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SHARING NOTABLE PRACTICE Holiday Inn, Regent’s Park, London 13 June 2012 - Abstract Book – Sharing Good Practice June 2012 SHARING NOTABLE PRACTICE 13 June 2012, Holiday Inn, Regent’s Park Programme th 0930 Registration 1000 Welcome and Introduction Dr Aileen Sced, NACT UK 1005 Martin Bromiley, Chair of the Clinical Human Factors Group Safe Prescribing 1030 1045 1100 1115 1130 Pharmacy 5 minutes – fast prescribing feedback to Foundation Drs, Dr Laura Backhouse and Mrs Emily Truscott, Gloucestershire Royal Hospital Introduction of an insulin prescribing chart is associated with a reduction in Insulin prescribing errors, Dr Natasha Hawkins, Poole Hospital Audit of the effectiveness of education and individual feedback for reducing prescription error rates among FY1 Doctors, Dr Julie Wilson, Crosshouse Hospital, Kilmarnock Avoiding Prescribing error Committee, Dr Lamis Chetouani and Dr Amy Gatward, Croydon University Hospital Coffee & Poster Session - Judges: Dr David Kessell & Dr Stuart Carney Safe Handover 1200 1215 1230 1245 1300 Documentation in Patient Notes during Consultant First Review at Post Take Ward Rounds, Drs Urvi Shah and Aderonke Akinmade, Queen’s Hospital, Burton on Trent The Transfer Checklist: a tool to assist the safe transfer of patients from EAU to wardbased care, Dr Anjella Balendra, Luton & Dunstable University Hospital A Standardised Patient Summary & Handover pro-forma can improve out-of-hours Patient Care, Dr Amit Kaura, North Bristol NHS Trust Recognising acutely ill patients in the Acute admissions Unit: An out of hours audit on compliance with (PARS) Guidelines, Dr Iqbal Khan and Dr Samir Khwaja, Barts and the London Trust Lunch & Poster Viewing Plenary Chair: Dr Stuart Carney, Deputy National Director, UKFPO 1400 FP Curriculum and an introduction to the work on piloting a patient feedback tool, Dr David Kessell, Chair Academy FP 1425 Breakout session 1 – The Elderly & Professional Development (2 Groups – 3 Oral presentations 10 mins each + 3 mins discussion) Breakout session 2 – Resources & Risk Management (2 Groups – 3 Oral presentations 10 mins each + 3 mins discussion) 1505 1545 Tea 1615 Poster Prize and short synopsis by winners 1625 Wrap-Up & Close -2- Sharing Good Practice June 2012 BREAKOUT SESSION DETAILS: Chairs: Dr Claire Mallinson, Chair NACT UK and Dr Rebecca Aspinall, NACT UK 1425-1505 The Elderly ‘Think Drink’: Do patients on elderly care wards have easy access to oral fluids? Drs Tim Wallis and Kathryn Smith, Poole Hospital Lack of cognitive testing: missing delirium in the elderly Dr Charlotte Thomas, Charing Cross Hospital, London An audit of the prescription of antipsychotic medication in those over 75 with dementia or delirium, Dr Rosalyne Westley, Newcastle upon Tyne Hospitals Professional Development Would Foundation doctors benefit from better surgical training?, Dr Balvinder Grewal, East Midlands Workforce Deanery How to make your portfolio stand out – providing advice for foundation doctors, Dr Benedict Wildblood, Bucks Hospitals Can Foundation Programme Doctors be involved in quality improvement? Dr Abiramy Jeyabalan, Southmead Hospital, Bristol 1505-1545 Resources Compliance with policy: antibiotic prescription as empirical therapy in patients over the age of 70, Drs Michael Paddock and Victoria Wright, Poole Hospital ‘I think I’m due a blood test, Doctor’: using audit cycles to improve adherence to recommended drug monitoring, Dr Isabel Mark, Bradgate Surgery, Bristol Unnecessary pre-operative testing of elective surgical patients: an audit and cost analysis of two district general hospitals, Drs Adarsh Shah and Chris Arrowsmith, Royal Bournemouth and Poole General Hospitals Risk Management Re-assessment of venous thrombo-embolism and bleeding risk: an intervention to improve patient safety, Dr Rebecca Wollerton, Southmead Hospital, Bristol Improving the consent process for epidurals for labour, Dr David Buckley, Yeovil District Hospital Improving venous thrombo-embolism (VTE) risk re-assessment – foundation doctor led intervention, Dr T’ng Chang Kwok, Kings Mill Hospital, Sutton in Ashfield POSTER PRESENTATIONS: 1. 2. 3. 4. 5. 6. 7. 8. 9. The Treatment Escalation Plan, Drs Anand Sundaringham and David Gannon and E Thomson, Colchester General Hospital Estimated Date of Discharge Audit, Drs Anneke Ashcroft, Joy Simmonds & Sarah Britton, Queen’s Hospital, Burton Fellows are more than Reps, Drs Clare van Hamel, Daniel Eden, Evie Cole, Sarah Johnston and Frances Richardson, Severn Deanery Foundation School, Bristol Increasing Efficiency with Disposable Equipment: two simple changes to save time and money in a difficult economic climate, Drs Edward Miles, Katherine Birchenall & Lilli Cooper, Bristol Royal Infirmary Foundation Placements Ranking Tool, Mrs Vicky Pyne, Severn Deanery Foundation School Doctor, quick, I need to do an audit, Miss Gaynor Smith and Dr Anthony Choules, Queen’s Hospital, Burton SCRIPT: An e-learning programme to improve the prescribing of newly qualified doctors, Ms Sarah Thomas, Prof Elizabeth Hughes, Mr Richard Seal, Dr David Davies, Prof’s John Marriott, Robin Ferner, Dr Vinod Patel, Miss Sukvinder Kaur and Dr Jamie Coleman, University of Birmingham Learning from clinical incidents to promote patient safety and improve foundation doctors prescribing practice, Drs Amy Ritchie & Ratan Alexander, Worcestershire Royal Hospital Re-thinking consent – Empowering Doctors and improving patient safety, Dr Harry Dean, Mrs Scarlett McNally, Drs George Absi, Julia Barbour & Simon Walton, Eastbourne District General Hospital -3- Sharing Good Practice June 2012 10. DAPS Handover wiki, Drs Will Barker & Ed Mew, St Peter’s Hospital, Chertsey 11. Workshops for ST/CT applications and careers advice for foundation trainees, Drs Gurkaran Samra, Eoghan McGrenaghan and Thomas Johnson, Victoria Hospital, Blackpool 12. The Development and Evaluation of a Clinical Guidelines Handbook for Foundation Trainees, Drs Christopher Griffin, Adam Barnett, Claire Greszczuk, Thomas Bannister & Marc Davison, Bucks Hospitals NHS Trust 13. Our Painful Experience, Drs Abigail McGinley & Richard Harrison, Torbay Hospital, Torquay 14. Accuracy of in-patient prescriptions and methods for preventing errors, DrsJames Cheaveau, Meera Thayalan, & Mr Timothy Bates, University Hospital, Bath 15. Practical Prescribing for Emergencies – A four week course for medical students, Drs Alec Paschalis & Mariana Noy, Basildon & Thurrock University Hospital 16. Prescribing Education for Final Year Medical Students and Foundation Year 1 trainees across the North West Deanery, Dr Deborah Kirkham, North Western Deanery 17. Near-peer teaching in Preparation for Professional Practice week benefits new doctors and their teachers, Drs Rachael Brock and Francesca Crawley, West Suffolk Hospital, Bury St Edmunds 18. Where do interventions to reduce bullying need to be targeted? Miss Helen Davis, Mrs Kerry Ferguson and Dr Namita Kumar Northern Deanery Foundation School 19. Where are foundation trainees most likely to be asked to take consent? Mrs Kerry Ferguson, Miss Helen Davis and Dr Namita Kumar Northern Deanery Foundation School 20. Helping our patients survive sepsis: an initiative to improve provision and accessibility of blood culture bottles, Drs Rebecca Wollerton Robert Tyrrell, Emma Wood, Joshua Nowak, Andrew Moore, Oliver Howard, Shirley Lau, North Bristol NHS Trust 21. Auditing Current Practice in The Diagnosis and Prevention of Delirium Against The Recommendations in The NICE Guideline in Patients With Neck of Femur (NOF) Fractures, Drs Rakhee Shah, Leon Dryden and Ramyah Rajakulasingam, Queen Elizabeth II Hospital, Welwyn Garden City 22. How do Foundation Programme Doctors Prefer to Learn? Drs Abiramy Jeyabalan and Evelyn Cole, Southmead Hospital, Bristol 23. What value has near-peer teaching? A comparison of students’ and clinicians’ views, Drs Nicholas Harris, Anna Harris and Min Hui Wong, Yeovil District Hospital 24. Doc to Doc: maternal delivery plan documentation and the potential legal implication on doctors, Drs Mohammed Bajalan, Aung and Mr Abubaker Elmardi, Mid-Staffordshire NHS Foundation Trust 25. Improving safe prescribing amongst junior doctors: a blended, multi-professional approach, Drs Aamir Saifuddin and Kavitha Vimalesvaran, Kent and Canterbury Hospital 26. The FY1 on Medical Nights, Dr Anjella Balendra, Luton and Dunstable University Hospital 27. Recognition and Initial Management of Septic Patients in a District General Hospital: a junior doctor patient safety intervention, Drs Laura Deacon, James Lingard, Thomas Dove and Vanessa Robba, Kings Mill Hospital, Sutton in Ashfield 28. Surgical weekend handover patient safety improvement project, Dr Joyce Ngai, Luton and Dunstable University Hospital 29. Experiencing Leadership and Management training through a Foundation Year 2 rotation in medical Education, Dr Simon Phillpotts, Royal Surrey County Hospital 30. Medical Trainee Support Information card, Mr Jason Yarrow, Ms Joan Reid & Ms Lisa Stone, KSS Deanery 31. Rectifying junior doctor induced malnutrition, Drs Lauren Simmonds, Rachael Cave, Sarah Cuff, Karishma Patel, Eleanor Soo and Anne Pullyblank, Southmead Hospital, Bristol 32. Peninsular Foundation School Welcome Event, Drs Georgia Jones & Natalie Band, SW Peninsular Deanery 33. A Review into Fractured Neck of femurs following and Inpatient Fall in a General Hospital, Drs Ashleigh Squires, Parul Shah & Sarah Hyde, Northampton General Hospital 34. Electronic Mapping tool for monitoring and planning of Foundation Programme Teaching, Drs Nicola Dowling, Heather Beastall & Koren Stickland, Worcestershire Royal Hospital 35. Combating pneumonia mortality in a DGH, Drs Jonathan Wilkinson, Heidi Archer & Charlotte Payne, Northampton General Hospital 36. Are we following the correct prescribing procedures?, Dr Mohammed Bajalan, Helen Wilson & Dr Raghava Reddy, Mid Staffordshire NHS Foundation Trust 37. Improving week-end F1 Doctor Ward Cover – A Patient Safety Issue, Drs Julius Bruch, Rebecca Allen, Kate Craufurd, Ahmed El Sobky, Richard Francis & Alistair Mackay, Salisbury District Hospital 38. Using Local Educational Audits to Improve the Quality of Foundation School Directors’ Reports – ‘the e-portfolio for programmes’, Dr Sara Mahgoub and Prof Paul Baker, Royal Bolton Hospital & North Western Deanery 39. Do Patients know their Consultants?, Dr Asli Kalin and Philippa Graham, North Middlesex Hospital -4- Sharing Good Practice June 2012 ORAL PRESENTATIONS Pharmacy 5 Minutes – fast prescribing feedback to Foundation Doctors, Dr Laura Backhouse and Mrs Emily Truscott, Gloucestershire Royal Hospital Background Lack of knowledge, busy and stressful working conditions (1) and changing clinical guidelines can all contribute to prescribing errors. To update prescribers and provide rapid feedback on prescribing errors, the Clinical Pharmacy and Foundation Programme team developed a weekly “Pharmacy 5 minutes” slot. This gives bite-sized bullet-point teaching to over 100 Foundation doctors on a range of clinical topics. The effectiveness of this novel initiative was evaluated. Methods An audit of antibiotic prescribing was carried out before and after teaching sessions on 5 elements of correct antibiotic prescribing. Results There was a marked improvement in antibiotic prescribing; after the teaching there was an increase in the percentage of prescriptions with the allergy status, indication and review date documented and appropriate antibiotics prescribed. Overall, there was a 49% increase in the number of antibiotic prescriptions with all 5 elements prescribed correctly. Key Messages The “Pharmacy 5 minutes” teaching session improved the prescribing of antibiotics by Foundation doctors. These brief weekly sessions correct and develop prescribers’ performance by offering prompt feedback. A repeat audit in 3 months aims to show that safe antibiotic prescribing continues. References (1) Dornan T, Ashcroft D, Heathfield H, Lewis P, Miles J, Taylor D, Tully M, Wass V. An in-depth investigation into causes of prescribing errors by foundation trainees in relation to their medical education: EQUIP study. Final report to the General Medical Council. University of Manchester: School of Pharmacy and Pharmaceutical Sciences and School of Medicine; 2009. -5- Sharing Good Practice June 2012 Introduction of an insulin prescribing chart is associated with a reduction in insulin prescribing errors, Dr Natasha Hawkins, M G Masding and J Abel, Poole Hospital Background In hospitals, insulin is a common source of prescription error, so we assessed whether introducing separate insulin prescription charts could reduce these errors. Method In November 2010, insulin and oral hypoglycaemic agent (OHA) prescription errors in our hospital were measured in a cross-sectional one-day audit. In February 2011, a separate insulin prescription chart was introduced. In July 2011, the audit of prescription errors of both insulin and OHAs of diabetic patients was repeated. Results In the first audit, there were 23 patients on insulin (type 1 = 8, type 2 = 15), of whom 20 (87%) had at least one prescription error, and 22 patients on OHAs, of whom 10 (45%) had at least one prescription error. On re-audit, of 24 patients (type 1 =5, type 2 =19) taking insulin, 11 (46%) had at least one prescription error (p=0.006 compared to 2010). There was no change in OHA prescription error (10 out of 16 patients (62%; p=0.204)). Key messages Following introduction of a specific insulin prescription chart, a reduction in insulin prescription errors was observed. No reduction in OHA errors was found, suggesting that the insulin prescription chart itself was important, rather than a general improvement in prescribing. -6- Sharing Good Practice June 2012 Audit of the effectiveness of education and individualised feedback for reducing prescription error rates among foundation year one doctors, Dr Julie Wilson, Dr Lynsay Addison and Dr Hugh Neill, Crosshouse Hospital, Kilmarnock Background Foundation year one (FY1) doctors are expected to write safe and legal prescriptions 1 but under-preparedness for prescribing is their most significant weakness 2. The EQUIP study 3 found a prescribing error rate of 8.4% among FY1s and recommended that FY1s should receive prescribing education and feedback on errors. Methods All inpatient prescriptions written by 19 FY1s were audited using a standardised form on a single day, with the NHS Ayrshire and Arran Code of Practice for Medicines Governance as the audit standard. Sixteen FY1s then attended prescribing education. All FY1s received written individualised, peer-comparison feedback. The audit was repeated four weeks later. Results 520 individual prescriptions were reviewed in the first cycle and 564 in the second cycle. Errors were identified in 373 (71.7%) prescriptions in the first cycle and 286 (50.7%) in the second cycle. Specific improvements noted were in the correct signing and dating of prescriptions, the clarity and correctness of ‘as required’ prescriptions and the correct discontinuation of prescriptions. Based on a Severity Error Classification Scheme 3, more than 99% of errors recorded were minor. Key messages Prescriptions written by FY1s have a high error rate. Education and individualised feedback can improve prescription error rates. References 1. Outcomes of the Medical Schools Council Safe Prescribing Working Group. http://www.medschools.ac.uk/AboutUs/Projects/Documents/Outcomes%20of%20the%20Med ical%20 Schools%20Council%20Safe%20Prescribing%20Working%20Group.pdf (Accessed 21/12/11) 2. Illing J, et al. How prepared are medical graduates to begin practice? A comparison of three diverse UK medical schools. Final Report for the GMC Education Committee. April 2008. http://www.gmcuk.org/FINAL_How_prepared_are_medical_graduates_to_begin_practice_Septem ber _08.pdf_29697834.pdf (Accessed 21/12/11) 3. Tim Dornan (Principal Investigator), et al. An in depth investigation into causes of prescribing errors by foundation trainees in relation to their medical education. EQUIP study. 2009. http://www.gmcuk.org/FINAL_Report_prevalence_and_causes_of_prescribing_errors.pdf_289351 50.pdf (Accessed 21/12/11) -7- Sharing Good Practice June 2012 Avoiding Prescribing error committee, Dr Lamis Chetouani and Dr Amy Gatward, Croydon University Hospital Introduction The F1s at CUH have set up an Avoiding Prescribing Error (APE) committee. We are junior doctors who aim to ultimately eliminate common prescribing errors made through better education. Methods 1. We undertook a prescribing test and needed to achieve 100% to pass. 2. Pharmacists record all prescribing errors in a centralised database (DATIX). As it is difficult to track which doctors make prescribing errors we issued stamps with each doctor’s name and GMC number to be used on drug charts. Once a prescribing error is found the doctor will be invited to a CBD with their SPR/consultant. If our stamping policy is successful there is potential for all doctors in the trust to receive them. 3. APE committee have monthly meetings to discuss DATIX reports and further ideas for education/prevention of errors such as specialised teaching sessions on prescribing in renal/hepatic impairment, pregnancy and surgery. We are in the process of developing reference aids with the most commonly prescribed drugs included. Results The intranet Junior Doctors’ page has been made more user friendly to allow easy access to hospital policies. There has been an introduction of prescribing and patient safety into the Foundation teaching curriculum. Key Messages 1. Better education for junior doctors on sources of error and prevention. 2. To demonstrate the success of APE at highlighting and preventing prescribing. -8- Sharing Good Practice June 2012 Documentation in Patient Notes during Consultant First Review at Post Take Ward Rounds, Dr Urvi Shah, Dr Sarah Britton and Dr Ronke Akinmade, Queen’s Hospital, Burton on Trent Background The post-take ward round (PTWR) is the first consultant review of acute admissions, and an opportunity for history review and care plan development. An admission may involve several healthcare professionals with quality of patient care affected by their verbal and documented patient information. This can be inadequate so losing the decision-making benefits. Methods A retrospective questionnaire audit of 25 randomly selected patient notes on the Emergency Assessment Unit (EAU) was performed to determine if PTWR documentation was compliant with best practice guidelines. A PTWR review proforma was subsequently introduced and 25 randomly selected patient notes re-audited. Results Poor compliance before the introduction of the PTWR review proforma. Following review proforma implementation, 100% compliance observed with documentation of patient name/number, review date, clinical summary, legibility and provision of a patient plan. An estimated date of discharge was documented in 80% of cases (24% prior to proforma) and clinical observations in 72% (20% prior to proforma). No improvements were seen in documentation of the consultant’s name and review time. Key Messages Introduction of the PTWR review proforma resulted in substantial improvements in documentation of patient notes, which will undoubtedly have a significant impact in improving patient care. -9- Sharing Good Practice June 2012 The Transfer Checklist: A Tool to Assist the Safe Transfer of Patients from EAU to Ward Based Care, Dr Anjella Balendra, Luton & Dunstable University Hospital Background The Emergency Admissions Unit sees a large quantity of patients being moved - from A&E to EAU and from EAU to both medical and surgical wards on a daily basis. This has become a patient safety issue in that both a high turnover of patients and shift-based work, means patients are moved before all their needs are met. Methods An audit was carried out over October 2011 tracking the movement of patients from EAU to 5 medical and elderly care wards. Nursing staff were asked to complete a transfer checklist upon receiving the patient (see Table 1), and state if action had been taken. Results Over one month 162 patients were moved to 5 wards – 110 (67.9%) of which came from EAU. 84.3% were moved out of hours (42.6% after 8pm and 41.7% after midnight). Table 1 illustrates checklist components and Table 2 indicates parameters where patients who were moved had inadequate action taken in response to the stated concern. Ward 3 Ward 11 Ward 14 Ward 15 Ward 18 TOTAL Obs Checked 30mins Prior to Transfer 20 13 17 16 5 71 (43.8%) Triggered 14 10 5 2 3 34 (21.0%) Confused 6 6 9 12 1 CBG outside Normal Limits 3 7 0 1 0 11 (6.8%) IV Fluids Prescribed but Not Given 2 1 3 3 1 10 (6.1%) IV Abx Prescribed but Not Given 3 3 1 0 0 7 (4.3%) In Pain 3 5 4 3 1 16 (9.9%) Relatives Not Informed of Transfer 3 2 7 2 2 16 (9.9%) Pressure Sores/Wounds 1 0 5 2 0 8 (5.0%) Total Number of Patients 37 46 32 32 15 162 Table 1: Checklist Criteria - 10 - 34 (21.0%) Sharing Good Practice June 2012 Table 2: Responses to Identified Concerns The transfer checklist has become a mandatory tool, being completed prior to moving patients from EAU. Areas for improvement are highlighted and discussed at monthly Patient Safety meetings. Re-audit after implementation is in progress with extremely positive feedback so far. Key Messages Simple tools such as this can ensure smooth transition of patients from the outset, by simultaneously reducing workload for colleagues and making the patient journey a far safer experience. - 11 - Sharing Good Practice June 2012 A standardised patient summary and handover proforma can improve out-of-hours impatient care, Dr Amit Kaura, Dr Hajeb Kamali, Dr Cara Harris, Dr Jarrod Richards, Dr Seema Srivastava, North Bristol NHS Trust Background Foundation doctors (F1s) at North Bristol NHS Trust (NBT) raised concerns about the lack of systematic or consistent methods for patient handover to out-of-hours teams. A quality improvement project was developed in order to create a standardised handover method. Methods F1s were invited to focus group meetings to discuss methods to improve handover. A patient summary and handover proforma was created. Once employed, the “Plan, Do, Study, Act” (PDSA) methodology was used to test the effectiveness of the tool on a geriatric ward. Baseline measurements were taken from nineteen F1s and feedback was received from seven F1s for each PDSA-cycle. Results - 12 - Sharing Good Practice June 2012 Baseline PDSA-1 PDSA-2 PDSA-3 Key Messages A standardised patient summary and handover proforma is a tool which can improve the safety, effectiveness and efficiency of care delivered by out-of-hours medical teams. Work is ongoing to implement this tool on other wards and integrate it with NBT IT systems. - 13 - Sharing Good Practice June 2012 Recognising acutely ill patients in the Acute Admissions Unit: an out-of-hours audit on compliance with patients-at-risk-score (PARS) guidelines, Dr Iqbal Khan, Samir Khwaja, Manjit Singh, Munayem Khan, Dorothy Ip and Julian Emmanuel, Barts and the London Trust Background A junior doctor should promptly review and escalate acutely ill patients in a timely manner [1,2] to avoid further deterioration [3]. Local Bart’s and the London Trust guidelines specify that patients with a ‘Patient-at-Risk (PAR)’ score ≥ 3 are seen by a junior doctor within 30 minutes. We conducted an audit to assess compliance. We also analysed clinical outcome at 12 hours. Methods All patients with a PAR score ≥ 3 out-of-hours were analysed over a 3 week period. We audited 74 patients. Statistical analysis using student’s t-test was undertaken on Microsoft Excel. Results The mean time (in minutes) to review of a patient with PAR-score ≥ 3 by a foundationyear doctor was 159.6 +/- 31.2. The average decline in 12-hour PAR-score was significantly better when the review occurred within an hour (3.92 +/- 0.35 vs 1.9 +/0.61, p<0.03). The mean time to review a patient with PAR-score ≥ 5 was 53+/- 15.3. Key Messages The prompt review of an acutely unwell patient by a junior doctor has a significant impact on clinical outcome as assessed by decrease in 12-hour PAR-score. We held a refresher for foundation-year doctors and nurses to highlight our findings. A re-audit is underway. References 1. Foundation Programme Curriculum 2012 2. NICE guideline 50 (2007) Acutely Ill Patients in Hospital 3. Ridley S. The recognition and early management of critical illness. Ann R Coll Surg Engl. 2005 Sep;87(5):315-22 - 14 - Sharing Good Practice June 2012 “Think Drink”: Do patients on elderly care wards have easy access to oral fluids?, Dr Tim Wallis, Dr Kathryn Smith and Dr Tim Battcock, Poole Hospital Background The elderly have a diminished thirst axis and are more likely to get dehydrated 1. On an elderly ward round we observed that a dehydrated patient did not have oral fluids within easy reach. That week the Care Quality Commission published its report into dignity and nutrition in older people. Our aim was to formally assess whether patients on our wards had Easy Access To Oral Fluids (EATOF). Methods A prevalence study on four elderly wards. Excluded: Patients nil by mouth. EATOF was assessed subjectively on an individual basis. Re-audit was after 3 months following presentation to senior nursing and medical staff, implementation of an educational program for all staff and a ‘Think-Drink’ poster campaign. Results Audit: 66% (n=88) achieved EATOF Re-audit: 74% (n=83) achieved EATOF. Key Messages Dehydration is an important cause of morbidity in the elderly. In starting to tackle this problem we have benefited from involving senior clinical staff. We have found the ‘Think-Drink’ campaign has been popular with relatives and healthcare staff. The campaign has increased awareness of the issue throughout the Trust. Further measures are necessary to tackle this fundamental care need. We aim to introduce red-coloured water jugs for patients at high risk of dehydration References 1) Naitoh M, Burrell L (1998) Thirst in Elderly Subjects J Nutrition Health and Ageing 2 172-7 - 15 - Sharing Good Practice June 2012 Lack of cognitive testing; missing delirium in the elderly?, Dr Charlotte Thomas, Dr A Shirley, Dr M Romain and Dr S Brice, Charing Cross Hospital, London Background Delirium is common, affecting up to 30% of medical admissions amongst the elderly1. Delirium leads to increased morbidity, measured by increased institutionalisation2, complication rates and increased length of stay3-4, in addition to significantly increased mortality at one year5. British Geriatric Society guidelines require identification of confusion in all older adults admitted to hospital by the use of cognitive testing6. Methods We aimed to assess the proportion of elderly patients who received cognitive testing within 48 hours of admission to Charing Cross Hospital through case-note analysis (n=46). Furthermore, we assessed in what proportion of patients a diagnosis of delirium was considered. Results 41% of elderly patients underwent cognitive testing within 48 hours of admission. Delirium was considered in 21%. Intervention was in the form of education, including presentation at a hospital-wide meeting. Subsequent re-audit demonstrated improvements in both standards: 72% of elderly patients underwent cognitive testing within 48 hours of admission. Delirium was considered in 100% of these individuals. Key Messages: This intervention demonstrated an impressive improvement in practice over a relatively short intervention period with implications for the diagnosis and subsequent treatment of delirium amongst the elderly. References 1. Siddiqi N, House AO, Holmes JD. Occurrence and outcome of delirium in medical in-patients: a systematic literature review. Age Ageing 2006; 35(4):350– 64. 2. Francis J, Martin D, Kapoor WN. A Prospective Study of Delirium in Hospitalized Elderly. JAMA 1990; 263(8):1097-1101 3. Inouye SK, Rushing JT, Foreman MD, Plamer RM, Pompei P. Does Delirium Contribute to Poor Hospital Outcomes? A Three Site Epidemiologic study. Journal of General Internal Medicine 1998; 13 (4):234-242 - 16 - Sharing Good Practice June 2012 An audit of the prescription of antipsychotic medication in those over 75 with dementia or delirium, Dr Rosalyne Westley, Newcastle upon Tyne Hospitals Background In the UK approximately 700,000 people have dementia1 . A report by the Department of Health Calls for the more to be done to reduce the prescription of antipsychotic medication in the elderly2. Method The audit involved all patients over 75 who had been prescribed antipsychotic medication during August 2011 in Sunderland Hospital. The prescriptions were reviewed to establish if they had correctly documented and appropriate reviewed. Results There were 76 prescriptions, 51 were suitable for the audit. - 17 - Sharing Good Practice June 2012 Key Messages Every prescription needs to be reviewed by a doctor on admission and stopped if appropriate, with adequate documentation in the medical notes. Doctors must be encouraged to specifically highlight antipsychotic medication for review by GPs after discharge. More input is needed from old age psychiatry. References 1. 2. M. Knapp and M Price, Dementia full report S Benerjee. The use of antipsychotic medication for people with dementia - 18 - Sharing Good Practice June 2012 Would foundation doctors benefit from better surgical training? Dr Balvinder S Grewal, East Midlands Workforce Deanery Background Basic surgical skills (BSS) are desirable amongst all hospital-specialties and GP. We evaluate whether foundation doctors (FD) are suitably equipped; and if a foundation programme (FP) BSS course would benefit. Methods Questionnaires were distributed amongst Trent Deanery FD and core-surgical trainees (CST), and responses analysed. A ten-week surgical-skills course was held at Royal Derby Hospital; attended by 15 FD and led by CST, with assessments at various stages. Results Of 86 FD, 48%(n=40) received BSS-training (BSSt). 46% felt confident as first-assistant in theatre. 83% wanted to acquire FP BSS competency; 66% wanted further training, especially knot-tying (47%) and suturing (52%). 11% intended to pursue a surgical career. Of 21 CST, 71%(n=15) felt they had received insufficient FP BSSt, 95%(n=20) felt it would have improved CST training-opportunities. At week-one of the BSSt course, FD averaged 43% in theory and 39% in skills (knot-tying: 30%, suturing: 28%) After weekly skill-specific teaching, scores improved (knot-tying: 97%, suturing 95%). Key Messages Most FD want to acquire FP BSS competency and want further BSSt. CST agree, feeling it would enhance future training-opportunities. FD exhibit poor BSS confidence, knowledge and technique. Early results demonstrate clear benefit from weekly BSSt, leaving FD better-equipped for future careers. Background At the NACT Foundation Programme Sharing Event 2011, we demonstrated that a simple peer-led teaching session was effective in improving foundation doctors’ understanding of the eportfolio[1]. Our feedback showed that foundation doctors remain unsure how to make their eportfolio stand out to future employers. Methods The teaching session was amended to focus on this and repeated for the 2011 FY1 cohort at Oxford University Hospitals. These doctors still reported significantly less confidence in making their eportfolio stand out, compared with knowing what their sign-off requirements were (p<0.001). We therefore contacted senior colleagues from each major specialty, and gathered advice on what foundation doctors should aim to achieve before applying to that specialty. We asked which courses and exams are relevant, and what other achievements are desired. This information was presented to the FY1s in a handout, which contained both general and subject-specific advice. - 19 - Sharing Good Practice June 2012 Results 89% of FY1s providing feedback found this information useful and 89% said it would change their practice. Key Messages These results show that FY1 doctors want more detailed advice on boosting their eportfolio than currently provided. This can be presented in a simple handout, which will help focus foundation doctors’ efforts for future job applications. [1] Wigley et al, 2011 - 20 - Sharing Good Practice June 2012 Can foundation doctors be involved in Quality Improvement? Dr Abiramy Jeyablan and Dr Eleanor Ngan-Soo, Southmead Hospital, Bristol Background Junior doctors are a valuable but underutilised resource in improving healthcare. North Bristol’s Quality Improvement (QI) Programme for Foundation Year 1 doctors (FY1) engages and harnesses the knowledge, skills and attitudes of FY1 in QI. Methods In 2010 all FY1 were invited to take part. Two sessions introduced core QI concepts. Subsequently, a brainstorm session allowed FY1 to identify QI challenges relevant to their clinical practice. Each team, supervised by Consultants, owned and developed their QI project. The programme culminated with each project presented to the Executive Board. Results All FY1 took part in the programme. Six projects focused on: standardisation of clinical equipment, weekend handover, phlebotomy coordination, venous thromboembolism reassessment, ECG verification and discharge bloods. The clinical equipment project received funding for Trust wide implementation. Two projects were presented nationally, and three projects continue by the current FY1s. Key Messages The programme provides FY1s with an opportunity to constructively contribute in QI, and thus continues this year. Importantly, it creates a platform for FY1s to develop skills aligned with the ‘Medical Leadership Competency Framework’, and the ‘Leadership and management for all doctors’ recently described by the General Medical Council - 21 - Sharing Good Practice June 2012 Compliance with policy: antibiotic prescription as empirical therapy in patients over the age of 70, Dr Michael Paddock, Dr Sian Evans, Dr Victoria Wright, Dr Sarah Wattley, Dr Anthony Chalmers and Dr Thomas Osbourne, Poole Hospital Background Compliance with Poole Hospital Trust (PHT) antibiotic policy is important to reduce risk of Clostridium difficile and multi-resistant pathogens, whilst at the same time ensuring effective treatment of sepsis. Hospitals have introduced restrictive policies to minimise inappropriate antibiotic prescription in the elderly: empirical use of cephalosporins should be limited to specific policy indications. Method Prospective regular case-note review of all in-patients over 70 years old on medical, orthopaedic and surgical wards over a non-consecutive 6-week period to identify and patients on ciprofloxacin, cefuroxime, cefotaxime, ceftriaxone, co-amoxiclav, tazocin and whether use is compliant with hospital policy. Results From n=68, respiratory tract infection (44%) was the most frequent indication for antibiotics with tazocin (57%) prescribed the most. According to policy, 54% (n=34) of inpatient prescriptions were incorrectly prescribed. Reasons for non-compliance: incorrect antibiotic (53%); incorrect indication (36%); discussion with Microbiologist (11%). Antibiotic duration: not stated (59%); duration or review date stated (41%). Of FY1 prescribing, 85% of prescription was non compliant, compared with 50% from each senior grade. 57% of all prescriptions were illegible. Key Messages A multidisciplinary approach to teaching and education is paramount in maximising compliance with policy, resulting in safe, effective and legible prescribing, particularly amongst FY1 doctors - 22 - Sharing Good Practice June 2012 “I think I’m due a blood test, Doctor”: Using audit cycles to improve adherence to recommended drug monitoring, Dr Isabel Mark and Mr Peter Kirmond, Bradgate Surgery Bristol Background Guidelines have been published recommending the monitoring frequency for certain commonly prescribed drugs (1). It is not known how well these are adhered to currently. Methods In May 2011, 467 patients at Bradgate Surgery, Bristol, taking one of 20 standard medications were audited to investigate whether recommended blood tests were completed. Subsequent efforts were taken to improve levels of compliance by contacting patients individually, inviting them for the relevant test. A re-audit was undertaken in January 2012. Results In May 2011, 44.8% of patients had received appropriate monitoring. Levels only increased to 46.8% in January 2012, despite considerable efforts. With such negligible improvement, alternative strategies were considered. Future plans include attaching a ‘hook message’ to patients’ notes. This message will be seen whenever the patient contacts the practice or requests a repeat script. Following this, a further audit will be undertaken in late May 2012. Key messages Guidelines for drug monitoring are not always followed and a variety of improvement strategies are needed to address the problem. Flexibility and persistence are needed when attempting to improve the standard of patient care. References 1. Erskine, D. Suggestions for Drug Monitoring in Adults in Primary Care. [Internet]. 2012 [updated 2008 May; cited 2012 March]. Available from: www.nelm.nhs.uk - 23 - Sharing Good Practice June 2012 Unnecessary pre-operative testing of elective surgical patients: an audit and cost analysis of two district general hospitals, Dr Adarsh Shah, Dr Chris Arrowsmith, Dr H Lee, Dr J Walsgrove, Dr C Lane, Dr M Taylor and Dr D May, Royal Bournemouth Hospital and Poole General Hospital Background NHS Trusts nationally are facing increasing financial pressures. Unnecessary preoperative investigations are a significant additional cost. We audited the pre-operative testing of elective surgical patients against NICE guidelines at two district general hospitals performing approximately 29,000 elective operations annually. Methods All elective surgical operations performed under general anaesthesia over one week were included. Relevant data was collected from patient records and blood test reporting software. Tests were only considered unnecessary if deemed so by NICE guidance and there was no clinical indication. Results 383 patients were identified. 57% and 63% of investigations were unnecessary at the two hospitals. Full blood count, urea & electrolytes, coagulation screen and liver function tests comprised over 80% of unnecessary tests. Extrapolating this data for the year we estimate unnecessary testing costs £57,000 per annum across the two trusts based on local pathology test prices. Key messages Unnecessary pre-operative testing represents a significant annual cost. The pathology test prices used in this analysis probably do not account for all costs associated with excess testing and therefore our calculation represents a conservative estimate. Other NHS trusts almost certainly face similar problems. Locally, work is underway to tackle the problem through education, implementation of simple algorithms based on existing NICE guidelines and computerised decision support systems. Reference National Institute for Clinical Excellence. CG3. Preoperative tests: The use of routine preoperative tests for elective surgery. 2003 - 24 - Sharing Good Practice June 2012 Re-assessment of venous thrombo-embolism and bleeding risk: an intervention to improve patient safety, Dr Rebecca Wollerton, Southmead Hospital, Bristol Background Venous thrombo-embolism (VTE) is directly responsible for 5-10% of hospital deaths (1) (2) (3) and is estimated to cost UK hospitals £280 million each year (4). Prophylactic use of heparin against VTE reduces mortality and the incidence of pulmonary embolism, but also increases frequency of bleeding events (5). Consequently, it is necessary to risk stratify patients prior to initiating prophylaxis and re-assess whenever the clinical situation changes (5) (6) (7) (8). This project aimed to increase the frequency of risk reassessment, identified as a priority by NICE, through the development of a drug chart prompt. Method Stickers prompting doctors to re-assess VTE/bleeding risk were inserted into drug charts of patients in the Renal Unit at Southmead. Doctors signed the stickers upon reassessment. The outcome measure was the maximum duration between re-assessment. Feedback obtained from colleagues facilitated sticker redesign prior to subsequent audit cycles. Results Over 3 cycles n=45 (n=number of stickers). Average maximum duration between reassessment decreased over cycles 1-3 (cycle 1: 9.4 days,.cycle 2: 4.5 days,.cycle 3: 3.7 days) and range narrowed (cycle 1: 3-17, cycle 3: 0-10). Key Messages Stickers in the optimal drug chart position successfully increase frequency of VTE/bleeding risk re-assessment. Further work in this area will evaluate whether printing this prompt in drug charts can improve patient safety. 1) 2) 3) 4) 5) 6) 7) 8) Lindblad B, Sternby NH, Bergqvist D. Incidence of venous thromboembolism verified by necropsy over 30 years. BMJ. 1991;302:709-11. Sandler DA, Martin JF. Autopsy proven pulmonary embolism in hospital patients: are we detecting enough deep vein thrombosis? J R Soc Med. 1989;82:203-5. 3) Alikhan R, Peters F, Wilmott R, Cohen AT. Fatal pulmonary embolism in hospitalised patients: a necropsy review. J Clin Pathol. 2004;57:1254-7. House of Commons Health Committee (2005) Report on the Prevention of Venous Thromboembolism in Hospitalised Patients. Qaseem A, Chou R, Humphrey L, Starkey M, Shekelle P. Venous Thromboembolism Prophylaxis in Hospitalized Patients: A Clinical Practice Guideline From the American College of Physicians. Clinical Guidelines Committee of the American College of Physicians. 2011 Nov 155(9) 625-631 NICE (2010a) VTE Prevention Quality Standard. http://www.nice.org.uk/aboutnice/qualitystandards/vteprevention/ NPSA (2011) Venous Thromboembolism Risk Assessment Whiteway A, Kendall J, Bacon S. Guideline for the prevention, diagnosis and treatment of venous thromboembolism in adults. North Bristol Trust Guidelines. October 2010. - 25 - Sharing Good Practice June 2012 Improving the consent process for epidurals for labour, Dr David Buckley, Yeovil District Hospital Background Obtaining informed consent from women in active labour for a potentially risky procedure is clearly difficult. This audit sought ways to improve the consent process for epidurals for labour (EFL). Methods All women who had received an EFL during a 4 week period at Yeovil District Hospital were contacted in the immediate postnatal period. They were given a questionnaire to ascertain their rate of recall concerning the information that had been given to them about the risks of their EFL. To improve this process, Epidural Information Cards (from the Obstetric Anaesthetists’ Association) were given out antenatally to women considering an EFL and early during labour to those women voicing a strong preference for an EFL. A re-audit was then carried out. Results The initial results showed a fair recall of the common risks (50-75%) but a poor recall of the less common (but more serious) risks (25-50%). The rate of recall was significantly improved after giving out the epidural information cards antenatally. Key Messages The use of epidural information cards antenatally or early during labour significantly improves the recall of risks associated with an EFL and thus improves the overall consent process for EFL. - 26 - Sharing Good Practice June 2012 Improving Venous Thromo-Embolism (VTE) Risk Re-assessment – foundation doctor led intervention, Dr T’ng Chang Kwok, Dr Puja Vasdev, Dr Lizzie Elling and Dr Simon Stinchcombe, King’s Mill Hospital, Sutton in Ashfield Background 25,000 patients in England die from Venous Thrombo-Embolism (VTE) annually1. National Institute for Health and Clinical Excellence suggests initial VTE risk assessment as well as reassessment after 24 hours of admission and whenever clinical condition changes2. In our trust, VTE risk is not effectively reassessed. Methods In this patient safety improvement project, we performed a prospective 2-week-audit in a 24-bedded ward. Then, we educated healthcare professionals and introduced a sticker in the drug chart to prompt VTE risk reassessment. Two further audit cycles were completed. Results Prior to this pilot project, only 15% of patients had documented VTE risk reassessment after 24 hours of admission, compared to 32% after two audit cycles. Our gold standard outcome measure was percentage of patients who have appropriate thromboprophylaxis amendments made due to changes in their VTE risks since admission. This improved from 53% to 75% after 2 audit cycles. The main reason for the low outcome measure initially was the failure to identify the error in the first VTE risk assessment before a significant clinical event occurs. Key Message Daily reviews of patients should incorporate VTE risk reassessment. We are performing further audit cycles and innovative ideas to improve our outcome measures. References 1. Donaldson L. On the State of Public Health: Annual Report of the Chief Medical Officer 2007. Department of Health. 2008 July 14. 2. National Institute for Health and Clinical Excellence. Venous Thromboembolism: Reducing the Risk. 2010 January. NICE clinical guidance 92 - 27 - Sharing Good Practice June 2012 POSTER PRESENTATIONS The Treatment Escalation Plan, Dr Anand Sundaringlam, Dr David Gannon and E Thomson, Colchester General Hospital Background We recognized the workload for the out of hours team was immense and this was especially true for the night staff. Anecdotally it was known that hours would be spent reviewing and assessing deteriorating patients in whom the parent team should have made prior arrangements. Method Over a two week period we attended the morning handover meeting and asked the night SHO and SpR to complete a questionnaire in order to quantify the number of patients reviewed and of those the number with a documented ceiling of care. In addition we asked them what problems they encountered with those patients. Results The study revealed that over 8 nights a total of 48 deteriorating patients needed review and of these only 4 had documented ceilings of care. Key Messages Lack of clear documentation of ceiling of care adversely affects patient care. Patients who should not be escalated are receiving invasive management overnight. The night team are stretched to the point where patient’s that do require their attention are not receiving it. Recommendation; The Treatment Escalation Plan (Document) to replace the DNAR form. References Obolenksy L et al, A patient and relative centred evaluation of treatment escalation plans: a replacement for the do-not-resuscitate process, J Med Ethics. 2010 Sep;36(9):518-20. - 28 - Sharing Good Practice June 2012 Estimated Date of Discharge Audit, Dr Anneke Ashcroft, Dr Joy Simmonds and Dr Sarah Britton, Queen’s Hospital, Burton Background Discharge is commonly delayed in the elderly1, 2. The Department of Health (DoH) recommends 10 key steps to ensure timely discharge, including setting an Estimated Date of Discharge (EDD) within 24-48 hours of admission. The EDD is the expected time for the patient to be clinically stable for discharge3 and should be managed daily2. Methods 50 notes of patients > 60 years old were randomly selected. The following was audited: 1) EDD set and documented? 2) Documented within 24 hours, 48 hours or longer? 3) EDD reviewed daily? Records were recalled after two months to quantify actual delay in discharge. Results 76% (38/50) had an EDD documented, 32%(16/50) within 24 hours and 48% (24/50) within 48 hours. 18% (7/38) were reviewed daily and 24% (9/38) were not reviewed al all. The average discharge delay was 11½ days. Causes identified included awaiting nursing home placement (31%) and intermediate beds (25%). Key messages There is poor compliance with (DoH) standards, a lack of local hospital guidelines and awareness. A post take ward round pro forma has been introduced, prompting clinicians to set and document an EDD on admission. Clearer guidance and revision of hospital policies are recommended. Re-audit due February 2012. References 1. Bryan K. Policies for reducing delayed discharge from hospital. British Medical Bulletin 2010; 95 (1): 33-46. http://bmb.oxfordjournals.org/content/95/1/33.full#abstract-1 (accessed 18 January 2012). 2. Department of Health. Ready to go? Planning the discharge and the transfer of patients from hospital and intermediate care. http://www.dh.gov.uk/prod_consum_dh/groups/ dh_digitalassets /@dh/@en/@ps/documents/digitalasset/dh_116675.pdf (accessed 18 January 2012). 3. Department of Health. Achieving timely ‘simple’ discharge from hospital. http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/di gitalasset/dh_4088367.pdf (accessed 18 January 2012 - 29 - Sharing Good Practice June 2012 Fellows are more than Reps, Dr Clare van Hamel, Dr Daniel Eden, Dr Evie Cole, Dr Sarah Johnston and Dr Frances Richardson, Severn Foundation School, Bristol Background Foundation Schools are required to have trainee representation for their committees. In the past our appointment process for the trainee representatives was very informal and the appointees variable in enthusiasm. I wanted to give trainees the opportunity to demonstrate excellence beyond the academic programmes by appointing fellows with special interests. Methods All F1 appointees to Severn in 2011 were offered the opportunity to apply for Foundation fellow positions covering Leadership, Simulation, Patient Safety and Education. The applications were in writing, outlining suitability for the roles and potential areas for future development for the school within their area of interest. The trainees were funded to go on a relevant development course to complement their position; they were also given opportunities to attend suitable events if possible. Results Usually we have approximately five expressions of interest to be a representative for the Foundation School Board. In 2011 we had approximately 60 applicants for the four posts. Each of the trainees has used their position to develop not only their only portfolio but also contribute to the school overall. Key Messages A formal application to a position creates greater enthusiasm and more suitable applicants. Each trainee will briefly describe their achievements over the past few months - 30 - Sharing Good Practice June 2012 Increasing Efficiency with Disposable Equipment: two simple changes to save time and money in a difficult economic climate, Dr Edward Miles, Dr Katherine Birchenall and Dr Lilli Cooper, Bristol Royal Infirmary Background The recent recession has impacted on the NHS. Nationally there is emphasis on efficiency measures to overcome financial deficits and maintain current service provision1. Nationally, budget cuts have been introduced. In our experience, reduction of waste is not emphasised. 1 Liberating the NHS. What might happen? The Roger Bannister Health Summit, Leeds Castle, 2010, available at www.nhsconfed.org Aims 1. To reduce disposable equipment wastage; 2. To reduce time taken to find equipment items in treatment rooms. Method At the Bristol Royal Infirmary (BRI), we: 1. Displayed bright price tags on disposable equipment items e.g. cannulas. We audited numbers used over 8 weeks on the Surgical Admissions Unit. Bright price tags were displayed. Four weeks later we re-audited 8 weeks’ disposable equipment use, with prices still shown. 2. Designed the BristolBox, a standardised storage unit containing commonly used disposable items, and introduced it to 5 surgical wards, previously laid out at the ward sister’s discretion. User feedback and restocking data was collected. The BristolBox Layout was revised accordingly. Results Awareness of cost of disposable items reduced spending by 4% overall; 8% per patient. Time-trials (n=10) to find lists of items for common procedures were 60% faster (p<0.001) with the BristolBox than a normal ward. Key messages Awareness of price may save 8% on disposable equipment use. Predictable layout may save 60% of time finding equipment items in hospital treatment rooms - 31 - Sharing Good Practice June 2012 Foundation Placements Ranking Tool, Dr Vicky Pyne, Severn Deanery Foundation School Background Each Foundation School has many placements that a new F1 applicant must rank in order of preference. In the past, the Severn Deanery used the FPAS system that requires applicants to passively review and manually rank their placements. Methods The Severn Deanery foundation placements spreadsheet was manipulated to create a semi-automated solution that allows ranking of each of the placements based on an applicant’s preferences. Available specialties and trusts can each be scored individually and then weighted as a group to allow either specialties or trusts scorings to take higher priority. Once the scoring and weighting is complete, the applicant can then automatically sort the placements from most wanted to least wanted and use this list to enter their ordered placements onto the FPAS website. Results The spreadsheet was presented at the Severn Deanery Foundation School Welcome Fair in December 2011 and was made available to everyone starting F1 in the Severn Deanery in August 2012. It was well received and has had good feedback since. Key Messages This simple, stable solution to the complex and time-consuming problem of correctly ranking preferred foundation placements has saved every soon-to-be-F1-doctor in the Severn Deanery countless hours and possible mistakes in ordering their placements - 32 - Sharing Good Practice June 2012 “Doctor, quick, I need to do an audit”, Miss Gaynor Smith and Dr Anthony Choules, Queen’s Hospital, Burton Background Audits conducted by junior doctors can be of limited value. Lack of knowledge and support and limited opportunities to undertake re-audit all contribute1. We wanted to improve the standard of audits with the aim of using them to provide good training and make a real impact on patient safety. Method We appointed a trainer in clinical audit to work with the Clinical Tutor and Patient Safety Lead. Eight important topics having impact across our Trust were agreed and allocated to groups of FY1 and FY2 doctors. Formal training was given, supported by workbooks and teaching sessions. Criteria for assessment2 of final projects were agreed. A showcase for presentation of projects was hosted by the Trust Chairman. A panel of assessors awarded a prize to the highest scoring group. Results The high standard of audits demonstrated effectiveness of the training and consequent understanding of the clinical audit process. Learners’ feedback testified to the value of the training. Completed workbooks provided evidence of learning activities for e-portfolios Key Messages Providing good support for junior doctors undertaking audit produces better results Good planning allows a focus on more meaningful audits Better audits help to develop better patient care A Trust wide, collaborative approach allows the opportunity for reaudit. 1. Guide to involving junior doctors in clinical audit, HQIP 2010 New Principles of Best Practice in Clinical Audit, Ed. Burgess, Radcliffe 2011 - 33 - Sharing Good Practice June 2012 SCRIPT: an e-learning programme to improve the prescribing of newly qualified doctors, Dr Sarah Thomas, Prof Elizabeth Hughes, Dr Richard Seal, Dr David Davies, Prof John Marriott, Prof Robin Ferner, Dr Vinod Patel, Dr Sukvinder Kaur and Dr Jamie Coleman Background The EQUIP study[1] found poor prescribing to be widespread in NHS hospitals, resulting in the underuse of medicines, avoidable adverse drug reactions and medication errors. To improve matters, NHS West Midlands commissioned the development of an eLearning programme that could be integrated into the Foundation Training Programme to improve prescribing competency. Method The Universities of Birmingham, Warwick and Aston, in collaboration with NHS West Midlands, developed SCRIPT (Standard Computerised Revalidation Instrument for Prescribing and Therapeutics). The e-learning material was produced by experts in each topic, allied with a clinical pharmacist or clinical pharmacologist, and using a template to enter standardized data. The material was illustrated by a specialist IT group, and each module was edited by the development team, overseen by an advisory board. Results SCRIPT is a suite of 40 e-learning modules providing background pharmacological knowledge and patient-centred learning of therapeutics[2]. They are designed to align with the competencies set out in the Foundation Curriculum[3] and the GMC guidance on safe prescribing[4]. All West Midland Foundation doctors have registered with SCRIPT (www.safeprescriber.org). In an outcome-based evaluation, 80% of respondents agreed SCRIPT has had a positive impact on their knowledge, skills or confidence as a prescriber, and 65% agreed they have changed aspects of their clinical practice as a result of using the programme. Trainees are required to complete 16 modules in their first year of training, and 15 in year 2. Key Messages SCRIPT e-Learning helps support both trainees and clinical tutors in ensuring standards of prescribing competency are achieved and maintained. 1. Dornan et al. 2009. An in depth investigation into causes of prescribing errors by foundation trainees in relation to their medical education. EQUIP study. Available online at www.gmc-uk.org 2. The UK Foundation Programme Curriculum. UK Foundation Programme Office (2010). Available online at www.foundationprogramme.nhs.uk 3. Taking a Safe and Effective Drug History. Demonstration module, available online at http://safeprescriber.org/taster/chapter/view/81 Good Practice in Prescribing Medicines. General Medical Council (2008). Available online at www.gmc-uk.org - 34 - Sharing Good Practice June 2012 Learning from clinical incidents to promote patient safety and improve foundation doctors prescribing practice, Dr Amy Ritchie and Dr Ratan Alexander, Worcestershire Royal Hospital Background The electronic Datix incident reporting system is an important tool for healthcare workers to report clinical incidents relating to patient safety. Prescription error incidents are not necessarily fed back to the prescriber, which may lead to recurrence and affect the safety of other patients. We describe the introduction of the delivery of a monthly report of the top 5 incidents for foundation doctors with specialist support aimed to reduce these incidents and improving patient safety. Methods Each month, prescribing error clinical incidents reported via the Datix system were collated and analyzed. A presentation detailing incident location, type of error, outcome and key learning points was collated and presented to foundation doctors at a mandatory teaching session. Results Foundation doctors and pharmacists feedback following each presentation helped guide what additional education sessions were required to address weak areas of prescribing. The monthly prescribing incidents were compared to identify recurrent errors and further address areas required to improve patient safety through better prescribing practice. Key Messages Anonymous feedback of critical incidents enables doctors to recognize and prevent repeated prescribing errors, promoting patient safety, in a blame free reporting culture. Foundation doctor prescribing can be continuously improved. - 35 - Sharing Good Practice June 2012 Consenting in Interventional Radiology: an opportunity for junior doctor training and improving practice, Dr Harry Dean, Mrs Scarlet McNally, Dr George Absi, Dr Julia Barbour and Dr Simon Walton, Eastbourne District General Hospital Background Foundation schools and GMC survey award “red flags” to Trusts allowing Foundation doctors to obtain consent. Yet consenting skills should develop in the spiral curriculum.1 Methods Data was gathered on 77 consecutive patients attending for radiological procedures at two DGHs. Results Consenting practice varied. At hospital A, a radiologist consented 100% of patients on arrival. At hospital B, a radiologist consented 13% and the referring team 87%; in only 22% was consent taken in advance (a recommendation of Radiological societies). Yet 75% of cases were elective, 25% emergency. Two patients were cancelled as no prior consent considered. We identified 8 categories of procedure. Further Work We reported these results internally to raise awareness. We pioneered simple ‘outline’ consent training. This was procedure-specific for our 8 categories. Training focused on alternatives, risks (bleeding, stent blocking/dislodging, failure to obtain specimen, damage to lung/liver, etc.) and using information leaflets. Key Messages Trainees within referring teams can be equipped to obtain ‘outline’ consent early for interventional radiology procedures, as per recommendations.2,3,4 This helps develop key curriculum skills.1 Interventional radiology can be de-mystified by training focused on alternatives and risks, useful for doctors’ future clinical practice. 1. The UK Foundation Programme Office, 2012.The UK Foundation Programme Curriculum. Section 2.5: Consent. Available online: http://www.foundationprogramme.nhs.uk/pages/home/keydocs 2. General Medical Council, 2008. Consent: patients and doctors making decisions together. Available online: http://www.gmcuk.org/Consent_0510.pdf_32611803.pdf 3. British Society of Interventional Radiology, 2002. Consent in interventional radiology. Available online: http://www.bsir.org/content/BSIRPage.aspx?pageid=52 4. Royal College of Radiologists, 2005. Standards for patient consent peculiar to radiology. Available online: http://www.rcr.ac.uk/docs/radiology/pdf/CRpatientconsentweb.pdf - 36 - Sharing Good Practice June 2012 DAPS Handover wiki, Dr Will Barker and Dr Ed Mew, St Peter’s Hospital, Chertsey Background Junior doctors struggle to learn and re-learn the ‘tricks of the trade’ on entering new firms. Be it scan requests, referrals, or the demands and rhythms of the job, time and effort is wasted learning information that was previously learned by preceding colleagues Methods we created an electronic handover tool accessible from every hospital in the country detailing roles and responsibilities of all F1 jobs and information needed to complete administrative tasks for the role. The site is a private wiki’, edited by nominated doctors from each hospital to keep it rapidly updated Results We collected information from a survey of junior doctors at St Peters hospital. 7 months after starting at the hospital they still lost on average 40 minutes a day due to unfamiliarity with referrals or forms. The main source of information was other doctors, rather than trust guidelines- implying a waste of other doctors’ time. Key messages Technological solutions can improve simple paper systems. Inefficiencies are not inherent in the system and the obstacles of handover can be overcome. The people we saw to talk through our idea were much more receptive when we showed them a workable ‘demo’ - 37 - Sharing Good Practice June 2012 Workshops for ST/CT Applications and Careers Advice for Foundation Trainees, Dr Gurkaran Samra and Dr Eoghan McGrenghan, Victoria Hospital, Blackpool Background The Foundation programme provides trainees a range of experiences enabling them to take on supervised responsibility for patient care, before choosing an area of medicine in which to specialise1. However, compared to the preceding year, in 2011 fewer trainees knew where to find information they needed to help plan their career2. Methodology A foundation year one trainee survey (March 2011, pre-application process) at Blackpool Teaching Hospitals found that – - Only 14% of trainees received careers advice - 36% of trainees were not aware of the application process - 30 out of 33 respondents felt career advice workshops would aid them in making their career decisions Career advice workshops focussing on the application process for different specialties were then organised by foundation year two trainees (FY2) with the following sessions: - ST/CT application process – an overview - Trainees’ experience of applications and interviews - Advice from Consultants Results A survey amongst FY2 s (post-application process) found that – - a higher percentage of trainees knew where to get sufficient information to assist career planning compared to the National Trainee Survey 2011 findings - the vast majority of respondents felt career advice workshops had aided their successful ST/CT application process - 1 2 http://www.gmc-uk.org/education/postgraduate/foundation_programme.asp The National Training Survey 2011, General Medical Council http://www.gmc-uk.org/education/postgraduate/foundation_programme.asp The National Training Survey 2011, General Medical Council - 38 - Sharing Good Practice June 2012 The Development and Evaluation of a Clinical Guidelines Handbook for Foundation Trainees, Dr Christopher Griffin, Dr Adam Barnett, Dr Claire Greszczuk, Dr Thomas Bannister and Dr Marc Davison Background Foundation doctors are challenged with having to quickly adapt to hospital life; prescribing, refreshing sub-specialty knowledge and adhering to trust policy guidelines [1, 2]. The aim of this study is to explore the perceptions amongst Foundation Year One (FY1) trainees following the introduction of a unique, trust specific guidelines handbook. Method A clinical handbook was developed at Buckinghamshire Hospital NHS Trust that illustrated relevant trust guidelines, and UKFPO curriculum learning objectives. These were issued to all FY1 doctors at induction (n=51). The entire cohort was surveyed, and a sample of the group took part in semi-structured interviews. Data analysis took place via thematic content analysis (TCA) and descriptive statistics. Results There was a 61% response rate to the survey, with 42% of respondents’ using the handbook at least once a week. Furthermore, 68% of respondents’ report the handbook having guided their clinical decision making. Opinions towards the handbook were largely positive. TCA of the interview data identified; self-perceived enhancement of clinical management skills; greater awareness and understanding of hospital policies; and improved self-confidence when making clinical decisions. Key Message This paper suggests that a foundation trainee clinical guidelines handbook can promote awareness, guide decision making, and promote self-perceived learning and confidence. References [1] Harding S, Britten N, Bristow D. The performance of junior doctors in applying clinical pharmacology knowledge and prescribing skills to standardized clinical cases. Br J Clin Pharmacol. 2010 Jun; 69:598-606. [2] Ali M, Kalima P, and Maxwell S. Failure to implement hospital antimicrobial prescribing guidelines: a comparison of two UK academic centres. Journal of Antimicrobial Chemotherapy. 2006 Feb; 57:959-962. - 39 - Sharing Good Practice June 2012 Our Painful Experience, Dr Abigail McGinley and Dr Richard Harrison, Torbay Hospital, Torquay Background Research suggests pain is one of the commonest reasons patients present to medical attentioni and patients often wait long periods for analgesia.ii The British Association of Emergency Medicine guidelines state all patients in moderate to severe pain should receive analgesia within 20 minutes of admissioniii. As foundation doctors we became increasingly frustrated seeing patients admitted in pain who had waited hours for analgesia. A quality improvement project was undertaken to help address this issue in our hospital. Methods The period of time people waited for administration of analgesia was calculated in 50 patients over 18 years old admitted onto the Emergency Admissions Unit with pain. The appropriateness of analgesia used and if the patient had a pain score on admission was also analysed. Results Only 16% of patients received analgesia within the target of 20 minutes. Also 28% of patients waited over 3 hours before being given analgesia. We introduced independent nurse prescribing of analgesics and doctor education with two key messages to decrease delays in analgesia administration. We are currently completing the audit cycle to assess if these changes have improved data. Key messages Pain is often poorly recognised and treated with analgesia in the acute setting. i Kirsch B, Berdine H, Zablotsky D, et al. Management strategy: identifying pain as the fifth vital sign. VHSJ. 2000;49–59. ii Todd KH, Sloan EP, Chen C et al. Survey of pain etiology, management practices and patient satisfaction in two urban emergency departments. CJEM 2002; 4(4):252-6 iii The British Association of emergency medicine guidelines on Management of Pain in Adults; http://www.collemergencymed.ac.uk/Shop-Floor/Clinical%20Guidelines/default.asp (website accessed 20/03/2012) - 40 - Sharing Good Practice June 2012 Accuracy of in-patient prescriptions and methods for preventing errors, Dr James Cheaveau, Dr Meera Thayalan and Mr Timothy Bates, University Hospital Bath Background Prescribing errors can have serious consequences for both the health of patients and also be costly for the NHSiii,iii. When an illegible prescription led to a patient getting an accidental ten-fold dose of midazolam, drug charts were audited to identify where potential improvements could be made. Method 119 randomly selected drug charts from 24 wards in one hospital, were examined for fulfillment of the hospital pharmacy prescribing criteria. Results The most common error was lack of appropriate prescriber identification; recording the bleep number (92%) and/or name (18%). Units were often written incorrectly (34%) with dalteparin a frequent source of this error. Indications and review dates for antibiotics were only recorded 8% of the time. Surgical wards were found to be the least compliant to hospital prescribing guidelines. Key Messages Implementation of improved prescribing included educating prescribers through workshops and posters. A drug chart with a space for a bleep and a pre-written prescription for dalteparin was developed with provision of stamps with prescriber’s name and GMC number to doctors, followed-up with re-audit to measure the success of the improvement targets. These simple and inexpensive changes made by identifying key prescribing errors can greatly enhance safety for patients iii Department of Health Expert Group. An organisation with a memory, 0113224419. London: The Stationery Office Limited; 2001 iii Smith J. Building a safer NHS for patients: Improving Medication Safety, 1459. Department of Health; 2004 - 41 - Sharing Good Practice June 2012 Practical Prescribing for Emergencies – a four week course for medical students, Dr Alex Paschalis and Dr Mariana Noy, Basildon and Thurrock University Hospital Background Research has shown that prescription errors are common in hospitals with an estimated rate of 8.9%. iii Furthermore, the majority of these have been shown to involve junior staffiii. Practical prescribing is not taught frequently during medical school and as a result junior doctors often feel apprehensive about prescribing. Methods A course was run for third year medical students at University College London focusing on the practicalities of prescribing. Each week two clinical scenarios were described and students were split into small groups lead by foundation doctors with whom they worked through the scenarios, deciding upon appropriate treatment and writing this up on drug charts using the British National Formulary. Results Feedback showed that students appreciated the course, commenting they had little in the way of similar teaching and would benefit from further sessions. Their confidence and accuracy in prescribing increased over the course, with students making fewer mistakes and needing less assistance. Key Messages Practical prescribing is not taught in detail during undergraduate training and consequently foundation doctors can initially feel uneasy Prescribing errors may be reduced by the provision of formalised teaching Formalised teaching appears to enhance students’ confidence and accuracy in prescribing References: i) http://www.gmc-uk.org/news/5156.asp ii) Medication errors. Williams, J. J R Coll Physicians Edinb 2007; 37:343–346 - 42 - Sharing Good Practice June 2012 Prescribing Education for Final Year Medical Students and Foundation Year 1 Trainees across the North Western Deanery, Dr Deborah Kirkham, North Western Deanery Background The EQUIP study1 found a prevalence of 8.4% for FY1 prescribing errors. Prescribing education recommendations for undergraduates and FY1s aimed to reduce prescribing errors. This project assessed the current prescribing educational practice for final year medical students and FY1 doctors in the North Western Deanery. Methods Questionnaires were sent to all final year undergraduate and Foundation Leads in the North Western Deanery (fifteen hospitals) to assess current prescribing educational practice with reference to the EQUIP study recommendations. Results Twelve hospitals contributed final year medical student data. Most students participate in student assistantships and prescribing in real-life contexts. Scope exists to improve teaching and assessment. Fifteen hospitals contributed FY1 data. The majority of FY1s are assessed at induction, and prescribing is included in the formal teaching programme, but ongoing assessment is uncommon. Foundation leads are frequently unaware of FY1 prescribing errors resulting in failure to identify and remediate weaker prescribers. Educational input from pharmacists is inadequate for both groups. Key messages 1. Student assistantships give vital experience in real-life prescribing. 2. Exposure to varied situations benefits learners. 3. Ongoing assessment and training is essential. 4. Contact with pharmacists should be maximised. 5. Inter-professional education is crucial for prescribers. 1 Dornan T. et al. An in depth investigation into causes of prescribing errors by foundation trainees in relation to their medical education. EQUIP study. Final report to the General Medical Council. University of Manchester: School of Pharmacy and Pharmaceutical Sciences and School of Medicine. 2003 - 43 - Sharing Good Practice June 2012 Near-peer teaching in Preparation for Professional Practice week benefits new doctors and their teachers, Dr Rachael Brock and Dr Francesca Crawley, West Suffolk NHS Foundation Trust Background Preparation for Professional Practice (PfPP) is a GMC-mandated period of shadowing and induction for new Foundation Trainees (FTs)1. Ward-based shadowing is commonly supplemented with an educational programme. In 2010, West Suffolk Hospital’s (WSH) programme comprised plenary sessions led predominantly by senior clinicians. Feedback indicated that participants wanted more advice on the day-to-day practical issues of being a FT. Near-peer teaching is effective in delivering targeted teaching and developing new teachers2. Widely used in medical schools, its efficacy has not yet been demonstrated in PfPP settings. Method In 2011, WSH introduced three PfPP sessions based on clinical challenges commonly encountered by FTs: ‘Handover’, ‘Asking for help’ and ‘ePortfolio’. These sessions were co-led by a current FT and senior clinician. Results FT-led sessions received an average rating of 91% from participants, compared to 76% for non-FT led sessions. Building on this success, the 2012 programme will include a daily FT-led session. In recognition of their teaching, FT session leaders will receive a certificate acknowledging their contribution. Key messages Educational sessions led by close peers may provide a learning experience more relevant to the challenges facing new FTs. Preparing and leading these sessions provides valuable teaching experience for FTs. References 1. General Medical Council (2009) Tomorrow's Doctors, London: General Medical Council. 2. Gregory, A., Walker, I., McLaughlin, K., Peets, A.D. (2011) 'Both preparing to teach and teaching positively impact learning outcomes for peer teachers', Medical Teacher, 33(8), pp. 417-22. - 44 - Sharing Good Practice June 2012 Where do inventions to reduce bullying need to be targeted? Miss Helen Davis, Mrs Kerry Ferguson and Dr Namita Kumar, Northern Deanery Foundation School Background Medicine has long been regarded as a hierarchical career with evidence of bullying in many areas. Within NDFS we have monitored bullying through our annual ‘Your School Your Say’ (YSYS) survey. We wished to explore this further in order to target intervention. Methods We looked at YSYS results from 2010 to 2011. We triangulated these results from GMC surveys. Results Undermining behavior from consultants has been reported within NDFS as red outliers in all GMC surveys to date. Absolute rate of bullying has reduced from 20% to 14% in YSYS. Trainees are far more aware of who to report to from 33% to 62% feeling they knew who to approach in their trust. Consultant bullying has reduced, but the proportion feeling bullied by managers has increased from 2% to 8%. Nurse bullying has remained static at approximately 40%. Free text comments suggest that a certain amount of bullying is expected in the hospital environment:“It seems endemic in our line of work with people being placed in stressful situations.” Key messages Bullying and undermining behavior continue to impact on foundation trainees Interventions have supported our young doctors to know how to report behaviour Managers are increasingly cited as bullies Therefore interventions need to be targeted. - 45 - Sharing Good Practice June 2012 Where are foundation trainees most likely to be asked to take consent? Miss Helen David, Mrs Kerry Ferguson and Dr Namita Kumar, Northern Deanery Foundation School Background It is nether safe for patients, good clinical practice nor good educational practice for any individual to take consent for a procedure with which the individual is not familiar. In times gone by this responsibility has often fallen to the most junior doctors of the team. We wished to establish how practices had changed within NDFS over the past 7 years. Methods Within NDFS we have monitored consent through our annual ‘Your School Your Say’ (YSYS) survey. We looked at figures and free text comments. Results To our surprise we found that the numbers never being compelled to ask for consent had reduced from 83% to70%, indicating this was occurring more often. Free text comments have indicated that areas most being problematic are Radiology (40%), Endoscopy (25%), Orthopaedics (20%) and cholecystectomy (15%). Key Messages More foundation doctors being compelled to take consent. This may further increase in times of austerity and staffing shortages. The taking of consent for cholecystectomies in particular may also be an indicator of this. We aim to target our interventions to the areas above, as although we were not surprised that the surgical areas were cited as problematic, interventional radiology was not an area that we were aware of. - 46 - Sharing Good Practice June 2012 Helping our patients survive sepsis: an initiative to improve provision and accessibility of blood culture bottles, Dr Rebecca Wollerton, Dr Robert Tyrell, Dr Emma Wood, Dr Joshua Nowak, Dr Andrew Moore, Dr Oliver Howard and Dr Shirley Lau, Southmead Hospital, Bristol Background Obtaining blood cultures prior to administration of antibiotics is a key recommendation of the surviving sepsis campaign (1). In the acute medical and surgical wards of North Bristol NHS Trust it was identified that blood culture bottles (BCBs) were not reliably available or accessible. The aim of this project was to improve availability and accessibility of BCBs in order to maintain patient safety in line with surviving sepsis guidance. Method Data was collected from acute medical and surgical wards across the trust using a standardized pro forma. The number of BCBs, time taken to locate BCBs and how/where they were stored was recorded for each ward. Information about the re-stocking process was also collected. Results 10 out of 26 wards provided consistently low or unattainable stock. On 45% of occasions it took over 2 minutes (range 2 seconds- 20 minutes) to locate BCBs and on 35% of occasions there were no BCBs in stock. Re-stocking processes varied. Key Messages We recommend inclusion of BCBs on recently trust-approved clinical equipment trolleys and anticipate this will reduce time spent obtaining blood cultures, thereby advancing initiation of antibiotics. Meanwhile, a uniform restocking process is being developed. Future audit will evaluate the success of these initiatives. References 1) Dellinger P, Levy M, Carlet J, et al.Surviving Sepsis Campaign: International guidelines for management of severe sepsis and septic shock: 2008. Critical Care Medicine. Jan;36(1):296-327 - 47 - Sharing Good Practice June 2012 Auditing Current Practice in The Diagnosis and Prevention of Delirium Against The Recommendations in The NICE Guideline in Patients With Neck of Femur (NOF) Fractures, Dr Rakhee Shah, Dr Leon Dryden and Dr Ramyah Rajakulasingam, QE II Hospital, Welwyn Garden City Background The prevalence of delirium in patients with NOF fractures has been shown to be between 10- 50%1 and is associated with increased morbidity and mortality, and length of stay (2,3,4) . Methods 23 patients admitted with a NOF fracture on the orthogeriatric ward over two weeks were audited. The NICE delirium audit tool was used to audit current practice5. Results Out of the 56% of patients that became acutely confused during their admission only 50% of them had a formal diagnosis of delirium. Delirium risk factors that were assessed in compliance with NICE guidelines included hypoxia, pain, polypharmacy, infection and constipation. Assessment of indicators of delirium such as changes in perception, changes in cognitive function, changes in social behaviour and sleep disturbances were noncompliant. Key messages Orthopaedic patients are at a high risk of delirium and therefore assessing for indicators of delirium needs to improve in these patients. The key to recognising delirium earlier is recognising a change in a patient’s baseline function. It is important to make a formal diagnosis of delirium, if present, to ensure complete investigation and management. We have designed a sticker to improve current practice in assessing for indicators of delirium and to improve diagnosing delirium. References 1. Lindesay J., Rockwood K. and Rolfson, D. The epidemiology of delirium. In Delirium in Old Age. Eds. Lindesay, J., Rockwood, K., Macdonald, A. Oxford University Press; 2002 pp 27-50. 2. Francis J & Kapor WE. Prognosis after hospital discharge of older medical patients with delirium. JAGS 1992; 40:601-606. 3. Francis J, Martin D, Kapoor WN. A prospective study of delirium in hospitalized elderly. JAMA 1990; 263:1097-1101. 4. Sciard D., Cattano D., Hussain M., Rosenstein A. Perioperative management of proximal hip fractures in the elderly: the surgeon and the anesthesiologist. Minerva anestesiologica 2011 7(77): 715-722. 5. National Institute for Health and Clinical Excellence. Delirium: diagnosis, prevention and management. (Clinical guideline 103) 2010. www.nice.org.uk/CG103 - 48 - Sharing Good Practice June 2012 How do Foundation Programme Doctors Prefer to Learn? Dr Abiramy Jeyabalan and Dr Evelyn Cole, Southmead Hospital, Bristol Background The aim was to identify the preferred learning style of Foundation Programme (FP) doctors in order to make recommendations to enhance delivery of the FP curriculum at North Bristol NHS Trust. Methods All FP doctors were asked to complete two questionnaires to identify whether they had a preference for visual, aural, read/write or kinaesthetic modalities of learning and to determine whether this matched their preference for particular teaching methods. Results Of the 58 (26 male) FP doctors who completed the questionnaires, 42 (71%) felt that teaching sessions had been delivered in a mode matching their preferred learning style. Case based teaching and simulation based training were ranked as the two most popular modes and elearning the least popular. Most trainees (38/56, 68%) preferred a multimodal style of learning with equal numbers of trainees favouring other modalities. Key Messages Foundation programme doctors prefer a multimodal approach to learning. This is further supported by a preference to learn using cases and simulation based training – modalities which accommodate multiple dimensions of learning style. The study increases our understanding of how FP doctors learn and encourages us to ensure that teaching methods encompassing multiple learning styles are implemented to deliver the FP Curriculum. - 49 - Sharing Good Practice June 2012 What value has near-peer teaching? A comparison of students’ and clinicians’ views, Dr Nicholas Harris, Dr Anna Harris and Dr Min Hui Wong, Yeovil District Hospital Background Junior clinicians have up-to-date experience of student exams and working life, and so are well placed to provide near-peer teaching. But is there a discrepancy between what students and clinicians believe is beneficial for learning? And does teaching at this level promote doctors as educators? Methods 57 students were involved in an FY1 led near-peer teaching programme at The Princess Alexandra Hospital in 2010/11. Doctors and students assessed the usefulness of this teaching using a Likert Scale. The doctors also assessed whether this experience encouraged them to teach further. Results 98.2% of students and 91.7% of clinicians believed OSCE’s to be the best modality to prepare for employment. 67% of doctors reported an interest in teaching before qualifying. Following the programme this rose to 87%. Additionally, 40% pursued formal teaching qualifications. Interestingly, students believed OSCE’s to be the best approach for preparing for employment, unlike junior clinicians. Future research could assess if this is due to the quality of the teaching given, or a fundamental change in the perception of learning needs as finalists make the transition from student to doctor. Key Messages The two groups’ perception of learning needs differ; this warrants further investigation. Early exposure to teaching promotes doctors as educators. - 50 - Sharing Good Practice June 2012 Doc to doc: Maternal delivery plan documentation and the potential legal implication on doctors, Dr Mohammed Bajalan, Mr Abubaker Elmardi and Dr Aung, Mid-Staffordshire NHS Hospitals Background Vaginal Birth After Caesarean-section (VBAC) is a highly preferred and encouraged method of delivery for many obstetricians over caesarean section. This mode of delivery is not without its risks however. It is the clinician’s responsibility to inform the patient of the significant risks and contingency delivery plan. Failure to do so could have catastrophic implications for the patient and serious legal implications for the clinician should an adverse event occur following lack of information provision. Methods The antenatal clinic notes of fifty patients who underwent VBAC were analysed. Consultant documentation as recommended by RCOG, legal requirements and local trust guidelines with regards to necessary information provision and documentation were analysed, recorded and independently verified. Results Amongst numerous alarming results identified by the study, 90% of patients had no specific advice with regards to VBAC risks documented and were thus presumed misinformed. Only 36% had delivery contingency plans documented. 90% of VBAC patients were presumed not to have been given information leaflets. Key Messages Numerous significant areas of discussion are being inadequately documented by consultants and can therefore legally be presumed not to have taken place. A new antenatal clinic proforma was created to aid the consultant clinician in informing patients of the risks versus benefits profile of VBAC. A new patient information leaflet was designed for patient education during their decision making process. By handing out the leaflet and ideally discussing its contents, trust solicitors have confirmed that documentation of this handout vindicates the clinician from misguided information and specific VBAC risks. - 51 - Sharing Good Practice June 2012 Improving safe prescribing amongst junior doctors: a blended, multi-professional approach, Dr Aamir Saifuddin and Dr Kavitha Vimalesvaran, Kent and Canterbury Hospital Background Poor hospital prescribing consistently compromises patient safety. Anecdotal evidence from pharmacists and findings from local audits and published research suggest junior doctors are commonly implicated. Methods As current FY1s, we are creating a blended learning module with pharmacists and consultant physicians, to be piloted with the new FY1s during induction in August. This aims to bridge the gap between theoretical prescribing taught at medical school and practical hospital prescribing. It will comprise locally accessible online resources providing practical advice on safe prescribing, supported by interactive case-based discussions to be facilitated by existing FY1s and pharmacists. Cases will follow patient journeys from admission to discharge, highlighting where errors occur and potential consequences. Results The teaching module will be completed before the conference in June. The objectives are to: Improve new FY1s’ understanding of typical errors; Encourage a mind-set where safe drug prescription is crucial; Increase confidence; Decrease reliance on pharmacists for identifying mistakes. Key messages Our integrated educational approach, which draws on the combined experiences of senior and junior doctors and pharmacists, aims to increase awareness of the importance of careful prescribing and the possible outcomes of poor practice. This should create more conscientious newly qualified doctors and have widespread, long-term effects on patient safety. - 52 - Sharing Good Practice June 2012 The FY1 on Medical Nights, Dr Anjella Balendra, Luton & Dunstable University Hospital Background Medical nights are a daunting prospect for the vast majority of FY1s. Juniors at our hospital feel that nights provide opportunities to manage acutely unwell patients independently. However, with no Hospital at Night service, few cannula trained nurses, and no established ward cover team, concerns over patient safety led to an audit to assess workload and level of support received by FY1s. Methods A pro forma was designed, collecting data from October- December 2011. The number of bleeps and tasks received by the Medical On-call FY1 were recorded (see Table 1), in addition to acutely unwell patients requiring senior input and for whom support was received. Results Statistical analysis revealed 40% of on call tasks were those neglected by day teams (prescribing: insulin, warfarin, fluids and cannulas. Lack of knowledge regarding bleep protocol led to inappropriate bleeps over non-urgent jobs. 30% of acutely unwell patients did not receive senior review and on one occasion 5 patients became simultaneously unwell - demonstrating demand for more staff. Consequently, a ward cover nurse, HCA and RMO have been appointed. Bleeps are filtered to the FY1 by the 555 matron. Early responses indicate improving levels of support and a re-audit is currently underway. Key Messages The FY1 experience on nights is an invaluable learning experience. It is possible to address patient safety concerns and increasing support for junior doctors without compromising their learning needs. - 53 - Sharing Good Practice June 2012 Recognition and Initial Management of Septic Patients in a District General Hospital. A junior doctor patient safety intervention, Dr Laura Deacon, Dr James Lingard, Dr Rebecca Lewis, Dr Thomas Dove, Dr Vanessa Robba Background Sepsis is a major cause of mortality, implementing a care ‘bundle’ can improve mortality ratesiii but this is done poorly in the NHSiii. Working in a district general hospital each investigator had experienced delay in the diagnosis and management of sepsis, increasing the risk of a poor outcome. Methods A retrospective audit of patients on intravenous antibiotics analysed compliance with the ‘Sepsis Six’ care bundle. Stickers detailing physiological signs of systemic inflammatory response syndrome (SIRS) and the ‘Sepsis Six’ were applied to notes folders. Post-intervention data was collected. F1s’ knowledge of sepsis was assessed with pre- and post-intervention questionnaires. Results and Key Messages The post-intervention sample was smaller. Medical review and administration of antibiotics was done more quickly and lactate measurement was increased. F1s’ knowledge was poor, it improved slightly post-intervention but highlights a need for further education. Managing sepsis continues to be ad-hoc. Further interventions are planned to improve the recognition and standardised management of sepsis. - 54 - Sharing Good Practice June 2012 Surgical weekend handover patient safety improvement project, Dr Joyce Ngai, Luton & Dunstable Hospital A good quality handover is necessary to ensure patient safety by providing the on-call team with the essential information to deliver timely care to patients within the time and resource constraint of a busy weekend shift. We report on a project carried out within the general surgery department at a district general hospital, where the emergency take and all surgical inpatients, from four different day teams, are the responsibility of a three person team. We identified the problem of incomplete handover regarding patients’ progress and vague weekend management plan as hazardous for patients and increasing the workload of the weekend team. We introduced a new design of the weekend handover list, and charted improvements over the weeks, having completed eight to date. It demonstrates that by dividing important information into categories, it serves to prompt the teams to provide the salient information. There is standardised quality of handover between the different teams. We have shown significant improvements over the weeks, which has resulted in notable successes in the rate of weekend discharges. We conclude that simple measures can make significant difference to patient care, and that discussion with and involvement of colleagues is crucial to ensure changes are sustainable. - 55 - Sharing Good Practice June 2012 Experiencing Leadership and Management training through a Foundation Year 2 rotation in Medical Education, Dr Simon Phillpotts, Royal Surrey County Hospital Background There is increasing emphasis on developing doctors’ training in leadership and management skills with the General Medical Council and royal colleges stating the importance of incorporating this into training. It is advised to start this early in a doctor’s career, suggesting that as a general principle the majority of training should be workbased and practical, rather than classroom-based (1-3). Discussion The four month rotation in Medical Education, provides exactly this opportunity through designing and running various projects including medical simulation, local competency assessments, and running a medical course. These roles each rely on developing a number of key skills which have been highlighted in the 2012 GMC guidance ‘Leadership and Management for all Doctors’ (4). Key in this rotation are a) leading a multidisciplinary team, which requires effective communication, approachability and accountability; b) using management skills to design and run the sessions and manage resources; and c) implementing service reform through discussion and feedback. Conclusion This interesting and challenging post provides both an introduction to and the opportunity to experience leadership and management in medicine. Since the governing bodies have stressed the importance of doctors developing these skills, foundation rotations such as this should be more widely available and encouraged. References 1. Gillam S. Teaching doctors in training about management and leadership. British Medical Journal. 2011; 343:d5672 2. Swanwick T, McKimm J. Clinical Leadership development requires system-wide interventions, not just course. The Clinical Teacher. 2012;9:89-93 3. Lombardo MM, Eichinger RW. The Career Architect Development Planner (3rd edn). MA, Minneapolis: Lominger Limited; 2000. 4. Leadership and management for all doctors. General Medical Council. January 2012 - 56 - Sharing Good Practice June 2012 Medical Trainee Support Information card, Mr Jason Yarrow and Ms Lisa Stone, KSS Deanery Background I work in the South Thames Foundation School and my team has produced an information support card for medical trainees. It is not uncommon for foundation trainees to find their first few years a very demanding and stressful time*. It was felt that it is difficult to suggest to trainees that they may wish to seek further support, such as counselling, confidential support for mental or physical health concerns and/or addiction problems. Methods We have produced a fold out card which is the size of a credit card which has information on ‘Sources of Support linked to health and wellbeing’ and ‘Sources of support provided by your NHS Trust’. The card has an attractive design and is discrete (see attachment). Results We have sent the cards to all the NHS Trusts within South Thames. We have given the cards out regularly at one-to-one careers sessions and have had very positive feedback from trainees. Key messages It is a difficult subject to suggest to a trainee that they may need to seek some further help. The trainee support information card helps trainees to know that they are supported. The cards are discrete and have all the information in one place. *Reference: You will survive, the guide for newly qualified doctors. Doc2doc and BMJ Careers (2011): (cited 23rd March 2012) Available from: http://doc2doc.bmj.com/assets/youwillsurvive.pdf - 57 - Sharing Good Practice June 2012 Rectifying junior doctor induced malnutrition!, Dr Lauren Simmonds, Dr Rachael Cave, Dr Sarah Cuff, Dr Karishma Patel, Dr Eleanor Soo and Dr Anne Pullybank, Southmead Hospital, Bristol Background Inexperience of Foundation doctors (F1) can result in cautious feeding decisions when admitting surgical patients, with many choosing a nil by mouth (NBM) regime. However, evidence shows patients kept NBM for more than 6 hours experience adverse outcomes1, and an overall reduction in quality of care. Methods An audit of the duration that patients are kept NBM was carried out. Factors contributing to extended NBM times were identified by mapping the SAU patient journey. This identified 126 steps from admission to definitive management and 24 potential improvement areas. A prioritization matrix facilitated determination of the most likely effective interventions. Utilising ‘Plan Do Check Act’ (PDCA) methodology, NBM documentation, patients’ experience and doctor and nursing knowledge of fasting prior to investigations were measured and acted upon. Results Average SAU NBM duration was 9.5 hours, with patient dissatisfaction correlating with prolonged NBM status. Subsequent PDCA cycles resulted in an improvement in documentation (68% to 80%). Measures assessing the impact of a newly developed ‘traffic-light’ system and increasing awareness through the F1 educational program are on-going. Key Messages Defining and having a clear understanding of the patient pathway identifies areas where F1s can reduce the issue of junior doctor induced starvation References 1 Stroud M, Duncan H, Nightingale J. Guidelines for enteral feeding in adult hospital patients. Gut 2003;52 (Suppl VII):vii1-vii12 - 58 - Sharing Good Practice June 2012 Peninsula Foundation School Welcome Event, Dr Georgia Jones and Dr Natalie Band, South West Peninsula Deanery Background In January 2012, the Peninsula Foundation School held a Welcome Event for its matched applicants. The aims were to help applicants make their post preferences and introduce them to the Foundation School. The event included presentations from the School and trainees, a Q&A session with the Foundation Programme Training Directors and Trust information stands. Methods An on-line survey was sent to all attendees to evaluate the event’s effectiveness. Results 60% (116) attended and 78% (91) completed an evaluation form. After the event, 42% made a different first choice of trust. This effect was greater for non-local applicants. 77% said that the most useful aspect of the day were the trainee presentations. 22% highly valued the trust information stands. 100% recommended the event. Suggested improvements for future events included more information about accommodation, rotas and banding, standardizing the type of information provided by different trusts and changing the question and answer panel format. Key Messages The Welcome Event was an effective way of providing applications with information for making their post preferences. The event had a greater effect on non-local applicants’ choices. Attendees valued information from current trainees most highly. The event also had a general positive effect of enthusing applicants about coming to the region. - 59 - Sharing Good Practice June 2012 A Review into Fractured Neck of Femurs following an Inpatient Fall in a General Hospital, Dr Ashleigh Squires, Dr Parul Shah and Dr Sarah Hyde, Northampton General Hospital Background Between April 2011 and April 2012 at Northampton General Hospital, 13 patients sustained a fractured neck of femur (#NOF) following an inpatient fall. In the UK, mortality following a #NOF ranges between 20%-35% in one year, in patients aged 82±7. In 2005/6, #NOF cost the NHS £384m (1); highlighting the seriousness of these incidents. Methods 12 case notes (n=12) were reviewed retrospectively to ascertain whether a medical cause could have contributed to the fall. Furthermore, post-fall care was assessed, including osteoporosis screen, medication review and appropriate post-fall referrals. Results This review found that 1/3 of patients fell secondary to a presumed medical illness, with 58.3% deemed confused at the time and 50% administered sedative medication prior to falling. Total mortality rate was 25%. 83% of patients were prescribed appropriate bone protection on discharge, 100% were referred to physiotherapy and 1/3 reviewed by a fall specialist. Key Messages Medical illnesses and sedative medications played a significant role in precipitating inpatient falls; factors often overlooked. The post-fall management was generally suboptimal. This review can be implemented in teaching to improve patient safety. A ‘PostFall Pathway’ was designed to aid assessment and management following an inpatient fall, with the intention of re-auditing. References (1) http://www.institute.nhs.uk/index.php?option=com_content&task=view&id=1907 &Itemid=4436 - 60 - Sharing Good Practice June 2012 Electronic Mapping tool for monitoring and planning of Foundation Programme Teaching, Dr Nicola Dowling, Dr Heather Beastall and Dr Koren Stickland, Worcestershire Royal Hospital Formal Foundation Programme teaching is a compulsory aspect of the foundation programme which is designed to complement the clinical experience of junior doctors to provide adequate training and experience.1 The Foundation Programme curriculum provides guidance regarding the content of these teaching programmes2 We have analysed the teaching programme at Worcestershire Royal Hospital using an objective tool, curriculum mapping, to establish which areas of the curriculum are covered by the current programme. This allows better planning of future teaching programmes. As an extension of this we have developed an electronic mapping tool which enables teaching programmes to be analysed in a prospective manner allowing continuous assessment and adjustment of teaching programmes. This work showcases the electronic tool and how it can be used in the organisation of foundation teaching. This tool could be applied to all foundation schools allowing fast and objective comparison between programmes. We believe this would facilitate the provision of high quality foundation teaching throughout all foundation trainees and that the principle could also be applied to other training programmes. References: General Medical Council [Internet] The New Doctor: Guidance on Foundation training; c September 2009 (cited December 2011) available from http://www.gmc-uk.org/New_Doctor Foundation Programme [Internet] The UK Foundation Programme Curriculum: Reference Guide; August 2011 (cited December 2011) available from www.foundationprogramme.nhs.uk - 61 - Sharing Good Practice June 2012 Combating pneumonia mortality in a DGH: A process mapping audit, Dr Jonathan Wilkinson, Dr Heidi Archer and Dr Charlotte Payne, Northampton General Hospital Background Pneumonia is common and associated with significant morbidity and mortality. Recent Dr Foster data has revealed that Northampton General Hospital’s mortality rate was one of the highest in the country. The Pneumonia Working Group was formed to address this issue. Methods This was a retrospective process-mapping audit (Dec 2010 - Jan 2011) of 44 living patients with low predicted mortality. Standards were set from BTS guidelines: ‘100% of patients seen, CURB-65 documented and antibiotics administered within 4 hours of patients presenting to secondary care.’ (1) Results 0% of patients had their CURB-65 score documented. 20% (n=9) were coded with the incorrect diagnosis and a further 30% (n=11) had multiple co-morbidities and consequently coded as low predicted mortality. Triage time to antibiotics time was a median of 225 minutes with a maximum of 48 hours. Only 50% of patients received antibiotics within 4 hours of presentation. Key Messages Lack of awareness of the importance of the CURB-65 score and classification of pneumonia were identified as key reasons for poor outcomes. Additionally doctors were not actively administering antibiotics themselves increasing waiting time by an average of an hour. Poor documentation, failure to commit to a diagnosis and a 50% shortfall in the numbers of coding staff has resulted in coding errors. The Pneumonia Working Group has set out new documentation pathways and the awareness of the CURB-65 score has been increased by various means. A re-audit will be conducted in June 2012. References (1)The British Thoracic Society Guidelines for the Management of Community Acquired Pneumonia in Adults: 2009 Update. http://www.britthoracic.org.uk/Portals/0/Clinical%20Information/Pneumonia/Guidelines/CAPQuickRef Guide-web.pdf - 62 - Sharing Good Practice June 2012 Are we following the correct prescribing procedures? Dr Mohammed Bajalan, Ms Helen Wilson and Dr Raghava Reddy, Mid-Staffordshire NHS Trust BACKGROUND Medication errors account for 25% of all adverse events in UK Hospitals. Prescribing errors account for 20% of these events.1 Our aim was to identify whether prescribers were following the correct prescribing procedures according to legal requirements and trust policy. METHODS Retrospective audit with the pharmacy team, using 60 prescription charts, totaling 480 prescriptions over a one month period. 10% of results validified by senior pharmacist. RESULTS 88% of prescriptions did not have traceable contact number (a legal requirement). 83% of amended charts did not have a re-written prescription or counter signature. 93% of discontinued prescriptions did not have a signature, date, time or reason for discontinuation, nor is the action and rationale being recorded in the patient’s medical notes. 22% of prescriptions did not have date or signature. 37% of prescriptions not written in upper case. KEY MESSAGES Prescribing is an area of medical practice relevant to all doctors from all specialties at all levels. It is imperative we address these issues alongside extensive additional areas identified by this audit. We further recommend; global name stamps for all registered prescribers, compulsory e-induction modules prior to employment, annual ‘re-fresh’ sessions, sufficient information to locum doctors and exploration of the role of electronic prescribing as demonstrated by sufficient evidence based results from the United States. References: An organisation with a memory. Dept of Health 2001 - 63 - Sharing Good Practice June 2012 Improving Weekend F1 Doctor Ward Cover – A Patient Safety Issue, Dr Julius Bruch, Dr Rebecca Allen, Dr Kate Craufurd, Dr Ahmed El Sobky, Dr Richard Francis, Dr Alistair Mackay Background Recent press coverage has highlighted a problem with patient safety over the weekends in the UK. At Salisbury District Hospital all (~250) medical beds are covered by one F1 doctor. Our aim is to improve patient safety by getting the right doctor to the right patient at the right time on weekends. Methods We monitored the response time and type of each job received by the F1 wardcover doctor. We also conducted surveys on patient expectations over the weekend, as well as nurses’ and doctors’ perceptions of urgency of different tasks. Results We found the mean response time to see an unwell patient to be 2:17 hours (15 minutes for critically ill patients). 60% of bleeps were avoidable. Main avoidable causes of delay were responding to unnecessary bleeps and logging in to computer systems. Nursing staff and doctors had discrepant perceptions of urgency for different jobs. Key Messages There is scope increasing efficiency of the weekend wardcover work. We suggest (1) to use the charge nurse on each ward to coordinate bleeps by bundling jobs and using a newly developed triage system and (2) non-urgent jobs to go in a separate electronic or paper list. - 64 - Sharing Good Practice June 2012 Using Local Education Audits to Improve the Quality of Foundation School Directors’ reports - ‘the e-portfolio for programmes’, Dr Sara Mahgoub and Prof Paul Baker, North Western Deanery Foundation School and Royal Bolton Hospital Background The North Western Foundation School introduced annual Foundation Programme Director (FPD) reports in March 2009. Programmes found the report deadline challenging, and many reports lacked any supporting evidence. One item of evidence that was particularly lacking was the local educational audits (LEA). Here, programmes varied in their methodology and content- some audited their practices whereas others failed to do so. Those that did audit, showed a wide variation in content that was needed to support the FPD report dataset. Methods All the local educational audits from the Foundation Schools (FS) in the North Western Deanery were collated. Only 37.5% of these schools had audits, these handful of audits were then dissected. Results A new LEA proforma was drafted using General Medical Council domains, it included a minimum set of trainer feedback - that fully supports the FPD report format.The new proforma was piloted amongst foundation trainees. This allowed us to alter the style of questions, keeping the content/outcomes the same. Key messages Overall, this will help ensure a consistency of reporting amongst the FS with strong supporting evidence. Furthermore, an automated audit and report processing system could be developed as a result. - 65 - Sharing Good Practice June 2012 Do Patients know their consultants? Dr Asli Kalin and Dr Philippa Graham, North Middlesex University Hospital Background A clear system by which patients know the team looking after them leads to a sense of belonging for patients, clearer communication and a point of contact once patients leave hospital. The lack of such a system at North Middlesex University Hospital has been leading to anxiety from patients and confusion during subsequent hospital admissions. Methods We asked all medical and surgical patients in our hospital (102 beds) the questions “What is the name of your consultant?” We also checked whether the white board by the patient’s bed had the correct consultant name present. Results 35% of patients knew the correct name for their consultant and 27% had the right name on the white board above their bed. Key Messages We designed small patient cards entitled “My Ward ID Card” which includes their consultant’s and junior doctor’s name and consultant secretary’s number. We also redesigned all white boards by patients’ beds to include patient’s name, their consultant’s name and junior doctor’s name and bleep number (for nurses’ use). The cards are being handed over to newly admitted patients on the post-take ward-round during which the white board is also being updated. The project has received excellent feedback from both patients and nursing staff. - 66 -
