07/2011 Cancelled
Results and Recommendations required
Changes not required
Changes required
3265 Audit of Obstetric
Anaesthetic
Handover
Matthew Size,
Consultant
Anaesthetics
Prospective audit of
the quality of
handover between
the obstetric
anaesthetists on call
at shift handover.
Surgery and
Critical Care
01/07/2011 Complete
31/08/2011 The length of handover (10 mins) seems appropriate No changes have been
but could be improved. Small numbers of handovers received 21/2/13 (CP)
measured due to problems during data collection
period. Significant number of patients not handed
over. Plan to introduce SAFE proforma and then reaudit 3 months after introduction. (Sick patients/At
risk of major anaesthetic problems/Followups/Epidurals).
3266 Investigation and Dr A Dutta, Consultant
Management of
Paediatrician, Dr
Babies Born to
Ashish Marwaha, ST1
Mothers with
Thyroid Disease at
Risk of
Thyrotoxicosis
(SMH)
Different policies exist Specialist
on how babies are
Services
managed; both recent
literature and the
local tertiary hospital
suggest investigating
only babies whose
parents have
hyperthyroidism. The
aim of the audit is to
see if we pick up any
extra cases and how
often these patients
are followed up;
would changing the
guideline reduce the
workload?
30/06/2011 Cancelled
09/04/2012 Audit cancelled. Doctor left Trust without completing Changes required
audit.
3267 General Surgical
Post-take
Proforma Audit
The consultant post- Surgery and
take ward round entry Critical Care
of general surgical
admissions from
1/5/11 to 31/5/11 will
be reviewed following
introduction of a new
proforma in order to
assess how well the
proforma is being
completed.
06/07/2011 Complete
27/07/2011 The recommendation from the General Surgical
M&M meeting where the audit was presented was
that the proforma should be slightly revised and
trialled for another month. This is in progress.
Mr Goede, Consultant
Surgeon (Tom
Bannister, F1, T&O)
Proforma revised and trialled
for another month.
3268 Maternity Record
Keeping Audit
Miss Veronica Miller
and Mr Tunde Dada
3269 Infection
Amanda Adkins,
Prevention &
Infection Control Nurse
Control
Knowledge Survey
2010
An audit of maternity Specialist
recording keeping
Services
carried out by SoM's
and band 7 midwives
annually. Required
for CNST.
01/01/2011 Complete
A questionnaire to
Specialist
assess staff
Services
knowledge of
Infection Prevention
& Control. In the past
this has been carried
out by post. This
year an online survey
was used.
01/11/2010 Complete
30/07/2012 Recommendations: Pregnancy and general - 1. VTE
assessment to be completed at designated times:
compliance to improve from 60% to 90%. 2. All
women with a growth chart to have this correctly
completed: compliance to improve from 78% to
90%. 3. All women to have lead professional and
place of care/birth to be correctly recorded on the
front of the pregnancy notes with appropriate
amendments: compliance to improve from 50% to
80%. 4. Special features boxes on inside front cover
of lilac notes to be completed appropriately:
compliance to improve from average of 52% to 80%.
5. All practitioners involved in care to provide a
sample signature: compliance to improve from
average 52% to 80%. 6. Betal blood sampling
results to be written on appropriate labour page:
compliance to improve from 50% to 80%. 7. Csection operative page to be fully and correctly
completed: compliance to improve from 67% to 80%.
8. All continuation sheets to be numbered:
compliance to improve from 63% to 80%. 9. All
continuation sheets to be headed with woman's
name and NHS number: compliance to improve from
21% to 80%. 10. CTGs, use of Pinards, monitor
number, otcomes, signature on completion, use of
fresh eyes stickers, signature on review, significant
events on CTGs: compliance to all areas to improve
from average 50% to 80%. 11. Prescription charts,
use of PGDs to be correctly documented: compliance
to improve from 68% to 80%. 12. All obstetric
emergencies to be recorded on appropriate pro
forma: compliance to improve from average of 80%
to 90%.
12/07/2011 376 clinical staff completed survey. Education
around when hand sanitiser must not be used needs
to be prioritised due to a total of 47% answering that
hand sanitiser can be used with patients with
diarrhoea, with Norovirus and when a ward is closed
due to Norovirus. Leading up to months when
H1N1can be an issue, information must be given to
the appropriate areas and staff groups around PPE
and what to wear and when. For low risk procedures
with no aerosol generation 37.2% would wear FFP3
masks instead of the correct theatre masks.
20% answered that the single use symbol means
single patient use. This could lead to cross infection
by reusing items that are
manufactured as single use only. 96% of staff
answered correctly that the first thing to do following
a needlestick injury is to bleed, wash and report it.
Completing the IPC mandatory training has changed
various staff's practice.
All the recommendations from
the knowledge survey have
been addressed. They were
highlighted in the IC times,
discussed at relevant meeting
e.g. Sister’s and Nursing and
Midwifery board meeting. The
AND’s have assured us all
audits are discussed at their
Clinical Governance and
Divisional Board meetings.
3270 Peri & Postoperative
Complications
Associated with
Cystectomy
following
Neoadjuvant
Chemotherapy
Mr N Haldar,
Consultant Urologist,
(Dr Chris Blick, SpR
Urology)
To compare operative Surgery and
and post operative
Critical Care
complications and
assess safety of
neoadjuvant
chemotherapy in
muscle invasive
bladder cancer.
27/07/2011 Awaiting
Report/Ac
tion Plan
Results and Recommendations required
Changes required
3271 LSVT Service in
SALT
Norma Ramsay,
Within Speech &
Specialist
Specialist SLT, Clinical Language Therapy,
Services
Lead for LTC team
LSVT (a specialised
voice treatment
programme) is a
specialist service to
patients with
Parkinson's Disease.
The waiting time has
been excessive at 12
months. They are
attempting to reduce
wait times and
provide equitable
geographical access
to service. Looking at
all patients April 2010
to April 2012.
14/07/2011 Cancelled
27/04/2012 Cancelled
Cancelled
3272 SALT Community Norma Ramsay,
Looking at all patients Specialist
Waiting List
Specialist SLT, Clinical April 2011 to April
Services
Management
Lead for LTC team
2012.
14/07/2011 Cancelled
27/04/2012 Cancelled
Cancelled
3276 Therapeutic
Hypothermia in
Cardiac Arrest
Dr Sarah McNeillis,
Consultant
Anaesthetist (Dr Peter
Valentine, CT2,
Anaesthetics)
A pre and post NICE
guideline audit of the
use of therapeutic
hypothermia in
Cardiac Arrest.
Surgery and
Critical Care
02/08/2011 Awaiting
Report/Ac
tion Plan
Results and Recommendations required
Changes required
3277 Audit of Outcome Dr John Edwin, Staff
of Sacroiliac Joint Grade, Anaesthetics,
(SIJ) Injections
Dr K Bakshi,
Consultant in Pain
Medicine &
Anaesthesia (Murli
Thiyagarajan, medical
student)
Audit of the outcome
following Sacroiliac
Joint (SIJ) injections
for patients with
chronic SIJ related
pain.
Surgery and
Critical Care
02/08/2011 Complete
(no
changes
reported)
04/12/2011 Sacroiliac joint injection is shown to be a clinically
Changes required
effective diagnostic tool and intervention, producing
short term pain relief for patients of chronic back
pain. Patients who do not get adequate pain relief
from SIJ injection should be considered for long term
pain relief interventions. Recommendations: A
further audit should be performed to look at the
reasons behind the large percentage of incomplete
notes; further research into the validity of sacroiliac
joint injection and its cost effectiveness; further
research into the effectiveness of long term treatment
such as radiofrequency denervation and ligament
prolotherapy.
3278 Audit of Refractive David Sculfor, Head of
Outcomes
Optometry
Following Cataract
Surgery
It recommended by
Surgery and
the College of
Critical Care
Ophthalmologists that
the glasses
prescription of
patients who have
had cataract surgery
is audited. If there is
a systematic error
then adjustments can
be made to lens
calculations.
02/08/2011 Cancelled
31/12/2011 Audit cancelled - no activity.
Project cancelled.
3279 Audit of The
Effectiveness of
Iontophoresis
Treatment for
Dermatology
Patients suffering
from
Hyperhydrosis
Sarah Colebrook,
Deputy Sister,
Derrmatology OPD
3280 Identifying
Mr A Graham, T&O
Patients at Risk
Consultant (Dr J
Following Fragility Wigley, SHO, T&O)
Fractures
3281 An Exploration of Gbonyefa Samani,
Attitudes and
Dietitian
Perceived Barriers
of Dietitians in
relation to Oral
Nutritional
Supplements
Patients who suffer
from hyperhydrosis of
their hands, feet and
armpits are given
Iontophoresis
treatment provided by
Dermatology OPD.
Once discharged
from Dermatology
OPD they are able to
continue this
treatment at home
using an
Iontophoresis
machine. The aim of
the audit is to find out
how many people
continued to treat
themselves, if they
find the treatment
useful and still
effective.
To idenitfy whether
patients who sustain
distal radius fractures
through a low energy
mechanism are
assessed for
secondary
presentation.
Integrated
Medicine
02/08/2011 Complete
03/01/2013 67% patients treated with Iontophoresis found the
treatment either 'significantly' or 'to some extent'
reduced their hyperhidorsos. Recommendations: All
patients must be provided with written information
and useful links to the internet. Time to be created
for patients to discuss any additional questions or
concerns prior to treatment. Look into the possibility
of machine rental for iontophoresis treatment to be
self-administered at home.
Patient information booklets
are sent out to each patient
with their appointment
schedules. These booklets
include links to useful
websites. Patients are also
provided with contact numbers
to discuss any questions or
concerns which may have
arisen before their treatment.
STD pharmaceuticals and
Ionto centre to be contacted
during January to establish if it
is possible to rent the
iontophoresis machines for
home use.
Surgery and
Critical Care
02/08/2011 Complete
20/10/2011 A considerable proportion of patients are not being
considered for the secondary prevention of fractures
in line with NICE guidelines. Recommendation that
all patients seen in fracture clinic be considered for
osteoporosis prevention. Patients over the age of
75 sustaining fragility fractures should be
commenced on empirical osteoporosis treatment,
and those under this age be referred for further
assessment or DEXA scan. Awareness of this issue
needs to be increased. A further audit will be
commenced in the months ahead to evaluate any
improvements.
Awareness of this issue and
subsequent recommendations
has been disseminated
throughout the department by
means of an ‘Academic day’
presentation.
02/08/2011 Cancelled
03/07/2012 Cancelled
Cancelled
Oral Nutritional
Specialist
Supplements (ONS) Services
are used for
undernutrition but
guidelines suggest
first line measures
should be tried first.
Survey of dietitians to
determine attitudes to
ONS.
3282 Effectiveness of
Hydrotherapy
Treatment
Keith Pickard,
Physiotherapist
Hydrotherapy given
Specialist
for various conditions. Services
Patient completes
MYMOP outcome
measure before and
after 6 week course.
To assess
effectiveness of
course.
03/08/2011 Draft
Report
with
Clinician
3283 BTS Emergency
Oxygen Audit
2011
Jenny Ricketts, ICU
Outreach Lead Nurse
National British
Integrated
Thoracic Society
Medicine
(BTS) audit to
establish the practice
of oxygen presribing
and delivery
throughout the Trust.
02/08/2011 Complete
3284 BTS National
Pleural
Procedures Audit
2011
Dr Charlotte Campbell, National audit looking Integrated
Respiratory Consultant at pleural procedures Medicine
- diagnosis, treatment
and outcomes.
03/08/2011 Awaiting
Report/Ac
tion Plan
Results and Recommendations required
Changes required
05/01/2012 Recommendations: All doctors must take
Changes required
responsibility for prescribing
oxygen. Junior doctor prescriptions should be
checked on
all senior ward rounds. All nursing staff/ healthcare
assistants should take responsibility for signing for
oxygen, when administered, in the same way as any
other drug. Senior staff nurses / matrons should do a
brief spot check at regular intervals to check this is
being done (eg weekly). The oxygen audit should be
repeated at 3 monthly intervals by each ward. Action
Plan: The oxygen audit results will be presented at
either the hospital audit meeting or a grand round
along side an educational lecture on the use and
prescription of oxygen. To be done following doctors
change over in February. Ward based education
should occur for nursing staff and healthcare
assistants regarding the use and prescription of
oxygen. The oxygen audit will be repeated (in house
only) three months after the educational programme.
Results and Recommendations required
Changes required
3285 British HIV
Association
National Audit
2010
Dr Veena Reddy, GU
Consultant, Dr Sunita
Duggal
3286 National Diabetes Dr Stephen Gardener,
Audit 2010 - 2011 Consultant, SMH and
(BHNHST)
Dr Ian Gallen,
Consultant, WH
National audit looking
at timeliness of HIV
diagnosis and impact
of 2008 national
testing guidelines, in
particular: local action
to promote testing,
circumstances of
diagnosis, previous
history and missed
opportunities for
testing, time from first
positive test to be
seen in HIV service.
A survey of local
testing policy and
practice.
Retrospective review
of patients first seen
post-diagnosis during
August-October
2010, regardless of
date of test. Up to 40
patients/site.
A national system for
routine data
collection, analysis
and feedback of
diabetes related data.
Specialist
Services
01/09/2010 Complete
Integrated
Medicine
04/08/2011 Awaiting
Report/Ac
tion Plan
01/10/2011 HIV specialists should re-double efforts to promote
Changes required
implementation of national testing guidelines. BHIVA
should engage nationally with primary care and
medical specialties, especially gastroenterology and
haematology. National monitoring of both CD4 count
at diagnosis and AIDS defining illness within 3
months should continue. Commissioners should
consider extending CQUIN and LES arrangements to
promote earlier diagnosis. Develop pathways to
ensure patients testing positive are seen quickly
(within 14 days).
Results and Recommendations required
Changes required
3287 National Inpatient
Survey 2011
National Inpatient
Survey of sample of
850 patients seen in
July 2011.
Trustwide
Complete
17/08/2012 There has been a decline in information given in
Changes required
A&E, waiting time for a bed, waiting time to be
admitted, explanation of how the operation had gone
and delay at discharge. Our Trust was worse than
other trusts for 5 questions but not better than other
trusts for any questions. Actions: A&E. The nursing
staff are reviewing the possible introduction of red
pegs/or alternatively do not disturb signs.
Documentation and Ops Policies are being reviewed
currently due to the amalgamation of staff onto one
site. Urgent Care Pathways for patients are
discussed and actions are brought forward to look at
best care pathways. The whole team are working on
being 18 week compliant by the end of August 2012.
Ward/Department managers are to ensure that the
bathrooms are specifically identified and designated
to the appropriate sex and that patients are informed
in order to provide appropriate dignity. Regular walk
rounds by nursing staff to ensure that patients are
comfortable during the night, lights are to be turned
down and a peaceful environment to be created to
enable sleep. Staff not to congregate at nursing
station. Staff asked to wear correct footwear to
ensure quiet walking. The Matron and Ward Manager
to work with the domestic team to ensure that
cleaning plans are robust and that regular audits are
carried out to ensure that they are compliant with
expected standards. Matron rounds in place to
monitor progress. Ward / Department areas to
ensure that patient property is kept safe at all times
providing patient property bags and the facility to
check valuables into the ward safe/general office as
required. Lockers to be maintained and in working
order.
Hand gel, posters to be evident at the beginning of
the ward / department and hand gel to be available
at every bedside with appropriate facilities for hand
washing for patients and relatives identified. Hand
hygiene audits to be monitored and evaluated.
Ward / Department and Matrons to ensure that
patients eating and drinking is assessed continuously
and any issues to be identified and assistance to be
given to patients with eating and drinking. Red Trays
usage to be enhanced on each ward area. Menu’s to
be used and specialist assistance from the Speech
and Language team and the nutrition team to be
sought in a timely manner. Matron’s rounds are
carried out weekly to monitor nutrition and hydration
charts. Patient drinks and food being in easy reach is
addressed at ward level.
Doctors
Customer service standards to be rolled out at
medical staffing induction with feedback from
patients to be shared with the medical teams.
Hand Hygiene audit results to be shared with the
medical teams and results of which to be discussed
and shared at Divisional Board.
Customer service standards to be rolled out at
induction, local induction to clarify expectations of
role, mentorship, preceptorship and clinical
supervision to pick up any individual development
issues. Ward / Department Managers to act as role
models and to promote best practice. Leadership
training and continuing professional development to
continue throughout the nursing teams to ensure
professional behaviour. Rota reviews, skill mix
reviews have taken place with each ADN.
Recruitment drives to ensure that vacancies are
filled. Sickness and leave to be managed by the
ward / department manager. Rosters to be
centralised and to ensure that they are robust and fit
for purpose allowing the ward manager to agree the
roster rules to provide sufficient staff on the ward.
Staffing skill mix requirements are review daily by a
Matron and in exceptional circumstances additional
resources may be identified and escalated to
support. Patient Experience Trackers to be
introduced to the organisation Sept/October to pick
up live reporting of quality issues. Verbal Quality
checks to be a part of day ro day nurse patient
communication.
Matrons templates to be reviewed to identify whether
patients are having the appropriate levels of
communication. The review of patients privacy
should be ongoing and the appropriate utilisation of
curtains, offices and quiet areas are to be used, the
review of the red peg for curtains to ensure that
patients are not disturbed are to be reviewed by the
organisation
Patients are to be assessed for levels of pain on a
regular basis, finding appropriate solutions to pain
control and monitoring and recording the
effectiveness of the analgesia administered. Nurse
led pain pathways in place .
All call bells to be responded to within five rings, this
can be responded to by any member of the ward /
department team who may need to seek further
advice as required. Areas that are not provided with
pre-op clinic are currently reviewing their pathway as
to what information the patients are receiving.
Enhanced recovery pathways are being rolled out to
elective surgery patients. Hip and Knee classes in
place for orthopaedics.
Dedicated anaesthetist for the pre operative pathway
working with the nursing team to highlight risks and
ensure correct assessment prior to surgery.
Development of information booklets by all
specialities to explain operative or investigatory
procedures. Daily facilitated Meetings (DFM) being
rolled out across all specialities ensure MDT
approach and involvement of patient and family.
Zone project on T&O emergency pathway ensures
patient involvement in understanding their recovery
pathway and reducing length of hospital stay.
Nurse led discharge for elective pathway in
Gynaecology and surgery.
3288 Audit of reasons
Marianne Smith,
for length of stay Clinical Excellence
of community
Lead
hospital inpatients
This audit is to
Integrated
ascertain the reasons Medicine
for delayed
discharged of
community hospital
inpatients.
05/08/2011 Complete
Green bag system assisting with delays . DFM’s
ensuring timely writing up of TTO’s.
Pharmacy are reviewing the process of how TTO
charts are getting to pharmacy and this is also being
picked up in medical induction
Pre – planning of patients discharge is of paramount
importance and discharge dates to be identified for
all patients on ward rounds
Continued development of patient leaflets by
specialities.
Nurses instructed to explain the take home
medications to patient and families on discharge to
ensure complete understanding. Patient Leaflets to
be utilised for specific conditions. Specialist Nurse
review for newly diagnosed patients with specific
conditions. Programme Manager for CRS to be
contacted to determine whether we can send letters
out to patients utilising the system or whether there
were alternative systems that we could review.
Matron and Ward managers to ensure staff promote
dignity becoming dignity champions for their patients
Ward rounds to involve senior nurse to actively
participate in the patients treatment plan, courtesy
and professionalism to be promoted at all times.
MDT’s to be attended by senior nurse and patients.
Matrons rounds, patients trackers and staff to ask
patients quality questions whilst delivery daily care to
raise any concerns or issues early. Ensure patient
involvement on a daily basis whilst delivering care,
asking the patients their views. Productive ward
surveys utilised whilst waiting for patient tracker
system to show involvement and quality of care for
app patients
Weekly Matron Rounds, Productive Ward feedback,
patient experience monitoring to commence for
monthly reviews October. Patient involvement in
changes, improvements and innovation ideas.
PALS, complaints team to do a walk around the site
to ensure enough marketing material is available to
each ward / department with regards to raising
concerns.
26/01/2012 Results: The average age of inpatients in the
community hospitals is 82.9 years and the main
reason for admission is for ‘reablement’ (88%). On
the whole, patients met the admission criteria;
however 6 (10%) patients did not, with 3/6 of these
patients requiring either placement or re-housing and
2/6 patients needing acute medical care. The
average length of stay at the time of the audit was
27.4 days. 3 patients had a length of stay of
between 85-112 days, 2/3 of these patients did not
meet the admission criteria. 8 patients who were not
recorded as a delayed discharge had exceeded their
Estimated Date of Discharge by between 3-46 days.
92% of patients who required a referral to social
services had the date of referral documented in their
notes. 94% had social services documentation with
section 2 completed filed in their notes. Where the
patient was fit for discharge section 5 of the social
services documentation had not been completed in
1. Training and
implementation of Social
Service Service referral via
Strata. 2. Accurate recording
of delayed discharge Training on completion of
return. Increase
understanidng of reporting
system using feedback from
weekly review meetings. 3.
Implement productive ward
module - admissions and
planned discharge. Implement
evidence based length of stay
for identified pathways and
MDT approach to treatment
completion dates for specific
pathways. 4. Identification of
lead professional for each
75% of cases. 16% of patients requiring a referral to
social services had not yet been assessed. For 45%
of patients being discharged to their own home, a
home visit had yet to be carried out and for 17% of
patients who required equipment, the equipment had
not yet been ordered. Finally, of the 23 patients
recorded as a delayed discharge - 30% were
awaiting a care package and 30% were waiting for a
nursing home placement. Recommendations: The
Community Hospital discharge planning process is
not currently standardised. It is recommended that
the Productive Series module on admission and
discharge planning is implemented at all units and
includes accurate and timely referral to Social
Services. A multi-disciplinary approach to decision
making for completion of Estimated Date of
Discharge is best practice. Currently Estimated Date
of Discharge does not relate to an evidence based
patient pathway and it is recommended that
pathways should be identified for development and
implementation. Planned completion dates for
treatment are not recorded consistently. Setting
agreed dates with the patient and multi-disciplinary
team would improve communication and discharge
planning.
Recording the date of referral to Social Services,
Section 2 and Section 5, is inconsistent across the
Community Hospitals. A standardised approach is
needed to this. Social Services are not required to
source the care required for discharge until a patient
has been declared fit for discharge and a Section 5 is
submitted by the Community Hospital. Submission
of Section 5s can be unreliable, causing delays in
discharge. A standardised approach to Social
Service referral should be an outcome of the
Productive Series admission and discharge module
implementation. Current recording of delayed
discharges by the Community Hospitals is inaccurate
and requires weekly revision when reviewed by the
Clinical and Operational Lead and Lead for Social
Services. Training to improve knowledge and use of
the reporting system is required. Complex discharge
management for patients who are non-weight
bearing, homeless and needing re-housing, are
admitted awaiting long term care or have other
complex discharge needs is not consistent across
the Community Hospitals. To improve
communication, planning and identify potential
delays a lead professional is required for each
complex discharge and the use of a facilitated
discharge meeting should be explored.
discharge. Explore options for
working relationship with BHT
discharge team. Explore use
of daily facilitated discharge
meeting in community hosital
setting.
3289 Audit of Elective
Angioplasty,
Stable Angina and
Optimal Medical
Therapy
Piers Clifford,
Consultant, Cardiology
(Alex Woodroffe,
Project Manager,
South Central
Cardiovascular
Network)
A case note audit in Integrated
advance of the NICE Medicine
guidance due to be
released in July 2011
on treating Stable
Angina to give an
indication of what
trends there are
within the procedure
data for South
Central.
15/08/2011 Awaiting
Report/Ac
tion Plan
Results and Recommendations required
Changes required
3290 2011 National
Comparative Audit
of the Medical Use
of Red Cells
Dr Ann Watson,
Consultant
Haematologist, Terry
Perry (WH), DonnaBeckford-Smith (SMH),
Haematology Nurse
Specialists
Audit to evaluate the Specialist
use of red cell
Services
transfusions in adult
medical patients
against standards
derived from the
BCSH guidelines and
to ensure that
associated clinical
documentation is
recorded consistently.
05/09/2011 Awaiting
Report/Ac
tion Plan
Results and Recommendations required
Changes required
3291 Can the
Nicola Bowers, Cardiac
Introduction of a
Research Sister
Cardiac Research
Nurse Role
Enhance Service
Development?
This audit is being
Integrated
undertaken as part of Medicine
a research project for
an MSc.
01/08/2011 Complete
14/11/2011 Not applicable
Not applicable.
3292 Review of
Umbilical Hernia
Repairs
Dr G Luzzi, Medical
Director and Mr A
McLaren, Divisional
Chair for Surgery
A review of recent
Surgery and
readmissions
Critical Care
following hernia
repairs, following a Dr
Foster alert.
26/08/2011 Complete
31/03/2012 All Umbilical / paraumbilical hernia repairs at Stoke
No changes required
or Wycombe Hospital between February and August
2011 were reviewed. Of 49 cases there were 3
(6.12%) readmissions within 28 days post surgery.
Results are similar to standard results published in
surgical journals.
3293 National Diabetes Dr Chatterjee,
National audit aiming Integrated
Inpatient Audit
Consultant Diabetes & to answer the
Medicine
2011
Endocrinology
following questions:
Did diabetes
management
minimise the risk of
avoidable
complications? Did
harm result from the
inpatient stay? Was
patient experience of
the inpatient stay
favourable? Has the
quality of care and
patient feedback
changed since NaDIA
2010?
30/09/2011 Awaiting
Report/Ac
tion Plan
Results and Recommendations required
Changes required
3294 National Health
Promotion in
Hospitals 2011
01/03/2011 Awaiting
Report/Ac
tion Plan
Results and Recommendations required
Changes required
Dr Luzzi, Medical
Director
Reaudit of 2645.
Trustwide
National audit to
assess the level of
health promotion
which takes place for
inpatients at the
Trust.
3295 Audit of Dog Bite
Treatment &
Outcomes
Mr T Heywood,
Consultant Plastic
Surgeon (Dr Adnan
Gul, SpR, Dr Ross
Muir, CT2, Plastics)
An audit of patients
treated for dog bite
injuries - treatment
received and
outcomes.
3296 Urology Cancer
PES 2011
Hilary Baker, Krystyna
Caine, Clinical Nurse
Specialists UroOncology
3297 Health Promotion Dr Piers Clifford,
in Cardiology PES Consultant Cardiologist
(Nicola Bowers,
Research Sister)
Surgery and
Critical Care
09/08/2011 Cancelled
26/11/2012 Junior doctor has left Trust, audit has not been
presented.
Obtain patient
Specialist
feedback regarding
Services
the service and
information provided.
Required for peer
review.
01/04/2011 Complete
31/08/2011 Results: The Uro-oncology Clinical Nurse Specialists Changes required
feel the report is a true, honest, fair report. As a team
we value patients’ comments, opinions, suggestions
and thoughts to help develop the service and
improve the care they receive. Recommendations:
To review pain management at time of patient
investigations and how this can be better
communicated and managed. To review discharge
information for patients following their investigations.
To emphasise the importance of patients bringing a
relative/carer/ friend when they receive the results of
their investigations.
To assess whether
health care
professional
intervention
influenced patient
uptake of physical
activity.
22/08/2011 Cancelled
05/11/2012 Cancelled.
Integrated
Medicine
Project cancelled.
Project cancelled.
3298 Readmissions
following
appendicectomy
Mr Chris Gatzen,
Consultant, Colorectal
Surgery (Mr Nigel
D'Souza, CT3,
Surgery)
There has been a
Surgery and
high readmission rate Critical Care
post appendicectomy
for intra-abdominal
abscesses. This
audit will investigate
the readmission rate
and determine what
risk factors are
present that may be
influenced.
01/09/2011 Complete
22/12/2011 Results: Wound infection and abscess rates are not
very high at Bucks; high rate of abscess after
Laparoscopic Appendectomy for uncomplicated
appendicitis; no clear or statistically significant
evidence showing Laparoscopic Appendectomy
worse than Open Appendectomy; longer operation
and more expensive; beneficial for post-op pain,
reduced hospital stay, return to work, wound
infection.
No recommendations for
change were made.
3299 IQP Community
Acquired
Pneumonia
2011/2012
Liz Hollman, Associate
Director Healthcare
Governance (Dr Mitra
Shahidi, Respiratory
Consultant, Dr Nandini
Biswas, Respiratory
Consultant)
IQP audit to assess
patients with
community acquired
pneumonia.
Integrated
Medicine
01/09/2011 Complete
13/06/2012 Dr Shahidi is investigating whether a report was
produced.
No report to date.
3300 Audit of
Cardiology
Patients with
Stable Angina
Dr Piers Clifford,
Consultant Cardiologist
(Nicola Bowers,
Research Sister)
Audit against NICE
guidance for
treatment of patients
with stable angina.
Integrated
Medicine
01/09/2011 Complete
19/03/2012 Overall the results highlight good clinical practice
Changes required
locally such as, all patients being considered or
prescribed Aspirin 75mg OD. For 97% of patients
with diabetes, ACE inhibitors had been considered
and documented. For 91% of patients it was
documented that GTN spray had been offered. For
98% of patients a statin was prescribed or
considered, 97% of patients were offered some form
of first line treatment, yet 3 patients went straight for
procedure. However, only 4% of patients were
clinically reviewed after being prescribed and starting
on first line therapy. No review prior to procedure
precipitated 41% of patient’s asymptomatic on day of
procedure. Recommendations: To improve
documentation within the medical records of clinical
decision making in relation to treatment plan and
choice of medication. Clinical review essential after
commencing a patient on a new drug therapy for
stable angina. If clinically appropriate, a third line
medical treatment to be offered prior to clinical
intervention. To increase the number of patients
taking the recommended 40mg OD Simvastatin and,
if not documented, justification for another lipid
lowering treatment being prescribed. GTN spray is a
cheap and effective treatment for patients with stable
angina, it should be offered, prescribed and
documented to all. To encourage second and third
line medical therapy, where appropriate, for patients
prior to consideration of interventional treatment.
3301 Audit of
Emergency
Laparotomy
Outcomes in line
with the
Emergency
Laparotomy
Network Guideline
Dr Jeremy Drake,
Consultant,
Anaesthetic (Dr
Duncan McLean, FY1,
Anaesthetics)
To gain baseline data Surgery and
for emergency
Critical Care
laparotomies using
Emergency
Laparotomy Network
data collection tool.
02/09/2011 Awaiting
Report/Ac
tion Plan
3302 VTE Prophylaxis
after leg
immobilisation
Dr Jonathan Pattinson,
Consultant,
Haematology (Dr
Ahmed Arif, F1,
Haematology)
Audit of VTE
Prophylaxis after leg
immobilisation
against NICE
guidelines.
02/09/2011 Cancelled
Surgery and
Critical Care
Results and Recommendations required
23/12/2011 Audit was not completed as the Plaster Cast
Pathway in A&E still does not incorporate VTE
prophylaxis.
Changes required
Project cancelled
3303 Bedside
Donna Beckford-Smith, April - June 2011.
Transfusion
Transfusion Nurse
National audit.
(National
Comparative Audit
of Blood
Transfusion)
Specialist
Services
01/04/2011 Complete
06/06/2012 Action Plan: Continued transfusions theory training,
education & competency assessments.
Research for the provision of wristband printers to
those areas which are still without.
Re-auditing ward wristbands.
In the future electronic bar-coding to the bedside.
3305 Allergy Clinic
Patient
Experience
Survey
Integrated
Medicine
02/09/2011 Draft
Report
with
Clinician
Results and Recommendations required
Liz Potts, Staff Nurse,
Dermatology
Re-audit of audit
1930 in 2007.
Theory training and
competency assessments
continue. We have capture the
porter and phlebotomist will be
addressed early in the new
year.
New assessors are being
trained to carry out
assessment in their areas and
divisions.
We have secured training for
representatives from the
community to assist us
competency assessor District
nurses, again this starts in Jan
2013.
We are still trying to secure
wristband printers to ensure
patient safety. To be
discussed again at our HTC.
Following configuration all
areas will need reassessing,
as the current Ward 20 are
without a printer now.
Blood transfusion nurses have
conducted Quick wristband
audits in keys areas such as
A&E, ITU etc. to continue with
auditing throughout 2013 for
Regional purposes as well as
for local data.
Electronic to the bedside is
subject to funding.
Changes required
3306 Patch Test Clinic
Patient
Experience
Survey
Sue Hyde, Nurse,
Dermatology
Re-audit of audit
1930 in 2007.
Integrated
Medicine
02/09/2011 Draft
Report
with
Clinician
Results and Recommendations required
Changes required
3307 VTE Prophylaxis
in the Urology
Patient Re-audit
Neil Haldar,
Consultant, Urology
(Dr Natalia White, FY1,
Urology), Jonathan
Pattinson, Consultant
Haematologist
To audit adherence to Surgery and
clinical guidelines on Critical Care
VTE prophylaxis risk
assessment and
prescription. Reaudit of 3223.
05/09/2011 Complete
13/04/2012 VTE prophylaxis compliance had increased from
No recommendations or action
10% in previous audit to 65% in this audit. Targeted plan from this re-audit.
interventions, including a urology admissions clerking
proforma (UAP) and guidance sheet advising on
routine VTE prophylaxis in urology, had improved
NICE guideline compliance greatly. No further
recommendations were made from this re-audit.
3308 Audit of Massive
Obstetric
Haemorrhage
Veronica Miller,
Consultant, Obs &
Gynae (Dr Tanya
Boland, FY1)
Audit of incidence of Specialist
massive obstetric
Services
haemorrhage (>1500
ml) between 04/06/11
and 02/08/11. Audit
against CNST, BHT
guideline 550.1 and
NICE.
30/08/2011 Complete
17/10/2011 Rates at this Trust reflect the national average.
Continuing CNST audit
Good documentation and use of the proformas by
21/2/13 (CP)
midwives at vaginal deliveries. At LSCS the
proformas are not used as well. The audit
recommends that there is a focus on better use of
the proforma at LSCS with a person being
designated to complete it at the time and proposes
that a separate proforma for use at LSCS is devised.
It also raised the question about releasing blood
once the immediate crisis has passed if it is not
required, highlighting the need for good
communication between staff and the lab.
3309 Paediatric
Occupational
Therapy Group
PES
Alison Lyle,
PES of parents of
Community Paediatric children attending
Occupational Therapist community
Occupational
Therapy groups and
talks.
Specialist
Services
05/09/2011 Complete
25/07/2012 Overall feedback was very positive. Actions: Parent Changes required
Groups: Attendees to be provided with a map
detailing parking. Ensure parents are aware that
alternative venues/times/days are available across
the county. Invitation method to be reviewed to
include this information.
Make parents aware of School Advice Clinics as a
method of reviewing child and answering specific
questions. Verbal reminder of SAC to be given to
parents at the end of group. Group
information/activity sheets to be updated to give
details of practical home ideas. Ensure handouts are
available. Handwriting pathway to be reviewed by OT
service.
Information sheet/group focus to be made available
for OT to include with invitation. Parent Talks:
Consider alternative venue at SMH. OT presenting to
inform parents of School Advice Clinics. Talk to
include information on methods of referral to OT.
OTs to be aware of pacing of the talk. Produce
suggested timeline for talks. Make OTs aware of
availability of Trust training on presentation skills.
Handout emailed to parents after talks. OT to ensure
handouts tally with presentation.
Consult managers for progress on website plans.
OTs referring parents to the talk should consider
individual situations. Review initial letter. Universal
Training: Handouts to be given at all talks, at
beginning. Training session to all staff involved to
maintain consistency of delivery across the county.
Create a flyer to advertise the training session
accurately. Create a document clearly stating the
requirements for the course to the school hosting the
training. Recent review has moved towards a
workshop style of delivery. Need to cover this in
training. Produce reference list of resource books.
OT to allow 30 minutes, if needed, for individuals to
ask any further questions. OT to inform participants
where Resource Pack available. Take set of
appropriate resources to each session. Time to be
set aside for this – part of final 30 minutes. Team
lead/managers to discuss the practicalities of offering
further training sessions. Greater use of flyers, OT
giving clear information on how to obtain Resource
Pack.
3310 Management of
Veronica Miller,
Emergency
Consultant, Obs &
Caesarian Section Gynae (Lee Aye,
GPVTS, Katie Eyre,
FY2)
Ongoing audit of
management of
LSCS.
Specialist
Services
01/05/2011 Complete
17/11/2011 68 notes in total identified using birth register on
On going CNST audit 21/2/13
labour ward and requested. 49 notes (72%) received (CP)
and analysed (5 excluded - 4 Category 4 sections
entered as emergencies excluded and 1 trial +/section). Completion of the proforma: 39/44 (89%)
Completed 5/44 (11%) Not completed/ in notes. Dec
2010 (64%) Completed Feb 2010 (64%) Completed
NICE classification 100%, also good compliance with
ABx, thromboprophylaxis and consultant awareness.
Points for improvement: 1. Forms often partially
complete. 2. Delivery times cat 2 & 3. Post-op review
?D1 reviews and mode delivery of next pregnancy.
3311 Audit of Driving
Advice Provided
by the A&E Dept
Dr Gillian Kelly, A&E
Consultant (Richard
Simpson, GPVTS)
To evaluate how well Integrated
A&E doctors provide Medicine
accurate and relevant
advice about driving
to patients who
attend the
department with
relevant
symptoms/signs.
06/09/2011 Complete
19/12/2011 Conclusion; All grades of practitioner missed
opportunities to give appropriate driving advice.
Documentation that appropriate driving advice was
given was poor. Patients presenting with severe
mental illness or a past diagnosis of epilepsy were
the scenerios where doctors were most likely to fail
to document the provision of appropriate driving
advice. Recommendations; Emphasis should be
placed on recognizing when driving advice is
necessary and checking what it should be from the
available guidance/poster. It should be an aim that
all patients who present with a seizure, collapse,
alcohol-related problems, mental illness and visual
problems should have driving advice specifically
documented. Poster to be drafted and put up in the
A&E department. Information leaflet for patients to
be drafted and distributed..
Changes required
3312 National Diabetes
Multidisciplinary
Footcare Team
Foot Ulcer Audit
Dr Stephen Gardner,
Diabetes &
Endocrinology
Consultant (Jane
Coles, Erin Lee,
Podiatrists)
This is a pilot project Integrated
being undertaken by Medicine
NHS Diabetes of
Diabetes Footcare
Services. Data to be
collected on all
patients presenting
with a new foot ulcer
between the 1st
September and 30th
November 2011.
06/09/2011 Awaiting
Report/Ac
tion Plan
Results and Recommendations required
Changes required
3313 VTE Audit Trauma Jonathan Pattinson,
& Orthopaedics
Consultant
Haematologist (Laura
Watts, Dr Panchal, F1s
T&O)
Part of rolling VTE
audit which involved
audits 3090, 3205,
3256, 3274 which
looks at VTE
assessment and
prophylaxis in each
division. This audit
relates to Trauma
admissions. 30
admissions from
26/8/11.
Specialist
Services
07/09/2011 Complete
3314 Post-Delivery
Blood
Transfusions
An audit of Hb level
at which patients are
transfused postdelivery and the Hb
level they are
transferred to.
RCOG guidelines.
Surgery and
Critical Care
07/09/2011 Complete
Dr Drake, Consultant
Anaesthetist (Eleanor
Harvey, CT2
Anaesthetics)
03/02/2012 Results: None of the 40 patients included in the audit
were non-compliant with the guideline (Table 1),
meaning that all patients received appropriate
prophylaxis. However, only 57.5% were fully
compliant with the guideline, leaving 42.5% in whom
appropriate prophylaxis was given, but without any
evidence of a VTE risk assessment having been
performed. Recommendations: Posters in the
trauma office reminding SHOs to fill out VTE
assessments when admitting new patients. A talk on
the importance of VTE prophylaxis. An email sent
out to admitting doctors reminding them that it is their
responsibility to complete the VTE assessment and
prescribe accordingly on admission. Add information
on DVTs and PEs to the weekly morbidity and
mortality meeting which happens every Friday
afternoon. Altering the VTE assessment form so that
it is more user friendly, and making in stand out more
by adding some colour and a larger title so that it is
more likely to be filled in.
Nominating members of staff to be responsible for
checking the VTE form. For example, increasing
awareness among nurses so that they could check
whether a VTE assessment had been completed for
their patient on admission. Also at the John Radcliffe
Hospital in Oxford on the post-take general medicine
ward rounds the post-take form which has to be
completed has a box stating whether the VTE
assessment has been completed.
15/10/2012 Appropriate adherence to RCOG Guideline for
transfusion is evident. The re-audit shows
improvement in measuring pre-transfusion Hb; 1015% transfusions were for Hb>8 (Guidance states
little evidence of benefit for fit healthy asymptomatic
pts, but most of these patients are deemed as
lethargic and hence tranfused); majority of
transfusions were 2 or 3 units of PRBC, appear to be
aiming for Hb of 10. No recommendations for
change were made.
Email sent to Trauma
consultants with some of our
results as a gentle reminder to
let the juniors know to
complete the form on
admission.
Also trying to add another
button to the PMS system to
remind everyone to complete
the form. This would remind
the juniors, let the consultants
know on the Friday round who
hasn't had one as it appears
on the list, remind the nursing
staff to pester the doctors to fill
it out as well as hopefully
make further auditing easier.
Contacted IT about this but
still awaiting reply.
No changes required.
3315 Fetal Monitoring
Audit
Miss Veronical Miller,
Consultant, Obs &
Gynae, Amanda
Mansfield, Consultant
Midwife, Lucy
Spanswick, GPVTS
Fetal monitoring in
labour against the
trust guidance for
best practice.
Specialist
Services
19/08/2011 Complete
17/11/2011
No changes as no results or
recommendations received
21/2/2013 (CP)
3316 NASH (National
audit of Seizure
Management)
Dr Mike Kazer, Staff
Grade, A&E
Audit tol examine the Integrated
facilities and care
Medicine
available to patients
presenting to
Emergency
Departments with
seizures in order to
identify how best to
change services to
reduce the numbers
presenting at
hospital.
01/10/2010 Awaiting
Report/Ac
tion Plan
Results and Recommendations required
3317 Personal
Protective
Equipment Audit
July 2011
Amanda Adkins,
Use of personal
Specialist
Infection Control Nurse protective equipment Services
tool in all wards to
evaluate if infection
control guidelines are
being followed.
13/09/2011 Complete
25/10/2011 Compliance by question varied from 92% to 100%,
with an overall compliance of 99%. 68 of the 80
areas were compliant for all applicable questions.
Action plans were only completed for 2 of the 14 “No”
responses.
Changes required
Infection Control are
responsible for ensuring that
all areas complete action
plans if non compliant for any
question and that action plans
are followed up to ensure
actions completed. Re-audit
next year.
3318 Rhuematology/Po Antonia Fisher,
Podiatry now involved Specialist
diatry Joint Annual Podiatry rheumatology in rheumatology
Services
Review Clinic PES lead
annual reviews.
Want to get patients
views on these.
13/09/2011 Complete
11/02/2013 Results: Low (63%) numbers of patients who saw a Changes required
podiatrist in the annual review clinics. The summary
of results for the specialist nurses were all very
positive, with all respondents very satisfied with the
assessment undertaken and the outcome of the
appointment and the action to deal with any
problems identified. All of the patients seen by the
podiatrist reported a positive experience.
Recommendations: Need more patients to fill the
clinics.
Need a podiatrist to see all the patients.
Need to look at increasing the things the specialist
nurses can do independently of the doctors.
Look at providing a pack of information or making
more information more readily accessible and to
include the outcome of the individual assessments.
3319 Biological Therapy Dr Sally Edmonds,
in RA: Are we
Consultant
NICE compliant? Rheumatologist (Dr
Jasroop Chana,
Rheumatology, ST5,
Dr Shoma Banerjee,
ST3)
Audit of patients
Integrated
commenced on
Medicine
biologics (anti TNF)
for RA since 2007 to
assess whether they
are being initiated
and monitored as per
NICE guidance.
14/08/2011 Complete
01/02/2012 General trend from 2007 to present was of increasing Changes required
guideline adherence. 6 monthly monitoring possibly
hindered by lack of appointments / cancellations /
DNAs. TNFi trialled for longer than 6 month period
due to issues with infections, low blood counts etc.
Excellent patient focused care but NICE would like
more information provided to patients. Overall
performance was good but there were differences
between sites. Recommendations: 1. Standard
format for Biologics data across all sites (better use
of database?). 2. Improve documentation. 3.
Provide patients with ‘Understanding NICE guidance’
booklet and information about the departmental
service. 4. Re-audit
3320 CEM Audit of Pain Dr Mike Kazer, Staff
in Children 2011
Grade, A&E (Clinical
Audit Lead A&E)
A national audit of the Integrated
management of pain, Medicine
in children, against
CEM standards.
01/09/2011 Cancelled
11/10/2012 Mike Kazer said that staff did not complete audit and Audit cancelled.
no data submitted. Change in computer systems
used in A&E and the difficulties this has produced in
extracting clinical reports for such audits.
3321 CEM Audit of
Severe Sepsis
and Septic Shock
2011
Dr Mike Kazer, Staff
Grade, A&E (Clinical
Audit Lead A&E)
A national audit of the Integrated
management of
Medicine
severe sepsis and
septic shock against
CEM standards.
01/09/2011 Cancelled
11/10/2012 Mike Kazer said that staff did not complete audit and Audit cancelled.
no data submitted. Change in computer systems
used in A&E and the difficulties this has produced in
extracting clinical reports for such audits.
3322 CEM Consultant
Sign Off Audit
Dr Mike Kazer, Staff
Grade, A&E (Clinical
Audit Lead A&E)
In December 2010
Integrated
the College of
Medicine
Emergency Medicine
published a standard
for “Consultant SignOff” in Emergency
Departments. The
purpose of this audit
is to assess current
levels of compliance
with this standarad.
01/09/2011 Complete
3323 Adult Asthma
Audit (BTS) 2011
Dr Anjani Prasad,
Respiratory Consultant
(Dr Su Lyn Leong,
SpR)
An audit of asthma
management in
adults against the
standards contained
in the BTS/SIGN
British Guideline for
the Management of
Asthma.
01/09/2011 Awaiting
Report/Ac
tion Plan
22/12/2011 National Audit results published 22/12/2011. In total, A re-audit will be carried out
9142 cases from 134 EDs, of which 126 were in
by the CEM in February 2013.
England (64% of English EDs), were included in the
audit between Monday 5th September 2011 (9 am)
and Monday 19th September 2011 (9 am). Overall
12% of discharged patients (Table 1) and 11% of all
admitted and discharged patients (Table 2) were
seen by a consultant/associate specialist. 44% of
discharged patients and 41% of all audited patients
were seen by an ED doctor of ST4 seniority or
above. In total, 22% were seen by or discussed with
a consultant/associate specialist. Overall, data from
134 EDs show that only 12% of patients in the
identified high risk groups are seen by a consultant
prior to discharge, but nearly half are seen by a ST4
trainee or more senior doctor, which is encouraging.
The current gaps in consultant cover are clearly
demonstrated, particularly in the evenings and
overnight, and progressive expansion within the
consultant tier should work to address this.
Results and Recommendations required
Changes required
Integrated
Medicine
3324 Bronchiectasis
Audit (BTS) 2011
Dr Anjani Prasad,
The source of the
Integrated
Respiratory Consultant standards for the BTS Medicine
Bronchiectasis audit
is the BTS Guideline
for non-CF
Bronchiectasis (July
2010).
01/10/2011 Data
Collection
Results and Recommendations required
Changes required
3325 Oxygen Therapy
Audit
John Quinn, SDU
Director, Pharmacy
(Satinder Bhandal)
Audit of the
Specialist
prescribing,
Services
administration and
monitoring of oxygen
therapy over a week
for all wards with the
exception of ITU and
neonatal intensive
care units.
01/04/2011 Complete
16/09/2011 Recommendations: The results of this audit need be Changes required
fed through the Divisional Structures and Safety
Score Cards within the Trust. Individual ward teams
must be made aware of their performance relative to
the standards and to other ward teams. Good
prescribing, administration and monitoring of oxygen
should form part of Key Performance Indicators for
the wards. Further ongoing training needs to be
carried out for all healthcare professionals involved in
the prescribing administration and delivery of oxygen
therapy. This audit needs to be repeated quarterly
with refinements as prescribing and monitoring rates
improve. Pharmacists must ensure patients do not
receive oxygen without prescription or with
inappropriate monitoring on wards to which they
provide a clinical pharmacy service.
3326 Management of
Multiple
Pregnancies
against CNST
guideline
Miss Aparna Reddy,
Consultant, (Joanna
Goldie, GPVTS) Obs &
Gynae
Audit of management Specialist
of multiple
Services
pregnancies based
on CNST guideline.
30 patients between
January and April
2011.
01/09/2011 Complete
17/11/2011 1. Twin information leaflets should be readily
available in consulting rooms to give to patients. 2.
Be aware of page 21 in antenatal book. It has
preferences to tick for options during labour- maybe
a good prompt. 3. A pre-prepared sticker with tick
boxes for the things that need to be documented
antenatally. This appears to have worked well for
VBAC discussions.
No changes received 21/2/13
(CP)
3327 Audit of Use of the
Customised
Growth Chart in
the Identification
of Small For
Gestational Age
Babies
Miss Aparna Reddy,
Consultant Jackie
Baxter, Divisional
Clinical Governance
Midwife, (John
Heathcote, FY), Obs &
Gynae
Audit of the use of the Specialist
customised growth
Services
chart in the
identification of small
for gestational age
babies. Prospective
audit of 100 maternity
case notes during the
month of October
2011.
01/10/2011 Complete
15/04/2012 Results: 96% records contained CGCs. 92% charts Changes required
contained 3 or more plots. 31/98 (32%) suspicious
patterns identified. 17/31 appropriate action taken.
14/31 incorrect management. 1/14 babies born with
low birth weight. Recommendations: Need for
further in house training and through National
Perinatal Epidemiology Unit. Ongoing audit with
presentations to multidisciplinary team.
3328 Audit of Malignant Mr M Tyler, Consultant
Melanoma in
(Jonathan Cubitt, ST3)
Buckinghamshire Plastics
2003 - 2005
Investigating patients Surgery and
who were diagnosed Critical Care
with melanoma in
2004 and 2005
focusing on the
presentation,
histology,
complications,
surgery and outcome.
Comparing results to
previous audit of
patients diagnosed in
2003.
19/09/2011 Complete
24/07/2012 This was a retrospective analysis of all patients who
were diagnosed with melanoma in 2003, focussing
on the new diagnoses of cutaneous malnoma and
excluding all non cutaneous melanoma and all
patients who received their initial diagnosis before
2003. 82.9% of patients survived 5 years with no
nodal, local or metastatic recurrence. 87.5% of
patients survived 5 years, overall, irrespective of
recurrence. There was no significant difference
between the recurrence rates in women or men.
3329 Audit of Malignant Mr M Tyler, Consultant
Melanoma in
(Jonathan Cubitt, ST3)
Buckinghamshire Plastics
2010
Comparing current
practice to the
recently published
guidelines.
19/09/2011 Complete
12/03/2012 SMH is adhering to The American Joint Commission No changes required,
on Cancer (AJCC).
guidelines are being adhered
to, continue adhering to
current guidelines.
Surgery and
Critical Care
No recommendations for
change made. Audit being
written up for publication.
3330 National Cancer
Intelligence
Network Secondary Breast
Cancer Project
Mr Giles Cunnick,
Consultant, Breast
Surgery (Fiona
Charlton, Surgical
Practitioner)
3331 Abdominal
Surgery
Mobilisation
Sam Burden, Physio
To support the
piloting of the
collection of data on
recurrent and
metastatic breast
cancer. The aim of
the pilot is to
ascertain what
information about
patients presenting
with local and distant
recurrences and
metastatic disease
can be gathered
through local MDTs
and to compare with
routine data collected
via cancer registries.
During 2011/12 we
will pilot the collection
of data on
recurrence/metastase
s on patients with
breast cancer with
the aim of
undertaking full
collection from April
2012.
A clinical indicator
has been developed
and tested by
consultant at London
Hospital stating that
80% patients having
major abdominal
surgery should be
walking 30m by day 3
after surgery. This is
an audit of surgery
patients at SMH to
determine how we
compare.
Surgery and
Critical Care
20/09/2011 Complete
01/06/2012 The following recommendations aim to support better
data collection and improved care for patients with
recurrent and metastatic breast cancer: 1) All breast
cancer units in England to submit data on patients
with recurrent and metastatic breast cancer through
the NCWTMDS. 2) Breast Unit MDT co-ordinators
and data managers should ensure, in collaboration
with clinical colleagues, that data are collected for
each breast team. 3) Additional information on
supportive care is to be collected as required from
January 2013 in the COSD. 4) GPs to ensure that
patients with a previous history of breast cancer and
symptoms that could indicate recurrent or metastatic
disease are referred urgently for assessment through
the existing cancer wait process. 5) Providers should
ensure that local arrangements are in place for
urgent clinical review of patients with suspected
recurrence or metastasis. 6) Patients with recurrent
or metastatic breast cancer should receive
multidisciplinary care and the support of a CNS, as
outlined in the NICE breast quality standard.
Specialist
Services
20/09/2011 Data
Collection
Results and Recommendations required
Data is collected on all breast
cancer patients as part of the
cancer waiting time targets.
Additional information on
supportive care, part of the
COSD, will be collected as
soon as possible. The
database has been purchased
and work is underway. All GP
referrals for breast patients are
now booked and seen within
two weeks (irrespective of
whether they suspect cancer),
in line with national guidance.
Local arrangements are in
place for urgent clinical review
of patients with suspected
recurrence or metastasis.
Patients with recurrent or
metastatic breast cancer
receive multidisciplinary care
and the support of a CNS, as
outlined in the NICE breast
quality standard.
Changes required
3332 NSIC/Shepherd
Centre Skype
Rehabilitation
Comparison
Kirsten Hart, Clinical
Specialist
Physiotherapist
A comparison of the Specialist
rehab process and
Services
discharge outcome
between 2 adolescent
SCI establishments,
NSIC and USA
privately funded
Shepherd Centre.
21/09/2011 Data
Collection
Results and Recommendations required
3333 Antibiotic
Prophylaxis in
Surgery
Dr Waghorn,
Consultant
Microbiologist, Trust
Antimicrobial
Pharmacist (no-one in
post)
We have guidelines
Specialist
relating to antibiotic
Services
prophylaxis at
surgery. Audit to look
at 12 different types
of surgery and
compare with
guideline. 15 cases
from each surgery
area to be audited for
a 6 month period
every year.
27/09/2011 Complete
30/04/2012 Results: 82/170 (48%) patients were given incorrect
antibiotic prophylaxis. Recommendations: 1.
Highlight the individual surgical category results of
this audit to the relevant SDU lead and make sure
they are aware of current prophylaxis guidelines. 2.
Highlight the results of prophylaxis documentation to
the anaesthetic SDU lead so that recording of
regimens particularly on prescription charts
increases.
3. Discuss with senior theatre management a
potential revision of the WHO Surgical Checklist to
improve the prompting of surgeons/ anaesthetist for
prophylaxis. 4. Confirm with senior theatre
management that there are member(s) of staff in
each theatre area responsible for holding the most
up to date surgical prophylaxis guidelines so that
they are immediately available for
surgeons/anaesthetists. 5. Next audit based on JulDec 12 data.
Changes required
Meeting held with Matron
Alison Byrne, Pre-op
Assessment. Asked to take
up improved documentation in
urology patients of
catheterisation status and preop urine culture results.
Audit report with individual
covering letter distributed to all
relevant SDU management
and clinical governance leads
requesting review of report,
dissemination of results within
their departments and
improvement in antibiotic
prophylaxis consistency with
Trust guidelines.
Anaesthetic SDU
representatives asked to
increase documentation of
antibiotic administration on
Trust prescription charts. New
Theatres Medicines Policy
also introduced November
2012 to support prophylaxis
documentation on drug charts.
Meetings held with senior
theatre and urology staff to
agree change to WHO surgical
checklist in order to raise
awareness of potential need
for antibiotic prophylaxis at the
pre-induction stage. Amended
checklists introduced
December 2012 across Trust.
Meetings held with senior
theatre and pharmacy staff to
establish specific responsibility
for making sure current
versions of Trust prophylaxis
guidelines are available in all
theatres across both Trust
sites. New folders containing
relevant guidelines introduced
Wycombe September 2012
and Stoke Mandeville October
2012.
3334 Sharps
Management
August 2011
Amanda Adkins,
Infection Control
Audit of sharps
management.
Specialist
Services
21/09/2011 Complete
10/10/2011 Scores varied by unit from 78% “Yes” responses to
100%. Overall compliance was 95%. 2 wards had an
overall compliance less than 85% target. Overall
compliances by division varied from 90% (Women &
Children) to 97% (Medicine). Compliance had
reduced considerably for the following questions: Are
sharps bins stored safely, away from the public and
out of reach of children? (90%), Is an empty sharps
bin available on the cardiac arrest trolley? (89%). 9
of the 54 units (17%) should have completed an
action plan but didn’t. 10 of the 54 units (19%)
returned incomplete action plans, where there was
no action for at least one of the “No” responses.
Infection Control are
responsible for ensuring that
all areas complete action
plans if non compliant for any
question and that action plans
are followed up to ensure
actions completed. Re-audit
next year.
3335 Omission of
Antibiotics SMH
Nov 2010
Timothy Lim, FY1
The omission or
Medicine
delay of doses of
critical medicines
such as antibiotics
can result in serious
patient harm, and
omissions of
intravenous
medications are
widely reported in
hospitals. The aim of
this audit is to
quantify omitted
doses of intravenous
antibiotics in Stoke
Mandeville Hospital.
01/11/2010 Complete
01/04/2011 2.74% (43/1569) doses were omitted during the
survey period affecting 16.8% (24/143) of patients.
Of these, 20.9% (9/43) of missed doses were
associated with documented harm affecting 20.8%
(5/24) of patients who had doses omitted. 2 patients
developed pyrexia >37.5°C with 1 developing
tachycardia and another hypotension. The other 3
patients developed low-grade fevers (37.3-37.5°C).
Despite the existence of medicine ‘not administered’
codes, the most common reason for omitted doses
was no entry on the drug chart (48.8%). Other
reasons included the patient being off the ward
(18.6%), lack of venous access (6.9%), wrongly
prescribed antibiotics (6.9%) and medications not
being on the ward (6.9%). Action Plan
1. Contact Nursing Director regarding training of
nurses in timely administration of IV antibiotics,
usage of ‘Medicine not administered’ codes and
cannulation skills.
2. Contact Pharmacy Director regarding changes to
drug charts, ensuring adequate supplies of
antibiotics and minimising the time that drug charts
Changes required
are off wards.
3. Teaching for junior doctors on antibiotic
prescribing and the importance of ensuring venous
access in patients needing IV antibiotics.
Re-audit will occur in November 2011.
3336 Parenteral
Nutrition (TPN)
and associated
Line Infection
Rates
Bernadette TavnerAllsopp, Dietitian
Intestinal Failure
Specialist
Network (SHIFNET) Services
formed as a result of
NCEPOD June 2010.
The hospitals which
provide TPN will
collate agreed TPN
data annually to
monitor use, safety
and good medical
practice. All adults
who receive TPN in
BHT to be audited.
27/09/2011 Complete
30/09/2012 Recommendations: 1.Collect data prospectively: this Changes required
will reduce error and reduce the incidence of missing
data. It will also allow a more rigorous reporting of
line sepsis and the timely completion of DATIX
forms. 2. Ensure each NT is collecting/ measuring
data in the same way: to prevent confusion and
misinterpretation enabling more consistency. 3.
Ensure appropriate lines are used in all cases. 4.
Ensure all CVC tips are sent for MC&S when TPN
lines are removed.
3337 Vetting of
Endoscopy
Request Forms
E Wells-Cole, FY1
Audit the vetting
Integrated
process over 1 month Medicine
of inpatient and
outpatient endoscopy
requests from non-GI
firms to see if
appropriate requests
and how they are
prioritised.
27/09/2011 Cancelled
22/12/2011 Cancelled
Not applicable
3340 Post Natal Medical Geraldine Tasker,
Discharge
Consultant (Daniel
Planning
Jackson, GPVTS) Obs
& Gynae
Audit of completion of Specialist
patient discharge
Services
forms for instrumental
births and caesarian
section.
30/09/2011 Cancelled
18/11/2011 Audit cancelled.
3338 Referrals to Level Dr Veena Reddy,
3 Sexual Health
Associate Specialist,
from Level 2
GUM
Analyse the reasons
for referral and
appropriateness.
26/09/2011 Complete
22/02/2012 As seen in the Standards for the management of
No changes required
sexually transmitted infections, level 3 should be able
to coordinate and support all levels of sexual health
delivery. The results demonstrate that the two
services had some differences in their reason for
referral to Level 3. Both services required the tertiary
expertise for genital wart management. However the
nurse led service was unable to manage
symptomatic females and needed further
assessment – in particular a bimanual examination to
exclude pelvic inflammatory disease. With the new
level 2 service insertion of coils is part of the
specification. This means that delivery must be by
professionals that are able to conduct a pelvic
assessment. A few instances of referral for
administration of hepatitis B vaccination could be
deemed inappropriate. There was duplication of
sample taking sometimes because results were not
sent with the referral and sometimes because the
patient was symptomatic and needed microscopy.
This has cost implications. At our annual meeting
with the Practice this issue was discussed and action
was taken to speed up the transfer of results. New
contracts for level 2 have now been issued so only
recommendation is that this is audited again after 1
yesr.
Specialist
Services
Project cancelled.
3341 Peripheral Line
Insertion and
Continuing Care
Audit June 2011
Amanda Adkins,
Patients with Iv
Specialist
Infection Control, SMH cannula device in situ Services
should have VIP form
properly completed.
05/10/2011 Complete
3342 Urinalysis Audit
Sexual Health
Dr G Luzzi, Consultant
GU Medicine (Dr
Amanda Roberts,
Associate Specialist,
GU Medicine)
To ascertain whether Specialist
too many MSUs are Services
sent and whether
treatment and follow
up are appropriate.
04/10/2011 Complete
3343 Audit of Accuracy
of Clinical Coding
of T&O
Procedures
Mr Biring, Dr Aneesh
Mohindra, T&O
An audit of the clinical Surgery and
coding of T&O
Critical Care
procedures in order
to assess whether
inaccurate clinical
documentation leads
to reduced income
from inappropriate
coding.
06/10/2011 Complete
03/01/2012 Results: Insertion: 1153 observations were made
from 40 wards/areas, the majority of which were from
theatres. Overall compliance 92%.
Continuing care: VIP forms were completed for 84%
patients with IV lines. Insertion documentation was
particularly badly completed. Overall the compliance
for all applicable elements has increased from 44%
to 47% since 2010. Recommendations: All high
peripheral cannula user areas MUST complete no
less than 20 assessments in both insertion and
continuing care. Use of the VIP chart must continue
to be promoted and is now part of the matron’s round
to help ensure compliance. The continuing need to
emphasise labelling of ALL giving sets that are used.
To continue using red emergency stickers for
peripheral devices that are inserted in a manner
deemed non-compliant with recommended practice.
That education/ training continues to ensure that
insertion and on going care of peripheral cannula
devices is provided for all healthcare workers
involved in this skill.
26/07/2012 Results: All patients with bacteruria were treated
according to Trust guidelines with correct antibiotics.
More MSU specimens were sent for testing by
following the Trust guidelines than would have been
sent by following NICE guidelines. This resulted in
patients with asymptomatic bacteruria being treated
which is against the NICE guidelines.
Recommendations: Only dipstick test those
pregnant or with symptoms
Only send MSU in symptomatic patients if there is
NO concurrent infection with BV, Candida, TV, GC or
known Chlamydia, unless dipstick is positive for
nitrites. Advise follow up for patients with haematuria
and positive MSU culture.
Education continued.
26/06/2012 Recommendations: Juniors: to be introduced to the
importance of co-morbidities and complete
documentation at admission and discharge via TTOs,
including any complications; to be provided with lists
of relevant co-morbidities at induction. Surgeons:
highlight complications and abnormalities arising
intra-operatively in the notes; consider coding book in
theatres for staff to indicate operative code; monthly
review of cases with senior surgeon (SpR/ Cons) for
cases that coders are unsure of. Coders: education
about fracture terms, e.g. Monteggia fracture being a
fracture dislocation; highlight confusing cases at
monthly meets in order to clarify and achieve
consistency in coding; consider at source coding (in
theatre) either via dedicated orthopaedic coder or via
surgeons noting the procedure codes.
Action plan: Meeting with hand consultant with cases
needing clarification i.e. re: K-wires, June 2012 (A.
Mohindra FY2); coders to be informed of finding of
this audit and items of concern (K.Rolls); consultants
Junior doctor induction now
includes information on the
importance of documenting
relevant co-morbidities. The
audit has been presented to
the surgeons and in addition,
Kevin Rolls from the coding
department has presented
talks to the department on two
academic half-days. It was
agreed that the coders would
get in touch with the relevant
surgeon when in doubt about
the codes rather than monthly
meetings. Employment of a
dedicated coder in theatres
was discussed in the business
meeting and was not
considered viable at present
due to the economic situation.
The recommendations have
been actioned.
Far fewer dipstick tests are
being done and far fewer
MSUs being sent after refining
the criteria for sending. One
change was made to the
recommendations which was
that all new patients would
have dipstick urine testing on
their first visit. This is currently
being done but will be part of
the next audit and will be
reviewed.
to discuss merits of at source coding June/July 2012 The audit has been extremely
(Mr Chennagiri/Mr Graham)
beneficial in opening up a
direct communication pathway
between the coding
department and T&O and it is
expected that coding efficiency
will improve.
3344 National Audit of
Dementia 2012
(2nd round)
Dr Dominic Walshe,
Consultant Medicine
for Older People (Ana
Phelps, SpR, MfOP)
A national audit
Integrated
looking at the care of Medicine
patients with
dementia in general
hospitals.
01/04/2012 Awaiting
action
plan
26/02/2013
Changes required
3345 Audit of
Complication Rate
and Cost of ORIF
of Distal Radius
Fractures
Ramesh Chennagiri,
Orthopaedic
Consultant (Nik Bakti
CT2)
To assess rate of
complications after
distal radius ORIF.
To assess implant
choice and cost.
12/10/2011 Complete
03/05/2012 Summary: complication rates are well within figures
described in literature; functional outcomes 1 year
post recovery satisfactory; acumed implants cost
effective in comparison to AO implants.
Recommendations: utilise other resources such as
physiotherapy to reduce number of outpatient visits;
improve communication, e.g. information leaflets to
patients to reinforce information at time of discharge.
A patient information leaflet is
being trialled along with early
discharge to physiotherapy.
This is currently being audited
with patients under the care of
Mr Chennagiri and Mr.
Graham to ensure that it
works well before it is
recommended for all patients.
Surgery and
Critical Care
3346 VTE Prophylaxis
in Acute Surgery
Dr J Pattinson,
Consultant,
Haematology (Camilla
Arthur, Surgery)
Audit to determine
Specialist
whether prescribing
Services
for DVT prophylaxis
is meeting NICE
recommendations for
patients undergoing
surgery for cancer, as
well as orthopaedic
(hip/knee
replacement, major
trauma and fractured
neck of femur). This
is part of rolling audit
which is repeated
each year.
12/10/2011 Cancelled
26/07/2012 Cancelled
Cancelled
3347 Audit on the Use
of Curosurf in
NICU
Ruth Waters, Lead
Pharmacist Women &
Children (Yogeeta
Bhupal, Pre-reg
Pharmacist)
To identify whether
Specialist
curosurf is being
Services
prescribed and
adminstered correctly
and therefore cost
effectively.
14/10/2011 Cancelled
05/11/2012 Results and Recommendations required
Changes required
3348 Audit of Consent
for Hysterectomy
Miss G Tasker,
Consultant, Obs &
Gynae (Dr Kandiah
Guruparan, SpR)
Retrospective audit of Specialist
consent for elective
Services
hysterectomy in order
to assess whether the
RCOG and GMC
standards were
maintained during
consent.
07/10/2011 Complete
18/04/2012 There was 100% compliance with Use of
Changes required
Addressograph / labeling in every page; proper form
usage [form 1]; details of procedure explained;
benefits discussed; risks discussed[4 risks];
discussion regarding anesthesia; legible writing.
Improvement required in leaflets given to patients
(42%); copy of consent form to patient [26%];
documentation in clinical notes and notes keeping.
3349 Baseline Audit of
Putting Feet First
Erin Lee, Band 7,
Podiatry, Jane Coles,
Band 7, Podiatry
A one-day audit of all Integrated
diabetic inpatients,
Medicine
looking at the number
of patients, their risk
rating according to
NICE guidelines and
the current inpatient
care. The audit aims
to draw up
specifications for the
proper management
of the diabetic foot in
secondary care.
21/11/11 - sent email
to request data
collection tools. (DB)
18/10/2011 Complete
17/08/2012 Results: 15% of patients over all 3 sites had their
Changes required
feet screened on admission with only 7% of these
patients beeing referred to the specialist team.
However at the time the audit was carried out on 8th
November 2011 it was indicated that 26% of patients
should have been referred to the specialist team.
Recommendations: Standardise screening tool.
Develop an appropriate referral pathway alongside
the Diabetes team. Develop the use of the Diabetic
foot list on the PMS system across all hospital sites.
Audit inpatient foot screening November 2013.
Business case for a inpatient podiatrist band 7.
3350 Long Term
Outcome of Muller
Resection for
Ptosis
Miss R Khooshabeh,
Consultant,
Ophthalmology (Neena
Porter, SpR,
Ophthalmology)
Looking at surgical
success rate of
posterior approach
ptosis surgery from
year 2000 at SMH
and WH.
18/10/2011 Complete
25/05/2012 In this audit of over 300 cases, we have shown that No changes required to
posterior approach Muller resection consistently
current practice.
achieves a high success rate, with 95 – 99% of
eyelids achieving any one of target height, symmetry
or contour, and 92% achieving all three. Its main
advantages are that it allows both intra- and postoperative adjustment, thus giving a more predictable
result with less frequent contour abnormalities and
lower re-operation rates compared with anterior
levator advancement. We conclude that isolated
subtotal resection of Muller's muscle is a safe and
effective procedure and can be used in the majority
of ptosis patients with moderate to good levator
function.
3351 Endoscopy Staff
Experience
Survey 2011
Sue Kenny, SMH
Endoscopy Unit,
Deborah DobreeCarey, WH Endoscopy
Unit
To assess levels of
Integrated
staff satisfaction and Medicine
identify any areas for
improvement.
Surgery and
Critical Care
01/09/2011 Draft
Report
with
Clinician
Results and Recommendations required
Changes required
3275 Evaluation of Child Gerry Linke, Named
To evaluate staff
Specialist
Protection
Child Protection Nurse satisfaction with the
Services
Supervision
group child protection
supervision sessions
provided to support
staff dealing with
children and their
families.
01/08/2011 Complete
06/02/2012 Recommendations: Feedback the results of this
Changes required
survey to staff. Up date staff regarding the
supervision policy/child protection process and all
legal processes. Actions: Arrange a series of
workshops to feedback the results of this survey to
staff. At the workshops also up date the: supervision
policy, child protection process and all legal
processes.
3352 Parkinson's
Hospital
Medicines
Management
Audit
Catherine Northey,
Pre-registration
Manager (Lex
Tomkins, Pre-reg
Pharmacist)
21/10/2011 Cancelled
04/02/2013 Cancelled
3353 An Audit of
Pharmacy
Medicines
Reconciliation in
Buckinghamshire
Healthcare NHS
Trust
Lisa Pazik, Lead
Audit to look at: no. of Specialist
Pharmacist Emergency reconciliations
Services
Medicines
completed within 24
hours of admission,
number of medicines
signed and dated,
more than one
reference source for
each item on the drug
history, POD
quantities recorded,
medicines not
prescribed have been
actioned & medicines
discontinued have a
reason stated.
Investigation into
Specialist
whether patients with Services
Parkinson's disease
have their
medications correctly
recorded and
administered.
21/10/2011 Analysis/
Report
Results and Recommendations required
Cancelled
Changes required
3354 Laparoscopic
Treatment for
Endometriosis
Patient Quality of
Life Survey
Mr Tunde Dada,
Consultant (Vasileios
Minas, ST5) Obs &
Gynae
A quality of life survey Specialist
for patients who have Services
had laparoscopic
surgery for
endometriosis.
21/10/2011 Complete
3356 Reaudit of WHO
Surgical Safety
Checklist
John Abbott, Deputy
ADO, Surgery
Re-audit of
Surgery and
compliance with the Critical Care
WHO Surgical Safety
Checklist May and
June 2012.
29/06/2012 Complete
3357 Long Line Venous Amanda Adkins,
To evaluate the
Specialist
Catheter October Infection Control, SMH results of the High
Services
2011
Impact Intervention
(HII) Central Venous
Catheter tool used in
the Saving Lives
Infection Control
programme. ITU and
St Andrews only.
01/10/2011 Complete
18/04/2012 Laparoscopic treatment of endometriosis results in
No changes forthcoming.
significant symptom relief, regardless of stage. This
effect appears to persist for up to 36-48 months
following surgery. There was overall a statistically
significant drop in QOL score from 47 to 27 following
surgical treatment
range 0-100, score=100 represents worst quality of
life. Recurrence rates are higher with longer follow up
and higher endometriosis stage.
Local recurrence rates are similar to those reported
in the literature.
The number of reported symptoms is not a reliable
factor in assessing severity of endometriosis preoperatively. Recommendations: 1. Surgical
treatment for endometriosis is operator-dependant,
therefore it may be important for Trusts to be able to
show own results. 2. Incorporate results in
leaflet/care pathway (perhaps use as aid in
counselling locally).
16/11/2012 To re-visit the patient checklist in the intra-operative Changes required
booklet for elective plastic and orthopaedic joint
replacements as an audit of the clinical notes by the
audit department within 6 months; matrons to spend
some clinical time with medical teams who are
reported to have poor engagement with the WHO
process; new WHO to go live in all theatre areas as
recently ratified by the Theatre Steering Board and
the Surgical Divisional Board; repeat full audit in 12
months time with suggested review of the WHO
policy.
20/01/2012 Compliance was very good but forms completed
incorrectly affecting results and giving an
underestimated compliance of 88%.
No signed off action plans
received. New procedure for
next peripheral line audit action plans will be created for
the wards by the OPAT team.
3358 Trustwide Consent
Audit 2011
To assess the extent Trustwide
to which appropriate
consent is obtained
from patients within
the Trust. To assess
the quality of consent
obtained from
patients within the
Trust. To educate
clinicians in the
standards of consent
expected by the
Trust.
01/11/2011 Draft
Report
with
Clinician
Mr Tunde Dada,
Consultant, Deborah
Bett, Diabetes
Specialist Midwife, Dr
Archana Ranganathan,
SpR, Obs & Gynae
An audit of outcomes Specialist
such as mode of
Services
delivery, birth weight,
admission to NICU
and number of babies
treated. Audit against
standards and
comparison of results
with audit in 2009
(2479)
01/11/2011 Complete
14/06/2012 Results: 1. Higher induction rates although median
Changes required
GA similar (?significance due to smaller numbers). 2.
Delay in IOL associated with increased CS rate. 3.
Elective LSCS rates higher. 4. Overall perinatal
outcomes are comparable to ACHOIS. 5. More
adverse perinatal outcomes in women diagnosed
after 36 wks. Recommendations: 1. Larger audit to
compare outcome of GDM induced at 38 + and 39 +
weeks. 2. ?Delaying IOL in VBAC to improve VBAC
rates.
3360 Review of the use Miss Deborah Sumner,
of HPV testing in Consultant, Obs &
Colposcopy Clinic Gynae
(BHNHST)
HPV testing has been Specialist
introduced to try and Services
help the management
of colposcopy
patients and hopefully
allow discharge of
patients from clinic.
This is a re-audit to
determine whether
HPV testing has
helped management
and whether patients
have been
discharged from
clinic. Previous audit
was 2949.
28/10/2011 Complete
18/04/2012 No recommendations for change were made.
3359 Outcome of
Pregnancies
Complicated by
Gestational
Diabetes
(BHNHST) ReAudit
Results and Recommendations required
Changes required
No recommendations for
change were made.
3361 Audit of GP 6
Month Follow-up
Appointment Post
Stroke
Dr Burn, Stoke
Consultant (Dr Alison
Rowlands, ST1
GPVTS
Audit of GP 6 month
follow up
appointments post
stroke to see what
checks are carried
out.
Integrated
Medicine
28/10/2011 Cancelled
01/03/2012 Cancelled - junior doctor realised the planned
methodology for this audit was flawed.
Not applicable - cancelled
3362 Pneumonia
Mortality Review
Dr G Luzzi, Medical
Director
Review of mortality in Trustwide
inpatients over 75
with a diagnosis of
pneumonia, during
December 2010 and
January 2011,
following an enquiry
from the CQC.
26/10/2011 Complete
Results and Recommendations required
Changes required
3363 Multiple Territory
Infarcts in MRS
and Malignancy
Dr C Durkin,
Consultant, Medicine
for Older People (Dr K
Nagaratnam, ST6,
MfOP)
Retrospective
Integrated
analysis of patient
Medicine
records, PACS and
pathological reports
of patients who
presented with stroke
(multiple territory
infarct) and a
diagnosis of cancer
that was either made
pre or post
cerebrovascular
event.
31/10/2011 Cancelled
06/11/2012 Cancelled. Dr did not provide any lists for audit. No
contact since January 2012.
Project cancelled.
3364 Delayed
Discharges from
Urology
Paul Hadway, ST7,
Urology
An audit looking at
Surgery and
Urology patients
Critical Care
discharged during
August 2011 and
identifying those
whose discharge was
delayed and the
reasons why.
03/11/2011 Cancelled
28/08/2012 Audit not completed due to lost data.
3365 OPAT IV in the
Community PES
Marie Coward & Sian
Bates, IV Specialist
Nurses
This PES is being
Integrated
carried out as part of Medicine
the admission
avoidance evaluation
project. Patients
receive iv antibiotic
therapy at home
rather than in
hospital. The
purpose of this
survey is to obtain
patient feedback
regarding the service
being provided Nov
2011-July 2012.
02/11/2011 Complete
31/08/2012 Without exception, the service has received very
Changes required
positive reviews and has been very well received.
Both the IV Therapy Team and the Adult Community
Healthcare Team have performed very well with all
patients reporting excellent, efficient and professional
service. Some patients did not receive information at
the point of discharge about the service, however,
they indicated that they were fully informed when at
home. Recommendations: 1. IV Therapy Team to
ensure every patient on the service receives a
questionnaire. A tick box will be added to the patient
discharge summary. 2. Ensure that all patients
receive written information about the service prior to
discharge and reaffirm that this information is
understood when at home.
To monitor length of
stay for THR and
TKR and to identify
reasons for delays in
discharge.
24/10/2011 Complete
03/04/2012 Recommendatons: Feedback the results of the audit
to Orthopaedic consultants, anaesthetists, nursing
staff and business manager, involved in the ERP;
establish data set for next audit period with reference
to ERP; compare 2012 benchmark LOS data for
primary elective joint replacement project against
prospective data as ERP becomes more established;
continue to increase percentage of patients with a
LOS of 4 days or fewer; establish pre-op education
for all primary THR & TKRs.
3366 Monitoring of
Jane Eastman, Jenny
Length of Stay for Grievson, Senior
Primary Elective
Physiotherapists
THR & TKR 2011
(BHNHST)
Surgery and
Critical Care
Project cancelled
Copies of the audit report were
issued to individuals involved
in the ERP. The data set was
discussed with the ERP team
and minor changes were
made for the next audit period
to tailor it to the ERP with
particular reference to
anaesthetics and recording a
POMS defined morbidity. The
data set for April to September
2012 is ready to be audited
and will be analysed to
determine the median LOS for
primary elective joint
replacement. It is hoped that
this latest data will reflect a
massive improvement in
attendance at pre-op
education.
3367 Prescription of
Mr M Belci, Spinal
Nifedipine for
Consultant (Temitope
Spinal patients at Ayorinde, SHO)
Risk of Autonomic
Dysreflexia
To assess rate of
Specialist
prescription of
Services
nifedipine among
patients at risk of
autonomic
dysreflexia. Compare
to NICE guideline.
07/07/2011 Complete
3368 Percentage of
Smokers who
Accepted a
Referral to
Support services
at Pre-op
Assessment
To establish whether Surgery and
the smoking status of Critical Care
patients is being
established at pre-op
assessemt and
whether smokers are
being
referred/accepting
referral to Smoking
Cessation Services.
07/11/2011 Cancelled
Alison Byrne, Sister
Pre-op Assessment
07/12/2011 Poor practice of prescribing antihypertensives for inpatients at risk of AD. This will increase the chances
of discharging these patients without an
antihypertensive. Inconsistent dosing regimen for
Nifedipine among adults. Recommendations: Current
NSIC guidelines need to be updated and should
include guidelines aimed at: 1. Mandatory
antihypertensive prescription PRN for patients at risk
of AD. 2. Consistent dose regimen for adults. 3.
Explicit description of how antihypertensives for AD
should be administered. Particular emphasis should
be made on the administration of Nifedipine as it is
the most used for this purpose in the NSIC. 4. All
relevant staff should be made aware of all existing
local guidelines for the management of AD. 5.
Method of prescribing Nifedipine should be reviewed.
Its current prescription of ‘sublingual’ appears
confusing especially to nursing staff who administer
the medication. 6. Improve the practice of prescribing
an antihypertensive for patients with injuries at or
above T6 especially among high lesions and more
complete injuries PRN. 7. Improve the practice of
providing additional instruction for when
antihypertensive is indicated in this group of patients.
8. Consider the introduction of a section for stating
the neurological level of patients on drug charts to
enable pharmacy to alert doctors and remind them
when a PRN antihypertensive prescription appears to
have been missed for a patient being discharged.
02/05/2012 Results and Recommendations required
The Spinal SHO guidelines
are in the process of being
updated.
There is more awareness now
among the doctors especially
SHOs and verbal reports from
pharmacy suggest that an
antihypertensive for AD is
being prescribed more for
relevant patients at risk. The
paediatric and adolescent
guideline for treatment of AD
has now been made available
in the training folder for all
doctors in the unit.
Prescription now includes bite
and swallow compared to sub
lingual as emphasised in the
updated spinal SHO clinical
guideline.
Working on getting it on the
Trust guidelines so that it
would be available on the
Intranet for other departments
in the hospital.
Changes required
3369 Screening for
Tuberculosis and
Blood-borne
Viruses in Patients
due to start AntiTNF Therapies
Dr Malgorzata
Magliano, Consultant,
Rheumatology (Dr
Olaa MohamedAhmed, FY1)
3370 Pre-op Blood Test Dr Caroline Pritchard,
Protocol
Consultant,
Compliance
Anaesthetics (Dr
Jennifer Taylor, FY1)
3371 Time Delay
between
Prescription and
Administration of
the First Dose of
IV Antibiotics in
NSIC
A retrospective, multi- Integrated
centre audit to
Medicine
consider whether
appropriate screening
is taking place in
Stoke, Wycombe and
Amersham patients
due to start anti-TNF
therapy. The audit
will also consider
whether efforts to
screen are effectively
documented in the
notes.
07/11/2011 Cancelled
To compare pre-op
Surgery and
blood bank tests (e.g. Critical Care
Hb group and save)
on elective surgical
patients with those
recommended by
hospital guidelines.
14/11/2011 Awaiting
Report/Ac
tion Plan
Results and Recommendations required
15/11/2011 Complete
15/11/2011 Results: The audit demonstrated a high percentage
(42 %) of potentially harmful incidences of delay in
administration of the 1st dose IV antibiotics in septic
patients. Only in 83.3 % of the incidents, 1st dose of
IV antibiotics was prescribed STAT. It also
demonstrated the lack of documentation of time by
nurses in 34% of incidences and by doctors 14%.
Mr Mofid Saif, Spinal
Prompt administration Specialist
Injuries Consultant (Dr of IV antibiotics is
Services
Wail Ahmed, SpR)
vital in management
of septic patients.
This audit assesses
the scale of the delay
in administering first
dose IV antibiotics in
septic patients in the
NSIC
06/11/2012 Cancelled. Doctor left trust without completing audit. Project cancelled
Changes required
A Sepsis – Integrated Care
Pathway (with adaptations for
spinal patients) was agreed
upon and came into practice.
Had discussions with
pharmacist to make sure that
the IV antibiotics are available
within reach of the wards,
especially during weekends
and out of hours time. Reaudit June 12. (3361) (AC)
3373 Outcome of
Occlusion Audit
Mr Nigel Cox,
Consultant Ophthalmic
Surgeon (Rachel
Gallaher, Head
Orthoptist, SMH)
To determine the
effectiveness of
occlusion treatment
at SMH
Surgery and
Critical Care
3374 British HIV
Association
National Audit
2011
Dr Veena Reddy, GU
Consultant
National audit looking Specialist
at timeliness of HIV
Services
diagnosis and impact
of 2008 national
testing guidelines, in
particular: local action
to promote testing,
circumstances of
diagnosis, previous
history and missed
opportunities for
testing, time from first
positive test to be
seen in HIV service.
A survey of local
testing policy and
practice. This was a
national audit for
which we submitted
information on 100
case notes. BHIVA
sends a report with a
breakdown of overall
results and Trust
results.
17/11/2011 Analysis/
Report
17/11/2011 Complete
Results and Recommendations required
01/11/2012 We performed in the top quartile for most areas. It
highlighted our lack of access to psychological
services (no action that we can take). The only
suggested action was to do a patient satisfaction
survey which is occurring.
Changes required
None required
3375 Mortality Review
April 2011 September 2011
Dr Graz Luzzi on
behalf of the
Healthcare
Governance
Committee
A review of 50 deaths Trustwide
requested by the
Healthcare
Governance
Committee as part of
an ongoing review of
mortality within the
Trust.
21/10/2011 Complete
(no
changes
reported)
30/05/2012 The Medical Director is to review the notes of the 4
Changes required
patients where death was potentially avoidable and 1
where it was probably potentially avoidable. The
Chief Nurse and Director of Patient Care Standards
is to review the notes of the 10 patients where fluid
balance was identified as being poorly managed as
well as the notes of the patient where the reviewer
stated that death was not potentially avoidable but
commented: ‘Unlikely but earlier fluid resuscitation
may have been helpful’. The outcome of the above
reviews will determine whether the cases should be
declared as Serious Incidents. Outcomes and
associated action required will be communicated to
the appropriate staff within the organisation.
3376 An Audit of
Ledwina Mutandwa,
Nursing Homes to Diabetes Specialist
See if Diabetics
Nurse
are Receiving
Appropriate Care
A pilot of 8 nursing
Integrated
homes. Includes
Medicine
questionnaire on
general care of
diabetics at nursing
home, diabetes quiz
for all staff and audit
of all diabetic patients
to see if received
appropriate care
18/11/2011 Complete
09/03/2012 Results: The pilot study showed that diabetes care
in nursing homes is not satisfactory. Blood sugar
was not tested frequently and annual reviews were
not carried out. Staff scored 78% on average in the
diabetes quiz but scores varied from 43% to 95%.
Basic questions to do with the patient's care were
often answered incorrectly. Recommendations: To
set up study days on diabetes for care home staff.
Send resource packages and care plans to all
homes. Identify link nurse in each home and arrange
meetings with them. Provide referral pathway and
contact numbers. May be necessary to train district
nursing team. Extend surveys to all care homes.
4 study days have been
carried out and more planned.
Still working on care plans.
Link nurses have been
identified but difficult to
maintain contact because of
staff turnover. Referral
pathway and contact numbers
have been provided to all
homes.
Working with district nurses to
find ways of getting them
involved.
Overall it has been a learning
curve with positive out comes
on care of people living with
diabetes in residential homes.
3377 Infected Hip
Hemiarthroplasty
Deep infection
Surgery and
following a hip
Critical Care
hemiarthroplasty for
fractured neck of
femur is an
uncommon but
serious complication.
This audit will look at
the natural history
and bacteriology of
the disease in
patients with proven
deep infection after
hip hemiarthroplasty,
with a particular focus
on factors affecting
the chances of
successful
debridement and
implant retention
(DAIR).
21/11/2011 Complete
22/06/2012 Older patients with significant co-morbidity appear to
be at greater risk of deep infection after hip
hemiarthroplasty. Debridement and implant retention
(DAIR) has a low chance of success in this
complicated group of patients and this may be
associated with the high incidence of coliforms as the
infecting organism. More than one attempt at DAIR
appears futile and a Girdlestone's Procedure is
advised after one failed DAIR.
The findings have been noted
by the consultants and a reaudit will take place in a year
or two.
Mr G Biring,
Consultant, T&O (Ben
Dean, Orthopaedic
Registrar)
3378 Mountain Bike
Injuries
Mr Belci, Spinal
Consultant
Shoaib, ST5)
Are we following
(R F correct guidelines
with regard to
recording of
mechanism of injury
and performing
correct
investigations?
Specialist
Services
22/11/2011 Analysis/
Report
Results and Recommendations required
Changes required
3379 Quality of
Orthodontic
Photographs
Helen Travess,
Consultant,
Orthodontics (Helen
Veeroo, SpR)
Audit of the quality of Surgery and
intraoral and extraoral Critical Care
orthodontic
photographs taken by
medical illustration.
28/11/2011 Complete
25/07/2012 90% of clinical photographs should meet gold
Findings were fed back to
standards; less than 5% should fall into category ‘not medical illustration with
clinically useful’. For clinical photographs taken at
suggestions as per the report.
start of treatment, 63% met gold standard and 11%
were not clinically useful. For clinical photographs
taken at end of treatment, 78% met gold standard
and 7% were not clinically useful.
Recommendations: improvement in positioning for
intra-oral buccal photos; check patient is smiling
naturally; confirm position of frankfort plane; repeat if
eyes closed; ensure nothing obscuring teeth; re-audit
in 2 years.
3380 Reporting of
Orthodontic
Radiographs
Helen Travess,
Consultant,
Orthodontics (Helen
Veeroo, SpR)
Audit of the reporting Surgery and
practices within the
Critical Care
Orthodontic
Department for
radiographs.
28/11/2011 Complete
25/07/2012 58% radiographs were not reported in clinical notes.
43% had no form of report at all. Recommendations
were to ensure that all radiographs are reported; use
stamp to help remember to report each xray taken;
even if tracing put in file refer to it in clinical notes; reaudit in 1 year.
Labels being printed to place
in notes to complete
radiography reports for each
xray taken, including
assessment of quality.
3381 Audit of
Retinopathy of
Prematurity
Screening
Dr G Sarkar,
Consultant
Paediatrician (Dr Sae
Run Nisa Rizwan, SpR
LAS)
An audit to assess
Specialist
whether the Trust is Services
complying with
retinopathy of
prematurity screening
guidelines.
29/11/2011 Analysis/
Report
Results and Recommendations required
Changes required
3382 Audit of
Mr A McLaren,
Cholecystectomie Consultant General
s
Surgery
Audit of all
cholecystectomies
between 1st May to
31st October 2011
looking at
complications.
Surgery and
Critical Care
29/11/2011 Draft
Report
with
Clinician
Results and Recommendations required
Changes required
3383 Isolation
Precaution Sign
Audit
Audit to determine if
isolation precaution
signs are being
displayed in line with
Isolation Policy.
Specialist
Services
01/10/2011 Complete
02/12/2011 The results show fairly poor use of the isolation
precaution signs. In the current infection control
manual there is no mention of precaution signs in the
isolation policy. This should be added.
The link infection control nurses on each ward should
emphasise, to the ward staff, the importance of
maintaining the isolation precautions sign for both
staff and visitors.
The link infection control nurses should monitor
compliance with the policy within their area and
promote the correct way in which to complete the
signs.
The audit should be repeated to check to see that
improvements have occurred.
Matrons should include monitoring of the isolation
precaution boards in their matrons rounds.
Danielle Parrott,
Student Nurse on
placement with IPC
department
Precaution signs have been
added to the isolation policy.
The use of the isolation
precautions sign has been
highlighted in the IPC Times
and to Infection Control Link
Practitioners. ICLP have
monitored use and promoted
signs in their areas. Matrons
are monitoring the signs in
their rounds. Audit was
repeated Jan 12.
3384 Surgical Site
Amanda Adkins,
Infection Pre-op
Infection Control
and Peri-op Audit T&O Theatres Oct
2011
Observational audit
T&O theatres only.
Specialist
Services
01/10/2011 Complete
3385 Home Oxygen
Service
Assessment and
Review
(Suzy Robertson,
Operations Manager,
Medicine). Lesley
Broad, COPD Nurse
Specialist, Hazel
Haines, Lead Nurse
A questionnaire to
Integrated
patients in order to
Medicine
assess and review
the home oxygen
service, which will
provide baseline
information on current
usage by patients
and an understanding
of their prescription
and needs.
01/12/2011 Complete
3386 Clinic Letter
Survey
Mr Shaun Appleton,
Consultant, Surgery
(Dr Deborah
Stevenson, F1)
Brief forms to be
Surgery and
handed out at
Critical Care
outpatients reception
asking if patients
would like to receive
copies of their clinic
letters.
06/12/2011 Cancelled
02/12/2011 Results: Only 40 % of the eligible patients were
IPC have been assured that all
screened for MRSA in this audit. Only New Wing
actions have been addressed.
Theatres at Stoke Mandeville Hospital participated in
this audit. 100% compliance with checking WHO
surgical checklist was achieved. All patients were
given prophylactic antibiotics where appropriate. 1 of
3 patients requiring hair removal had hair removed
by shaving which is unacceptable. There was 100%
compliance with maintenance of Normothermia.
Recommendations: All areas with non participation
must produce an action plan on how they are
monitoring the compliance with this audit.
Areas who did not produce an action plan and return
an action plan at the time of completing the audit
must produce and action plan to show how areas of
non-compliance have been addressed.
All areas with ‘No’ answers are required to sign off
this action plan to confirm all actions have been
completed and then return to the IPC.
02/02/2012 The report will be used to prioritise patients alongside No changes required.
the concordance report. There are no specific
recommendations.
28/08/2012 Audit cancelled.
Audit cancelled.
3387 A Review of
Waiting List
Booking Cards
3388 A Survey of
Gynae-oncology
Patients' Needs
for a Planned
Nurse-Led Clinic
3389 Rate of UTIs in
Spinal
Miss Geraldine Tasker, Gynaecology
Consultant, Obs &
operating lists are
Gynae
generated by booking
co-ordinators who
require accurate and
detailed information
on the waiting list
booking card in order
to list a patient
correctly. Cards are
frequently inadequate
resulting in extra
workload for coordinators and could
result in patients
being placed on the
wrong list, in incorrect
time slot, alerts not
shared and late
cancellations.
Francesca Lis, Gynae- Feedback is required
oncology Clinical
from patients In order
Nurse Specialist,
to gauge potential
Jeanette Tebbutt, Lead uptake for a nurse-led
Cancer Nurse
gynae-oncology
clinic, which will meet
patients'
requirements.
Specialist
Services
21/11/2011 Complete
06/02/2012 More attention to detail is needed. 1. Contact phone
number is extremely helpful. 2. Relevant medical
problems should be carefully documented, and if no
problems identified, that should be stated. 3.Weight
documentation should be mandatory. 4. Theatre
time allowed should be the operating time – the
booking co-ordinators will allow for the anaesthetic
time according to type of theatre (15mins/patient for
DSU and 30 mins/patient for NW list).
Specialist
Services
01/12/2011 Data
Collection
Results and Recommendations required
Debbie Green, Matron, To examine rates of Specialist
NSIC, Jean O'Driscoll, catheter related UTIs Services
Infection Control
in Spinal and
compare with national
rates. Analyse
patients' notes to see
if any trends.
Prospective recording
of numbers of
catheters and all UTIs
for 3 months in each
spinal ward.
07/12/2011 Complete
31/12/2012 No recommendations or action plan.
Recommendations
communicated at academic
half day in Feb 2012.
Additionally an email was sent
to clinicians in the department.
Re-audit to commence in
October 2012 – to ensure
more detail documented on
W/L cards.
Changes required
No recommendations
3390 Spinal Outreach
Service
Debbie Green,
Outreach
Outreach visits spinal Specialist
patients in other
Services
hospitals to talk to
patients about care
and to train staff.
Audit Outreach
service against policy
in terms of delays etc
and evaluate training
with an experience
survey.
07/12/2011 Not yet
started
Results and Recommendations required
Changes required
3391 BTS Paediatric
Asthma National
Audit November
2011
Sunil Raga,
National BTS Audit of Specialist
Consultant, Paediatrics the Management of
Services
(Dr Rizwan)
Paediatric Asthma November 2011.
01/12/2011 Complete
31/07/2012 Total cases audited 3148. Results very similar to
Changes required
2010 audit. 98 percent received beta agonist
bronchodilators with a quarter treated by nebulizer
alone, and just over third by spacer alone, and just
over third treated by a combination of nebuliser and
other devices. Half the children also received
ipratropium. Eighty two percent received
corticosteroids. 3% receiving IV aminophylline, 3% IV
Magnesium and % IV Salbutamol and 4% being
admitted to ICU. Area where care remains least well
done is around discharge planning. only 44% of
children are recorded as having their device use
checked and only 41% are recorded as being given a
written discharge plan. Since the evidence suggests
that good discharge planning decreases future
admissions this is an area that many units might
target for improvement.
3392 BTS Paediatric
Pneumonia
National Audit
November 2011
Sunil Raga,
National BTS Audit of Specialist
Consultant, Paediatrics the Management of
Services
(Dr Rizwan)
Paediatric
Pneumonia November 2011.
01/12/2011 Complete
31/07/2012 101 institutions submitted data (up from 77 in 2011) Changes required
reporting over 2800 cases (male 52.9%). The age
distribution was very similar to that of previous years
with 45% under the age of three years and 71%
under the age of five. Duration of admission was
short with 45% staying less than 48 hours (40%
2010-2011) and 85% less than five days. On
admission 99.1% of children had their oxygen
saturation recorded in air and nearly 40% were
hypoxic (oxygen saturation less than 92%). 30% of
children had a fever greater than 39 degrees
centigrade. Wheeze was noted in 40% of those
under the age of five and 24% of older children. 43%
of children were given a bronchodilator, 28% had
intravenous fluids and 52% had some intravenous
antibiotics. The commonest intravenous antibiotic
was Augmentin, then Cefuroxime both given for one
to two days. Overall antibiotic choice did not change
between 2010-2011 and 2011-2012 with Augmentin
being the most popular antibiotic in both time
periods. Despite macrolides being suggested as
only second line antibiotics in the 2011 guidelines,
macrolide use increased to 27.2% of antibiotics given
in 2011-12 compared with 20% in 2010-2011.
Physiotherapy is not recommended in the
management of pneumonia but 17% of children
nevertheless received it (15% 2010-2011). Despite
only three children in 2011-2012 having a significant
complication, some 33% of children received an
appointment for hospital follow-up and 11% had a
chest X-ray repeated at follow-up. This would appear
on an unnecessary high use of secondary care
resources.
3393 Audit of Gastric
Ulcer Follow-up
(WH)
Dr Sue Cullen,
Consultant (Naomi
Warner)
Gastroenterology
3394 The Role of CT
Tom Meagher,
Scan in the
Consultant, Radiology
Management of
(Dr Wail Ahmed, SpR)
Suspected Sepsis
in Patients with
Spinal Cord
Injuries
Patients who have a Integrated
gastric ulcer
Medicine
visualised at
endoscopy should
have a follow up
appointment within 12
weeks. Are these
patients being
followed up?
12/12/2011 Complete
12/12/2012 As well as advice to stop anticoagulants prior to their Changes required
OGD, patients should be advised to have clotting
checked 3-5 days prior to the procedure to enable
abnormal clotting to be corrected or the OGD
rescheduled. If unable to obtain H. pylori result via
Clo test, and no other obvious aetiology for
ulceration (eg NSAID use), alternative test for H.
pylori, or empirical therapy with re-scope should be
considered.
Early diagnosis of
Specialist
septicaemia is vital in Services
management of
sepsis in SCI
patients. Audit to
assess if CT scans
reported accurately
and, if positive,
findings acted on
appropriately. NICE
guidelines exist. Aim
to establish Trust
guidelines for use of
CT for diagnosis of
sepsis.
13/12/2011 Complete
16/10/2012 Specific radiological diagnosis was found in 14 % of No changes required
cases and 67 % of these required surgery for
treatment of sepsis. Correlation between clinical and
radiological findings was found in 55 % of cases. No
relationship was found between the severity of sepsis
and specific radiological findings. CTChest/Abdomen/Pelvis is a valuable and expensive
diagnostic tool with high radiation dose, however it is
only useful in a limited number of sepsis cases in
spinal cord injured patients
Multidisciplinary spinal/radiology meetings are
extremely important for discussion of complicated
cases and planning further management with
consideration of early surgical intervention.
3395 Re-admissions
Audit
Dr Graz Luzzi, Medical Audit of the notes of Trustwide
Director
all patients readmitted during April,
May and June for a
reason appearing to
relate to the reason
for their original
admission.
13/12/2011 Design
3396 Surgical Site
Infection Peri-op
Audit - Urology
Dec 11/Jan 12
Amanda Adkins,
Infection Control
Observation audit Urology only.
Specialist
Services
01/12/2011 Complete
3397 Emergency
Department IV
Fluid Prescribing
in Surgical
Patients
Dr Stewart McMorran,
A&E Consultant (Dr
Carly Grandidge, FY2,
Medicine)
Audit against British
Consensus
guidelines on IV fluid
therapy for adult
surgical patients.
Integrated
Medicine
15/12/2011 Cancelled
Results and Recommendations required
28/02/2012 One of the patients screened tested positive for
MRSA. This patient was not given MRSA
decontamination and the patient notes were not
alerted. The failure to take the required actions
following the positive MRSA result should be
investigated and the outcome of the investigation fed
back to the Infection Prevention and Control Team. If
necessary, this should be reported as an adverse
incident via the Datix system. 100% compliance for
completing WHO surgical checklist. Some of the
questions on the proformas for some patients were
not answered. It is important all questions are
completed.
Audit cancelled.
Changes required
These are discussed at the
IPCC and we have been
reassured by the AND all
actions have been addressed.
Project cancelled.
3398 Outcome for
Shoulder
Replacement
Surgery
Geoffrey Taylor,
Consultant
Orthopaedic Surgeon,
Vicky Russell, Clinical
Specialist
Physiotherapist
Use Oxford Shoulder Surgery and
Score (a validated
Critical Care
outcome measure) to
measure function preop and 3 and 12
months post shoulder
replacement. Also
patient satisfaction
survey at 12 months.
16/12/2011 Not yet
started
3399 Use of
Tranexamic Acid
in Traumatic
Fracture Neck of
Femur Surgery
Dr Sara McNeillis,
Consultant,
Anaesthetics (Dr Bijal
Kothari, CT1, Dr
Rebecca Medlock)
Audit looking at
Surgery and
retrospective notes of Critical Care
traumatic hip fracture
and use of
tranexamic acid.
19/12/2011 Cancelled
Audit of contraceptive Specialist
implant removals.
Services
Was counselling
given before
insertion? Have
treatments been
considered/tried prior
to removal?
15/12/2011 Draft
Report
with
Clinician
3400 Audit of
Dr Elizabeth Vincent,
Contraceptive
Associate Specialist,
Implant Removals Contraception, WH
Results and Recommendations required
21/02/2012 Project cancelled
Results and Recommendations required
Changes required
Project cancelled
Changes required
3401 Audit of
Adherence to the
Guideline for
Management of
Reduced Fetal
Movements in
Pregnancy (SMH)
Dr Gemma Brierley,
ST2, Obs & Gynae,
Miss A Reddy,
Consultant
Re-audit of 3065.
Women &
Children
02/01/2012 Complete
3402 Surgical Site
Infection Peri-op
Audit Ophthalmology,
ENT & Oral Nov
11
Amanda Adkins,
Infection Control
Observational audit
Specialist
Services
01/11/2011 Complete
3403 An Audit of Miss
Shaikh's
Strabismus
Surgery Outcomes
Miss Asifa Shaikh,
Consultant
Ophthalmologist, Dr
Christine Kiire, ST4,
Ophthalmology
Audit against the
Royal College of
Ophthalmologists
guidelines for the
management of
strabismus in
childhood.
Surgery and
Critical Care
04/01/2012 Awaiting
Report/Ac
tion Plan
Entered on database in error. See audit 3457.
03/01/2012 Results: Pre-operative component: 11 patients out
of 46 should have been screened for MRSA but one
of the 11 wasn't screened.
Peri-operative component: All patients undergoing a
surgical procedure must have the WHO surgical
checklist completed. 98% were. Some forms were
completed incorrectly with "No" instead of "N/A".
There was 100% compliance for monitoring
normothermia. For 6 (13%) the glucose control
question was not completed. Recommendations: 1.
Staff should be reminded to screen all relevant
patients for MRSA. 2. Staff should be reminded to
complete the forms correctly, particularly when
differentiating between "No" and "N/A" responses. 3.
All elements of the tool must be completed. If the
audit is not applicable in theatres then the must send
a blank form back crossed through with not
applicable documented. An action plan should be
completed by all areas where there was any noncompliance. This should be returned to the IPCT
office.
Results and Recommendations required
NA
All actions have been
addressed. Staff reminded to
screen all relevant patients for
MRSA. Staff reminded to
complete the forms correctly
and completely. Staff
reminded that if the audit is not
applicable must send a blank
form back crossed through
with not applicable
documented.
Changes required
3404 Accuracy of CT
Pneumocolon
against
Colonoscopy
Dr R Sekhar,
Consultant
Gastroenterologist (Dr
Harjit Bains, ST5)
Audit against BSG
guidelines.
Integrated
Medicine
05/01/2012 Cancelled
Audit cancelled. Doctor left Trust and no information Project cancelled.
supplied on whether it was ever carried out.
3405 Spinal
Mr Edward Seel,
Orthopaedic Clinic Consultant
Patient
Orthopaedic Surgeon
Satisfaction
Survey
A brief questionnaire
survey of patients'
experiences in
outpatients. Sheets
will be handed to
patients immediately
after their OPA to be
completed
anonymously. The
forms will be
collected before they
leave.
Surgery and
Critical Care
01/03/2012 Data
Collection
Results and Recommendations required
3406 Audit of Goal
Dr Jane Duff,
Planning & Needs Consultant Clinical
Assessment
Psychologist, NSIC
Programme
2010/11 in NSIC
Needs assessment & Specialist
goal planning
Services
programmes provide
measures of the
clinical outcomes of
rehabilitation. To
measure service
standards regarding
completion of NAC
and commencement
of goal planning
06/01/2012 Complete
Changes required
31/07/2012 Results: Team were proactive in allocating and
Changes required
completing NACs with patients who were mobilised
on admission.
47% of patients had an NAC within 2 weeks of
mobilisation.
Of those that were delayed a significant number were
not allocated a Keyworker. 70% of patients
commenced goal planning within 2 weeks of the
NAC. Evidence of GPM documentation in notes
needs improvement, and implementation of Goal
planning on IMS. Actions: Improvement in ensuring
all patients have a Keyworker and therefore complete
an NAC.
Action: set a standard for allocation of
Keyworker.
3407 Renal Tract
Computed
Tomography In
Spinal Cord
Injured Patients :
Trends,
Indications &
Outcomes
3408 National Cancer
Patient
Experience
Survey
Dr Tom Meagher,
Renal tract stones
Consultant Radiologist affect up to 7%
spinally injured
patients and are
common cause of
infection and
scarring. They
present differently in
spinally injured
patients as they may
not cause discomfort
but can cause renal
loss if not identified.
Renal tract CT
commonly used but
frequency needs to
be considered. Audit
to evaluate accuracy
of CT scans, increase
in scans and
incidence of ureteric
calculi.
Rick Panigraphi,
All patients
Jeanette Tebbutt
diagnosed with
cancer between Sep
and Nov 11 are
identified. Names
sent to co-ordinators
who then sent out
questionnaire,
analyse and report.
Report produced
summer 2012.
3409 Audit to Ensure
Amanda Adkins,
Infection Control
Infection Control Nurse
Manual in Every
Clinical Area is Up
To Date
Each clinical area to
complete audit form
which looks at each
part of infection
control manual in
their area to see if
complete and up to
date.
Specialist
Services
06/01/2012 Complete
16/04/2012 There was a year on year significant increase in use Report sent to Urology. No
of CT. CT is increasing in use in the spinal cord
other recommendations.
injured population, most frequently for the monitoring
of stone disease. The incidence of ureteric stones
supports early use of CT in patients with
hydronephrosis. No recommendations other than to
send report to Urology
Specialist
Services
06/01/2012 Complete
04/01/2013 Results: The Trust was the same or better than other Changes required
Trusts for all questions except one. This question
was "The patient was offered a written assessment
and care plan". Actions: Each site specific tumour
team do a yearly internal patient satisfaction survey
which they then write an action plan and will
incorporate themes from the national survey.
Some of the issues around patient care are going to
be dealt with by Lynne Swiatczak as part of a quality
care working group.
Specialist
Services
09/01/2012 Complete
22/05/2012 All infection control manuals checked and updated.
No changes required.
3410 Workplace Health Marion Carnell, Health
& Safety Audit
& Safety Facilitator,
2011
Stoke Mandeville
Hospital
Annual audit of
Trustwide
compliance with legal
requirements
regarding workplace
health and safety.
15/11/2011 Complete
3411 Cervical Disc
Mr Stuart Blagg
Replacement (IPG
100, IPG143)
Audit of new
procedure against
associated NICE
guidance as
requested by the
NCP Committee.
(NN022)
Surgery and
Critical Care
20/10/2006 Not yet
started
Results and Recommendations required
Changes required
3412 Administration of
Anaesthetic to
Carpal Tunnel
Decompression
Patients
Audit of new
procedure as
requested by the
NCP Committee.
(NN027)
Surgery and
Critical Care
14/10/2007 Not yet
started
Results and Recommendations required
Changes required
Tony Heywood
03/05/2012 Annual process. No report produced by CA&E figures given across in table format for Marion
Carnell.
Changes required
3413 Thrombolysis for
Acute Ischaemic
Stroke
Dr Mathew Burn and
Dr Chris Durkin (Dr
Harjit Baines, SpR)
Audit of new
procedure as
requested by the
NCP Committee.
(NN028)
Integrated
Medicine
04/04/2012 Ongoing
data
collection
Data is collected on all patients who have been
Changes required
thrombolysed, and has been since procedure started
in December 2007. The database is maintained by
Susie MacTavish. We also discuss all patients
thrombolysed in a monthly clinical governance
meeting. Our complication rate is as expected, with
our activity and Door-To-Needle times better than the
national average. Recommendations from 2012
audit: Ensure the neurological deficit score ids
recorded at the 24 hours post-thrombolysis stage.
3414 Audit of Smoking
Prevalance
Amongst Patients
with Spinal Cord
Injury
Dr A Prasad,
Respiratory Consultant
(Alyson Moss,
Smoking Cessation
Co-ordinator)
To determine
Integrated
smoking prevalence Medicine
amongst patients with
spinal cord injury in
order to put
appropriaite
measures in place for
effective
management and
better health
outcomes for patients
who smoke.
11/01/2012 Cancelled
06/11/2012 Audit cancelled. No further information.
3415 Audit of Smoking
Prevalance
Amongst Inpatient
Population of the
Spinal Injuries Unit
Dr A Prasad,
Respiratory Consultant
(Alyson Moss,
Smoking Cessation
Co-ordinator)
To determine
Integrated
smoking prevalence Medicine
amongst patients with
spinal cord injury in
order to put
appropriaite
measures in place for
effective
management and
better health
outcomes for patients
who smoke.
11/01/2012 Complete
08/06/2012 1. Smoking status of patient should be assessed at
Changes required
time of admission to NSIC and recorded on the IMS
system. 2. All patients who smoked before injury
should be asked if they plan to start again if they
were able. Training session for NSIC Doctors and
Nurses in NRT use, and referral to Bucks Smokefree
Support Service (BSSS). 3. All current smokers
should be offered NRT on and during admission to
NSIC and a referral made to the BSSS unless they
opt out. 4. Clinical Audit of NSIC outpatients to be
repeated in September 2012.
Project cancelled
3416 Fetal Fibronectin
Jackie Hall
Audit of new
procedure as
requested by the
NCP Committee.
(NN030)
Specialist
Services
18/04/2008 Complete
3417 Laparoscopic
Radial
Prostatectomy
(IPG 193)
Mr Neil Haldar
Audit of new
procedure as
requested by the
NCP Committee.
(NN031)
Surgery and
Critical Care
18/04/2008 Not yet
started
Audit of new
procedure as
requested by the
NCP Committee.
(NN034)
Surgery and
Critical Care
17/10/2008 Complete
3418 Endovascular
Mr Andrew Northeast
Exclusion Stenting
of Abdominal
Aortic Aneurysms
20/04/2010 A sample of 20 patients undergoing fetal fibronectin No changes required. New
tests between August 2009 and February 2010 were Clinical Procedure audit.
included in the audit. The main results were:
admissions were high in negative test results (57%);
28% of those with negative results were given
steroids; 75% of PV bleeds had negative results, all
were discharged with no steroids. In 3 cases tests
were performed outside the gestational age marked
by guideline. There was no record of intercourse
prior to the test in any of the 20 cases.
Results and Recommendations required
05/04/2012 The results of the formal audit were forwarded to the
committee on 30 July 2010. The procedure is
continually audited and the results in April 2012 are:
54 interventions; current 30 day mortality 0% v
national vascular database reported 3%; 6 (11%) reinterventions (all developed late leaks that were all
re-stented successfully) vs published EUROSTAR 5
year re-intervention rate 58%; 2 required urgent reintervention during their inpatient stay for major
complications - no comparable national data
available for this; 4 EVARS subsequently died but
were outside the 30 day moratorium and of unrelated
causes. All our major vascular procedures are
continually audited at both a local and national level
by submitting them to the National Vascular
Database.
Changes required
All major vascular procedures
are continually audited at both
a local and national level by
submitting them to the
National Vascular Database.
3419 Potassium-titanyl- Mr Jon Greenland
phosphate KTP
(Green Light)
Laser
Vapourisation of
Prostate for
Benign Prostatic
Obstruction
Audit of new
procedure as
requested by the
NCP Committee.
(NN036)
Surgery and
Critical Care
17/04/2009 Complete
05/04/2012 An audit was carried out, the findings were discussed
with Andrew McLaren at the end of last year, 2011,
he was satisfied with the results and was happy for
us to continue.
3420 Microwave
Ablation of
Varicose Veins
Mr Andrew Northeast
Audit of new
procedure as
requested by the
NCP Committee.
(NN037)
Surgery and
Critical Care
16/10/2009 Awaiting
Report/Ac
tion Plan
Results and Recommendations required
Changes required
3421 Hysteroscopic
Sterilisation
Mr Tunde Dada
Audit of new
procedure as
requested by the
NCP Committee.
(NN040)
Specialist
Services
Results and Recommendations required
Changes required
Not yet
started
3422 Subtenons Local Richard Smith
Anaesthesia for
Intraocular
Surgery Delivered
by ODP
Audit of new
procedure as
requested by the
NCP Committee.
(NN041)
3423 Audit to determine Susie Gaynard,
the percentage
Physiotherapist
change in Elderly
Mobility Scores for
inpatients
completing a
course of
physiotherapy at
Buckingham
Community
Hospital
Looking at the
Integrated
sensitivity of change Medicine
of an outcome
measure to see if it is
appropriate for use in
the ward inpatient
setting.
01/12/2011 Complete
3424 Paediatric A&E
Liaison Forms
Analysis of data
Specialist
collected at
Services
Wycombe EMC
through the Renass
reporting system from
January 2011 when
the new system, First
Net, went live in
October 2011.
12/01/2012 Complete
Sydnella Terry,
Paediatric Liaison
Officer
Surgery and
Critical Care
16/04/2010 Complete
12/08/2012 The procedure is inherently safe with an extremely
Changes required
low incidence of significant complications. Audit of
the last 29 procedures - 13/07 - 13/08/2012. No
patients found the administration of LA
uncomfortable or painful; during the procedure 27
patients had no pain, 1 patient had mild sensation
and 1 required additional subtenons LA. Surgeon
had excellent access to operative site in 22 patients,
and good in 5 patients. There were no complications
or situations where someone else had to take over to
complete the procedure. The quality of the blocks the
ODP is undertaking is comparable to those
undertaken by experienced anaesthetists. The
feedback from nursing staff who have been present
in the anaesthetic room when the blocks take place
is that patients find Graham’s manner calm and
reassuring, and that they do not find the procedure
upsetting. Recommendation is that this procedure is
safely carried out by the ODP and no longer requires
a higher level of surveillance than would be expected
for medical staff undertaking the procedure.
22/02/2012 Results: 10/20 patients made an improvement of
No changes required.
more than 50% in their Elderly Mobility scores. 12/18
patients improved from functional dependence to
independent functional status on reassessment.
3/18 patients improved from dependant to borderline
functional status.
3/18 patients remained at dependant functional
status, but all patients made improvement from
baseline assessment. All patients made an
improvement in their outcome measure following
rehabilitation. Recommendations: Use the Elderly
mobility score as the standard outcome measure for
inpatients at Buckingham Community Hospital. i
03/03/2012 Report sent but no particular recommendations made Sydnella Terry reported that
as changing to Remass system.
so far (September 2012) there
has been little progress in
improving documention of
information on children. 2
meetings were arranged with
A&E staff - first meeting they
did not attend; the second
highlighted the fact that there
are many other issues with
other specialities children are
referred to whilst in A&E, who
do not document information
on the A&E system. Those
reports are usually blank.
3425 Audit of Tetanus
Esa Rintakorpi, Lead
Prescribing in A&E Nurse, A&E, Abigail
(SMH)
Ashby, ENP, A&E,
SMH.
An audit of the
Integrated
prescribing of tetanus Medicine
vaccination in A&E at
Stoke Mandeville.
12/01/2012 Complete
03/05/2012 The results demonstrate the need to revisit the
Changes required
present guidelines, to see if the advice given with
regards to those patients with clean wounds needs
revision, as this audit provides evidence that overprescribing of Revaxis® is taking place. The
recommendation is that the Trust guidelines are
reviewed sooner than the planned revision date of
September 2013. Once the guidelines are reviewed,
the documented action plan for improved
documentation, education for staff, and a new
Summary Guideline can be implemented, all of which
would lead to improved clinical practice, best practice
with regard to Revaxis® use, unity and parity with
regard to prescribing and implementing treatment
amongst all disciplines, and the reduction of financial
costs to the Trust.
3426 High Intensity
Mr Andrew McLaren
Focussed
Ultrasound (HIFU)
Ablation of
Parathyroid
Lesions
Audit of first 10
procedures carried
out as requested by
the NCP Committee.
(NN042)
Surgery and
Critical Care
01/04/2011 Cancelled
09/04/2012 Removed from New Procedures Approved List as kit Project cancelled.
not approved.
Integrated
Medicine
01/04/2010 Not yet
started
29/01/2013 Project cancelled.Nnow National and Trust standard
practice to use ultrasound.
3427 Chest Wall
Ultrasound
Dr Charlotte Campbell Audit of new
procedure as
requested by the
NCP Committee.
(NN044)
Project cancelled
3428 Nurse Led Service Mary Miller, Lead
for Fascio-iliaca
Nurse, Pain
Blocks for
Management
Preoperative Pain
Control for
Patients with
Fractured Neck of
Femur
Audit of new
procedure as
requested by the
NCP Committee.
(NN046)
Surgery and
Critical Care
01/11/2010 Not yet
started
Results and Recommendations required
Changes required
3429 Inguinal Sentinal
Node Biopsy in
Melanoma
Mr Peter Budny,
Consultant, Plastics &
Burns (Helen
Katsarelis, CT1)
Quality control audit
of new sentinel node
biopsy as requested
by the NCP
Committee. (NN049)
Surgery and
Critical Care
01/10/2011 Awaiting
Report/Ac
tion Plan
Results and Recommendations required
Changes required
3430 Improving the
Prescription of
Medication when
the Integrated
Care Pathway for
the Dying is
Commenced
Dr F Hami, Consultant WH scored in the
Specialist
(Mills/Gbinigie/Aires,
bottom 25% hospitals Services
Core Medical Training) in the National Care
of the Dying Audit for
drug prescribing
when starting a
patient on the ICP.
Subcutaneous drugs
should be prescribed
on a prn basis for 5
symptoms.
16/01/2012 Complete
09/07/2012 Recommendations: 1. Cross-site education with
posters and teaching.
2. Ongoing audit of prescription of end of life
medications. 3. Review reasons why certain
medications aren’t prescribed. 4. Regular teaching
slots for FY1s and FY2s at both sites.
There are regular teaching
sessions on the ICP, where
anticipatory prescribing is
highlighted.
Dr Hami teaches the FY1 and
FY2 doctors on their
mandatory teaching sessions.
The audit will be repeated by a
Junior in the next year.
3431 Audit of Screening Dr Jane Duff,
Needs
Consultant Clinical
Assessment
Psychologist, NSIC
Checklist on St
Patrick's Ward
The screening needs Specialist
assessment checklist Services
is a way of assessing
rehabilitation or
changed health
needs of readmitted
patients. Check in
each patient's
admission file if
admission anticipated
to be 3 weeks or
more. Full needs
assessment checklist
and goal planning to
be commenced if
indicated by
screening
assessment.
16/01/2012 Analysis/
Report
Results and Recommendations required
Changes required
3432 Transanal
Haemorrhoidal
Dearterialisation
Audit of new
procedure as
requested by the
NCP Committee.
(NN038)
Surgery and
Critical Care
17/07/2009 Data
Collection
Results and Recommendations required
Changes required
Analysing
management of
necrotising fasciitis,
looking at the
presentation,
investigations,
management and
outcome. Aiming to
evaluate prognostic
criterion.
Surgery and
Critical Care
18/01/2012 Awaiting
Report/Ac
tion Plan
Results and Recommendations required
Changes required
Mr Andy Huang
3433 The Management Sudap Ghoona,
of Necrotising
Consultant (Jonathan
Fasciitis
Cubitt ST3, Paul
PoynterSmith, Plastics)
3434 A Review of the
Michelle Holmes, SALT
Quality of Speech
and Language
Therapy
3435 Voice Therapy
Patient
Experience
Survey
Julia Mee, Head of
Therapies (Barbara
Reynolds, Team Lead
ENT)
Audit to identify the
quality of SLT case
notes across the
three hospital sites
and will evaluate
improvements which
have been made
since the previous
audit completed 18th
january 2011. It has
been decided that
new audits will be
undertaken for each
year rather than
quarterly audits
previously proposed.
The areas assessed
have been taken from
the Trust guidelines
and from what is
though to be
important by senior
SLT staff. Historically,
SLT managers have
regularly
assessed/audited the
staffs' case notes and
this project ensures
that this situation
continues.
To obtain patient
feedback about their
experience of voice
therapy from booking
an appointment to
discharge from
therapy. This will be
used to inform
change.
Specialist
Services
17/01/2012 Complete
31/03/2012 Results: Admin - 100% standards achieved in 47%
cases. Clarity 100% standards achieved in 74%
cases. Content/care give 100% standards achieved
in 82% cases. Recommendations: Inform staff of
the particular areas for improvement. Continue to
use the same case note checklist format for future
audits. Repeat audit in January 2013.
Staff informed of results. Due
to be re-audited in Jan 13.
Specialist
Services
13/01/2012 Complete
05/10/2012 19 patients returned completed questionnaires. All
Changes required
patients were satisfied, overall, with their care. All
patients would recommend the service.
Recommendations: 1. For the Voice Therapy Team
members to continue to offer the high level of care to
voice patients as was demonstrated by this audit. 2.
Team members will take care to arrange voice
therapy appointments with patients on the phone
wherever possible to give patients maximum
available choice of appointment times.
3. Team members will take care to explain the
process of voice therapy and to explain the diagnosis
and potential causes of voice and throat symptoms.
4. Team members will be encouraged to discuss
patient expectation of voice therapy at the beginning
of treatment also. 5. Team members will be
encouraged to discuss discharge planning with
patients so that they feel involved in this process.
3436 Audit of
Management of
Head Injuries in
Children against
NICE Guidelines
Jenny Woodruff, ST3, Audit of adherence by Specialist
Zahrah Neshat,
the paediatric team to Services
Paediatrics
NICE guideline
CG56, Head Injury in
Children, including:
GCS documentation
at presentation; CT
scan criteria;
Admission criteria;
Neuro observations
frequency and
accuracy; Discharge
information.
19/01/2012 Complete
01/09/2012 Recommendations: 1. Sticker with CT scan criteria Changes required
and a yes/no tick box. 2. Adjustment to neuro obs
charts to include the frequency of observations, and
a statement that a) sleeping children should be
woken. b) if GCS drops inform a doctor.
3437 Fast Track
Physiotherapy
Service Patient
Experience
Survey
Katie Glover,
Advanced
Physiotherapist
20/01/2012 Complete
04/02/2013 Results: 57% staff waited one week or less between Changes required
their referral from Workplace Health and their first
physiotherapy appointment. 89% staff were seen
within 2 weeks.
All staff were satisfied with the process of referral,
80% very satisfied.
82% staff were given a choice of where they received
their physiotherapy.
All staff were satisfied with the timing of their
physiotherapy appointments, 80% very satisfied.
67% achieved less pain as a result of their
physiotherapy and 53% achieved improved flexibility.
Only 10% staff felt it had made no difference to their
problem.
92% staff whose job was affected by their problem,
felt that the physiotherapy enabled them to carry out
their job more easily than they would have done
without the treatment.
90% staff felt that the physiotherapy enabled them to
carry out other activities more easily than they would
have done without the treatment.
All staff were satisfied with the Fast Track
Physiotherapy Service, 83% very satisfied.
Recommendations:
Ensure staff requiring access to this service are
referred promptly to WPH.
Raise all BHT staff awareness that this service is
available to them to access.
Ensure referral pathway is maintained as efficient as
possible.
Waiting time for first appointment or telephone triage
is within service standards.
Continuation of the service on at least the three main
BHT sites.
Survey of patients
referred to fast track
physiotherapy by
Workplace Health
with musculoskeletal
problems.
Specialist
Services
3438 Evaluation of Staff
Knowledge of
Diabetes Pre &
Post the Think
Glucose
Campaign
Dr S Chatterjee,
Diabetes Consultant,
(Nicki Skillen & Mary
Harding, Community
Diabetes Nurses)
To measure the level Integrated
of knowledge of
Medicine
diabetes of staff on
the wards in the
Community Hospitals.
This information will
be used to develop a
training programme
to improve the
effectiveness of Think
Glucose and patient
care.
21/07/2011 Complete
23/01/2012 Baseline audit only.
No changes required.
3439 Evaluation of
Head Injury
Semantic
Differential Scale
Dr Andy Tyerman,
Consultant Clinical
Neuropsychologist &
Head of Service,
Community Head
Injury Service
Pooling of data for
Integrated
detailed psychometric Medicine
analysis of the Head
Injury Semantic
Differential Scale
which is used in the
initial assessment of
patients referred to
the service.
23/01/2012 Complete
26/11/2012 Not sure if results/recommendations will be
forthcoming.
NA. No formal
results/recommendations.
3440 Coding of
Revision Hip
Surgery
Mr B. Mann,
Consultant, T&O (Dr
Georgina Burcher,
FY2)
Comparison of coding Surgery and
with outcomes for
Critical Care
revision hip surgery.
Looking to achieve
80% compliance with
coding and
outcomes.
24/01/2012 Complete
30/06/2012 Recommendations included: increase coding capture Changes required
rate via education (Surgeons & Coders); type written
operation notes; indicate diagnosis, implants
removed & inserted (fixation method also important);
ex-PBR claims are a significant source of extra
income - now processed by Arthroplasty Fellow
prospectively.
3441 Use of Acitretin in Dr Mohsin Ali,
Dermatology
Consultant
Dermatologist (Dr
Caroline Champagne,
ST3, Dermatology)
3442 Retrospective
Audit of Digoxin
Loading Doses
used to Treat AF
within the
Buckinghamshire
Healthcare Trust
Is Acitretin being
Integrated
prescribed safely in
Medicine
dermatology
according to the BAD
guidelines.
Particularly focusing
on its use in women
of child bearing age
and its effects on liver
and lipid metabolism.
25/01/2012 Complete
Lisa Pazik, Lead
Comparing actual
Specialist
Pharmacist Emergency prescribed and
Services
Medicine
administered loading
doses of digoxin for
AF with those
calculated from
population
pharmacokinetic data
and assess the
therapeutic effect of
the loading dose.
25/01/2012 Awaiting
Report/Ac
tion Plan
09/11/2012 Results: 100% of the women of child bearing age
were tried or considered for an alternative to
Acitretin. However in those where an alternative
systemic agent was not documented as being
considered it isn’t clear whether the doctor did
consider alternatives and simply didn’t document
these options. The precautions that should be taken
in women of child bearing age were not clearly taken
and certainly not documented. In most cases
baseline bloods were performed but in the majority
no fasting glucose levels were checked. In the
majority of cases blood tests were not intensely
monitored as per guidelines in the first two months.
Of those patients who developed abnormalities in
their blood tests almost all were correctly managed.
Recommendations: Presentation of these audit
findings at a departmental academic meeting to raise
awareness of the issues and areas where practice
does not meet the expected standards.
Provide advice on better documentation of
discussions with women of childbearing age
regarding contraception. Also focus on the need for
more intense blood monitoring during the first 2
months after treatment is initiated. Re-audit in one
years time.
Results and Recommendations required
A pre-treatment checklist was
produced as a result of the
audit to use when prescribing
Acitretrin.
Changes required
3443 Pain in Children
Dr Robert Janas, SpR, A review of children
Dr Stewart McMorran, aged 5-15 years
Consultant A&E
presenting to A&E
with moderate to
severe pain.
Integrated
Medicine
3444 Radical
Retropubic
Prostatectomy
Patient
Experience
Survey
Hilary Baker,
A patient experience Surgery and
Macmillan Uro-oncolgy survey to review the Critical Care
CNS
experiences of
patients undergoing a
radical retropubic
prostatectomy for
prostate cancer.
25/01/2012 Data
Collection
Results and Recommendations required
Changes required
3445 What do
Intrapleural Blocks
mean for the
Mastectomy
Patient?
Dr Bunsell, Consultant,
Anaesthetics (Sam
Michlig, CT1, Bijal
Kothari, CT1)
26/01/2012 Awaiting
Report/Ac
tion Plan
Results and Recommendations required
Changes required
Looking at all patients Surgery and
undergoing
Critical Care
mastectomy with and
without intrapleural
blocks to compare
LOS and morphine
usage.
25/01/2012 Cancelled
11/10/2012 Audit cancelled. No response from clinician.
Audit cancelled.
3446 Lung Cancer
Ongoing Patient
Experience
Survey
Jill Mowforth, Lung
Cancer Specialist
Nurse
To record patient
satisfaction and
experience of the
diagnostic pathway
for lung cancer and
mesothelioma.
Specialist
Services
30/01/2012 Data
Collection
Results and Recommendations required
3447 Surgical Site
Amanda Adkins,
Infection Peri-op
Infection Control
Audit - Gynae Feb
12
Observational audit
gynae only, week of
13th-19th Feb.
Specialist
Services
13/02/2012 Complete
3448 Sharps
Management
February 2012
Audit of sharps
management.
Specialist
Services
01/02/2012 Complete
27/04/2012 Results: 100% compliance MRSA screening. 100%
compliance WHO checklist. Glucose monitoring was
indicated for 5 (28%) patients but glucose control
was maintained in only one. For 3 (17%) procedures
this question was not answered. 3 patients were not
given prophylactic antibiotics when they were
indicated. In 8 (44%) cases hair removal should
have been completed but wasn't.
Recommendations: 1. All staff completing the audit
must be competent in this. Training should be offered
where required. 2. Staff to be reminded to complete
all questions. 3. Trust antibiotic regime for relevant
procedures to be available and used. 4. Where
applicable hair should be removed appropriately
following national guidelines using clippers and not
shavers. 5. Staff need to be aware of the need for
maintaining glucose control in diabetic patients and
to answer all questions. 6. All patients where
applicable must have the normothermia monitored
and recorded.
09/07/2012 Results: Overall compliance was 96%. Scores
varied by ward/area from 78% “Yes” responses to
100%. 3 wards had an overall compliance less than
85%. Recommendations: 1. Non participation
should be discussed at SDU/clinical governance
meetings and relevant areas should complete the
audit. 2. The report, results and issues highlighted
for further focus should be discussed and
disseminated to all relevant staff across the Trust. 3.
Appropriate training for staff completing the audit tool
should be provided to ensure returned data is robust.
Ongoing training, promotion of good practice and
compliance monitoring should continue. 4. Actions
identified should be completed and closed as part of
the audit cycle and actions must be signed off by the
Divisional ADN’s. 5. The collation of data on reported
sharps injuries should continue to inform further
training and facilities.
Amanda Adkins,
Infection Control
Changes required
Infection Control say that all
recommendations addressed.
IPC assure us that all actions
completed.
3449 Audit of Acute
Dietetic Referral
Forms
Liz Pryke, Dietetic
Manager
Specialist
Services
31/01/2012 Complete
01/05/2012 Dates and names completed well on referral form.
However MUST only 62%-65%, weight 54%-71%.
Low response to questions on whethet patient lost
weight, whether MUST action plan implemented.
Referral forms only completed for 19%-33% cases.
Recommendations: 1. Only 1 type of referral form be
used. 2. Training to raise awareness of use. MUST
training. 3. Decision to be made whether to continue
using referral forms or stop using them as hardly
used.
3450 Gastric Aspiration Heike Melbourne,
Volume in
Specialist Dietitian
Enterally Fed
Patient on ITU
A survey of ITU
Specialist
doctors and nurses
Services
on knowledge of
gastric residual
volumes in enterally
fed patients on ITU
and a survey of
practice amongst ITU
doctors related to
stopping enteral
feeding prior to a
procedure..
01/11/2011 Analysis/
Report
Results and Recommendations required
3451 Transfer Form
Audit Feb 12
Audit of transfer form Specialist
completion.
Services
01/02/2012 Complete
Amanda Adkins,
Infection Control
To investigate if
newly implemented
adult acute dietetic
referral forms are
being correctly
completed by
referring staff.
We are now only using 1 type
of referral form across all
acute sites
Training is ongoing [monthly
basis]
We have decided to continue
using the referral forms to
allow us to prioritise
appropriately, and we are reenforcing the importance of
them at ward level.
Changes required
31/05/2012 32/257 (51%) transferred patients had infection
Infection Control always
control and prevention issues handed over. 20/30
assure us all actions
(67%) patients with infection control issues had the
completed
issues handed over. Recommendations: Staff
member transferring a patient should ensure IC
handover given. Document in patients notes if verbal
handover for IC issues received. Audit report to be
discussed at all Ward/ Unit meetings in addition to
Clinical Governance, Ward/ Team Leader meetings.
Staff completing the audit to ensure they know how
to complete it correctly. All areas listed as non
participating should complete an audit for their
record.
3452 Evaluation of
Meals in NSIC
Samford Wong,
Dietitian, NSIC
Questionnaire to
Specialist
patients and staff re Services
meals provided.
Repeat of audit of
March 2011. New
menu was introduced
in May 2011 and a
new regeneration
system has been
installed. Want to
see if improved.
31/01/2012 Complete
03/09/2012 Actions: Ensure nutrition screening on admission is
Changes required
implemented effectively in order to determine the risk
of malnutrition, implementing the appropriate care
plan, and repeat periodically according to nutrition
pathway. Arrange education sessions for catering
staff, nursing staff, medical staff . Review the
quality (texture, temperature) of hospital food. To
involve volunteer help in meal ordering; to make sure
food is cut up and placed within their reach. Menu
available to all patients. Breakfast / Lunch / Supper
club – to let patient to have company and
encouragement while they eat. AHP involvement
(e.g OT) to provide the need of feeding aid, bedside
water system.
3453 An Audit of One
Stop Breast
Clinics 2011
Dr Kadir Hasan,
consultant radiologist
A previous audit
Specialist
(2596) of waiting
Services
times in the one stop
breast clinics (where
patients have all
necessary scans and
see doctor at same
appt) was carried out
in 2008. This is a reaudit to see if
improved. Data from
patients seen
10/10/11 to 1/12/11.
10/10/2011 Complete
23/04/2012 Results: Patients had a median wait of 30 minutes in
the Radiology Department, excluding the time taken
for the scans. However, 9 patients experienced
extremely long waits of over 1 hour 15 mins, with a
maximum wait of 2 hrs 6 mins. Problems occurred at
all 3 waiting points (waiting for mammography,
ultrasound and report) although the biggest problems
occurred when waiting for ultrasound, with 7 patients
waiting over 1 hour. Recommendations: 1. Equal
distribution of number of patients booked into each
clinic. 2. Book the follow up mammograms and
patients for the family history clinics on a different
day prior to the clinics to reduce workload in the one
stop clinics. 3. Provide adequate staff in all clinics.
4. Install a second digital mammography unit to
reduce waiting for mammography.
3454 Metacarpal
Fracture Audit
Mr T Heywood,
Consultant Plastic
Surgeon (Dr Kana
Miyagi, LAS ST3,
Plastics)
Metacarpal fracture is Surgery and
a common hand
Critical Care
injury. There are
concerns that we may
be over treating these
injuries with surgery.
This audit will
evaluate those cases
which have
undergone surgery
and assess whether
they met the current
recommended criteria
for surgery. There
are no national
guidelines at present.
31/01/2012 Awaiting
Report/Ac
tion Plan
Results and Recommendations required
Moving to new unit in 2013.
New equipment will be
purchased. There has been
more effort to book equal
numbers of patients in each
clinic and staff numbers have
been improved to some
extent.
Changes required
3455 Endoscopy Unit
PES 2012
Sue Kenny, Sister,
WH, Deborah DobreeCarey, Sister, SMH (Dr
Sekhar, Consultant
Gastroenterologist,
SMH & Dr Sue Cullen,
Consultant
Gastroenterologist, WH
A patient experience Integrated
survey in line with the Medicine
Global Rating Scale,
which will help to
develop and assess a
patient centred
service.
27/01/2012 Cancelled
3456 Health Visitor User Caroline Axten, Health To benchmark the
Specialist
Experience
Visitor Clinical Practice level of satisfaction
Services
Survey 2012
Teacher
amongst clients with
the current health
visiting service. This
information will be
used to compare the
level of satisfaction
following the health
visitor implementation
plan year on year up
to 2015.
02/02/2012 Draft
Report
with
Clinician
3457 Re-audit of
Adherence to the
Guideline for
Management of
Reduced Fetal
Movements in
Pregnancy
10/01/2012 Complete
Gemma Brierley, ST2,
Obs & Gynae
Audit of adherence to Specialist
Trust Guideline 419.3 Services
Management of
Reduced Fetal
Movements.
05/11/2012 Audit cancelled. Project proposers did not get back
to us.
Project cancelled.
Results and Recommendations required
Changes required
21/06/2012 Results and Recommendations required
Changes required
3458 LFTs in Right Iliac Nigel d'Souza CT3
Fossa Pain
(Diallah Karim F1)
Biliary pathology can Surgery and
be a cause of right
Critical Care
iliac fossa pain.
Standard practice is
to check LFTs in all
patients with acute
abdomens. This is a
prospective audit to
see how many
patients admitted with
right iliac fossa pain
have LFTs checked
and how many are
abnormal.
08/02/2012 Awaiting
Report/Ac
tion Plan
3459 An Assessment of
GP Gynaecology
Referrals Under 2
Week Wait
Mr Tunde Dada,
Consultant (Dr Cheryl
Phillips, ST1 and Dr S
McKelvie ST1) Obs &
Gynae
An assessment of the Specialist
quality and
Services
appropriateness of
GP referrals under 2
weeks wait against
NICE and Trust
guidelines.
09/02/2012 Complete
3460 Integrated Care
Pathway for the
Dying Adult (WH)
Re-Audit
Dr Faqa Hami,
2011-2012 Re-Audit Specialist
Consultant in Palliative to compare the end of Services
Medicine
life care received by
patients in the acute
wards of Wycombe
Hospital against the
new ICP for the Dying
Adult.
09/02/2012 Draft
Report
with
Clinician
Results and Recommendations required
Changes required
14/03/2012 Results: 1. Majority of referrals appropriate. 2.
Junior doctor audit, no
Examinations are not documented well – are they
changes received 21/2/136
being done? 3. Appropriate tests not always
(CP)
documented/done prior to referral e.g. smears,
Ca125. 4. Good access for GPs to US. 5.
Occasionally poor referrals made with little
information. Recommendations: 1. Update GPs on
latest gynae cancer referral guidelines. 2. Target
endometrial cancer referrals. 3. Adjust referral
proforma. 4. More space for clinical details. 5. Test
results to be included. 6. Information on PMH and
co-morbidities. 7.To review rejected referral letters.
Results and Recommendations required
Changes required
3461 Isolation
Precaution Sign
Re-audit
Amy Burgess, Student Audit to determine if
Nurse, Infection
isolation precaution
Control
signs are being
displayed in line with
Isolation Policy. Reaudit of 3383
3462 Patient Hand
Hygiene Audit
November 2011
Infection Control
3463 Evaluation of
Dr Atanu Dutta,
Paediatric Training Consultant, Paediatrics
Sessions for
Junior Doctors
Specialist
Services
01/01/2012 Complete
13/02/2012 Results: Although many of the isolation boards were
in place, none were completed completely correctly.
Medicine and Surgery have improved in some areas
since last audit, CSS stayed the ssame and NSIC
and Women & Children were less compliant.
Recommendations: 1. Display precaution chart
instruction from Infection Control manual in wards. 2.
IC department to advise link nurse on how to educate
staff on correct method of hand hygiene according to
particular infection. 3. Link nurse to educate staff. 4.
IC to produce table of common infections and best
method of hand hygiene to be displayed on ward. 5.
Link nurse to encourage nurses to remove or wipe
clean board between patients to avoid confusion. 6.
Matrons and link nurses to monitor use and
compliance of isolation boards. 7. Remind staff to deisolate patients when isolation no longer necessary.
8. Audit to be repeated.
These are discussed at the
IPCC and we have been
reassured by the AND’s all
actions have been addressed.
Re-audit of audit
Specialist
carried out in August Services
11 to check to see if
patients are
encouraged to
perform hand hygiene
after
bathroom/commode/b
efore meals etc.
01/12/2011 Complete
These are discussed at the
IPCC and we have been
reassured by the AND’s all
actions have been addressed.
Continual evaluation
of training sessions
run by the paediatric
department for junior
doctors.
01/02/2012 Data
Collection
13/02/2012 Results: Prompted after assisted to bathroom 78%.
Offered assistance with hand hygiene after
bedpan/commode 79%. Individual hand wipe
provided for the patient prior to meals 48%. Offered
assistance to open/use the hand wipe prior to
mealtime 44%. Offered an alternative method of
hand hygiene facility prior to meals 73%. Patients
read hand hygiene leaflet 10%. Assistance after
bathroom/commode and before meals improved
slightly since last audit. Provision of hand wipe
worse compliance since last audit. However, smaller
audit last time. Overall compliance very low.
Recommendations: 1. Areas to produce action plan
to show how compliance will be monitored. 2. Wards
should ensure have adequate supplies of patient
leaflet. 3. Wards should have system to ensure
patients given leaflet on admission. 4. Winning
poster on hand hygiene to be distributed for display.
5. Discussion and education re patient hand hygiene.
6. Include in IPC corporate induction. 7. Assess
patient's abilities to perform hand hygiene and assist
if necessary.
Results and Recommendations required
Specialist
Services
Changes required
3464 Audit of the
Management of
Group B
Streptococcus
Mothers
Dr A Dutta, Consultant, An audit of the
(Dr Bolutito Akinbiyi,
management of
ST2) Paediatrics
Group B
Streptococcus
mothers who have
delivered live infants
at Stoke Mandeville,
in order to review
current GBS
guidelines and to
compare with GBS
Network/NICE
guidelines and
current local
guidelines.
Specialist
Services
15/02/2012 On hold
3465 VTE Prophylaxis
after Plaster Cast
Immobilisation
Dr Jonathan Pattinson,
Consultant,
Haematology (Dr
Ahmed Arif, F1,
Haematology)
Specialist
Services
16/02/2012 Cancelled
14/01/2013 Cancelled
Audit of hand hygiene Specialist
facilities and practice. Services
01/01/2012 Complete
16/04/2012 Overall compliance increased from 94% to 96% but 5 Infection Control say that all
wards less than 85%. 69 areas took part.27/37
recommendations addressed.
submitted complete action plans.
Recommendations: 1. Those not taking part to
complete audit. 2. Those areas with low compliance
to reaudit. 3. Those areas with non-compliant wash
basins to highlight on IPC work programme.
3466 Hand hygiene
Amanda Adkins,
Facilities Audit Jan Infection Control
2012
Audit of VTE
Prophylaxis after leg
immobilisation
against NICE
guidelines.
Results and Recommendations required
Changes required
Cancelled
3467 Clinical Evaluation Mr Edward Seel,
of Spinal
Consultant Spinal
Interventions and Surgeon
Treatment
A clinical evaluation Surgery and
of spinal interventions Critical Care
and treatment
through pre- and
post- treatment
questionnaires
(Oswestry).
01/04/2012 Design
Results and Recommendations required
Changes required
3468 Community Heart
Failure Service
Patient
Experience
Survey
Tracey Apps,
Community Heart
Failure Specialist
Nurse
A Patient Experience Integrated
Survey to determine Medicine
the effectiveness of
the Community Heart
Failure Service in the
care they provide for
their patients.
30/01/2012 Complete
20/12/2012 Overall 98% patients were either "very satisfied" or
Changes required
"satisfied" with the service and treatment which they
received from the Heart Failure Specialist Team.
Recommendations: 1. Raising the profile of the
hospital based Heart Failure Support Nurse. 2.
Obtain more clinic space for 2013 in the North of the
county. 3. Look into increasing the length of clinic
appointments. 4. Appoint new administrator to
improve contact to the service. 5. Remind patients of
the BHF literature which they are provided with at
their initial assessment as useful reference.
3469 Transport Survey
Ian Garlington, Director A Transport Survey is Trustwide
of Property Services
being carried out at
Wycombe Hospital
aimed at visitors, and
at Stoke Mandeville
Hospital aimed at
patients visiting their
first assessment
clinic/outpatients
clinic, to assess their
current travelling
arrangements and
experience of
hospital.
20/02/2012 Complete
16/07/2012 Reorganisation of Trust Departments - ongoing.
No changes required
3470 CQUIN Discharge Liz Hollman,Associate
Summary Audit
Director Healthcare
Governance, Sharon
Webb
CQUIN audit
Trustwide
reviewing the quality
of discharge
summaries for 50
patients discharged
from the Trust during
November 2011
3471 Alcohol Related
Liver Disease
NCEPOD Audit
3472 Upper
Gastrointestinal
Cancers Patient
Experience
Survey
Maureen Kiely,
Barbara Reid, Upper
GI Cancer Specialist
Nurse
Evidence for peer
Specialist
review and to obtain Services
patient feedback
regarding the service
and quality of
information provided.
20/02/2012 Complete
Recommendations: 1. Ensure that the following
Changes required
information is included on discharge summaries: full
consultant and GP identification; mode of admission;
route of admission; discharge destination and
method; cognitive function; outpatient Consultant and
hospital for outpatient appointment; results awaited;
grade of doctor completing discharge summary. 2.
Discharge summary template to be reviewed to
ensure it contains all the necessary information.
10/01/2012 Complete
01/12/2012 None
No changes required
22/02/2012 Complete
25/02/2013 The survey illustrates that the Upper Gastrointestinal Changes required
team are giving the right amount of information
guided by the patients’ requirements and level of
understanding. The diagnosis was given in a caring
and sensitive manner resulting in the patient feeling
supported. In addition, the patients had trusted, and
had a good rapport with both doctors and nurses.
It was noted that not all patients were advised to
have a relative or friend present to support them
when receiving results, fortunately no patients were
upset by this. Patients may be informed of potential
diagnosis during the initial investigation stage. This
may preclude a friend/relative being present at that
time. Potentially, patients may not always remember
the advice given due to raised anxiety levels or
sedation given during procedures.
The survey demonstrated that patients may not be
aware of what a written treatment is. The 2012 Peer
Review outlined 100% compliance in their findings
out treatment plans in notes, for that reason,
suggestive that patients may have received a written
treatment plan.
Overall the survey demonstrates that patients are
content with the volume, consistency and the way
diagnosis and information was delivered. There is a
general consensus with the overall care throughout
the colorectal cancer pathway, which suggests that
the patient group is very happy with their care and
treatment.
RECOMENDATIONS
The plan for this year is continue the good work
already in place. To recommend from first contact
where appropriate the benefits of having a relative or
friend present during consultations, without causing
undue anxieties. To continue giving all patients a
written treatment plan, amending the plan to give
clearer visibility to the document title and content. To
ensure patients have an awareness of the document.
Rea
3473 Audit of NSIC Pain Imogen Cotter, Clinical To Translate the
Specialist
Care Pathway
Psychologist, NSIC
MASCIP Guidelines Services
for the Management
of Neuropathic Pain
in Adults following
SCI into Clinical
PracticeAim to
implement a NSIC
pain care pathway in
June 2012 and to
audit it 6-12 months
after implementation.
22/02/2012 Not yet
started
3474 Audit of Evidence Dr Patrick Ukwale,
Based Practice of Consultant, (Dr Edward
Asthma
Harvey, GPVTS1) A&E
Management in
A&E
29/02/2012 Complete
An audit to measure Integrated
the adherence to BTS Medicine
guidelines in the
management of acute
asthma in the A&E
setting.
Results and Recommendations required
Changes required
31/05/2012 Recommendations: 1.Educate staff by presentation Changes required
of CEM standards and current performance. 2.
Encourage better documentation. Consider asthma
proforma instead of CAS cards. 3. Standard referral
forms to GPs with tick boxes to reduce time spent on
paperwork. 4. Re-audit in 3 months time.
3475 Audit of the
Dr Bogdanov,
Difficult Airway
Consultant,
Trolley Equipment Anaesthetics (Dr
Phillip Duggleby, SHO,
Dr Tom Barge FY1,
Anaesthetics)
A survey of all grades Surgery and
of anaesthetists
Critical Care
assessing the
frequency of use,
training and
confidence in using
the different pieces of
equipment on the
new Difficult Airway
Trolley, using the
Difficult Airway
Society guidelines on
difficult intubations.
31/01/2012 Complete
(no
changes
reported)
3476 Audit of Screening Jo Birrell, Matron,
of Patients with
Medicine for Older
Dementia
People
An audit to look at the Trustwide
screening given to
patients with a
diagnosis of dementia
within the first three
days of an admission.
Replicating some of
the methodology from
project 3186.
20/02/2012 Analysis/
Report
3477 Audit of
Dabigatran
An audit with the
Haematology
Department to
correlate dabigatran
levels and post op
wound oozing, a
follow up to audit
3060.
27/02/2012 Cancelled
Nik Bakti, CT1,
Surgery
Surgery and
Critical Care
11/05/2012 Results: Confidence using equipment declines as
Changes required
frequency of elective use decreases; several pieces
of ‘difficult airway’ equipment used infrequently on
elective lists e.g. video laryngoscope, intubating
LMA, flexi bronchoscope; juniors and middle grades
need monthly use of equipment to maintain
confidence; poor awareness of what equipment
available in an emergency. Recommendations: 1.
Encourage use of ‘non-routine’ equipment of elective
lists, especially alternative laryngoscopes/ video
laryngoscopes, more experience intubating through
LMA with flexi bronchoscope and need for additional
cannula/surgical cricothyroidotomy simulation. 2.
Trainees record sheet - logbook for use of selected
pieces of equipment, e.g. McCoy, video
laryngoscope, 2nd generation LMA, intubating LMA;
encourages ‘see one, do one, do two, do three etc’
training on elective lists; development of technical
skills in low pressure environment. 3. Education of
contents of difficult airway trolley, e.g. posters, email, FRCA Teaching Group. 4. Re-audit in 1 month.
5. Consider standardisation of trolleys.
Results and Recommendations required
Changes required
24/10/2012 Project cancelled by clinician.
Project cancelled by clinician.
3478 Audit of the
Jill Roberts, Senior
Transrectal
Staff Nurse, Urology
Ultrasound and
Biopsy of Prostate
Service
A patient experience Surgery and
survey with the aim of Critical Care
improving the service
where required.
27/02/2012 Draft
Report
with
Clinician
3479 Audit of the
Paediatric EWS
Chart (PEWS)
An audit of the
correct use of the
Paediatric
Observation Chart
and PEWS
Specialist
Services
01/03/2012 Complete
30/06/2012 The audit shows that, across all areas caring for
Changes required
children within a hospital setting within the Trust,
PEWS Charts are not being fully completed to
provide a complete assessment of the child. PEWS
Charts are not being completed in line with the Trust
Guideline on Physiological Observations. This may
be due to lack of awareness of the Trust Guidelines
or lack of education in the use of PEWS. Despite
children triggering a PEWS, doctors were not always
informed. The lack of documentation regarding
doctors being contacted or the rationale for
performing reduced observations is also poor.
Recommendations: 1. Review of the PEWS Chart.
2. Review of the Trust Guideline.
3. Education of staff in assessment of the child using
PEWS, the importance of documentation and the
reporting of PEWS scores to Medical staff.
An audit of
Women &
intravenous
Children
antibiotics during the
intrapartum period in
prolonged rupture of
membranes in the
term infant. To
assess if antibiotics
are being given in line
with guideline. To
assess record
keeping in relation to
decision and
discussion about
infant outcomes.
01/03/2012 Complete
14/03/2012 Reviewed the outcome of 20 cases: 12
Spontaneous labour; IOL; 1 emergency LSCS. 2
patients late or omitted IV ABx, all women given
information but no evidence of being given written
information. To be raised at Labour Ward Forum.
Kirsty Johns, Practice
Development Nurse,
Paediatrics
3480 Intravenous
Tunde Dada,
Antibiotics in the
Consultant (Gillian
Intrapartum Period Rivlin, FY2) Obs &
Gynae
Results and Recommendations required
Changes required
No action plan received, no
changes received 21/2/13
(CP)
3481 Venous
Thromboembolism
Prophylaxis Audit
Medicine
Jonathan Pattinson,
Consultant
Haematologist (Dr Ivie
Gbnigie, Dr Junie
Wong, CT2 Medicine)
As a follow up to
Specialist
audit 3090 and part of Services
rolling VTE audit.
03/03/2012 Cancelled
3482 Exercise
Leonora Assirati,
Tolerance Testing Student Cardiac
Physiologist,
Cardiology Department
An iInvestigation into Integrated
the efficacy of
Medicine
exercise tolerance
testing as an indicator
of coronary artery
disease in patients
referred to the rapid
access chest pain
clinic
01/12/2011 Analysis/
Report
3483 An Audit of 3rd
and 4th Degree
Tears
An audit of 3rd and
Specialist
4th degree tears
Services
against CNST/RCOG
Greentop 29
Guidelines for
diagnosis, follow up
and treatment, to be
combined with a
study also being
carried out in Oxford.
06/03/2012 Complete
Tunde Dada,
Consultant (Sarah
Barker, ST2) Obs &
Gynae
14/01/2013 Cancelled
Results and Recommendations required
Cancelled.
Changes required
18/05/2012 70% sustained in LW setting. 77% primigravidas.
Changes required
72% babies between 3000-4000gms. 47% NBFD
deliveries. 42% delivered by midwives. 57% second
stages longer than one hour. 55% tears associated
with episiotomies including all 4th degree tears. All
tears were documented as identified. In all cases
where documented, the correct sutures and
technique were used (should be documented in all
notes). All tears were repaired in theatre. All tears
were sutured by appropriate member of staff.
Recommendations: 1. Need to ensure appropriate
medication (Fybogel and Lactulose) prescribed for all
women upon discharge. 2. Need for proforma to be
completed even if op note filled in.
3484 Burns Outreach
Service Patient
Survey
Ann Fowler, Burns
Outreach Specialist
Nurse
A patient experience
survey to assess the
service of the Burns
Outreach Specialist
Nurse.
Surgery and
Critical Care
06/03/2012 Not yet
started
Results and Recommendations required
Changes required
3485 National
Emergency
Survey 2012
Clinical audit
department
A patient experience
survey relating to
A&E visits in Feb
2012.
Integrated
Medicine
01/04/2012 Draft
Report
with
Clinician
Results: BHT was rated same as other Trusts for
most questions, better for none and worse for five,
including length of time in A&E and overall A&E
experience. Mean score for overall experience on
scale 0 to 10 was 7.1.
Changes required
3486 Measuring
Compliance With
Accepted
Standards For
Perioperative
Fasting
Dr Sara McNeillis,
Consultant (Dr
Rebecca Medlock,
CT1), Anaesthetics
An audit to determine Surgery and
if patients are being
Critical Care
fasted according to
RCoA standards.
07/03/2012 Cancelled
28/08/2012 Junior doctor has left Trust - audit will not be
completed.
Project cancelled
3487 Audit of the
Shared Care
Protocol of
Disease-Modifying
Anti-Rheumatic
Drugs
Dr Magliano,
Consultant,
Rheumatology (Lee
Aye ST1, Dhuv
Panchal, FY1)
To see if shared care Integrated
protocols are being
Medicine
adhered to.
3488 Audit of Video
Calls via SKYPE
as an alternative
to Peripetetic
Home Visits
following
Discharge from
NSIC
Debbie Green, Matron, If patients prefer
Specialist
Outreach, NSIC
some patients will
Services
receive SKYPE call
instead of home visit
after NSIC discharge.
Starts in June 2012.
Audit of staff and
patient experience.
07/03/2011 Design
3490 Are SEND
Discharge
Summaries being
completed
appropriately?
(SMH)
Dr Gopa Sarkar,
Consultant, (Dr Amy
Garrett, ST4)
Paediatrics
12/03/2012 Complete
Record keeping audit Specialist
of SEND discharge
Services
letters used by the
Neonatal Unit at
SMH. Compare the
information in the
SEND discharge
letters with the
information in the
notes to see how up
to date/complete the
information in the
SEND discharge
letter is.
07/03/2012 Complete
07/06/2012 Recommendations: 1.Qualitative study into why GPs
have not signed shared care protocol. 2. Patient
survey into what is more convenient and practicable
for centre of prescribing and safety monitoring. 3.
More transparent database for flagging patients who
have missed blood tests as part of safety monitoring.
4. DMARD proforma for when starting on shared
care to ensure appointments and blood tests not
missed for prescribing clinician.
Results and Recommendations required
A laminated pathway for
staring DMARD has been
placed in each doctor's room
to remind them about the
forms and documents which
need to be filled in.
Changes required
11/02/2013 45 notes from babies admitted to the neonatal unit
Changes required
between January and February 2012 were reviewed
against the standard set for completing the SEND
discharge form. A previous audit of SEND had been
completed in 2010. Results - None of the 45 notes
were fully completed, the mostly commonly missed
information was discharge gestation - 6 of 45 were
complete except for these details. Father's details
were often missing from antenatal history although
available in the nursing notes. Drugs were general
well documented but some summaries missed drugs,
in 2010 audit it was noted that SEND forms showed
sodium chloride being used to flush IV medication
instead of normal saline, in this audit that was only
recorded on one occasion. The Parental
communication and Social sections often contains
phrases such as kept up to date, see notes and see
yellow sheets without any other information. In one
case with social concerns the social section showed
"see notes" but no indication of concerns or people
involved included in the summary. Discharge details
generally well completed - 43 were signed, 2 by
consultants the rest by SHO's or Registrars. No
recommendations given.
3491 Neuro
Rehabilitation Unit
Record Keeping
Audit
Lesley Fox, Neuro
Rehab Physiotherapy
Clinical Support
Worker
3492 Colposcopy Clinic Cathie Hansen,
Survey
Colposcopy Nurse
Record keeping audit
of Neuro
Rehabilitation Unit
notes.
07/03/2012 Analysis/
Report
Results and Recommendations required
PES of colposcopy
Specialist
clinic at WH. As
Services
previous audit (2567),
record results by
colposcopist.
06/03/2012 Complete
05/07/2012 Overall, the responses and comments made by the
patients are very encouraging. As department has
recently moved into new premises it was rvery
encouraging that the Colposcopy Suite met the
approval of the majority (96%) of patients.
Recommendations: 1. Ensure that the telephone
numbers are correct on all of the paperwork. 2.
Investigate how it can be made it easier for patients
to speak to the appropriate person. This poses some
difficulty as some phones are shared with the antenatal clinic. 3. Take on board comments made about
the reception staff.
Changes required
Paperwork has been checked
and corrected. Reception staff
have been spoken to about
their manner.
3493 Preventing
Amanda Adkins,
Surgical Site
Infection Control
Infection – Peri
Operative Audit for
Spinal Elective &
Emergency
Procedures
Observational audit
Specialist
carried out for 1 week Services
in March 2012
12/03/2012 Cancelled
3494 On the Day
Surgical
Cancellations
Caroline Pritchard,
Consultant,
Anaesthetics
To audit all on the
Surgery and
day surgery
Critical Care
cancellations that are
documented as
medically unfit, and
review reasons.
13/03/2012 Data
Collection
3495 Audit of Proximal
Femoral Fracture
Shivali Patel, CT1,
Anaesthetics
Waiting for PPF.
20/3/12 Shivali Patel
cancelled this audit
as it is similar to
another audit.
13/03/2012 Cancelled
Surgery and
Critical Care
09/07/2012 Cancelled
Results and Recommendations required
20/03/2012 Audit cancelled - never started.
Cancelled
Changes required
Audit cancelled - never
started.
3496 Thromboprophylax Tunde Dada,
is in Gynaecology Consultant, (Samantha
Lyons, FY2) Obs &
Gynae
Audit against Trust
Specialist
Guideline 539.1 to
Services
see if high risk
patients for
thromboembolism are
identified and the
correct doses of
fragmin are
prescribed for the
correct duration. To
identify if VTE scores
have been completed
and calculated for
patients who have
undergone gynae
surgery, both
emergency and
elective.
15/03/2012 Complete
13/07/2012 Results and Recommendations required
Changes required
3497 Gynae-Oncology
Patient
Experience
Survey 2012
Francesca Lis, GynaeOncology Clinical
Nurse Specialist,
Cancer Services
A patient experience
survey to assess the
experience of
patients with
gynaecological
cancer. (reaudit)
Specialist
Services
15/03/2012 Complete
3498 VTE Audit Day
Surgery
Jonathan Pattinson,
Consultant
Haematologist
Part of rolling VTE
Specialist
audit which looks at
Services
VTE assessment and
prophylaxis in each
division. This audit
relates to day
surgery.
01/03/2012 Cancelled
10/10/2012 The results of the survey show that patients find the Changes required
service helpful and valuable. Many comments about
how comforting they found it to have someone who
understands the anxieties experienced during
investigations, diagnosis and treatment, and
appreciated being able to contact their Specialist
Nurse without having to make an appointment.
Negative comments focussed on the difficulties
experienced in contacting their Specialist Nurse by
phone. 2 patients said that they had not been given
their diagnosis in a caring and sensitive manner;
these had been given by doctors.
Recommendations: 1. Offer women to come back to
our new nurse led clinic on a Wednesday in CCHU
for 30-45 minutes (Level 2 psychological support). 2.
Distress Thermometer assessments to be recorded
and printed from Infoflex, to put in the notes. 3. Offer
women time with the CNS in the clinics alongside the
consultant.
14/01/2013 Cancelled
Cancelled
3499 Perineural
Invasion in
Cutaneous
Squamous Cell
Carcinoma
Mr P Budny,
Consultant Plastics
(Roman Mykula, SpR
plastics)
Audit cases of
Surgery and
cutaneous SCC with Critical Care
persistant invasion in
last 4 years,
treatment,
recurrence, follow up.
21/03/2012 Awaiting
Report/Ac
tion Plan
3500 Audit of
Information Given
to Women Prior to
Induction of
Labour
Miss Felicity Ashworth,
Consultant, (Dr
Katherine Talbot, SpR)
Obs & Gynae
A prospective audit
on the information
provided to women
prior to induction of
labour – against
NICE Guidelline
CG70, and Trust
guidelines.
Specialist
Services
12/03/2012 Complete
18/05/2012 Recommendation: Information leaflet on Induction of Information leaflet currently
Labour should be revised in order to clarify - possible being revised.
length of time before birth; potential increase in pain
level; need for electronic fetal monitoring; partner not
able to stay in hospital during period after admission
for IOL and birth.
Hand hygiene audits Specialist
carried out on all
Services
wards monthly (audit
3107) and recorded
in spreadsheet. To
analyse spreadsheets
to produce annual
summary.
01/04/2012 Complete
12/06/2012 Results: Overall hand hygiene/”bare below elbows” Infection Control always
was carried out in 98% of opportunities observed
assure us all actions
during the year, a slight improvement on the previous completed
year’s figure of 97%. This compliance varied
between doctors and nurses, with doctors recording
a compliance of 94% and nurses and HCAs, 99%.
All staff groups have improved or maintained their
compliance since 2010/11. Compliance by
ward/area varied from 84% to 100%.
Recommendations: 1. There must be a system in
place to show that ward staff have seen the audit
report. Even though the overall month’s result may
be at the compliance level, staff who are responsible
for the hand hygiene data must look at the month’s
data. If the data shows certain areas are below the
compliance level a mini action plan must be
completed to show how these issues are being
addressed. If the month’s compliance level is below
the recommended level then weekly audits must be
completed along with an action plan. This must
show how low compliance is being addressed. 2.
Areas of non participation throughout the year (not
3501 Hand Hygiene
Amanda Adkins,
Observational
Infection Control, SMH
Audit April 2011 to
March 2012
Results and Recommendations required
Changes required
highlighted in this audit) should be addressed on a
monthly basis. 3. All hand hygiene results must be
displayed at ward level for public information.
3502 Audit of
Management of
Term Breech
Deliveries (SMH)
Mr Tunde Dada, Miss
Nutan Misra,
Consultants (Dr Uloma
Okwuosa, ST5) Obs &
Gynae
An audit of
Specialist
management of term Services
breech presentations,
with emphasis on
delivery and early
perinatal outcomes,
against Trust and
RCOG guidelines.
02/04/2012 Complete
3503 Management of
Miscarriage
Patient
Experience
Survey (SMH and
WH)
Mr Chris Wayne,
Consultant (Dr Uloma
Okwuosa, ST5) Obs &
Gynae
A patient experience Specialist
survey for
Services
management of early
pregnancy loss.
02/04/2012 Data
Collection
13/07/2012 Results: Very high caesarean section rate for breech. Changes required
Vaginal breech - too few for sufficient conclusions.
Detection and reduction of incidence ae the best
measures for reducing C-section rate. Better
counselling regarding ECV. Impact on training and
skills. Recommendations: 1. Improve detection with
portable scans in community. 2. Midwifery USS
training. 3. Improve ECV uptake. 4. Reminders and
stickers. 5. Improve documentation. 6. Improve
training and skills - Videos at maternity study days. 7.
Collect further data on outcome of vaginal breech
deliveries.
Results and Recommendations required
Changes required
3504 Audit of
Denosumab and
Zolendronate
Prescriptions for
the Treatment of
Osteoporosis
Dr Magliano,
Consultant
Rheumatologist (Agnes
Fong, FY2)
Retrospective study
of patients receiving
Denosumab &
Zolendronate
between Feb 2011
and Feb 2012. Audit
against Trust
guidelines on
indications for
prescribing.
Integrated
Medicine
02/04/2012 Complete
10/09/2012 Recommendations: Consider strontium before
starting parenteral therapy. Consider denosumab
before prescribing zoledronate. Patients to have
serum Ca/Vit D checked and replaced prior to
starting parenteral therapy. Clinical audit lead to
make clinicians aware of guidelines.
Changes required
3505 NIHSS Scoring in
Stroke Patients
Dr A Misra, Consultant,
(Deborah Stevenson,
Jennifer Brown, FY1)
Medicine
Assessment of
Integrated
percentage of stroke Medicine
patients with an
NIHSS score pre and
post introduction of
proforma labels.
26/03/2012 Cancelled
28/08/2012 Audit abandoned due to lack of time.
Project cancelled.
26/03/2012 Complete
28/08/2012 Results: Of the 64 patients audited 37 (57.81%) had Changes required
a formal random glucose sample taken; 21 (32.81%)
had either a lipid profile or total cholesterol sample
taken within 1 week of admission; 46 (71.87%) had a
chest radiograph on admission. Recommendations:
1. A brief summary of admission investigations for
suspected stroke to be added to trust intranet
guideline. 2. A poster form of this summary to be
displayed in relevant areas in EMC. 3. This summary
to be emailed to all medical and EMC staff. 4. if
chest radiograph is to be made a standard
investigation for all stroke patients, this needs
agreement with the radiology department. 4. Rreaudit after six months.
3506 Investigations for Dr A Misra, Consultant, To determine how
Stroke Admissions (Jennifer Brown, FY1) many patients
Medicine
admitted with
suspected strokes in
January had a CXR,
lipid profile and
random glucose on
admission. If not on
admission, when?
Integrated
Medicine
3507 Audit of
Management of
Paediatric UTI
Dr Boon Tang,
Consultant, (Dr Rachel
Weerasinghe) ST1,
Paediatrics
3508 Assessing
Jenny Ottaway,
Knowledge of
Specialist Dietitian
Nutrition
Supplements used
on the Wards
3509 Audit of VTE
Prophylaxis in
Emergency
General Surgery
An audit to assess
Specialist
whether children
Services
presenting with UTI
are assessed, treated
and investigated
appropriately against
NICE CG54 and
Trust guideline 380.3.
03/04/2012 Complete
To assess nurses'
and HCAs'
knowledge of
supplements, the
differences between
them, and dosages.
Using questionnaire
on 10 nurses/HCAs
on each ward.
Specialist
Services
05/04/2012 Analysis/
Report
Specialist
Services
05/04/2012 Cancelled
Dr Pattinson,
Part of rolling VTE
Consultant
audit
Haematologist (Adnan
Rozario, FY1, Surgery)
04/09/2012 In summary we need to improve our knowledge of
Will re-audit in December
the UTI guidelines to make sure unnecessary scans 2012.
and OPD appointment are not requested. How we
obtain and diagnose UTIs for the most part seems
satisfactory, but we should improve our
documentation. Recommendations: 1.To promote the
use of the hospital guidelines when dealing with
children with a suspected UTI. 2. To encourage
better documentation when obtaining urine samples.
3. To educate colleagues as to when to perform a
dipstick and how to interpret this result. 4. To
emphasise that the imaging strategies are different
for different ages and that all clinicians should review
the guidelines when planning investigations and
follow-up.
Results and Recommendations required
14/01/2013 Cancelled
Changes required
Cancelled
3510 Audit of Lower
Limb Revision
Surgery
Mr Biring, Consultant
(Mr Rishi Chana,
Arthroplasty Fellow),
T&O
To audit the revision Surgery and
workload and profile Critical Care
casemix of cases
undertaken by
BHNHST. To include
where patients have
their primary surgery,
how they are doing
now and a cost
benefit analysis.
11/04/2012 Awaiting
Report/Ac
tion Plan
Results and Recommendations required
3511 WHO Surgical
Safety Checklist
Obstetric
Procedures
John Abbott,
Operations Manager,
Critical Care
Continuation of WHO Specialist
surgical safety
Services
checklist audit.
11/04/2012 Complete
01/05/2012 Of 20 sets of notes audited, 3 had a WHO Maternity
Checklist present, 1 of these was not 100%
completed.
3512 Mortality Review
October 2011 March 2012
Dr Graz Luzzi on
behalf of the
Healthcare
Governance
Committee
A review of 50 deaths Trustwide
requested by the
Healthcare
Governance
Committee as part of
an ongoing review of
mortality within the
Trust.
16/04/2012 Draft
Report
with
Clinician
Results and Recommendations required
Changes required
Action plan completed with
theatres. There is an amended
process for emergency
caesarean sections.
Changes required
3513 Pain Management
Following Open
Reduction Internal
Fixation (ORIF) of
Wrist
Dr Carl Morris,
Consultant,
Anaesethetics (Dr
Athanassoglou, SpR)
An audit of pain
scores following
ORIF wrists.
Surgery and
Critical Care
3514 VTE Audit
Orthopaedic
Jonathan Pattinson,
Consultant
Haematologist (Laura
Watts, Dr Panchal, F1s
T&O)
Part of rolling VTE
Specialist
audit which involved Services
audits 3090, 3205,
3256, 3274 which
looks at VTE
assessment and
prophylaxis in each
division. This audit
relates to Trauma
admissions. Re-audit
of 3313
16/04/2012 Notes
being
pulled
01/04/2012 Complete
(no
changes
reported)
Results and Recommendations required
Changes required
16/04/2012 There have been substantial improvements in the
Changes required
numbers being fully compliant with the NICE
guideline on VTE assessment and prophylaxis, very
nearly but not quite meeting the audit standard of
90%. This suggests that our interventions have been
effective and should be continued to result in further
improvements. However, there remains a major
problem with prescription of mechanical prophylaxis
which should be rectified in future.
Recommendations: 1. Spread the intervention
which has been trialled on the orthopaedic wards to
other wards of the hospital where orthopaedic
patients are found. In this intervention nursing staff
are asked to check for a VTE assessment when
accepting a new patient to the ward, and write
reminders to the doctors on the nameboard and in
the notes. 2. Continue discussions with IT about
changing the computer system where patient lists are
compiled so that there is a box or reminder next to
each patient name for when the VTE assessment
has not been completed. This has started, but is
likely to be a long term intervention. 3. Consider
changing the admission proformas so that the VTE
assessment stands out more, for example by putting
a red box around it. This should reduce the number
of instances where the admission proforma is being
used but the VTE assessment is not being filled in.
3515 Audit of
Miss Aparna Reddy,
Emergency
Consultant (Timothy
Caesarian Section Williams, FY2) Obs &
Gynae
Continuous audit
against CNST
standards, Trust
Guideline 463.4 and
NICE CG132.
3516 Antibiotic
Mr Mann, Consultant,
Prophylaxis
T&O (Adam Sykes,
Prescribing for Hip CT3)
& Knee
Arthroplasty
3517 Audit of HIV
Veena Reddy,
testing of children Associate Specialist,
of HIV positive
GUM
patents
Specialist
Services
01/05/2012 Complete
13/07/2012 Results and Recommendations required
Changes required
A retrospective audit Surgery and
of the prescription of Critical Care
antibiotics for hip &
knee arthroplasty
surgery during March
2012 against Trust
guidelines. A
prospective audit of
June data will also be
undertaken.
19/04/2012 Complete
03/12/2012 Recommendations included: educating the SHOs;
The Junior Doctors' Handbook
further education for the anaesthetists; revision of the and the antibiotic guidelines
T&O Junior Doctors Handbook; revision / rehave been revised.
formatting of the antibiotic guidelines.
A retrospective audit Specialist
of HIV testing of
Services
children of HIV
positive parents. To
identify children who
have not been HIV
tested from an at risk
vertical transmission
population. Audit
against BHIVA
recommendation - do
not forget the
children.
19/04/2012 Complete
07/06/2012 GUM services should: 1. Proactively manage the
cohort of possible parents. 2. Proactively manage
ongoing cases with a view of the ‘ticking clock’
working in partnership with parents to agree the
process of testing, whilst acknowledging/alleviating
the parents' fears. 3. Raise the issue; stress that this
is routinely discussed with all HIV-positive parents
and that it is routine for all children of HIV-positive
parents to be tested. 4. Explain the facts on the
possibility of a positive diagnosis, depending on the
child’s age. 5. Plan for all outcomes, which include
the support and information needs of the child if told
the parent’s diagnosis.
6. Support more complex cases and cases of
absolute parental refusal with a more intensive
multidisciplinary approach and develop the
relationship needed to ensure that child is tested.
We have a dedicated HIV social worker who
supports our parents through some of the dilemmas
associated with testing children 7. Have clear
thresholds to escalate referrals to the next level of
responsibility when necessary. A set protocol,
Every new patient to the
service has the children’s
questionnaire completed at
baseline and the issue
addressed. The cohort of not
tested have been reviewed
and revisited again with each
patient- raising awareness and
offering support to facilitate
testing. We have not
overridden any parents
wishes.
however, would not be appropriate. An individualised
approach is required. If a child is sick then
considerations to escalate to safeguarding would be
appropriate. As clinicians we have a duty to
signpost and facilitate best practice.
3518 Transfusion –
National Audit of
Labelling and
Correction on
Group and Save
Samples
Donna Beckford-Smith, The national
Terrie Perry,
comparative audit of
Transfusion Nurses
the labelling of blood
samples for
transfusion starts on
the 1st of May and
runs for 3 months.
The aim of the audit
is to audit 3 rejected
samples per week.
3519 Antenatal Day
Assessment Unit
(DAU) Audit
Miss Nutan Mishra,
Consultant (Lizzie
Bartlett, FY2) Obs &
Gynae
Specialist
Services
01/05/2012 Awaiting
Report/Ac
tion Plan
An audit of the
Specialist
referral patterns to
Services
the Antenatal DAU in
relation to guidelines,
highlighting
inappropriate
referrals and
workload.
Comparison of results
to those of 2011
audit.
01/02/2012 Complete
Results and Recommendations required
Changes required
18/04/2012 More patients are being seen in DAU than during
Changes required
2011. Only 6%-7% inappropriate referrals, which are
commonly self-referrals. More patients are
discharged from DAU than any other outcome
showing DAU are successfully managing patients
who have needs not met by primary care, but who
are not unwell enough to be admitted. Referrals are
from a variety of different sources showing that
generally, healthcare professionals are aware of
DAU and its role. Recommendations: 1. Find out
how aware GPs/A&E/other relevant health care
professionals are of the role of DAU and how to refer.
2. Inform SHOs of the role of DAU on induction. 3.
To continue a similar audit yearly for 5+ years to
ensure DAU is being utilised as it is intended and to
ensure the inappropriate referrals are kept to a
minimum.
3520 Re-audit of
Prescription of
Intravenous Fluid
and Electrolytes in
Emergency
Surgery
A Goede, Consultant,
Surgery (Charis
Manganis, FY1,
General Surgery)
Prospective re-audit
of fluid prescription
and administration in
emergency surgery,
based on British
Association for
Parenteral and
Enteral Nutrition
(BAPEN) guidelines:
British Consensus
Guidelines on
Intravenous Fluid
Therapy for Adult
Surgical Patients.
(Re-audit of 3239)
3521 Management of
Hypertension in
Pregnancy against
NICE and Trust
Guidelines
Miss Nutan Mishra,
Consultant (Dr M
Walia, GPVTS, Dr
Samantha Scammell)
Obs & Gynae
3522 National
Paediatric
Diabetes Audit
2011-2012
Dr A Dutta, Paediatric
Consultant, SMH, Dr M
Russell-Taylor,
Paediatric Consultant,
WH
Surgery and
Critical Care
24/04/2012 Cancelled
01/10/2012 Project cancelled.
Project cancelled.
Continuous audit of
Specialist
hypertension 1st
Services
December 2011 to
31st March 2012. For
Labour Ward Forum.
01/04/2012 Complete
14/06/2012 Results: 1. Good documentation of management of
severe PET in the patient notes. 2. Management
according to trust guidelines and CNST. 3.
No differentiation from PET/HTN in the delivery book.
4. PET proforma not being used at all. 5. Good
understanding of Severe PET classification amongst
the staff on labour ward. Recommendations: 1.
Proforma to be completed and inserted in the patient
notes. 2. Correct documentation in delivery book. 3.
Severe PET teaching for students.
New guideline completed
(September 2012).. To be
launched at APEC study day
13/9/12. Posters to be created
posters for dating scan area.
Check list for community
midwives developed by
JM/JH.
A national system for Specialist
routine data
Services
collection, analysis
and feedback of
diabetes related data.
Data from Apr 2011
to Mar 2012.
25/04/2012 Awaiting
Report/Ac
tion Plan
Results and Recommendations required
Changes required
3523 Appropriate Use of
D-Dimer in
Suspected
Pulmonary
Embolism
Compared to BTS
Guidelines
Dr Chris Wathen,
Consultant,
Respiratory Medicine
(Dr Muaad Abdulla,
FY1)
To compare the use Integrated
of d-dimer in
Medicine
suspected PE against
BTS guidelines.
24/04/2012 Complete
30/08/2012 Results: 46% (21/46) patients had correct use of D- Changes required
Dimer prior to CTPA for possible Pulmonary
embolus, in accordance with risk guidelines outlined
by the British Thoracic Society. Recommendations:
1. Clinical probability (using BTS guidelines) or a
proforma should be included in the notes; 2. d-dimer
should not be requested in patients aged over 80,
and those with recent obstetric/surgical histories; 3.
d-dimer tests to be requested only with the approval
of senior doctors and only in cases where the risk of
pulmonary embolus is low or intermediate; 4. A
regular review of the appropriate use of d-dimer for
acute medical presentations; 5. Re-audit.
3524 Management of
Miss Hall, Consultant,
Shoulder Dystocia (Dr Laura Lewis
GPVTS 1) Obs &
Gynae
To follow up previous Specialist
audit and compare
Services
performance to NICE
and Trust guidelines.
(Previous numbers
2270, 2354,
2960,3227).
27/04/2012 Complete
14/06/2012 Results: 1.The proformas are often not completely
Changes required
filled in, we must improve upon this – fill in every
section, if it doesn’t fit neatly into a box free text is
acceptable. 2. We often don’t have any
documentation of time of calls for help or order of
manoeuvres. 3. The record of postnatal discussions
is incomplete in the majority of cases. 4. We are very
poor at completing Datix forms and the trust requires
that they are completed for every case.
Recommendations: 1. Datix forms must be
completed. 2. Proforma must be completed fully. 3.
Record details of the postnatal discussion in
maternity notes as well as ticking the box on the
proforma.
3525 Care of Ventilated Amanda Adkins,
Patients May 2012 Infection Control
Part of IPC audit plan Specialist
Services
01/05/2012 Complete
02/08/2012 Results: Reg obs Only 2 wards took part. 100%
Infection Control assure us
compliance. Ongoing obs 3 wards took part. 100% that all actions completed.
compliance. Recommendations: 1. The Infection
Control team will liaise with the ITU Senior Staff to
review the audit to ensure that work that is already
being carried out is not repeated. 2. Wards that have
not participated should complete this audit.
3526 Urinary Catheter
Care May 2012
Amanda Adkins,
Infection Control
Part of IPC audit plan Specialist
Services
01/05/2012 Complete
22/08/2012 Results: Urinary Catheter Care – Insertion. 98% full Infection Control assure us
compliance was achieved. 5 areas had elements of that all actions completed.
non-compliance and should have produced action
plans. However, only one of the areas did.
Urinary Catheter Care – Ongoing Care: Overall, all
applicable elements were performed in 90% cases.
7 areas had elements of non-compliance and should
have produced action plans. However, only 2 of the
areas did. Recommendations: 1. The tool must be
adapted to include “Not applicable” options for all
elements. 2. The tool to include a question on if the
UCAM form completed on each patient with a
catheter for more than 24 hours. 3. All patients with
an existing catheter or a catheter inserted must have
a form commenced. 4. All staff who undertake
catheter insertion and ongoing care must have
appropriate training to ensure patient safety is
maintained.
3527 Long Term
Condition SLT
Team Outcome
Audit
Ali Greenwood, SALT
Provide therapy for
Specialist
acquired neurological Services
conditions. Look at
success of
interventions using
Kent Outcome
measures on 15
patients from Aug 11
to Jan 12.
24/04/2012 Complete
06/06/2012 Aims of therapy were achieved in 80% of cases.
Where they were not achieved, the client had
declined further assessment or therapy.
Recommendations: 1. Continue to ensure that
outcome measures sheets are recorded in patient
case notes on discharge. 2. Provide team training for
goal setting. 3. Review other outcome measure
systems. 4.
Audit a larger sample of discharged patients’ case
notes to include communication impairments. 5.
Audit samples from both North and South
Buckinghamshire LTC teams. 6. Complete Action
Plan on the above in discussion with LTC speech
and language therapy teams, South and North, by
September 2012.
Continued to ensure that
outcome measures sheets are
recorded in patient case notes
on discharge. This will be
audited over the next month
as part of the larger casenote
audit covering the whole
department.
Setting goals within our
current system of outcome
measures has been informally
discussed and clarified within
the Long Term Conditions
Team. However, the team are
keen to review/investigate
other systems of measuring
outcomes which might be
better suited to communication
impairments, in particular,
aphasic difficulties. As the
Long Term Conditions Team
has a number of major
projects in progress this
financial year, it was proposed
to continue with the current
measures until the following
year.
A larger sample of casenotes,
to include North and South
teams, will be audited as part
of this year’s casenote audit.
This will record inclusion of
outcome data in casenotes but
will not audit outcomes of
therapy.
Audit of therapy outcomes will
follow any changes in outcome
measures proposed/used in
the next financial year.
3528 Effectiveness of
the Clinicians’
Companion
Software for
Patients with
Parkinson's
Disease
Chloe Cripps, SALT
Specialist
Services
27/04/2012 Cancelled
3529 Outcomes for
Teletherapy with
Dysphasic
Patients
Julia Parsons, SALT
Outcomes measured Specialist
after treatment. Trial Services
treatment starting
May 2012. Start
measuring outcomes
at end of 2012.
27/04/2012 Data
Collection
To gather data from
AAA patients before
and after Cardiology
Assessment was
introduced to
determine whether
outcomes have
improved.
30/04/2012 Cancelled
3530 Effects of PreDr Aneil Malhotra,
operative Cardiac Registrar, Cardiology
Assessment in
(Charles Miller, SHO)
Abdominal Aortic
Aneurysm
Patients
Integrated
Medicine
31/12/2012 cancelled
Results and Recommendations required
23/08/2012 Project did not start due to initial problems.
cancelled
Changes required
Project cancelled
3531 What Proportion of Dr Briley, Consultant,
First Time
Neurology (David
Seizures are
Ledingham, FY1)
Referred for a
Neurology Review
To review the notes
Integrated
of patients presenting Medicine
with seizures for the
first time to ascertain
whether the patients
are referred to a
specialist in the
managemnet of
epilepsy to ensure
early diagnosis and
treatment in line with
NICE guidelines.
30/04/2012 Cancelled
06/11/2012 Doctor never started audit.
Project cancelled
3532 Negative
Appendicectomy
Rates
Marwan Farouk,
Consultant, Surgery
(Nigel D'Souza, CT3)
To check negative
appendicectomy
rates and rates of
microscopic
inflammation of
appendix.
Surgery and
Critical Care
03/05/2012 Complete
21/01/2013 Trust NAR 16.8% - 25.4%. This was found to
increase after ultrasound scan, however caution is
urged with this finding as it is appreciated that the
patients going straight to theatre without ultrasound
are likely to be more ‘obvious’ cases of appendicitis.
Changes required
3533 Ultrasound in
Appendicitis
Marwan Farouk,
Consultant, Surgery
(Nigel D'Souza, CT3,
Kirsty Steele, David
Grant)
To look at sensitivity
and specificity of
ultrasound for
appendicitis and
compare with
published results.
Surgery and
Critical Care
03/05/2012 Complete
21/01/2013 The appendix was not visualised in 66.4% of
Changes required
ultrasound scans. Ultrasound ‘contributes’ to
diagnosis or management in only 44% of scanned
patients. It was found to be most useful in females
over 16 (58%). Recommendations: Ultrasound may
be useful in females over 16 presenting with RIF
pain, its role mainly in excluding other diagnoses. In
other groups ultrasound is less valuable. More
weight should be put on clinical suspicion; this would
require close monitoring of NAR. There may be a
role for CT, other studies have shown reduced NAR
but it would expose patients to significant radiation.
3534 Thyroid Function
Tests
Dr Sudesna
Chatterjee, Consultant
(Dr Sarah Ng, FY1)
Diabetes and
Endocrinology
To assess the
Integrated
number of TFTs
Medicine
requested during
acute medical intake
and whether they are
requested
appropriately. If they
are abnormal, are
they acted upon
appropriately.
20/04/2012 Complete
24/06/2012 45.84% of thyroid function tests in acute medical
Changes required
inpatients are not justified or have unclear
indications. This leads to the wastage of a significant
amount of financial resources which could be put to
better use. Tthyroid function tests were requested in
22.5% of medical patients. Only one in 10 of these
patients at the most could have abnormal thyroid
function, as indicated by the abnormal TSH value.
Clinical information is commonly not written on the
request card or clinical indications not given clearly,
which makes it difficult for the laboratory to decide
the most appropriate thyroid function test to perform
to yield the most cost-effective test which yields the
highest diagnostic result. Abnormal thyroid function
tests are often difficult to interpret in acutely unwell
patients and should be retested once the patient has
recovered, usually within 3-6 months. A TSH
concentration above the reference range with FT4
within the normal reference range suggests
subclinical (mild) hypothyroidism. In these patients,
TFTs need to be repeated in 3-6 months after the
initial results to exclude transient causes of a raised
TSH. Only then can a diagnosis of subclinical
hypothyroidism be made. Two months is the
minimum period to achieve stable concentrations
after a change in thyroxine done. Thyroid function
tests should not normally be requested before this
period has elapsed. Discharge summaries should
include information to the GP regarding the abnormal
thyroid function tests, the initial indication for
requesting it, and also the action plan required for
further testing and possible commencing of
treatment. Manifestations of thyroid disease are
often subtle and interpretation of thyroid function
tests in unwell inpatients are often difficult. Our audit
reinforces the principle that TFT results very rarely
influence the management of acutely unwell medical
inpatients, and should not be performed routinely in
this group of patients. Recommendations 1. Present
audit findings to educate junior doctors regarding
appropriate indications for thyroid function testing,
the limited usefulness of thyroid function tests
requests in acute illness, importance of providing
clinical information to aid the laboratory in performing
testing, timeframe to repeat thyroid function tests,
and the importance of good communication to
general practitioners through clearly written
discharge summaries for follow-up of abnormal
thyroid function tests diagnoised in hospital. 2. Set
up hospital guidelines on the Bucks Healthcare
Intranet. 3. Include recommendations in Bucks Trust
Clinical Guidelines handbook.
3535 Use of Oxycontin / Mr Gurdeep Biring,
Oxycodone
Consultant, T&O (Mr
Analgesia in Hip
Rishi Chana, Fellow)
and Knee Primary
Arthroplasty
To look at the use of Surgery and
local anaesthetic and Critical Care
oxycontin /
oxycodone analgesia
in hip and knee
primary arthroplasty
to determine role in
enhanced recovery
post-operative
regime.
04/05/2012 Awaiting
Report/Ac
tion Plan
Results and Recommendations required
Changes required
3536 Fascia Iliac Blocks
as a Replacement
for Morphine in
Fractured Neck of
Femur
Alistair Graham,
Consultant T&O
(Andrew Jones, Lydia
Hanna, FY2)
Monitoring analgesia
and response to
analgesia in patients
with #NOF using
fascia iliac blocks as
a morphine
replacement.
Auditing against
current pain control
standards.
04/05/2012 Awaiting
Report/Ac
tion Plan
Results and Recommendations required
Changes required
3537 Personal Child
Health Record
Record Keeping
Audit
Elaine Tranter, Corinne Record keeping audit Specialist
Hibbert, Dawn Smith, of babies' Personal
Services
Community Midwives Child Health Record
("Red Book").
30/09/2012 Data
Collection
Results and Recommendations required
Changes required
Surgery and
Critical Care
3538 Extra-Cardiac
Findings on
Cardiac MRI
Dr M Hart, ST4
Assesses the
prevalence of extracardiac findings from
cardiac MRI and
evaluates their
clinical significance.
3539 Audit of Analgesic
Requirements and
Satisfaction Post 3
Index Operations
Matt Size,
Anaesthetics
consultant (Hosnieh
Djafari Marbini (ST5)
3540 Audit of Length of
Stay on Postnatal
Ward Post
Delivery
Dr Sanjay Salgia,
Consultant, (Dr
Elizabeth van Boxel,
ST1) Paediatrics
Specialist
Services
15/04/2012 Complete
(no
changes
reported)
08/05/2012 186 cardiac MRIs checked. 193 ECF detected. 39% Changes required
had one or more clinically significant ECF. High
prevalence of extra-cardiac findings on MRI which
could impact on patient's treatment/life, therefore it is
crucial to look for extra-cardiac findings when
reporting cardiac MRI. Recommendations: 1. To
follow up on clinically significant extra-cardiac finding
to ensure appropriate clinical management. 2.
Present results and educate department in the
importance of looking for extra-cardiac findings. 3.
Reaudit in 12 months.
To assess pain relief Surgery and
peri-operatively in 3
Critical Care
index operations,
noting use of opioids
and central &
peripheral nerve
blocks. Then looking
at patient pain scores
and how quickly
satisfaction reached
in recovery.
08/05/2012 Complete
21/01/2013 All patients should have a pain score of below 4 on
Changes required
waking in the Recovery Room and no patient should
return to the ward with a pain score of 4 or more
(Royal College of Anaesthetists). Pain scores were 4
or more for 6% patients on waking and for 4%
patients on leaving recovery. It is difficult to analyse
from case notes alone what could have been done to
ensure all patients had lower pain scores postoperatively. There are several cases where a
peripheral nerve block was performed, which may
have been sub-optimal, and it is also difficult to
appreciate retrospectively factors such as workload
in the recovery room at a particular time. This might
be a further avenue for research for a prospective
study, or also to evaluate patients for longer postoperatively, as well as to ask for pain scores preoperatively, which are not routinely recorded.
An audit to assess
delays in the
discharge of babies
from Rothschild
Ward.
30/11/2011 Complete
14/07/2012 Areas for improvement: Paediatrics: 1. Senior
Changes required
involvement and decision making - ?Avoiding
erroneously given IV abx. Avoiding delay in
discharge to arrange FU for renal pelvis dilatation. 2.
Burden of administrative work on postnatal SHOs Subtracts from time available to perform baby checks
(particularly at weekend) and arrange complex follow
up. 3. Review of non-antibiotic related guidelines Not always easy to find – different versions of the
same guideline! Obstetrics: 1. Coverage with
intrapartum antibiotics - Insufficient maternal IV abx
accounted for 24% of delays. 2. Communication
between Paediatrics and Obs/ Midwifery - Avoid
erroneously given IV abx. Anticipate problems such
as need for apnoea monitor. Microbiology: 1.
Suspected sepsis guidelines: lower threshold for
treatment than some others in network? 2.
Communication with microbiology – ability to access
and interpret results.
Trustwide
3541 IMS
Mr Saif, Consultant (Dr
Documentation of Helen Banks,
Admission
Rehabilitation registrar)
Neurology
Examination
Audit to assess
Specialist
completeness of
Services
neurology
examination for new
patients admitted to
NSIC and use of IMS
proforma to
document findings.
Audit of last 40
patients admitted.
11/05/2012 Complete
29/05/2012 Results: Complete ASIA assessment (Sensory
This will be re-audited but
exam, sensory level, motor exam, motor level, overall none of the other
level, AIS score, anal reflexes, Frankel grade) for
recommendations actioned.
only 13% of patients. No neuro exam documented in
IMS for 4 patients (10%). 75% of neuro
assessments took place on the day of admission.
Remainder were carried out within 2 days of
admission. 86% of assessments carried out by
SHOs. Recommendations: 1. Ensure interpretation
sections filled in. 2. Improve examination and
documentation of reflexes. 3. Ensure additional
components of neurology exam are completed and
documented. 4. Consider changing training for new
SHOs to further highlight the importance of full
assessment and documentation.
3542 Local Maternity
Survey February
2012
Audrey Warren, Head
of Midwifery
Local maternity
Specialist
survey, based on the Services
National Maternity
Survey 2010, for all
mothers who gave
birth in February
2012.
09/05/2012 Complete
3543 Audit on the
Dr Punit Ramrakha,
Management of
Consultant, (Dr Gillian
Hyperglycaemia in Rivlin) Cardiology
ACS Patients
Re-audit of blood
Integrated
glucose monitoring in Medicine
patients with
suspected ACS and
adherence to ACS
protocol. (re audit of
3236)
14/05/2012
11/12/2012 1. 77% of women said they were not given
Changes required
information about the NHS Choices website. 2. 57%
of women rated their care during pregnancy as
excellent or very good. This was 75% in 2009. 3.
14% of women gave birth in a Birth Centre. 4. 22%
of the women were left alone when it worried them at
some point. 5. 76% rated their care during labour
and birth as excellent or very good. This was 81% in
2010. 6. Feeding - Midwives had discussed infant
feeding, at least to some extent, with 72% mothers
during their pregnancy. 53% babies were exclusively
breastfed (or fed expressed breast milk). 18% (40)
mothers responded that their babies had been fed
only formula milk and 25 of these mothers said that
they had not put their baby to the breast at all.
7.Care at home - 11% felt they were not given active
support and encouragement to feed their baby. 59%
saw a midwife either once or twice after they went
home. 32% would have liked to see a midwife more
often. 8. 68% of women felt that during their stay in
hospital they were always treated with kindness and
understanding.
Cancelled.
Project cancelled.
3544 Operative Vaginal Mr Chris Wayne,
Delivery
Consultant (Dr
Raveendran Ruben, Dr
Shiraush Patel) Obs &
Gynae
Ongoing audit of
operative vaginal
delivery (last audit
3229).
Trustwide
15/05/2012 Complete
13/07/2012 Results and Recommendations required
Changes required
3545 Management of
Hyperemesis
Gravidarum
Mr Tunde Dada,
Consultant, (Faye
Boundy, Ahmed Arif)
Obs & Gynae
To assess
management of
hyperemesis
gravidarum and
whether it is done
according to Trust
guidelines (452.3).
Trustwide
18/05/2012 Complete
16/10/2012 Results: Good adherence to guidance in initial
Changes required
investigation and management of HG. Consider
ways to reduce length of hospital stay. Limited data
to evaluate re-admission rates/ severity of condition.
Recommendations: 1. Review at 2 hours and again
at 6 hours. 2.
Decision on admission / discharge based on specific
criteria. 3. Implementation and re-audit with
prospective study.
3546 Management of
Massive Post
Partum
Haemorrhage
Miss Sangeeta Suri,
Consultant (Dr Edward
Harvey, Dr Rebecca
West ST1) Obs &
Gynae
Ongoing audit of
Specialist
incidence of massive Services
obstetric
haemorrhage (>1500
ml) between Audit
against CNST, BHT
guideline 550.1 and
NICE. (previous audit
3308).
15/05/2012 Complete
13/07/2012 Results and Recommendations required
Changes required
3547 Colorectal Patient Clare Bossom,
Experience
Colorectal Clinical
Survey 2012
Nurse Specialist,
Cancer Services
A patient experience
survey to assess the
experience of
patients with
colorectal cancer.
(reaudit)
Specialist
Services
19/05/2012 Complete
3548 Speech &
Debbie Begent, Acute
Language
SLT Service Manager
Therapy Annual
Statistics - Usage
and Waiting Times
Looking at patients
seen etc. Waiting
times are
recommended by
Royal College.
Specialist
Services
18/05/2012 Complete
24/02/2013 Recommendations: The plan for this year is to
Changes required
continue the good work already in place. To address
the issue of making patients aware of what the
Keyworker role is, and to take this further by
highlighting to them their Keyworker name in written
format. To liaise with the Colorectal MDT lead, to
filter down to all the medical team the importance
and benefits of having a colorectal nurse present,
when relaying a diagnosis of cancer to patients.
MDT members will be advised on how to contact
colorectal nurses on both hospital sites. To
recommend from first contact where appropriate the
benefits of having a relative or friend present during
consultations, without causing undue anxieties.
Acute referrals at Wycombe Hospital increased
significantly even before the Hyper Acute Stroke Unit
opened. There was an increase in staff of 0.3 WTE
but this has not been enough to cope with increased
demand. The Long Term Conditions Team at Stoke
Mandeville have a steady referral rate and an
increase in referrals. The Long Term conditions
team at Amersham/Wycombe have had a reduction
referral rates. Despite being without a Clinical Lead
for 6 months have managed to keep waiting time
breaches minimal. There is a steady increase in the
referral rates to the Voice team and LSVT.
Recommendations: 1. Monitor statistics and redistribute staff as required in response to changes in
the Trust. 2. LSVT will be newly established at Stoke
Mandeville, keep separate referral statistics for LSVT
in the North of the Bucks. 3.
Separating statistical collection to monitor acute
stroke vs medical referrals. 4. Separating statistical
collection to reflect the increase in Head and Neck
Cancer referrals and Voice Team to discuss further
efficiencies possibly in administration systems. 5.
Continued collection of statistics in order to monitor
referral and response rates so that we can be flexible
in an organisation that is changing and developing.
All recommendations being
carried out. Staff redistributed
to cope with changed demand.
More statistics being recorded.
3549 PROMS Outcome Mr Johnstone,
Measure Mid
Consultant T&O (Peter
Term after Knee
Smitham, SpR)
Replacement
Audit TKR over 5
years using PROMS
outcome measures.
Compare with
national PROMS
database which is
just done 6 months
after surgery.
Surgery and
Critical Care
22/05/2012 Draft
Report
with
Clinician
Results and Recommendations required
3550 Physio Outcomes Rosi Haunton-Barron
in Gynaecology
To look at outcomes
for all obs, gynae &
urology patients
referred to physio in
2011/12.
Specialist
Services
23/05/2012 Complete
01/06/2012 Recommendations: 1. To reduce the initial
appointment assessment time to ½ hour for Drams,
3rd and 4th degree tears and Pelvic Girdle Pain. 2.
With Mr Greenland’s consent – to prescribe
medication for Over Active Bladder through the GP if
felt it would be beneficial thus reducing the number
of patients referred back to the consultant. 3. Review
of patients’ follow up appointments with consultants.
Initial appointment
assessment time reduced to ½
hour for Drams, 3rd and 4th
degree tears and Pelvic Girdle
Pain. Medication prescribed
for Over Active Bladder
through the GP so number of
patients referred back to the
consultant reduced. Reviewed
patients’ follow up
appointments with consultants
so some discharged earlier.
3551 Audit of
Interventional
Radiology
Audit of complications Specialist
following
Services
intervensional
radiology procedures.
23/05/2012 Complete
21/09/2012 Report has been reviewed by the SDU Lead, who
has put together an action plan that will be taken
forward with the support of the Medical Director.
Changes required
Jael Ramcharitar
Changes required
3552 Audit of VTE
Prophylaxis in
Burns & Plastics
Surgery
Dr Pattinson,
Part of rolling VTE
Consultant
audit
Haematologist (Robyn
Perkins, FY1, Plastics)
Specialist
Services
25/05/2012 Cancelled
3553 Obesity
Management in
NSIC - Staff
Questionnaire
Samford Wong, NSIC
Dietitian
Examining staff
Specialist
opinions and practice Services
on weight
management for SCI
patients.
Questionnaire also
sent to doctors in
several other trusts.
25/05/2012 Analysis/
Report
3554 Awareness of
Guidelines on
Management of
Delirium in T&O
Ramesh Chennagiri,
Consultant T&O (Dr
Chris Griffin, Dr Esther
Trafford FY1 T&O)
Following a neck of
Surgery and
femur fracture
Critical Care
delirium is as
prevalent as 50%.
Research suggests
delirium is poorly
recognised and
inefficiently managed.
Audit of recognition
and assessment of
delirium at admission
in T&O patients over
65.
25/05/2012 Cancelled
14/01/2013 Cancelled
Results and Recommendations required
07/02/2013 Project cancelled, may be reactivated.
Cancelled
Changes required
Project cancelled
3555 Surgical Site
Infection Peri-Op
Burns & Plastics
June 12
Amanda Adkins,
Infection Control
Part of IPC audit
plan. Carried out in
week 11/6/12 to
17/6/12.
Specialist
Services
01/05/2012 Complete
3557 Improving Current
Practice for
Treatment of
Weber B
Fractures
R Chennagiri,
Consultant (Howard
Chan CT2, Cat
Fortescue CT1 T&O)
Review practice for
Surgery and
current treatment of
Critical Care
Weber B fractures
and identify areas for
improvement.
Audited against RCS
standards.
25/05/2012 Awaiting
Report/Ac
tion Plan
3556 Haematology
Cancer Patient
Experience
Survey
Marie Pennell,
Haematology Clinical
Nurse Specialist,
Cancer Services
Obtain patient
Specialist
feedback regarding
Services
the service and
information provided.
Reaudit of 2889.
27/05/2012 Complete
01/09/2012 A report wasn’t compiled due to only 4 observations Not applicable
being completed. This was discussed with Jean
O’Driscoll who was going to follow up the issues with
low compliance.
Results and Recommendations required
Changes required
15/02/2013 Results: 91% of respondents were very satisfied and Changes required
9% were satisfied with the care provided and
reported having confidence and trust in the clinical
nurse specialists. The audit indicated very positive
responses to the support received from the CNS.
100% of the respondents were given contact details
of the key worker.
4 out of 19 patients did not completely understand
their treatment plan and 2 out of 17 patients were not
given a written summary of the treatment plan. 1
patient said they did not see CNS very often.
Recommendations: Ensure all patients are given a
written summary of the treatment plan.
Check patients understanding using a different form
of words in order to give the patient the opportunity
to say they did not understand.
All patients need to be provided with information on
support groups and self-help groups by CNS.
Plan a holistic assessment clinic and give patients
the opportunity to meet with the CNS at a set
appointment time.
3558 Patient Hand
Hygiene Audit
April 2012
Infection Control
3559 National Inpatient
Survey 2012
3560 No. of USS Slots
Required for DVT
Clinic
Re-audit of audits
Specialist
carried out in August Services
11 and Nov 11 to
check to see if
patients are
encouraged to
perform hand hygiene
after
bathroom/commode/b
efore meals etc.
National Inpatient
Survey of sample of
850 patients seen in
July 2012.
Dr Richard Hughes,
Consultant Radiologist
(Dr Yvonne Obura,
FY1)
Trustwide
Collecting data on
Specialist
number of patients
Services
who present in DVT
clinic but cannot have
USS on same day
due to lack of
availability.
01/04/2012 Complete
Not yet
started
09/05/2012 Complete
30/05/2012 Assistance on hand hygiene is being offered to 65%
of patients after using the bathroom but some
patients do not need this. Staff are making
sure the patients are receiving hand wipes with their
meals, the audit results indicate 78% of patients
asked said they were receiving the hand wipes. The
audit results demonstrate that only 29% of patients
received the ‘Hand Hygiene Benefits Everyone’
leaflets. All patients should receive this leaflet as part
of their healthcare management. This means that
71% of people said that they had not received or
read the
leaflet. Recommendations: Areas of low compliance
to re –audit to check all actions have been
addressed. Areas of non compliance to complete
audit and action plan to ascertain compliance.
Recommendations and areas of low compliance to
be discussed at next IPCC meetings. Staff to assess
individual patients ability to perform hand hygiene for
themselves and ensure assistance given where
required.
Results and Recommendations required
Infection Control always
assure us all actions
completed
Changes required
04/12/2012 Recommendations:
Changes required
The FY1 is aware of how many USS slots are
available for the day and when the earliest slot is if
none are free on the day.
All referrals are made to the FY1 on-call. The
registrar directs all such referrals to the FY1 for
booking of an USS slot.
Patients are only seen in the DVT clinic following a
scan. They should therefore be assessed in EMC,
receive dalteparin if applicable and be referred to the
clinic once an USS slot has been established.
Re-assessing the protocol as to the clinical need of
having a re-scan.
Holding conclusion as to whether the service
requires more USS slots pending implementation of
the above recommendations.
3561 Investigating the
Impact of a
Pharmacist at PreAdmission Clinics
on Peri-Operative
Medicines
Management
Saadia Khalid Lead
Pharmacist, Surgery
(Brenda Ogbuji, MSc
student Pharmacy)
3562 WHO Maternity
Checklist Audit
Miss Aparna Reddy,
Consultant (Dr Neha
Singh, FY2) Obs &
Gynae
3563 Audit of Last
Minute
Cancellations of
Procedures in
Ophthalmology
Dr Allaaeldin
Abumattar, Associate
Specialist,
Ophthalmology
Pharmacy will be
providing an
enhanced service to
pre-assessment
clinics at WH for
elective total knee
replacement patients.
This will start in May
2012. Audit will
involve collecting
data from before and
after pharmacist
introduced and will be
looking at specific
data, such as
medicines
reconciliation and
management of
medicines in the periop period.
An observation audit
of the use of the
WHO Maternity
Checklist to be
carried out in New
Wing Theatres, and
complemented by an
audit of 20 sets of
case notes.
Specialist
Services
01/06/2012 Complete
Specialist
Services
06/06/2012 Awaiting
Report/Ac
tion Plan
An audit to compare Surgery and
the Trust's last minute Critical Care
cancellation rate to
the DH nationally
tolerable rate and to
address any
avoidable reasons
accordingly.
06/06/2012 Complete
15/10/2012 When nurses alone handled medicines reconciliation Changes required
of patients in the PAC, a large proportion (62%) of
patients had medication discrepancies upon
admission. The most common of these was the
omission of some of the patient’s home medications.
The involvement of pharmacists in the PAC led to
more correct and accurate medication histories being
obtained for the patients which can help to reduce
medication discrepancies upon their admission to
hospital. It also improved the level of pharmaceutical
service received by elective surgery patients.
Results and Recommendations required
Changes required
01/10/2012 Results: Main causes of loss - a. DNA / cancelled by Changes required
patient. b.Patient illness and pre-existing medical
condition. C. Operation not necessary / required /
cancelled by surgeon. d.Administrative errors. e.
Data Missing. Recommendations: 24-48 hours
before admission a reminder / check by telephone (or
any alternative) to identify patients who are unable or
too unwell to attend their surgery { potential DNA}
giving the hospital chance to substitute these
patients. This “waiting list last minute validation” is to
check whether patient is still able and willing to
undergo the procedure and whether they have
received all the details, arranged transport.
3564 Survey of Patients'
Views on the Use
of a Computerised
Visual Aid to
Explain Prolapse
Mr Tunde Dada,
Consultant, (Dr Alvaro
Bedoya-Ronga, ST6)
Obs & Gynae
3565 Management of
Dr Gopar Sakar,
Neonatal Jaundice Consultant, (Dr
Katharine Irving, ST1,
Dr A. Ray Narayaran,
ST5) Paediatrics
A survey to assess
Specialist
patients' views on the Services
use of the
computerised visual
aid and leaflets in
order to explain
prolapse and its
treatment.
An audit of notes in
order to determine
the management of
neonatal jaundice
against Trust and
NICE guidelines.
Specialist
Services
Complete
06/06/2012 Complete
14/06/2012 CVA is a useful tool to communicate with patients,
helps patients to understand their prolapse and the
surgery and is at least as good as the leaflet. It is
being used routinely. Recommendations:
Encourage and increase the use of CVA. Develop
procedure specific leaflets.
Changes required
10/10/2012 1. Implement NICE charts for monitoring bilirubin
levels across the neonatal & paediatric department
for all gestational ages. Discontinue use of current
Trust charts and remove these from wards. 2. Print
the summary sheet from the Trust guideline
“Appendix 1” (see page 3 of this document) on the
reverse of the two term NICE charts (37-week and ≥
38-week) that will be used in the postnatal ward. This
summary sheet to be completed by all staff
(midwives, nursery nurses and junior doctors) for
every jaundiced baby, and to be included in the
patient records and hand-held notes. 3.Compile a
file of documentation and information specifically for
“Jaundice” to be kept in the nurse’s station or
Doctors office in the postnatal ward. This file should
be for general use by all including midwives, nursery
nurses and doctors. It should comprise sections
containing at least: a. Guidelines on management
and assessment: The NICE guidance summary and
our Trust protocol;
- NICE bilirubin charts for various gestational ages
(with the “Appendix 1” summary sheet photocopied
on the reverse page as described above); b. A
parent education leaflet, which should be given to all
parents with jaundiced babies (available from NICE
guidance website)
- GP letter template for jaundiced babies that should
be completed at discharge from the ward. c. Master
copies of all documentation should be given to SCBU
secretary Jan for safe keeping. This file could be
developed by one of the SHOs working in the unit
currently. Failing this, Katharine Irving will complete
this task. 4. Distribute list of recommendations to
postnatal ward and SCBU management staff. Points
to be discussed with midwifery and neonatal staff. Dr
Sarkar to organise these meetings and dissemination
of information. 5. Re-audit in 1 year following
implementation of recommendations discussed to
complete cycle. This should take place around
September – October 2013. Dr Sarkar to supervise
this.
Not all recommendations need
to be implemented. Guideline
693.3 updated October 2012.
The NICE treatment graphs
(Appendix 5) need to be
interpreted with common
sense judgement and
discussion with the paediatric
team is mandatory if treatment
is triggered by the charts.
Patient information leaflet.
3566 Critical Care
Mortality Review
Dr G Luzzi, Medical
Director
Review of February
Surgery and
2012 mortality in
Critical Care
Critical Care, SMH,
following an alert.
Notes to be reviewed
using mortality review
tool.
01/06/2012 Draft
Report
with
Clinician
Results and Recommendations required
Changes required
3567 Paediatric
Consent Audit
Miss Jo Hicks
Review of the
consenting of 50
paediatric patients
who underwent a
procedure from 1st
September 2011 to
30th April 2012.
01/06/2012 Cancelled
Cancelled
Cancelled
Specialist
Services
3568 Pain Audit in New Barbara Leach, Senior Audit of pain scores Surgery and
Wing Recovery
Acute Pain Nurse
after anaesthetic and Critical Care
pain scores leaving
Recovery. To
improve patient
experience and postoperative care and
achieve shorter
length of stay in
Recovery.
11/06/2012 Complete
01/11/2012 The recommendation was to improve the recording
of pain scores on wards. Action will include running
Pain Assessment Study days. Pain nurses will also
get involved in student nurse education in acute and
chronic pain study sessions.
Changes required
3569 Audit of PostOperative
Endophthalmitis
Mr Khurram Rahman,
Associate Specialist,
Ophthalmology
To analyse the
Surgery and
incidence rates of
Critical Care
post-operative
endophthalmitis
(severe eye infection
following eye surgery)
in the Ophthalmology
Unit at Stoke
Mandeville Hospital
between 2008 and
2011. A re-audit of
2478.
11/06/2012 Complete
09/10/2012 Results: The endophthalmitis rate in the Trust is
slightly higher than national average; the culture
positive rate in both vitreous and esp. aqueous is
low; vitreous biopsy gives a better yield than vitreous
tap. Recommendations: to continue with post
operative prophylaxis as before; to consider using
intracameral cefuroxime.
3570 Audit of Clinical
Management of
Pre-Term Labour
before and after
introduction of
Fetal Fibronectin
Testing
Miss Suri, Consultant
(Ayesha Choudhary,
Amar Maroo) (Dr
Katherine Talbot) Obs
& Gynae
Audit of Clinical
Specialist
Management of Pre- Services
Term Labour before
and after introduction
of Fetal Fibronectin
Testing.
15/06/2012 Awaiting
Report/Ac
tion Plan
Results and Recommendations required
Changes required
Mouth care is
Surgery and
important on ITU
Critical Care
because patients are
often ventilated and
at high risk of
infection. Audit of all
patients on ITU on
set date (estimate of
8-10 patients) looking
at duration of stay so
far. Auditing against
Trust guideline 355.2.
Also questionnaire to
ITU nurses & doctors.
11/06/2012 Awaiting
Report/Ac
tion Plan
Results and Recommendations required
Changes required
3571 Mouth Care in ITU Dr Panikkar,
Consultant
Anaesthetics/ICU (Dr
David Bruce, FY1 ITU)
As the large multicentre
European study was flawed,
the decision to change to
using intracameral cefuroxime
was left to individual
practitioners.
3572 Chemotherapy
Patient
Experience
Survey
Annie Richards,
Matron for Cancer &
Haematology
Obtain patient
Specialist
feedback regarding
Services
the service and
information provided.
Reaudit.
12/06/2012 Draft
Report
with
Clinician
3573 Peripheral Line
Care June 12
OPAT Team
Part of IPC audit
plan. To be carried
out by OPAT team.
Specialist
Services
13/06/2012 Complete
3574 Audit on the
Process of
Induction of
Labour
Miss Felicity Ashworth,
Consultant, (Dr Meena
Bhatia, SpR) Obs &
Gynae
A prospective audit
on the process of
induction of albour
against Trust
guidelines.
Trustwide
12/03/2012 Complete
Results and Recommendations required
Changes required
07/09/2012 Results : Insertion: All 4 elements of tool complied
Changes required
with for 68% observations. Continuing Care: VIP
forms were completed for 88% patients with IV lines.
All applicable elements were complied with in only
20% cases. Recommendations: 1. To individualise
more of the elements in the insertion audit, to avoid
discrepancy in assessment process and help focus
any further training needs. 2. Areas that were
involved in the audit and showed non compliance will
have individual action plans to complete, with results
being returned to the IV team.
3. Medical staff must be informed of the results as
they play a significant role in the element of insertion.
4. The importance of filling in documentation should
be emphasised through educational processes.
Education/ training continues to ensure that insertion
and continuing care of peripheral cannula devices is
provided for all healthcare workers involved in this
skill.
30/06/2012 Recommendations: 1. IOL only bay. 2. IOL specific Changes required
staff on Roths in am. 3. No rest day with Propess
(primps). 4. Consider out patient-IOL (NICE
guidance). 5. Update of leaflet regarding timings. 6.
Improve explanation women receive about why they
are being induced, what the process involves and
delays they can experience.
3575 Survey of
Dr D Walshe,
Information Given Consultant, (Dr Ana
to Patients on
Phelps, SpR) MFOP
Ward 5B MFOP
A survey on the
Integrated
information given to
Medicine
patients and patients'
relatives/carers on
admission and
discharge to Ward 5B
SMH, MFOP.
18/06/2012 Data
Collection
3576 Documentation of Dr Louise Dodd,
Anaesthetic Risks Consultant,
Anaesthetics (Dr
Deborah Stevenson,
FY1)
Audit to investigate
how many patients
are informed of all
anaesthetic risks for
GA/spinal/epidural.
19/06/2012 Complete
28/08/2012 Recommendation: Make changes to the anaesthetic Changes required
chart to include a ‘risks explained’ section with
tickboxes for each type of anaesthetic, giving the
relevant risks in order to act as a reminder of the
need for discussing risks with the patient prior to
surgery and as an aid to saving time in the
documentation of this discussion. In order to
facilitate this and ensure support from the
department this would ideally be done after surveying
consultants on their opinion of these changes, and
on which specific risks should be included.
3577 Underlying
Causes of Insulin
Administration
Errors
To audit the causes
Integrated
of insulin
Medicine
administration errors.
The learning
outcomes of this audit
should be cross
transferable to other
medical
administration errors.
20/06/2012 Complete
28/09/2012 Results: 11/14 errors (78%) were identified as
Changes required
primary active failures. 7/14 errors (50%) involved a
lapse in memory or attention; lack of staffing was
identified as a risk factor in 9/14 errors (64%), and a
heavy workload was cited in 7/14 errors (50%).
Agency staff made 5/14 errors (33%).
Recommendations: clear knowledge of the
medicines policy so all staff know of their role and
responsibilities with regard to insulin administration;
clear usage of the self administration of insulin policy;
clear messages with regard to the role of agency
staff; education in a structured and ongoing manner
incorporating the safe administration of insulin and
variable rate intravenous insulin infusion e-learning
packages; dedicated quiet space to prepare
medication; charts to be tagged together; reduction
in the use of agency staff and the employment and
investment of high quality regular staff to improve
retention rates; robust supervision of staff to maintain
skill set and competency.
Louise Meakes, Lead
Nurse, Diabetes,
Satinder Bhandal, VTE
Lead Pharmacist
Surgery and
Critical Care
Results and Recommendations required
Changes required
3578 Personal
Protective
Equipment July
2012
Amanda Adkins,
Infection Control
Part of IPC audit plan Specialist
Services
01/07/2012 Complete
3579 Nutritional
Knowledge of
Paediatric Staff
Survey
Dr Baneera Shrestha,
Consultant,
Paediatrics, Samford
Wong, Dietitian
A survey of the
Specialist
knowledge of staff
Services
working in a
paediatric setting of
"nutrition matters"
prior to implementing
training.
26/06/2012 Complete
12/11/2012 Results: 167 of the 836 questions (20%) were
Changes required
incorrectly completed with a tick rather than number
of observations out of 10. 158 of the 836 questions
(19%) were considered to be not applicable to that
ward/area. For the other 511 questions, average
compliance was 97%. Compliance by question varied
from 85% (Q11) to 100% (Q10). Compliance by area
ranged from 79% to 100%. However, many
questions were incorrectly completed in some area,
therefore their compliance will not be accurate. For
all 801 correctly completed, applicable questions,
compliance was 97%. 34 areas had some noncompliant responses so should have produced action
plans. Only 5 areas (15%) produced an action plan.
Recommendations: Staff who complete the audit
must answer the questions correctly and use not
applicable rather than no where necessary. The
results of audit are to be reviewed by the Associate
Directors of Nursing and the relevant actions
identified need to be completed in an action plan and
returned to the Infection Prevention & Control Team.
14/11/2012 Total number of respondents was 53 - maximum
Changes required
possible score on survey was 17. Number of
responses from Dr's was 12 who had a average
score of 64.7%. Number of responses from Nurses
was 36 with an average score of 47.1%. 5 Dietitians
responded with an average score of 73.5% Results
summary - 73% of staff aware of the nutritional
screening tool, 98% of patients were weighed on
admission, 40% of child's height not measure and
approx 1/3 of patients growth chart not plotted on
admission. There were some areas of poor
knowledge identified including energy requirements
of children, fluid requirements and indictors of
overnutrition and undernutrition.
Conclusions/recommendation - Need for further
eduction in health professionals, feedback back is
required to ward staff, need of stadiometer, make
charts available via intranet, ward folders, put
nutiritional screening tool and care plans on intranet
and involve hospital management in
education/training for AHP's with an MDT approach.
No action plan
3580 Audit of Risk
Factors and
Outcomes
Following Colonic
Stenting
Mr Huang, Consultant,
General Surgery
(Catherine Bradshaw,
CT2, Charles Evans,
SpR)
3582 Effectiveness of
Maureen Coggrave,
Bowel Preparation CNS (Ruth Penn,
in SCI Patients
Research Nurse)
Prior to
Colonoscopy
Audit of radiological
Surgery and
and surgical
Critical Care
outcomes of patients
with an obstructing
lesion of colon/rectum
using colonic stents,
against NICE
guidelines and
national standards.
27/06/2012 Complete
01/10/2012 This was a retrospective review of 21 patients who
Changes required
underwent SEMS treatment for large bowel
obstruction in Buckinghamshire Hospitals NHS Trust
between 2008 and 2012. 25 procedures were
included in the audit and the success rate was 44%.
Currently awaiting results of 2 large RCTS a) ESCO
– 103/144 patients recruited, no adverse events to
date and b) CReST – recruiting since 2009.
Similar audit carried Specialist
out in 2010. (audit
Services
2204). As a result of
that audit a bowel
prep protocol was
introduced in Sep
2011. This audit is to
assess whether this
protocol is being
followed.
27/06/2012 Complete
16/11/2012 RESULTS: The bowel preparation medications and Changes required
enemas followed the protocol in 13/27 (48%) cases.
The endoscopist categorised the quality of bowel
preparation as satisfactory in 4/27 (15%) cases, suboptimal in 12/27 (44%) cases and poor or very poor
in 11/27 (41%) cases.
The procedure was completed effectively in 8/27
(30%) cases and not completed effectively in 19/27
(70%) cases. CONCLUSIONS:
There has been no significant improvement in the
outcome of bowel prep.
Protocol not prescribed in majority of cases.
Very poor compliance with protocol when prescribed.
Inadequate IMS & patient notes make compliance
with prep difficult to assess.
Ineffective procedures cost inconvenience and
money.
RECOMMENDATIONS:
Review protocol – medications and clarity.
Improve use of protocol.
Educate staff about protocol.
Ensure protocol is accessible – upload to spinal
drive, format for IMS & provide laminated copies to
wards.
Empower patients with improved preparation
information – could Endoscopy send out with
appointment?
Liaise with Endoscopy to define rating to improve
assessment of prep.
Develop follow-up guidelines for ineffective
procedures.
Repeat mini audit in 6 months.
3581 Audit of Category
3 and 4 Heel
Pressure Ulcers
Sam Goodman,
Pressure Ulcer Nurse
To establish if there
Integrated
are any themes within Medicine
the development of
heel ulcers in the
Trust. Will audit all
category 3 and 4 heel
ulcers over 6 month
period.
27/06/2012 Data
Collection
Results and Recommendations required
Changes required
3584 Patient Outcome
after Zone 3
Extensor Tendon
Repairs
Comparing
Immobilisation
Regime with SAM
Regime
Elizabeth Mawby
Physiotherapist, Nicola
Hyde, OT Hand
therapy
Comparing outcomes Specialist
Apr-Jun 12 using
Services
BHT guidelines
treatment regime
involving
immobilisation and
comparing with
outcomes Jul-Sep
using SAM (short arc
motion) rehab
regime. Guidelines
have already been
changed to SAM
regime.
29/06/2012 Data
Collection
Results and Recommendations required
Changes required
3585 Audit of Speech & Nicola Cook, Specialist
Language
Speech & Language
Therapy Outcome Therapist
Measures on
Medical Wards at
WH
To establish whether Specialist
outcome measure
Services
tool is being used and
what the outcomes
and variances were
by retrospective
random selection
from SLT department
inpatient referral and
discharge registration
book.
01/01/2012 Complete
31/03/2012 Results: Outcomes were recorded for 80% of the
patients (standard=100%). 92% outcomes recorded
were fully achieved. Actions: All SLTs to
consistently complete outcomes for acute patients; to
be highlighted at the acute team meetings. Clarify
administration process at the acute team meeting.
Re-audit in one year.
At acute team meeting in May
12 it was highlighted that all
SLTs should complete
outcomes. Also the
administration process was
clarified.
3586 Review of Stroke
Patient Portfolio
Todd Kaye, Clinical
Specialist
Physiotherapist, Neuro
and Rehab and Susie
MacTavish
Retrospective
Specialist
questionnaire
Services
investigating patient
opinion of Stroke
Patient Portfolio to
aid in the
enhancement and
any possible
improvements for
publication of version
2.
22/06/2012 Draft
Report
with
Clinician
3587 Audit of Screening Dr A Dutta, Consultant
of Prolonged
(Dr Naomi Jefferis)
Paediatric
Paeds
Jaundice
An audit of
Specialist
management of
Services
prolonged jaundice in
a paediatric setting.
01/06/2012 Complete
3588 Junior Doctors'
Record Keeping
Audit 2012
Dr Graz Luzzi, Medical Annual Trustwide
Director
record keeping audit
carried out by junior
doctors.
Trustwide
04/08/2012 Not yet
started
Results and Recommendations required
Changes required
14/07/2012 The total cost of the prolonged jaundice screen at
Changes required
BHNT is £271.65 per patient. BHNT are currently
not following NICE guidelines. Unnecessary
investigations are being requested. Financial
savings can be made, benefiting both patients and
the paediatric department if current guidelines are
revised in line with NICE 2010 or other local hospitals
ie: JRH. Recommendations: Change parameters of
direct bilirubin,for obtaining expert advice regarding
babies, to a direct > 25 micromol/litre (currently 20).
No need to request TSH and T4 as thyroid problems
should have been detected via the blood spot
screen. Extend this audit to gauge adherence to
current BHNT guidelines. Current cost = £271.65.
Proposed cost= £44.57 ( +/- £49.24). If only
essential Ix, saving of £227.08 per patient. If
essential and additional Ix, saving of £177.84 per
patient. Total savings to Trust Proposed guidelines,
saving of £44,280.60.
Results and Recommendations required
Changes required
3589 Emergency Burns
Care - A Survey of
Appropriateness
of Referrals
Gail Miller, Sister,
Suzanne Nunn, Burn
Care Adviser, Plastics
and Burns
An audit of the
appropriateness of
referrals to the local
burns service from
Eds both pre and
post implementation
of training from Burn
Care Advisors.
Surgery and
Critical Care
05/07/2012 Complete
19/02/2013 An initial audit of referrals from emergency
departments to one burn service was carried out pre
and post implementation of burn care traning. The
results indicate that 30% of referrals were
inappropriate before training yet 40% remained
inappropriate after early implementation of training.
Several factors to take into consideration are:
Training predominately for nursing staff whereas it is
the A&E doctors who will often refer patients to the
burns service. New rotation of doctors between the
first and second audit. Still staff to be trained. The
results highlight the importance of the Burns Care
Advisor's continued role in the training and education
of referring services. period
Burns Care Advisors have set
up burns link nurse framework
across their catchment areas.
Initiated the development of
burns information folders in
varied clinical areas.
Produced a minor burns injury
information leaflet.
Commenced a burns first aid
information leaflet. Initiated a
standard burns pack.
3590 Contact Lens
Related Keratitis
Mr K Rahman,
Associate Specialist,
Ophthalmology (Raj
Mukhopadhyay, SpR)
Contact lens related Surgery and
keratitis is one of the Critical Care
most common causes
for eye casualty
appointments. The
patients receive
variable treatment
regimens and risk
factors are not
assessed uniformly.
This audit will
compare standards of
care with the current
evidence.
10/07/2012 Complete
01/10/2012 The number of patients seen with contact lens
Changes required
related keratitis in our population was very similar to
the standard (2.5%). In a significant proportion of
patients, history was not detailed regarding type of
contact lens, hand hygiene and smoking.
Recommendations were made to note the risk
factors in every case of keratitis. It was felt that it is
difficult to obtain a definitive diagnosis at the initial
visit. It was recommended that these patients would
benefit from a corneal opinion. Feasibility of a rapid
response cornea clinic would be explored for
managing these patients quickly and take a
significant load off the casualty. The treatment
protocol, though variable, reflected the variations
described in the literature. There is no consensus on
the correct treatment modality and again, it was felt
that a corneal opinion would be valuable. The final
visual outcome was excellent. Our patients fared
much better than standard. However, this might also
be biased because the notes of patients needing
admission and hence with more severe disease were
not always kept at casualty. A re-audit at an interval
of one year was suggested to evaluate the effect of
the recommendations of this audit.
3591 Incidence and
Mr G Matthews,
Impact of
Consultant, (Dr Ross
Radiolucence in
Muir, CT2) T&O
Oxford
Unicompartmental
Knee
Replacement
Retrospective audit of Surgery and
x-rays, operation
Critical Care
notes and follow up.
10/03/2012 Awaiting
Report/Ac
tion Plan
Results and Recommendations required
Changes required
3592 Audit of ACHT
Service
Specification GP
Satisfaction
Survey
Jackie Allain,
Operational and
Clinical Lead, ACHT
An audit to assess
Integrated
whether the GP
Medicine
Service Specification
is delivering the
promised level of
service.
07/07/2012 Draft
Report
with
Clinician
Results and Recommendations required
Changes required
3593 Community
Nursing Team for
Children with
Learning
Disabilities Client
Experience
Survey
Ane Poll, Clinical
Nurse Specialist for
Children with Learning
Disabilities
Client Experience
Specialist
Survey to obtain
Services
feedback on the
service provided by
the Community
Nursing Team for
children/young
people with a learning
disability.
07/07/2012 Draft
Report
with
Clinician
Results and Recommendations required
Changes required
3594 Diabetes and
Endocrinology
PES
Dr Sudesna
Chatterjee, Consultant
Diabetes and
Endocrinology, SMH
A Patient Experience Integrated
Survey carried out to Medicine
assess the level of
patient satisfaction
with the Diabetes and
Endocrinology
Outpatient Clinics at
Amersham, Stoke
Mandeville and
Wycombe Hospital.
17/07/2012 Draft
Report
with
Clinician
Results and Recommendations required
Changes required
3595 Maternity Notes
Record Keeping
Audit
Mr Tunde Dada,
Consultant and
Hannah Hunter, SoM
SMH
An audit of maternity Specialist
notes record keeping Services
01/05/2012 Data
Collection
Results and Recommendations required
Changes required
3596 Isolation
Precautions
August 2012
Amanda Adkins,
Infection Control
Part of IPC audit plan Specialist
Services
01/08/2012 Complete
12/11/2012 There were 7 “No” responses in total, leading to an
Changes required
overall compliance of 99%. Recommendations:
Monitoring of the isolation precautions boards, which
should be available and completed when a sideroom
is being used for an ‘infected’ patient, should
continue when matrons’ rounds are taking place.
Areas of non participation must address any ‘no’
answers within their area.
3597 Suprapubic
Stomas in SCI
Patients
Debbie Green, Matron, Cancelled.
NSIC, Jean O'Driscoll,
Infection Control
Specialist
Services
01/08/2012 Cancelled
10/08/2012 Cancelled
3598 Rapid Incremental Wail Ahmed, Spinal
Closed Reduction Injuries SpR
of Cervical Facet
Fracture
Dislocation in SCI
Retrospective review Specialist
of the effect of closed Services
reduction of cervical
fracture dislocations
on patients'
neurology and
complications. Of the
procedure. Also
assessed success
and failure rates and
reasons for failure.
26/07/2012 Complete
26/07/2012 Our rapid incremental closed reduction success rate No recommendations or
was 39 %.
actions.
Out of the seven patients who had successful
reduction, three had improved motor level by 1 level,
two by 2 levels and one by 4 levels.
Most patients who underwent successful closed
reduction had one stage surgical stabilization
(ACDF), whereas most patients who underwent
unsuccessful closed reduction had two stage surgical
stabilization ( Posterior ORIF + ACDF).No
recommendations or actions.
3599 Lumbar Puncture
Success and
Documentation
Lumbar punctures
Specialist
are used to diagnose Services
meningitis but are
often unsuccessful in
neonates. To audit
current success rates
before trying to make
changes to procedure
to improve success.
27/07/2012 Complete
13/12/2012 90 patients included in audit, 6 had repeat LP's
Changes required
performed. Results - Audit standard was to have
100% documentation of LP, 50% of LP's successful
and samples to be sent to lab within 30 minutes of
procedure and to be analysed within 30 minutes of
arrival at lab. Results showed the following
documentation rates from notes - date and time
recorded 83% of the time Indication 3%, consent
48% of the time, aseptic technique being used 86%
of the time, number of attempts at performing LP
80% of the time, appearance of csf 80% of the time
and the grade of doctor recorded 93% of the time. LP
were successful 34% of the time. In 5% of the time
samples were sent to the lab in under 30 minutes
and 81% of the time they were processed in under
30 minutes of arrival in the lab. Recommendations 1. a sticker has been proposed to increase
documentation of LP's within notes. 2. To improve
success rates the introduction of LP manikin and
ultrasounds for previous bloody LP's 3. Highlight
importance of samples getting to lab quicker to junior
doctors and improve communication with porters 4.
Dr Sarkar, Paediatric
Consultant (Andy
Marshall, Paediatric
registrar)
Cancelled
Proposed LP logistics guideline giving advice on how
LP's should be dealt with administratively. All
recommendations under review by consultants Andy
to advise once finalised 14/12/12 (CP)
3600 Palliative Care
PES 2012
Rachel O'Donnell,
Palliative Care CNS
Team Leader
An audit to determine Specialist
if patients with
Services
palliative care needs
benefit from the
current palliative care
service.
3601 Paediatric
Occupational
Therapy Group
PES July 2012
Alison Lyle,
PES of parents of
Community Paediatric children attending
Occupational Therapist community
Occupational
Therapy groups and
talks. Re-audit of
audit 3309.
Specialist
Services
01/08/2012 Data
Collection
Results and Recommendations required
Changes required
02/08/2012 Data
Collection
Results and Recommendations required
Changes required
3602 Medical
Occupational
Therapy Record
Keeping
Rebecca Bull, OT
Audit 30 sets of
notes, auditing
against Trust &
professional record
keeping standards.
Specialist
Services
31/07/2012 Complete
3603 Antibiotic
Prescribing for
Sore Throat and
Laryngitis in
Children
presenting in
Emergency
Department
Dr Stewart McMorran,
Consultant (Dr S.
Tiwari, ST6)
Emergency Medicine
An audit of the
Integrated
prescribing of
Medicine
antibiotic prescription
rates for paediatric
patients presenting
with sore throat and
pharyngitis in the
Emergency
Department.
Cancelled
3604 Re-Audit of
Patient
Readmissions
within 28 days
following
Discharge from
Medicine
Dr Mitra Shahidi,
Consultant,
Respiratory Medicine
(Dr Quentin Jones,
ST3)
Audit to look at the
Integrated
reasons for
Medicine
readmission of
patients within 28
days following
discharge from
Medicine. Results
will be compared with
those of the previous
audit, 3184.
06/08/2012 Complete
15/01/2013 Results: OT entries generally very good with regard Changes required
to patient details, dated, signed. 88% timed, 68%
designation of author. Recommendations: Consider
name stamp with designation, use of felt
pens/stickers. Consider extending audit to cover
other areas.
11/12/2012 Project cancelled. No response from doctor.
Cancelled
06/02/2013 Results: similar statistics to 2010; re-admissions of
Changes required
related conditions is a common problem, particularly
in the elderly; respiratory complaints, acopia and
cancer were the main causes of related readmission;
the majority of readmissions – both related and
unrelated are often secondary to chronic conditions;
community support packages are not being utilised.
Recommendations were to make staff aware of
support/care packages in the community; adapt
medical discharge summaries to include details of
care packages; reduce avoidable admissions for
palliative patients.
3605 Postnatal Bladder Mr Ian Currie,
Audit of postnatal
Care
Consultant (Dr Leyan bladder care against
Ham-Ying GPVTS, Dr Trust Guideline 687.
Matthew Mayer
GPVTS) Obs & Gynae
Specialist
Services
Complete
16/10/2012 Results - 82% of decisions regarding catheter use
Changes required
were appropriate and well documented. Inconsistent
levels of documentation regarding time and volume
of 1st void. Insufficient data to comment reliably on
management of retention, but signs are promising.
Recommendations: 1. Standardise documentation
paperwork. 2. Promote importance of early bladder
care and relevance of 1st void. 3. Posters/Morning
meeting/Staff bulletin/Education.
3606 EPAU Guidelines
Audit Management of
Miscarriage
Mr Chris Wayne, (Dr
Emily Moss, Dr Abigail
Taylor GPVTS) Obs &
Gynae
Audit of management Specialist
of miscarriage
Services
against EPAU Trust
guideline 640.2.
Complete
14/11/2012 Referral source - following guidelines.Number of
Changes required
patients presenting with a history of fewer than 3
miscarriages has reduced. Still too many patients
presenting at < 6 weeks gestation. Too many
patients having to stay overnight to wait for a scan.
Recommendations: MDT discussion as to where to
direct patients who are <6 weeks gestation. Suggest
booking appointment and scan at 6 weeks.
3607 Antibiotic
Prophylaxis in
Gynaecology
Surgery
Mr Tunde Dada,
Consultant (Dr
Mohammed Ahmed
GPVTS, Dr Deborah
Stevenson FY2) Obs &
Gynae
Audit of antibiotic
prescribing in
Gynaecology
Surgery.
Complete
16/10/2012 Recommendations: 1. Clarification of definition of
‘emergency surgery’. 2. Review need for antibiotic
prophylaxis in hysteroscopic surgery. 3.
Simplification of guideline, e.g. table format. 4.
Recirculation of policy amongst gynaecologists and
anaesthetists. 5. Re-audit and include Abx
administration time relative to procedure. 6. Stream
Guideline (e.g. Flow chart, RCOG pelvic floor
advice…). 7. Further audit into management of
retention. 8. Patient satisfaction / feedback survey.
8. Re-Audit after 6-12 months of changes.
Trustwide
Changes required
3608 Emergency
Gynaecology
Admissions
3609 Management and
Investigation of
Children
Diagnosed with
Sensory Neural
Deafness, April
2007 to March
2012
Mr Tunde Dada, (Dr
Arnold Babumba
GPVTS, Dr Nicola
Solomon FY2) Obs &
Gynae
To review the current Specialist
trust guideline for
Services
emergency gynae
admissions (427.1).
To evaluate the
effectiveness and
efficiency of seeing
acute gynaecology
patients in the
Emergency Gynae
Clinic as opposed to
A&E.
Complete
Dr Sawhney,
Consultant, Paediatrics
(Dr Edward Gaynor,
SpR, Dr Manju Kanga,
Associate Specialist,
Community
Paediatrics)
Audit of the
Specialist
Management and
Services
Investigation of
Children Diagnosed
with Sensory Neural
Deafness, April 2007
to March 2012
against local
guidelines. Aim is to
create a pathway for
the Trust.
Data
Collection
3610 Availability of
Liz Pryke, Dietetic
Snacks to Prevent Manager, Karen Orriss,
Hypoglycaemia for Dietitian
Patients with
Diabetes on
Medical Wards
To assess the
Specialist
knowledge of staff on Services
the wards regarding
suitable snacks;
development of a
poster to remind staff
about snacks and the
importance of
providing snacks.
17/08/2012 Complete
14/11/2012 Most patients are seen in A&E (1/3 in EGU). A&E
Changes required
waiting times on average 2 hrs (up to >4 hrs). EGU
patients get a scan the same day, but A&E have to
wait (usually overnight). Proforma needs
improvement (time of referral, arrival, and time seen
not being recorded). Recommendations: 1. Proforma
needs revision (currently using EPAU proforma). 2.
Staffing and facilities need to be addressed. 3.
Guideline needs updating to include a standard of
care. Re-audit. (Discussion at AHD referred to
Reading model where unit has more slots and is
open all day. Our unit currently open only in
afternoons and has only 4 slots to see patients and 2
scans per day. Doctors too thinly spread over EGU
and A&E with 1 dedicated nurse and oncall registrar).
A&E patients stay in hospital longer
But no significant difference between number of
operations for A&E/EGU patients
?Longer stay due to delay in obtaining scan
Results and Recommendations required
Changes required
14/12/2012 After nurse training the results show that the number No recommendations
of Hypoglycaemic events have been reduced
significantly between meals and at bedtime but the
number at breakfast have only slightly reduced. No
recommendations.
3611 Time Delay
between
Prescription and
Administration of
the First Dose of
IV Antibiotics in
NSIC
Mr Mofid Saif, Spinal
Prompt administration Specialist
Injuries Consultant (Dr of IV antibiotics is
Services
Wail Ahmed, SpR)
vital in management
of septic patients.
This audit assesses
the scale of the delay
in administering first
dose IV antibiotics in
septic patients in the
NSIC. Re-audit of
3371.
01/08/2012 Complete
21/08/2012 Re-audit demonstrated a lower percentage (24 %) of Changes required
potentially harmful delays in administration of the 1st
dose IV antibiotics in septic patients compared to 42
% in the first audit. 91 % of 1st dose of IV antibiotics
were prescribed STAT compared to 83.3 % in the
first audit. No absence of time documentation by
nurses was detected compared to 34% in the first
audit, whereas absence of time documentation by
doctors remained at 14%, similar to the first audit.
This re-audit demonstrated overall improvement in
the performance and implementation of sepsis
guidelines. Recommendations: 1.To incorporate the
Sepsis Pathway into IMS. 2. The next audit should
include all management of sepsis including IV
antibiotic use. 3. All doctors and nurses should be
encouraged to comply with the Trust Sepsis
Integrated Care Pathway and use it in every sepsis
incident.
3612 Fractured Neck of Dr Jeremy Drake,
Femur Operations Consultant
Delayed due to
Anaesthetist
Classification as
Medically Unfit
An audit of the delay
in procedures for
patients with
fractured neck of
femur due to being
classed as medically
unfit with the aim of
reducing the current
cancellation rate.
Surgery and
Critical Care
21/08/2012 Complete
26/11/2012 There are no major themes indicating that we could No changes required
reduce delays by instigating specific measures.
Delays will continue to be reviewed and discussed at
the monthly hip fracture meeting.
3613 Skin Cancer
Nurse Led
Diagnosis Clinic
Patient
Experience
Survey
To assess service
provided by skin
cancer CNS during
period leading up to
and immediately
following diagnosis.
Specialist
Services
22/08/2012 Complete
01/02/2013 Results: 92% patients were told their diagnosis face Changes required
to face. All were given their diagnosis in a caring and
sensitive manner. 96% definitely had confidence
and trust in the Specialist Nurse. There had been
improvements in most areas since the previous audit
in 2010. Recommendations: All clinical staff who
interact with cancer patients should attend the
advanced communication course.
When a patient is given their diagnosis it is important
that the value of the MDT discussion is emphasised.
Lindsey Lane, Skin
Cancer CNS
3614 Infection Control
Amanda Adkins,
Environmental
Infection Control
Audit Community
& Integrated Care
Part of IPC audit
plan. Infection
control audit of
kitchens and patient
equipment. Carried
out by division. This
audit is for CIC.
Specialist
Services
29/08/2012 Complete
14/12/2012 Of the 7 areas audited all achieved the minimum
Infection Control assure us
compliance of 85%. The action plan must be
that actions completed
completed by ward managers to address the areas of
non-compliance. All actions must have a completion
date and the final plan returned with all actions
closed to ensure the audit cycle is completed.
3615 Acute Hand
Infections:
Topography and
Microorganism
Profile in A&E and
Plastic Surgery
Mr Eric Tan, ST5,
Plastics (Lucy
Farrimond, FY1,
Plastics)
An audit to determine Surgery and
the most common
Critical Care
site, level and
microorganism
responsible for hand
infection. Results will
be compared with
those of JHSA 2010:
35A/25-28. The audit
will include 200 A&E
hand infection cases
and 100 cases
treated by the Plastic
Surgery team at
Stoke Mandeville
Hospital.
30/08/2012 Awaiting
Report/Ac
tion Plan
Results and Recommendations required
Changes required
3616 Expediting
Discharges in
Medicine for Older
People
Dr Simmie
Manchanda,
Consultant, (Dr
Nathalie Fennell) MfOP
A retrospective audit Integrated
of last 100 discharges Medicine
from MfOP, recording
when pre-existing
care arrangements
were documented
and multidisciplinary
team made aware;
when patient became
medically fit; when
assessed by
physiotherapy,
occupational therapy
and social work, and
total length of hospital
stay. Aim to design
an intervention to
reduce length of
hospital stay.
21/09/2012 Data
Collection
Results and Recommendations required
Changes required
3617 Perioperative
Transversus
Abdominal Plane
(TAP) Blocks vs
Rectus Sheath
Blocks for DIEP
Flaps
Mr Eric Tan, ST5,
Plastics (Rhona
Sproat, CT1) Plastics
Retrospective audit of Surgery and
notes of DIEP flap
Critical Care
patients looking at
intraoperative and
postoperative
analgesia
requirements.
05/09/2012 Data
Collection
Results and Recommendations required
Changes required
3618 A Survey on the
Availablity of
Drinking Water for
Rheumatology
Patients
Dr Richard Stevens,
Consultant
Rheumatologist (Dr
Simon Clough, FY2)
A survey to determine Integrated
what proportion of
Medicine
ward based patients
are safely and
independently able to
drink and have a
drink within easy
reach.
10/09/2012 Complete
Results and Recommendations required
Changes required
3619 Lip Lacerations
Hugh Wright, SpR
Plastics (Rhona
Sproat, CT1 Plastics)
Audit of current
Surgery and
management of lip
Critical Care
laceration, cost of
management and
cancellation of
theatre time. No
standards exist hence
large variation in
practice and probable
potential for
improvement.
07/09/2012 Awaiting
Report/Ac
tion Plan
Results and Recommendations required
Changes required
3620 Preventing
Amanda Adkins,
Surgical Site
Infection Control
Infection - Peri
Operative Audit for
General Surgery
and Vascular
Procedures
September 2012
Part of IPC audit plan Specialist
Services
01/09/2012 Complete
26/11/2012 Results: 53 procedures were audited. 100% patients Not required
had MRSA screening. 100% had WHO surgical
checklist completed. !00% given antibiotic
prophylaxis where indicated. 100% used clippers if
hair removed. Glucose monitoring was maintained
where relevant. Normothermia was maintained
where relevant. Overall 100% compliance so no
recommendations necessary.
3621 Sharps Handling & Amanda Adkins,
Management
Infection Control
September 2012
Part of IPC audit plan Specialist
Services
01/09/2012 Complete
22/01/2013 Non participation should be discussed at
SDU/clinical governance meetings and relevant
areas should complete the audit.
The report, results and issues highlighted for
further focus should be discussed and
disseminated to all relevant staff across the Trust.
Ongoing training, promotion of good practice and
compliance monitoring should continue. Actions
identified should be completed and closed as part of
the audit cycle and actions must be
signed off by the Divisional AND’s.
The collation of data on reported sharps injuries
should continue to inform further training and
facilities.
3622 Laryngectomee
Valve Changes
To count the number
of laryngectomee
valve changes that
took place in
Wycombe SLT
between Sep 2011
and Sep 2012.
10/09/2012 Analysis/
Report
Results and Recommendations required
Barbara Reynolds,
Speech & Language
Therapist - ENT Team
Lead
Specialist
Services
IPC assure that all completed.
Changes required
3623 DNA Rates in
Voice Therapy
Barbara Reynolds,
Speech & Language
Therapist - ENT Team
Lead
Monitoring DNAs. In Specialist
a previous audit DNA Services
rates fell when
contacted by phone
to arrange
appointments.
10/09/2012 Data
Collection
Results and Recommendations required
Changes required
3624 Waiting Times for
Initial Voice
Therapy
Appointments
Post ENT
Barbara Reynolds,
Speech & Language
Therapist - ENT Team
Lead
Waiting time not
monitored at the
moment. Patients
may be more
responsive if wait
reduced. Plan to
discuss referral
criteria with ENT
consultants at end
2012 and review
waiting time before
and after this.
Specialist
Services
10/09/2012 Data
Collection
Results and Recommendations required
Changes required
RE-audit of 2843 at
Integrated
both hospitals. Audit Medicine
against DKA
treatment standards.
11/09/2012 Awaiting
Report/Ac
tion Plan
Results and Recommendations required
Changes required
3625 Diabetic
Dr Chatterjee,
Ketoacidosis Audit Consultant Diabetes
(Kirsty Beckett, FY2)
3626 Initial MRI in
Patients Referred
to NSIC
Tom Meagher ,
Consultant Radiologist
(Luis Lopez de
Heredia, Clinical
Scientist, Radiology)
Access to initial MRI
for patients with
traumatic SCI is
essential to plan
management,
investigate
complications and
identify neurological
deterioration.
Determine numbers
of patients with
traumatic SCI that
had initial MRI
2006/2012. Audit
standard 80%.
Specialist
Services
12/09/2012 Complete
17/12/2012 The percentage of new traumatic SCI patients
Changes required
admitted to the NSIC with an initial MRI scan loaded
into PACS was only 40%, considerably lower than
the audit standard of >80%.
In a mini pilot study from the list of patients that had
no initial MRI scans loaded into PACS, 10 patients
were randomly selected for control purposes. The ITRadiology department was asked to find/request the
original MRI scans of these patients from the
referring hospitals. 3 out of these 10 patients had an
initial MRI scan from their referring hospitals which
was not uploaded into PACS. Although, this was
done in a small sample group, it suggests that there
are a substantial number of patients (30%) missing
their original MRI scans. Recommendations: Talk to
the spinal consultants and the IT department to
upload all the scans so they are available on PACS.
Re-audit 6-12 months.
3627 Orthodontic
Patient
Experience
Survey
Sylvia Tan, Specialty
Doctor, Orthodontics
To monitor patient
experience within
Orthodontic
department.
Surgery and
Critical Care
14/09/2012 Complete
31/10/2012 Recommendations: 1. Tto discuss findings/outcome Changes required
of audit at next departmental meetin. 2. Iincrease
staff capacity at reception desk to greet patients. 3.
Ensure all notification letters are being sent to correct
address by constant updates of patients’ contact
details by reception staff. 4. Recognise patients'
parking problems – to feedback to clinical lead. 5.
Rrewrite some questions in the questionnaire for the
next audit as many of the questions were multiple
question. 6. Discuss with colleagues and staff in the
department on where best to distribute the
questionnaires for the next audit as giving them out
at the clinic and returning them to reception could
possibly have affected staff behaviour as it would
have been obvious to them that they were being
assessed. 7. Re-audit in 3 years.
Selective laser
Surgery and
trabeculoplasty is a
Critical Care
technique used to
lower the intraocular
pressure in patients
with glaucoma. The
laser was first
acquired by the
Ophthalmology
Department in
February 2012. The
aim of this audit is to
look at the outcome
of treatments with the
laser to date and to
define a departmental
protocol for
treatment.
17/09/2012 Complete
04/12/2012 Recommendations included: treatment protocol;
better note keeping; better follow-up; re-audit in 1
year.
3628 Initial Experience Miss Anna Mead,
of Selective Laser Consultant,
Trabeculoplasty - Ophthalmology
First Six Months
Changes required
3629 Audit of Intestinal
Failure
Management
Mr A Goede,
Collection of data for Surgery and
Consultant (Reju Joy, presentation to the
Critical Care
CT1, General Surgery) Intestinal Failure
Committee, of
intestinal failure
patients requiring
TPN for more than 14
days over 3 year
period in preparation
for national peer
review visit in
October.
3631 The Use of X-Ray Mr Peter Budny,
in Upper Limb
Consultant (Iain
Laceration
MacLeod, CT2),
Plastics
3632 Audit of
Investigations in
Children with
Hearing Loss
To evaluate the use Surgery and
of x-rays in arm/hand Critical Care
lacerations to
establish whether we
over use them in
investigations, and to
reduce harmful
radiation usage.
Dr Ruth Hill, Specialist Audit of compliance
Specialist
in Neurodisability and with guidelines for
Services
Paediatrics
aetiological
investigation of
infants with
congenital hearing
loss identified through
newborn hearing
screening.
14/09/2012 Complete
25/10/2012 This was collection of data for presentation to the
Intestinal Failure Committee rather than an audit so
no recommendations for change were made.
20/09/2012 Data
Collection
Results and Recommendations required
25/09/2012 Complete
No changes required.
Changes required
29/01/2013 15 out of 21 cases met the 1st criterion and were
Changes required
offered aetiological investigations. 20 out of 21 cases
did not meet the national guideline standards for
investigations. In all 20 cases the recommendation to
offer written information on the investigations was not
met. An aetiological cause for the hearing loss was
made in 25% of cases. Recommendations- All
parents of deaf children should be given written
information on the investigations as found on
National Deaf children's society web site, re-audit in
2 years.
3633 Knowledge and
Understanding of
PSA Testing
Patient Survey
Mr Bdesha, Consultant A patient survey of
Surgery and
(Rebecca Geyton, Le experience and
Critical Care
Ha, FY1) Urology
understanding of PSA
testing.
25/09/2012 Analysis/
Report
Results and Recommendations required
Changes required
Specialist
Services
17/09/2012 Data
Collection
Results and Recommendations required
Changes required
3635 Audit of GP Direct Dr Weldon, Consultant An audit to assess
Integrated
Access
(Lucinda Shaw, ST2)
the information
Medicine
Gastroscopy
Gastroenterology
provided by GPs on
the Direct Booking
Gastroscopy Request
Form and to
determine the
proportion of patients
being incorrectly
referred to
gastroscopy for
dyspepsia.
28/09/2012 Complete
16/10/2012 5 patients met the criteria for referral (for 2 week
wait). 6 patients met the criteria for direct access
endoscopy (>55, trial of appropriate pharmacological
agents for an appropriate length of time). 19 (63%)
did not meet the criteria for referral of patients to
endoscopy due to either age (<55 should not be
scoped) or due to insufficient trial of pharmacological
agents. Recommended interventions to GPs: 1.
Review medications for causes of dyspepsia e.g.
NSAIDs, orticosteroids. 2. Test for (and treat) H.
Pylori infection. 3. Breath test or stool antigen test
Metronidazole or amoxicillin, with clarithromycin. 4.
Diet and lifestyle changes. 5. Avoid known
precipitants - head up, weight loss, smoking
cessation. 6. CBT- rule out cardiac/ musculoskeletal/
biliary causes for symptoms. Recommendations for
department: 1. Re-design GP Direct Access referral
forms to include NICE Guidelines. 2. Re-audit to
assess if changes have been made to referrals. 3.
Assess waiting times for 2 Week Wait referrals.
3634 Assessment of
Eric Woo, Consultant
Left Ventricular
(Kartika Selvam, SHO)
Ejection Fraction Radiology
by Cardiac MRI
and
Echocardioograph
y
A retrospective
assessment of left
ventricular ejection
fraction by cardiac
MRI and
echocardioography.
Dr Gorard emailed GPs in
Stoke Mandeville and
Wycombe catchment area
1/10/12. Local guidelines sent
out as a reminder. Awaiting
feedback from GPs.
3636 Patient
Francesca Lis, GynaeSatisfaction
oncology Clinical
Survey Following Nurse Specialist
Implementation of
Distress
Thermometer in
Psychological
Assessment
A patient experience Specialist
survey to obtain
Services
information from
patients with
gynaecological
cancer. This will be a
pilot phase prior to
introducing a nurseled holistic
assessment clinic in
order to put in place
any changes or to
continue.
01/10/2012 Data
Collection
Results and Recommendations required
Changes required
3637 BTS Emergency
Oxygen Audit
An annual BTS audit Integrated
of Emergency
Medicine
Oxygen presribing
and delivery
throughout the Trust.
(see previous audits
2495 and 3283)
01/10/2012 Awaiting
Report/Ac
tion Plan
Results and Recommendations required
Changes required
A restrospective
Surgery and
assessment of
Critical Care
implant failure rate of
intra-medullary
gamma nails in
treatment of proximal
femoral fractures in
the Trust from 2009
to 2012.
02/10/2012 Complete
Jenny Ricketts,
Consultant Nurse,
Critical Care
3638 Gamma Nailing for Mr Ramesh
Proximal Femoral Chennagiri,
Fractures
Consultant, T&O
(Aleem Hussein, FY2)
22/01/2013 The overall failure rate between 2010-2012 was
Changes required
7.52%. The failure rate before May 2010 was
10.52%. The failure rate after May 2010 (set and jig
changed) was 5.45%. Change of jig (May 2010) for
proximal sliding screw led to a significant decrease in
implant failure rate. Recommendations: Change of
practice (jig verification); identification of further intraoperative risk factors for implant failure; radiological
assessment of all nails placed in audit period; criteria
for technical competence.
3639 Initiation and
Monitoring of
Azathioprine in
Dermatology
Department
Dr Emily Davies, SpR,
Dermatology
To audit the initiation
and monitoring of
Azathioprine in
Dermatology
Department against
BAD guidelines
between January
2012 to Sept 2012
Integrated
Medicine
3670 Intermountain T&O Patient
Pathway
Mr Ramesh
Chennagiri,
Consultant, T&O
(Georgina Williams,
CT)
To answer
Surgery and
fundamental
Critical Care
questions about the
role of follow-up in
order to design a new
booking system and
set of outpatient
templates, with the
aim of improving the
quality of patient
contact, the
confidence of patients
and commissioners in
our service, efficiency
of the service, and
optimising use of
consultant staff.
04/10/2012 Complete
3671 Thames Valley
Cancer Network
Enhanced
Recovery
Programme
Project for Gynaeoncology Patients
Miss Geraldine Tasker,
Consultant, (Neveen
Khan, ST6), Obs &
Gynae
A baseline audit and
patient satisfaction
survey of enhanced
recovery for patients
undergoing
hysterectomy for
endometrial cancer,
before implementing
ERP principles. A
TVCN/TSSG Gynae
Cancer led project.
03/09/2012 Data
Collection
Specialist
Services
02/10/2012 Awaiting
Report/Ac
tion Plan
Results and Recommendations required
Changes required
21/12/2012 93% outpatient follow-up appointments are made for Changes required
the correct clinic; 74% are made for the correct time.
Incorrect timings are related to a lack of capacity
within the clinics rather than administrative error.
Recommendations: trail for appointment booking
forms, e.g. an ordercomms tab; combine with a
system to flag those appointments made outside
appropriate timeframe; consultants to have more
control over their clinics, e.g. access to CRS and to
checking their appointment availability before
requesting appointment dates.
Results and Recommendations required
Changes required
3672 Urology Cancer
Patient
Experience
Survey (BHNHST)
Hilary Baker, Joe
Kearney, Krystyna
Caine, Uro-oncology
Clinical Nurse
Specialists
A survey to obtain
Surgery and
feedback regarding
Critical Care
the service and
information provided
to patients with
urological cancer.
(Previous survey see
database number
2891).
10/10/2012 Data
Collection
3673 Antibiotic
Prophylaxis in
Surgery
Dr Waghorn,
Consultant
Microbiologist, Trust
Antimicrobial
Pharmacist
We have guidelines
Specialist
relating to antibiotic
Services
prophylaxis at
surgery. Audit to look
at 12 different types
of surgery and
compare with
guideline. 15 cases
from each surgery
area to be audited for
a 6 month period
every year. This
audit Jul-Dec 2012.
Re-audit of audit
3333.
15/10/2012 Data
Collection
3674 BTS Paediatric
Pneumonia Audit
2012-13
Dr Craig McDonald,
Annual BTS audit of
Consultant (Dr Ralph
Paediatric
Robertson) Paediatrics Pneumonia
November 2012 January 2013.
Specialist
Services
01/11/2012 Data
Collection
Results and Recommendations required
Changes required
Changes required
Results and Recommendations required
Changes required
3675 Splinting the Nail
Bed after Repair
Mr Heywood,
Consultant, Plastics
(Rachel Clancy, ST3)
An audit and a patient Surgery and
survey to determine Critical Care
a) if splinting the nail
bed after repair
improves outcome
and b) whether using
the nail as a splint
introduces infection.
09/10/2012 Data
Collection
Results and Recommendations required
Changes required
3676 Standards for
Paediatric
Services - Facing
the Future
Dr Michelle RussellTaylor, Consultant
National audit
Specialist
directed by RCPCH
Services
to look at their
aspirations for the
future and where
units are at present
for just 2 standards, 1
and 2.
20/09/2012 Awaiting
Report/Ac
tion Plan
Results and Recommendations required
Changes required
3677 Medical
Management of
Thyroid Eye
Disease
Dr Sonia Mall, ST6
Specialty Registrar,
Ophthalmology
Retrospective audit of Surgery and
patients who have
Critical Care
had medical
treatment for thyroid
eye disease to
assess whether the
current protocol of
treatment has been
followed.
09/10/2012 Awaiting
Report/Ac
tion Plan
Results and Recommendations required
Changes required
3678 Distal Radius
Fracture - Early
Discharge to
Physiotherapy
after Surgery
Mr Ramesh
Chennagiri,
Consultant,
Orthopaedics (Lynn
Bath, Musculoskeletal
Clinical Lead
Physiotherapist)
Currently these
Surgery and
patients have a mean Critical Care
of 3.5 follow up
appointments in
fracture clinic. The
aim is to reduce this
to 2 FU appointments
by discharging these
patients to
physiotherapy after
follow up at 7-14 days
post op, with a FU
booked at 8 weeks to
be cancelled by
physio if not required.
11/10/2012 Data
Collection
Results and Recommendations required
Changes required
3679 Nutrition Status of Liz Pryke, Dietitian,
Patients with
Lynsey Spillman,
Fractured Neck of Dietitian
Femur
An audit to look at the Integrated
nutrition status of
Medicine
inpatients with
fractured neck of
femur.
10/10/2012 Data
Collection
Results and Recommendations required
Changes required
3680 BTS Paediatric
Asthma Audit
November 2012
Annual BTS audit of
Paediatric Asthma
November 2012.
01/11/2012 Analysis/
Report
Results and Recommendations required
Changes required
Dr Craig McDonald,
Consultant (Mark
Bamber CT5)
Specialist
Services
3681 Audit of
Management of
Placenta Previa
Mr Tunde Dada,
Consultant (Dr Shilpa
Gandhe, SpR), Obs &
Gynae
An audit to ascertain Specialist
whether patients with Services
placenta praevia are
being managed
correctly with regards
to length of stay and
follow-up process,
including scan.
30/09/2012 Notes
being
pulled
Results and Recommendations required
Changes required
3682 Preventing
Amanda Adkins,
Surgical Site
Infection Control
Infection - Peri
Operative Audit for
Trauma &
Orthopaedic
November 2012
Part of IPC audit plan Specialist
Services
01/10/2012 Cancelled
Cancelled
Cancelled
3683 Enuresis Clinic
Patient
Experience
Survey
To assess patient
experience of
enuresis service.
16/10/2012 Complete
Ellen Hope, Team
Lead SCPHN (School
Nursing)
Specialist
Services
28/11/2012 Parents generally very satisfied with service. One or Changes required
two comments re lateness of referral.
Recommendations: To keep GPs up to date
regarding the enuresis service. To enable children to
be referred appropriately and timely into the enuresis
service.
To maintain the excellent service provided to clients
across the trust and maintain up to date knowledge
for the clinic nurses.
Arrange to update enuresis training 2013 and budget
for one nurse to attend ERIC conference 2013.
Training for staff on feedback from ERIC conference.
Ensure clinic nurses monitor equipment regularly at
each clinic visit to avoid batteries running low.
3684 Audit of
Dr Nicola Hanson,
Caesarean
SpR, Anaesthetics
Section under GA
2010/11
A continuous audit of Specialist
caesarian section
Services
under general
anaesthetic.
01/01/2012 Data
Collection
Results and Recommendations required
Changes required
3685 UK IBD Audit
(Round 4) 201213
Dr Ravi Sekhar,
Consultant,
Gastroenterology
National audit to
Integrated
assess the processes Medicine
and outcomes of up
to 50 consecutive
prospectively
identified admissions
for ulcerative
colitis. Re-audit of
IBD service provision
against the IBD
Standards.
01/01/2013 Data
Collection
Results and Recommendations required
Changes required
3686 Cancer Target
Times in Tertiary
Referrals
Dr Geraldine Spain,
ST5, Obs & Gynae
To assess whether
any of the patients
referred to tertiary
centres for treatment
have breached their
dates, if so, is there
anything that can be
done about this.
01/10/2012 Data
Collection
Results and Recommendations required
Changes required
Specialist
Services
3687 Review of Serious Jackie Smith, Patient
Incidents for
Safety Manager
Revalidation
A review of Serious
Incidents for
revalidation
purposes.
3688 Stoma Care
Service Patient
Experience
Survey
Assessment of
Specialist
service - may help to Services
prove case for further
nurse.
Collette O'Brien,
Stoma Care Nurse
3689 Audit of GP Direct Dr Weldon, Consultant To reduce
Access
Gastroenterologist
inappropriate
Endoscopy
(Raman Goyal, FY2)
endoscopy requests.
To audit to see how
many are
inappropriate and if
reasons explained.
Trustwide
Integrated
Medicine
17/10/2012 Not yet
started
Results and Recommendations required
Changes required
17/10/2012 Data
Collection
Results and Recommendations required
Changes required
17/10/2012 Data
Collection
Results and Recommendations required
Changes required
3690 Male Lower
Urinary Tract
Symptom (LUTS)
Clinic Evaluation
Pamela Ging, Prostate To audit the patient
Surgery and
CNS
experience of the
Critical Care
Nurse led male LUTS
clinic.
18/10/2012 Data
Collection
3691 Mortality Review
February 2012
Dr Graz Luzzi on
behalf of the
Healthcare
Governance
Committee
A review of 50 deaths Trustwide
in February 2012
requested by the
Healthcare
Governance
Committee following
an increase in
mortality rate for this
period.
19/10/2012 Cancelled
3692 Assessing
Infection Rates in
Patients with
Inflammatory
Arthritis on antiTNF Drugs
Dr M Magliano,
Consultant (Dr Kuljeet
Bhamra, SpR and Dr
Shilpa Selvan, SpR)
Rheumatology
Comparing
occurrence of
infection in patients
with inflammatory
arthritis on
cetolizumab against
etanercept and
adalimumab.
18/10/2012
Integrated
Medicine
Results and Recommendations required
14/11/2012 Project cancelled, usual 6 month review to be done
instead.
Results and Recommendations required
Changes required
Project cancelled.
Changes required
3693 Detection of Small Dr Sarulatha
for Gestational
Palaniappan, SpR,
Age Babies by
Obs & Gynae
Ultrasound
An audit of the
Specialist
detection of small for Services
gestational age
babies by ultrasound.
01/11/2012 Data
Collection
Results and Recommendations required
Changes required
3694 Risk Factors for
Laparoscopic
Cholecystectomie
s
Mr S. Appleton,
Consultant, General
Surgery (Dr Gijsbert
Vanboxel, CT2)
Retrospective
telephone audit of
laparoscopic
cholecystectomy
patients 2011-12.
Surgical site
infections identified,
audit will look at the
risk factors.
Surgery and
Critical Care
23/10/2012 Awaiting
Report/Ac
tion Plan
Results and Recommendations required
Changes required
3695 Consent for NJR
Mr Ramesh
An audit to accurately Surgery and
Chennagiri, Consultant identify the
Critical Care
(Dr Ed Bray)
percentage of
patients who are
consented for the use
of their personal
details on the NJR
and ensure it is being
reported accurately.
24/10/2012 Complete
22/02/2013 In 2012 Wycombe hospital quoted an NJR consent
Changes required
rate of 96%. In this audit 47 sets of patient notes
were reviewed and no patients had been consented
for the use of their personal data in the NJR. One
set of notes contained the NJR consent form but
there was no signature. This suggests that those
filling in the NJR database post op are stating that
the patient has been consented without checking the
notes.
Recommendations: Reiterate the responsibility of
those completing the NJR database form post op to
complete it with accurate information to ensure
compliance with the Data Protection Act 1998;
increase the number of patients being consented for
the use of their data on the NJR by using a number
of media to highlight the lack of consent to the
orthopaedic department, e.g. emailing all doctors
involved in consenting patients, use of posters in the
admissions area where patients are consented to
remind and highlight the requirement for consent;
provide access to consent forms in the surgical
admissions area to ensure that it is as easy as
possible for consent to be taken; educate the
admissions nurses regarding the requirement for the
forms to be in the admissions pack with the usual
consent form
3696 A Re-audit of
Waiting List
Booking Cards
Miss Geraldine Tasker, Re-audit of 3387
Consultant, Obs &
(2011) to assess the
Gynae
thoroughness of
documentation using
the same
methodology.
3697 Vaginal Birth After Heidi Beddell,
Caesarian Section Consultant Midwife,
Obs & Gynae
Audit against CNST
standards to assess
compliance with
Trust/NICE VBAC
guideline.
Specialist
Services
01/10/2012 Complete
16/01/2013 Results and Recommendations required
Changes required
Specialist
Services
16/10/2012 Data
Collection
Results and Recommendations required
Changes required
3698 Audit of the
Management of
Latent Phase of
Labour
Heidi Beddell,
Consultant Midwife,
Obs & Gynae
Audit of compliance
with the Trust
Guideline on Latent
Phase of Labour
(503.2).
Specialist
Services
16/10/2012 Data
Collection
Results and Recommendations required
Changes required
3699 Audit of Wart
Treatment in
Genito-urinary
Medicine
Dr Veena Reddy, Dr
Graz Luzzi (Rosemary
Binks, Deputy Sister,
Lynne Fearn, Senior
Staff Nurse)
A retrospective audit
of wart management
against Shaw Clinic
guidelines 2011
(based on BASHH).
Specialist
Services
25/10/2012 Data
Collection
Results and Recommendations required
Changes required
3700 A Comparison of
Visual Outcome of
Macular Hole
Surgery with
Standards
Mr Richard Bates,
Consultant,
Ophthalmology (Dr Raj
Mukhopadhyay, ST3)
A comparison of
Surgery and
visual outcome of
Critical Care
macular hole surgery
with Trust standards.
29/10/2012 Complete
21/12/2012 The audit found that of the 56 macular holes
Continue current practice.
operated over the last 3 years, 100% closed after
primary surgery. This is better than the national
average of around 90-95%. Visual improvement was
on average 3 Snellen lines - in line with national
average. Visual outcome was marginally better than
the previous audit in 2000. Conclusion was therefore
to continue current practice.
3701 Trauma &
Mr Gordon Matthews,
Orthopaedics 3
Consultant, T&O
Monthly
Complications and
Deaths Review
An audit of mortality
and morbidity
following T&O
procedures during
July, August and
September 2012.
Surgery and
Critical Care
30/10/2012 Complete
14/11/2012 Notes pulled for M&M meeting.
No changes required
3702 Audit of
Effectiveness of
the Enhanced
Recovery
Programme in
Patients Admitted
for Colorectal
Surgery
Glynis Howat, Surgical
Care Practitioner, Dr
Siegfried Wagner, FY1,
General Surgery
An audit of patients
Surgery and
who have been
Critical Care
recruited into the
enhanced recovery
programme for
laparoscopic
colorectal surgery.
Data will be collected
regarding their
postoperative
recovery and in
particular on feeding,
analgesia and
mobilisation.
31/10/2012 Awaiting
Report/Ac
tion Plan
Results and Recommendations required
Changes required
3703 Audit of
Decreased
Conscious Level
in Children
C G Rastogi,
Follow up to 3197.
Specialist
Consultant, Dr Abhijit
Concentrating on 1.
Services
Mazumdar, Paediatrics documentation of the
clinical history
features; 2.
documentation of the
observations of heart
rate, respiratory rate,
blood pressure and
temperature on
presentation to
hospital; 3.
documentation of
GCS measurements
within the
recommended
frequency; and 4.
documentation of
capillary blood
glucose taken within
15 minutes of
presentation to
01/11/2012 Data
Collection
Results and Recommendations required
Changes required
hospital.
3704 Audit of
Management of
Early Inflammatory
Arthritis
Dr M Magliano,
Consultant (Dr C Yong,
SpR, Ursula Perks,
Research Nurse)
Rheumatology
An audit of
Integrated
compliance with the Medicine
BSR guideline on the
management of early
inflammatory arthritis.
01/11/2012 Notes
being
pulled
3705 National
Parkinson's Audit
2012
Dr Syed Hasan,
Consultant, MFOP
This is a national
audit designed to
help Trusts evaluate
their Parkinson's
service against the
NICE Guideline and
National Service
Framework for Long
Term Neurological
Conditions, compare
their Parkinson's
service to others
around the UK,
highlight strengths
and weaknesses in
current service and
develop an action
plan to improve
services.
01/11/2012 Complete
Integrated
Medicine
Results and Recommendations required
Changes required
11/01/2013 Results and Recommendations required
Changes required
3706 The Effectiveness Michelle Holmes,
of Joint Voice
Deputy Manager,
Clinics in
SALT
Accurately
Diagnosing Vocal
Fold Pathologies
The equipment in
Specialist
joint voice clinics can Services
sometimes identify
conditions missed by
other assessment.
This audit will identify
how many patients
between July 12 and
Jan 13 had original
diagnosis altered as a
result of attending
clinic. This will act as
baseline for future
audits.
05/11/2012 Data
Collection
Results and Recommendations required
Changes required
3707 A Review of
Michelle Holmes,
Quality of Speech Deputy Manager,
& Language
SALT
Therapy
Casenotes
Identify quality of
notes and compare
with previous audit
Specialist
Services
05/11/2012 Data
Collection
Results and Recommendations required
Changes required
3708 TB Patient
Experience
Survey
Patients' views of TB Integrated
service.
Medicine
05/11/2012 Data
Collection
Results and Recommendations required
Changes required
Margaret Holland, TB
Nurse
3709 Upper GI Cancer
GP survey
Maureen Kiely, Upper
GI Cancer Nurse
This is to get
feedback from GPs
regarding the
effectiveness of
communication
following MDTs.
Specialist
Services
05/11/2012 Data
Collection
Results and Recommendations required
Changes required
3710 VTE Assessment
in NSIC
Mr M Saif, Consultant
(Dr K Collins and Dr F
Qureshi)
VTE assessment
audit.
Specialist
Services
01/07/2012 Complete
Results: Only 50-80% of patients had VTE
Changes required
assessments. 85% done within 24hrs of admission.
85% done by admitting doctor. Recommendations: 1.
Separate VTE tab on IMS. 2. Reminder cards on
each computer. 3. Raise awareness of VTE
assessment. Brief introduction to VTE assessment
in new SHO IMS training (from Dec 2012). Monthly
feedback to all clinicians on percentage VTE
assessments done. Suggest monthly prize / accolade
for doctor doing most VTE assessments.
3711 Survey of
Paediatric Patient
Orientated
Eczema Measure
Scores
Dr Mohsin Ali,
Consultant, (Dr Emily
Davies, SpR),
Dermatology
A survey of Patient
Integrated
Orientated Eczema
Medicine
Measure (POEM) in
patients attenting the
Paediatric
Dermatology Clinic
October 2012 to
March 2013.
01/10/2012 Data
Collection
Results and Recommendations required
Changes required
3712 National
Trabeculectomy
Audit
Mr Bruce James,
Consultant
Re-audit of
Surgery and
trabeculectomy to
Critical Care
perform view of
intraocular pressure
one year after
surgery carried out in
2010. Needed for
revalidation.
01/11/2012 Awaiting
Report/Ac
tion Plan
Results and Recommendations required
Changes required
3713 National Maternity Audrey Warren
Survey 2013
National survey of
mothers giving birth
in Jan/Feb 2013.
Specialist
Services
01/04/2013 Not yet
started
Results and Recommendations required
Changes required
3714 Audit of Operative Mr Tunde Dada,
Vaginal Delivery
Consultant, Obs &
Gynae
Continuous audit of
operative vaginal
delivery for CNST.
Specialist
Services
01/10/2012 Analysis/
Report
Results and Recommendations required
Changes required
3715 Audit of
Caesarean
Section
Mr Tunde Dada,
Consultant, Obs &
Gynae
Continuous audit of
Specialist
caesarean section for Services
CNST.
01/10/2012 Analysis/
Report
Results and Recommendations required
Changes required
3716 Audit of Vaginal
Breech Delivery
and other
Operative
Procedures
Mr Tunde Dada,
Consultant, Obs &
Gynae
Continuous audit of
Specialist
Vaginal Breech
Services
Delivery and other
operative procedures
for CNST.
01/10/2012 Analysis/
Report
Results and Recommendations required
Changes required
Continuous audit of
shoulder dystocia for
CNST.
01/10/2012 Analysis/
Report
Results and Recommendations required
Changes required
3717 Audit of
Mr Tunde Dada,
Management of
Consultant, Obs &
Shoulder Dystocia Gynae
Specialist
Services
3718 Audit of
Management of
Obstetric
Haemorrhage
Mr Tunde Dada,
Consultant, Obs &
Gynae
Continuous audit of
management of
obstetric
haemorrhage for
CNST.
Specialist
Services
01/10/2012 Analysis/
Report
Results and Recommendations required
Changes required
3719 Audit of Oral Drug Reet Nijjar, CT1
Therapy for
Anaesthetics
Patients who are
Nil by Mouth
Are patients getting
Surgery and
medications e.g.
Critical Care
usual medicines,
painkillers preoperatively on
emergency lists when
nil by Mouth.
05/11/2012 Data
Collection
Results and Recommendations required
Changes required
3720 Mortality Review
April - September
2012
A review of 50 deaths Trustwide
requested by the
Healthcare
Governance
Committee as part of
an ongoing review of
mortality within the
Trust.
14/11/2012 Data
Collection
Results and Recommendations required
Changes required
Dr Graz Luzzi on
behalf of the
Healthcare
Governance
Committee
3721 Telephone
Questionnaire for
all Joint
Replacement
Patients
Jenny Carro, Ward
Manager, T&O
A telephone
Surgery and
questionnaire carried Critical Care
out for all joint
replacement patients
on day 7 following
discharge from
hospital. Part of the
Enhanced Recovery
Programme.
13/11/2012 Data
Collection
Results and Recommendations required
Changes required
3722 Management of
Diabetes PeriOperatively
Dr Henrietta Brain,
Consultant, Diabetes &
Endocrinology (Dr
Daniel Conaway, F2)
Integrated
Medicine
15/11/2012 Analysis/
Report
Results and Recommendations required
Changes required
3723 Audit of Missed
Fractures
Dr Stewart McMorran,
Consultant A&E SDU
Lead
An audit of the
management of
diabetes perioperatively against
the new peri-op
diabetes guidelines.
To include a
prospective audit of
all day cases with
diabetes admitted to
WH on a defined day
as well as a
retrospective audit of
30 major elective
operations on
patients with diabetes
across a defined time
period across
specialties, including
general surgery,
orthopaedics, gynae
and vascular.
A retrospective audit
of missed fractures in
A&E SMH over a
three month period
following a SUI.
Surgery and
Critical Care
16/11/2012 Data
Collection
Results and Recommendations required
Changes required
3724 Diabetes
Specialist Nurse
Patient
Experience
Survey
Una Vince, Diabetes
Specialist Nurse
A patient experience
survey of the service
offered by Diabetes
Specialist Nurses.
Integrated
Medicine
3725 Quality of
Orthodontic
Extraction Letters
Helen Travess,
Consultant,
Orthodontics (Helen
Veeroo, SpR,
Orthodontics)
Audit of orthodontic
Surgery and
extraction letters sent Critical Care
to dental practitioners
compared to national
guidelines.
3726 Early Supported
Discharge Team
SALT, Service
Users Survey
Debbie Begent, Acute Survey of patients'
SLT Service Manager experience of SALT
early supported
discharge team.
Specialist
Services
19/11/2012 Data
Collection
Results and Recommendations required
Changes required
01/12/2012 Not yet
started
Results and Recommendations required
Changes required
01/04/2012 Complete
21/11/2012 Results:
Changes required
100% of respondents would recommend this service
to other people.
76% of responses were ‘highly satisfied’.
A couple of issues which require some reflection
are; different perceptions of the patient’s involvement
in planning and the gap in service between ESD and
community/long term service.
A theme emerged about less improvement with
cognition, than physical recovery.
Recommendations:
ESD Team to check with individuals that they feel
involved in the decision making process, some
people are happy to be guided by the professional,
others prefer more involvement.
Work with community services to improve transition
of care.
The team have already identified training required in
cognitive rehab and put forward a flexible funding
bid.
3727 Endoscopy Patient Suzy Robertson,
Experience
Operations Manager,
Survey 2013
Endoscopy (Janet
Hercules,
Administrative
Manager, Sue Kenny,
Sister, Endoscopy Unit,
SMH & Deborah
Dobree-Carey, Sister,
Endoscopy Unit, WH)
Re-audit - an
Integrated
experience survey of Medicine
patients attending for
endoscopy. The
questionnaire has
been designed in line
with global rating
scales for excellence.
23/11/2012 Data
Collection
Results and Recommendations required
Changes required
3728 Endoscopy Staff
Experience
Survey 2013
Suzy Robertson,
Operations Manager,
Endoscopy (Janet
Hercules,
Administrative
Manager, Sue Kenny,
Sister, Endoscopy Unit,
SMH & Deborah
Dobree-Carey, Sister,
Endoscopy Unit, WH)
To assess levels of
Integrated
staff satisfaction and Medicine
identify any areas for
improvement.
23/11/2012 Data
Collection
Results and Recommendations required
Changes required
3729 Central Venous
Catheter Audit
Dec 12
Marie Coward, Sian
Part of IPC audit plan Specialist
Bates, IV therapy team
Services
01/12/2012 Draft
Report
with
Clinician
Results and Recommendations required
Changes required
3730 International
Mr Belci, Consultant
Comparison of
Spinal (Salman lari,
Non-Traumatic
SpR Spinal)
Spinal Cord Injury
Rehabilitation
Outcomes
A Retrospective Case Specialist
Review of Patients
Services
with Non-traumatic
Spinal Cord Injury
between 2009 and
2011
26/11/2012 Data
Collection
3731 Tip Apex Distance Mr R Chennagiri,
in Dynamic Hip
Consultant, T&O
Screws
(Yeuyang Li, FY2)
To assess tip apex
Surgery and
distance over a 3Critical Care
month period in all
dynamic hip screw
operations performed
at Stoke Mandeville.
27/11/2012 Complete
3732 A Comparison of Tom Chapman,
Endoscopically vs Registrar (Helen Tyrrell
Radiologically
CT1)
Placed Stents for
Oesophageal
Cancer
A comparison of
Integrated
endoscopically
Medicine
versus radiologically
placed stents for the
relief of dysphagia in
oesophageal cancer.
No nationally agreed
standards exist.
27/11/2012 Data
Collection
Results and Recommendations required
Changes required
21/01/2013 Results: TAD acceptable 28 (75.6%); TAD
Changes required
unacceptable 9 (24.3%). Audit results from Jan-Apr
'08 TAD: acceptable 24 (69%), unacceptable 11
(31%). Recommendations: Ensure adequate XRays, aiming to get best possible AP and lateral
views; posters in scrub areas in Theatre 4 and 5;
audit TAD regularly – quick and easy to collect data;
possibly compile prospective data of cut-out rate and
compare with TAD audits.
Results and Recommendations required
Changes required
3733 Audit of Primary
Retinal
Reattachment
Rates
K Manuchehri,
Consultant
Ophthalmologist
Audit of Primary
Surgery and
Retinal Reattachment Critical Care
Rates
01/11/2012 Awaiting
Report/Ac
tion Plan
Results and Recommendations required
Changes required
3734 Audit of Use of
STAMP on
Paediatric Ward
Carol Clarke,
Paediatric Dietitian
Liz Pryke, Dietitian
Manager
To determine whether Specialist
patients are being
Services
nutritionally screened
within 48 hours of
admission and
STAMP (paediatric
nutrition screening
tool) is being
computed with
resulting careplan.
26/11/2012 Analysis/
Report
Results and Recommendations required
Changes required
A staff evaluation of Integrated
the First Response
Medicine
Service, a new single
point of contact for all
enquiries to the
Children and Families
Service (Social Care).
01/12/2012 Data
Collection
Results and Recommendations required
Changes required
3735 Staff Evaluation of Tricia Bratby, Lead
First Response
Professional, Gerry
Service
Linke, Named Nurse,
Child Protection
3736 Audit of Mortality
in Inpatients on
Ward 8/9 at
Wycombe Hospital
Dr A K Misra,
Consultant, Ashneet
Sidhu, Clinical Attache,
MFoP
An audit of inpatient
mortality on Wards
8/9 at Wycombe
Hospital.
3737 TB Audit for
Health Protection
Agency
Margaret Holland, TB
Nurse
3738 The Use of,
Storage and
Requirements for
Medical Gases
supplied in
Cylinders on
Wards
Liz Sutton,
Procurement
Pharmacist (Wura-Ola
Akinrinsola, Pre-Reg
Pharmacist trainee)
Integrated
Medicine
01/12/2012 Not yet
started
Results and Recommendations required
Changes required
Health Protection
Integrated
Agency require some Medicine
TB notes to be
audited by Jan 7th.
03/12/2012 Data
Collection
Results and Recommendations required
Changes required
Counting cylinders on Specialist
wards and noting how Services
they are stored and
finding out what they
are required for.
There are Health &
Safety Standards
related to this.
Manual count &
inspection and
questionnaires to
staff.
04/12/2012 Data
Collection
Results and Recommendations required
Changes required
3739 Audit on the
Application of
Ozurdex in
Buckinghamshire
Healthcare NHS
Trust
Dr Siegfried Wagner,
FY1 General Surgery
Data from the notes Surgery and
of patients who have Critical Care
been administered
Ozurdex treatment for
ophthalmic disease to
be collected. Data to
include the clinical
indication, visual
acuity and results.
10/12/2012 Awaiting
Report/Ac
tion Plan
Results and Recommendations required
Changes required
3740 Audit of
Management and
Follow-up of
Paediatric Allergy
and Anaphylaxis
Dr Baneera Shrestha,
Consultant, (Dr Laura
Lewis, GPVTS)
Paediatrics
An audit of the
Specialist
Management and
Services
follow-up of paediatric
patients presenting
with either allergy or
analyphylaxis,
against RCPCH care
pathways.
11/12/2012 Data
Collection
Results and Recommendations required
Changes required
A re-audit of
Trustwide
compliance with legal
requirements
regarding workplace
Health & Safety.
06/12/2012 Data
Collection
Results and Recommendations required
Changes required
3741 Workplace Health Marion Carnell, H&S
& Safety Audit
Facilitator, Stoke
Mandeville Hospital
3742 Ensuring Patients
Are On Correct
Medication PreAngioplasty
Ghazala Yasin, Sister,
Cardiac Day Unit
(Nicola Bowers,
Cardiac Research
Nurse)
An audit of patients
Integrated
coming in for
Medicine
angioplasty to see if
they have been
taking the correct
medication and to
determine reasons for
non-compliance.
14/12/2012 Data
Collection
Results and Recommendations required
Changes required
3743 Re-Audit of the
Dr Jackie Moncur,
Use of Emergency Speciality Doctor, GU
Contraception
Medicine
(EC) and Record
Keeping
Re-audit of the use of Specialist
EC to ascertain
Services
whether this,
especially the IUD, is
being use
appropriately,
whether women are
being offered a
choice of EC and to
determine how many
women present for
EC within 72 to 120
hours. Also to check
full detailed
documentation of
decisions/recommend
ations are being kept.
14/12/2012 Analysis/
Report
Results and Recommendations required
Changes required
3744 Audit of
Adherence to
NICE Guidelines
for CT Scans in
Head Injury
Patients
An audit to assess
whether patients
presenting to the
Emergency
Department with a
head injury are
appropriately having
a CT head scan in
accordance with
NICE guidelines for
head inuury (CG56).
01/01/2013 Data
Collection
Results and Recommendations required
Changes required
Mike Kazer,
Consultant, (Dr David
Robertshaw, FY2)
Emergency Medicine
Integrated
Medicine
3745 Monitoring of
Jane Eastman, Senior
Length of Stay for Physiotherapist, T&O
Primary Elective
THR & TKR 2012
(BHNHST)
To monitor length of
stay for THR and
TKR and to identify
reasons for delays in
discharge.
Surgery and
Critical Care
09/10/2012 Complete
30/01/2013 Recommendations were to feedback the results of
Changes required
the audit to Orthopaedic consultants, anaesthetists,
nursing staff and business manager involved in the
ERP; establish data set for next audit period with
reference to ERP; compare 2012 benchmark LOS
data for primary elective joint replacement project
against prospective data as ERP becomes more
established; continue to increase percentage of
patients with a LOS of 4 days or fewer; establish preop education for all primary elective joint
replacements.
3746 Hand Hygiene
Amanda Adkins,
Facilities Audit Jan Infection Control
2013
Audit of hand hygiene Specialist
facilities and practice. Services
01/01/2013 Analysis/
Report
Results and Recommendations required
Changes required
3747 Preventing
Amanda Adkins,
Surgical Site
Infection Control
Infection - Peri
Operative Audit for
Urology Jan 13
Part of IPC audit plan Specialist
Services
01/01/2013 Data
Collection
Results and Recommendations required
Not required
3748 Re-audit of Use of Jackie Baxter, Clinical
the Customised
Governance Midwife,
Growth Chart in
Obs & Gynae
the Identification
of Small For
Gestational Age
Babies
A re-audit of 3327 of Specialist
the use of the
Services
customised growth
chart in the
identification of small
for gestational age
babies. Prospective
audit of 100 maternity
case notes during the
month of November
2012.
01/11/2012 Analysis/
Report
Results and Recommendations required
Changes required
3749 Preventing
Amanda Adkins,
Surgical Site
Infection Control
Infection - Peri
Operative Audit for
Ophthalmology,
ENT and Oral
November 2012
Part of IPC audit plan Specialist
Services
01/10/2012 Data
Collection
Results and Recommendations required
Changes required
Jeanette Tebbutt, Lead Survey of all patients Specialist
Cancer Nurse, Cancer having chemotherapy Services
Services
between May and
August 2012. Survey
produced by Quality
Health. Trust to send
list of patients and
Quality Health to
organise sending of
questionnaires, 2
reminders and
analysis.
04/01/2013 Data
Collection
Results and Recommendations required
Changes required
3750 National
Chemotherapy
Patient
Experience
Survey
3751 National Cancer
Patient
Experience
Survey
Jeanette Tebbutt, Lead Survey of all patients Specialist
Cancer Nurse, Cancer diagnosed/treated (?) Services
Services
between Sep and
Nov 2012. Survey
produced by Quality
Health. Trust to send
list of patients and
Quality Health to
organise sending of
questionnaires, 2
reminders and
analysis.
3752 The Accuracy and Richard Smith,
Acceptability of
Consultant,
Squint Surgery
Ophthalmology
3753 Re-audit of Insulin Louise Meakes, Lead
Administration
Nurse, Diabetes,
Errors
A review of the
Surgery and
records of all patients Critical Care
operated on for squint
between November
2011 and November
2012 (approx 59
patients), looking at
the preoperative and
postoperative
measurements and
patient satisfaction.
The results will be
used to refine the
algorithms for
estimating the
amount of muscle
adjustment required
to achieve a
particular amount of
correction.
Re-audit of 3577.
Integrated
Medicine
04/01/2013 Data
Collection
31/12/2012 Complete
07/01/2013 Design
Results and Recommendations required
Changes required
19/02/2013 Results: In general, treatment algorithms seem to be Changes required
correct and there was no systematic tendency to
undercorrect or overcorrect in any sub-group.
Results compare favourably with available national
comparators. Recommendations: Aim for
undercorrection in children with global developmental
delay.
Results and Recommendations required
Changes required
3754 Infection Rates
Following Surgery
for Fractured Neck
of Femur: Staples
vs Sutures
Mr Edward Seel,
Consultant, T&O (Dr
Sarah Milliken, FY1,
T&O)
To compare infection Surgery and
rates following
Critical Care
surgery for fractured
neck of femur in
those closed by
sutures vs those
closed by staples.
04/01/2013 Data
Collection
3755 Infection
Amanda Adkins,
Prevention &
Infection Control Nurse
Control
Knowledge Survey
2012
A questionnaire to
assess staff
knowledge of
Infection Prevention
& Control. An online
survey was used.
Specialist
Services
01/05/2011 Complete
3756 Rapid Incremental Wail Ahmed, Spinal
Closed Reduction Injuries SpR
of Cervical Facet
Fracture
Dislocation in SCI
Retrospective review Specialist
of the effect of closed Services
reduction of cervical
fracture dislocations
on patients'
neurology and
complications. Of the
procedure. Also
assessed success
and failure rates and
reasons for failure.
This is a continuation
of audit 3598.
15/01/2013 Data
Collection
Results and Recommendations required
Changes required
12/01/2013 Only 366 staff members completed survey. There
Changes required
were several areas where there were too many
incorrect responses. Recommendations: This survey
must be disseminated to all relevant staff and to be
discussed at relevant meetings e.g. ward meetings,
clinical governance meetings. More emphasis on
publicising the survey during the time leading up to
the period that it is to be undertaken in order to
obtain more responses. This survey highlights how
important mandatory training is and this is reflected
in some of the percentages to the questions. It is vital
that staff are allocated time to complete their
mandatory training to help provide correct IPC
practices and provide a safe and clean hospital has
outlined in the Trust’s 5 patient promises.
Results and Recommendations required
Changes required
3757 Validation Check
of Safety
Thermometer
Returns
Christine Nuttall,
Cheryl Pepper
A validation audit of
Trustwide
data returned for the
Safety Thermometer,
December 2012.
15/01/2013 Analysis/
Report
25/02/2013 Results and Recommendations required
Changes required
3758 Audit of Nonobstetric
Emergency Care
Mr Tunde Dada,
Consultant (Dr Rufaro
Ndokera, FY2) Obs &
Gynae
Audit of
Specialist
assessment/admissio Services
n of pregnant patients
presenting to A&E
against Trust
guideline 411.6.
01/01/2013 Notes
being
pulled
Results and Recommendations required
Changes required
3759 Audit of Use of
Mr Tunde Dada,
Oxytocin in Labour Consultant (Dr Kat Fu,
Dr Richard Smith
GPVTS) Obs & Gynae
Audit of use of
Specialist
oxytocin for the
Services
purpose of induction
and aumentation in
labour, against CNST
and RCOG
guidelines.
01/01/2013 Data
Collection
Results and Recommendations required
Changes required
3760 Staffing Levels on Lucy Duncan, Matron, Audit of staffing levels Specialist
the Labour Ward (Jennnifer Taylor FY2 ) of midwives,
Services
Obs & Gynae
consultants,
registrars and SHOs
on the Labour Ward
SMH.
01/01/2013 Data
Collection
Results and Recommendations required
Changes required
3761 Audit of
Continuous Fetal
Monitoring during
Uncomplicated
Pregnancies
Mr Chris Wayne,
Consultant, (Mariam
Abbas Syed, GPVTS)
Obs & Gynae
Audit of continuous
Specialist
fetal monitoring
Services
during uncomplicated
pregnancies, against
Trust guideline 425.6.
01/01/2013 Data
Collection
Results and Recommendations required
Changes required
3762 Paediatric Cystic
Fibrosis Clinic
Patient Survey
Marianne Tomlin,
Paediatric Dietitian
Parent satisfaction
survey of CF clinic.
At this clinic patient
sees physio, CF
nurse, dietitian,
consultant.
21/01/2013 Data
Collection
Results and Recommendations required
Changes required
Specialist
Services
3763 Outcomes after
EPL Repairs of
Hand
Laura Sutherland, OT Looking at outcomes Specialist
Plastics Hand therapist after EPL repairs
Services
comparing 2 different
therapy regimes,
static vs early active
movement (EAM).
Currently no
standards.
21/01/2013 Data
Collection
Results and Recommendations required
Changes required
3764 Sharps Audit Feb
13
Amanda Adkins,
Infection Control
Sharps Audit Feb
2012. Part of IPC
audit plan.
Specialist
Services
01/02/2013 Data
Collection
Results and Recommendations required
Changes required
3765 Transfer Form
Audit Feb 13
Amanda Adkins,
Infection Control
Transfer Form Audit
Feb 2013. Part of
IPC audit plan.
Specialist
Services
01/02/2013 Data
Collection
Results and Recommendations required
Changes required
3766 Preventing
Amanda Adkins,
Surgical Site
Infection Control
Infection - Peri
Operative Audit for
Gynaecology Feb
13
Preventing Surgical
Site Infection - Perioperative Audit for
Gynaecology, Feb
2012. Part of IPC
audit plan.
3767 Patient
Experience and
Understanding of
Neutropenic
Sepsis
Dr Robin Aitchison,
Consultant,
Haematology
(Jonathan Chambers,
CT1)
3768 Audit of the
Management of
Induction of
Labour
Miss Gita Suri,
Consultant (Sarah
Barker, ST3) Obs &
Gynae
Specialist
Services
01/02/2013 Data
Collection
Results and Recommendations required
Changes required
Patient questionnaire Specialist
to be used on
Services
chemotherapy unit to
assess understanding
of neutropenic sepsis
and experience in
previous admissions.
22/01/2013 Design
Results and Recommendations required
Changes required
An audit of the
management of IOL
against NICE
guidelines.
01/12/2012 Data
Collection
Results and Recommendations required
Changes required
Specialist
Services
3769 Analysis of
Shoulder
Stabilisation
Surgery with
reference to
Failure Rate and
Complications
Mr Geoffrey Taylor,
Consultant, Vicky
Russell, Clinical
Specialist
Physiotherapist
An audit of shoulder
stablisation surgery
with reference to
failure rate and
complications.
Surgery and
Critical Care
25/01/2013 Not yet
started
Results and Recommendations required
Changes required
3770 Paediatric Septic
Screen Audit
Dr Shrestha,
Consultant, Paediatrics
(Kushalinii Ragubathy
ST1)
Audit against NICE
guidelines on the
management of the
febrile child.
Specialist
Services
28/01/2013 Data
Collection
Results and Recommendations required
Changes required
3771 Paediatric Health
Assessment
Patient
Experience
Survey for
Children in Care
Cherry Gregory,
Designated Nurse,
Children in Care
Patient experience
survey to establish
children's view of
health care
assessment by
Paediatrician,
completed when
entering care, and 6
monthly/annually
thereafter until they
leave care.
Specialist
Services
04/03/2013 Not yet
started
Results and Recommendations required
Changes required
3772 Sentinel Lymph
Node Biopsy
Patient
Experience
Survey
Peter Budney,
Consultant Plastics,
Lindsey Lane, Skin
Cancer CNS
This is a new service, Surgery and
patients can be
Critical Care
referred from other
hospitals. Want to
ensure patients have
a smooth journey
from referral.
28/01/2013 Data
Collection
Results and Recommendations required
Changes required
3773 Survey of
Staff/Patient
Perceptions of
Rehabilitation in
Spinal
Physiotherapy
Katie Wilson, Spinal
physio
Some patients/staff
Specialist
have perception that Services
rehab only occurs in
spinal gym whereas it
should be a
continuous process.
This is a patient and
staff survey in rehab
wards (George,
David, Joseph )
assessing
perceptions of rehab.
30/01/2013 Design
Results and Recommendations required
Changes required
To assess
compliance with the
membrane sweep
guideline based on
NICE antenatal
quality standard. 6
monthly guideline
audit.
28/01/2013 Data
Collection
Results and Recommendations required
Changes required
3774 Membrane Sweep Heidi Beddall,
Audit
Consultant Midwife
Specialist
Services
3775 Maternal Request Heidi Beddall,
for Caesarean
Consultant Midwife
Section
This audit is an
Specialist
ongoing review of the Services
number of maternal
requests for
caesarean section,
the reasons for
requests, number of
maternal request
caesareans
performed and birth
outcomes of this
group of women.
30/01/2013 Data
Collection
Results and Recommendations required
Changes required
3776 Clinical Risk
Assesment in
Labour
Helen Beddall,
Consultant Midwife
To ensure that the
Specialist
maternal risk
Services
assessment tool is
completed at the
onset of labour and to
ensure that
management plans
are documented and
adhered to (re audit).
29/01/2013 Data
Collection
Results and Recommendations required
Changes required
3777 Re-audit of
Malnutrition
Universal
Screening Tool
(MUST)
Liz Pryke, Nutrition &
Dietetic Service
Manager
To audit most wards Specialist
across Trust (acute & Services
community) to ensure
that MUST forms are
being completed
properly. Last
audited April 2011.
Planning to audit Feb
2013.
01/02/2013 Data
Collection
Results and Recommendations required
Changes required
3778 The Success of
Surgical Canine
Exposures in the
MOBB Region
Mr Bahattin Bagdadi,
Specialty Doctor, Oral
and Maxillofacial
Surgery
A regional audit to
Surgery and
check the success
Critical Care
rate of canine
exposure procedures.
04/02/2013 Notes
being
pulled
Results and Recommendations required
Changes required
3779 Audit of Adult
Community
Acquired
Pneumonia (BTS)
Dr Mitra Shahidi,
Respiratory
Consultant, Fiona
McCann, Consultant,
ITU
To assess adherence Integrated
to local and BTS
Medicine
guidelines regarding
the management of
pneumonia and to
identify any areas for
improvement.
25/01/2013 Notes
being
pulled
Results and Recommendations required
Changes required
To assess whether
Integrated
confirmed Pulmonary Medicine
Emboli cases could
be managed as
outpatients and to
look at current length
of stay.
04/02/2013 Notes
being
pulled
Results and Recommendations required
Changes required
3780 Audit of
Dr. Lucy Houghton,
Management of
FY1
Pulmonary Emboli
3781 Analgesia
Stewart McMorran,
Prescription for
SDU lead, A&E (Neil
Patients with Long Dawson, ST4)
Bone Fractures in
A&E
Retrospective CAS
Integrated
card review against
Medicine
College of
Emergency Medicine
guideline for the
management of pain
in adults.
05/02/2013 Data
Collection
Results and Recommendations required
Changes required
3782 NEWS Track and
Trigger
Observation Tool
Audit
Jenny Ricketts,
Consultant Nurse,
Critical Care
Audit to assess
whether the NEWS
Track and Trigger
Observation tool is
completed correctly
as per Guideline 26,
physiological
observations of adult
non obstetric
inpatients.
Trustwide
18/02/2013 Design
Results and Recommendations required
Changes required
3783 IV Tharapy Team
Service User
Survey
Marie Woodley, Sian
Bates, IV Therapy
Specialist Nurses
Survey of doctors and Integrated
senior nurses to
Medicine
identify knowledge,
use, barriers to
referring patients for
IV therapy at home
and other aspects of
OPAT services.
06/02/2013 Design
Results and Recommendations required
Changes required
3784 Neuro
Rehabilitation Unit
Record Keeping
Audit
Lesley Fox, Neuro
Rehab Physiotherapy
Clinical Support
Worker
Re-Audit of record
keeping audit of
Neuro Rehabilitation
Unit notes.
3785 Quality of T&O
Operation Notes
Mr Kankate,
Consultant T&O (Ying
Teo, SHO, T&O)
3786 Environment Audit Amanda Adkins,
NSIC & CSS Oct Infection Control
2012
Integrated
Medicine
08/02/2013 Notes
being
pulled
Results and Recommendations required
Changes required
Re-audit of trauma
Surgery and
operation notes to
Critical Care
compare with national
guidelines.
13/02/2013 Notes
being
pulled
Results and Recommendations required
Changes required
Audit of environment. Specialist
Services
01/10/2012 Analysis/
Report
Results and Recommendations required
Changes required
3787 Retrospective
Analysis of Lung
Cancer and
Mesothelioma
Admissions
Between March
2012 and October
2012
Dr Prasad, Consultant,
Respiratory (Jill
Mowforth, Hayley
Steiner, Lung Cancer
Specialist Nurses)
3788 Gynaecology
Denise Read, Deputy
Outpatients Clinic Sister
(Wycombe)
Patient
Experience
Survey
3789 FIM/FAM Audit
2010-1013
A review of patient
clinical records to
identify trends and
patterns in patients
admitted to hospital
with lung cancer and
mesothelioma.
Integrated
Medicine
Survey of patients'
Specialist
views of gynaecology Services
outpatients service.
Karen Earp, Advanced A reaudit of patient
Physiotherapist
outcome post
rehabilitation from
stroke.
Integrated
Medicine
15/02/2013 Design
Results and Recommendations required
Changes required
15/02/2013 Data
Collection
Results and Recommendations required
Changes required
22/04/2013 Not yet
started
Results and Recommendations required
Changes required
3790 Completion of
Drug Charts in
NSIC
Dr Ibrahim Ussef
(Naulizio Belci,
Consultant and Dot
Tussler, Head PT
EICEE Chair)
A reaudit of drug
chart completion
against trust
guideline.
3791 Elective
Abdominal Aortic
Aneurysm
Surgery, 2008
Geraldine Delacy,
General Surgery
3792 Physiotherapy
PES
Helen Hine, Band 6
physio, SMH
Specialist
Services
01/02/2013 Data
Collection
Results and Recommendations required
Changes required
Data for National
Surgery and
Vascular Database to Critical Care
be published in public
document in June
2013.
20/02/2013 Notes
being
pulled
Results and Recommendations required
Changes required
To review therapy
Specialist
service to establish if Services
we are meeting
patients' expectations
and needs.
24/02/2013 Design
Results and Recommendations required
Changes required
3793 Paediatric Pre-Op Sue Smith, Tracey
Assessment Clinic Fox-Clinch, Deputy
Sisters
Planning to set up
pre-op assessment
clinic for children so
they can meet play
specialists, nurses
before surgery.
Would like parent
feedback on the
needs of this facility.
3794 Schwartz Rounds
Focus Groups
Dr Liz Pounds, Clinical
Psychologist (Zoe
Chessell, Assistant
Psychologist)
3795 BASHH
Management of
Young People in
Sexual Health
Settings
Dr Luzzi (Dr
Roberts/Dr Law,
Brookside)
Specialist
Services
24/02/2013 Design
Results and Recommendations required
Changes required
Two focus groups
Specialist
(regular attendees
Services
and speakers) to
measure the value of
Schwartz rounds - a
local staff support
initiative at NSIC
24/02/2013 Data
Collection
Results and Recommendations required
Changes required
BASHH Management Specialist
of Young People in
Services
Sexual Health
Settings
Complete
24/02/2013 Our Trust came out well in report.
None required
3796 HPA HIV
Diagnosis Audit
Dr Veena
Reddy/Sunita Duggal
Audit carried out by
Specialist
Health Protection
Services
Agency using
information gatheried
from Shaw Clinic.
Lost opportunities for
HIV diagnosis.
Data
Collection
Results and Recommendations required
Changes required
3797 BHIVA audit
Dr Luzzi/Dr Veena
Reddy
Patients dropped out
of system.
Awaiting
Report/Ac
tion Plan
Results and Recommendations required
Changes required
Specialist
Services