Download 2013 - 2014 - Dartford and Gravesham NHS Trust

Clinical Audit & Effectiveness
Annual Report
April 2013 – March 2014
Contents
Section
1
2
Page
Clinical Audit & Effectiveness Chairman’s Report
3
Clinical Audit & Effectiveness Manager‘s Report
4
2.1
2.2
2.3
2.4
2.5
4
4
6
6
7
Introduction
Summary of Audit Outcomes and Achievements
New Developments
Risks
Going Forward
3
Clinical Audit and Research Competition
8
4
Projects Scored as ICE 1
9
5
Audit Leads Committee (ALC)
11
Appendices
A
Clinical Audit & Effectiveness Department Service Evaluation
Questionnaire & Responses
B
Abstracts from ICE 1 initial audit projects
C
Abstracts from ICE 1 re-audit projects
12
13
35
2
Appendix B
1. Clinical Audit and Effectiveness Committee Chairman’s Report
There have been some significant changes in the structure of clinical audit management within
the Trust over the last twelve months.
The most important change in the way forward plans regarding audit activity are being managed.
The directorate and departmental leads for clinical audit activity are being actively encouraged to
develop robust forward planning for their past, current and future audit projects.
This formal planning has been overseen by the clinical audit department facilitators, who actively
engage with the audit leads.
Quite strict rules apply regarding which audit project should be allowed to go ahead into the next
part of the audit cycle. For example a re-audit will not be permitted when it has been clearly
demonstrated that the action plan recommended from the previous audit, has clearly not been put
in place.
There has been quite significant progress in obtaining good quality reports regarding national
audits within the Trust. There is also clear evidence of a unification in the format of the audit
meeting agendas. By and large, most of the agenda items are following the correct template right
across the Trust.
The clinical audit and effectiveness committee continues to meet regularly and the schedule of
reports from each directorate or department has confirmed good quality ongoing audit activity with
very strong evidence of clear forward planning.
Our aim for the coming year is to continue the efforts to streamline audit activity across the Trust
and to remove failing or abandoned audits from the forward plan.
We are aware of the need for clearer and more robust reporting of audit activity to the quality and
assurance committee. We welcome the fact that this committee will be looking at audit activity in
more detail and monitoring the progress of the important audits.
Finally, it was a pleasure to see that the annual audit and research competition, once again,
yielded very good quality work and clearly demonstrated changes in important clinical practice as
a result of the audits and research projects that had been undertaken.
Mr M H Jones
Consultant Obstetrician and Gynaecologist
Clinical Audit Chairman
3
Appendix B
2. Clinical Audit and Effectiveness Manager’s Report
2.1 Introduction
This report represents the headlines regarding audit activity from 1st April 2013 to 31st March 2014
and summarises the outcomes and achievements of clinical audit during the year, as well as
some of the changes recently implemented and those still to be made.
2.2 Summary of Audit Outcomes and Achievements
Actions Arising
382 actions arose from the 152 audits completed within the year, of which 271 (71%) have been
completed; of the 111 outstanding audits 85 are overdue. The chart below shows the breakdown
of these actions by directorate.
Percentage Completion of Actions Arising from Clinical Audits Completed Between
1/4/13 - 31/3/14
100%
1
80%
1
8
72
3
29
38
60%
10
4
40%
27
9
1
5
7
4
39
5
13
1
9
2
6
Not complete - Overdue
1
2
1
2
Ra
di
ol
Su
og
rg
y
ica
lS
pe
cia
W
om
lt i
es
en
an
d
Ch
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ild
re
rv
ice
n
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ve
lo
pm
en
t
G
ov
er
na
nc
e
Pa
th
ol
og
y
s
at
r ic
Pa
ed
i
g
O
pe
ra
t io
ns
Nu
rs
in
Co
nt
ro
l
In
fe
ct
io
n
Em
er
ge
nc
y
M
al
C
ed
ici
ne
ar
e
0%
Cr
itic
14
19
2
1
20%
46
Not complete but not yet due
Completed
Last year I reported that an ongoing challenge for clinical audit is ensuring real changes are
identified, implemented and sustained where required to improve healthcare delivery, and patient
outcomes and experience. All completed audits are now required to have an action plan
submitted if there are recommendations for changes to be made; previously recommendations
were noted but without any need to identify who or when actions would be implemented by.
Unfortunately due to directorate audit meetings often being chaired by different people, or
including many different specialties, we have been unable to implement an effective process to
manage these actions.
It is anticipated that the requirement for directorates to report progress against ICE 1 action plans
to the Quality and Safety Committee, and the introduction of directorate action plans following the
Lafferty review will ensure actions arising from audit are given the same focus and priority as
those agreed following incidents and complaints.
Completed Audits
The chart below shows the 152 completed audits by department and the related ICE scores,
including those still implementing actions at 31st March 2014 (46/152). The 22 ICE 1 audits are
shown in section 4 of this report.
4
Appendix B
Summary of Audits Completed by Specialty and ICE Score
50
Count of ICE Score
45
14
40
No. of audits
35
30
9
25
3
20
3
2
15
10
5
0
20
2
9
5
5
2
Critical
Care
10
6
5
Emergency
Medicine
5
2
1
Infection
Control
5
3
5
4
5
5
1
1
Operations Paediatrics Pathology
Radiology
7
3
3
Surgical
Specialties
Women
and
Children
3
3
1
Other
ICE Score
ICE 1 (n.22)
ICE 2 (n.54)
Discontinued Audits
ICE 3 (n.48)
Not scored (n.28)
Directorate
Before an audit is discontinued 2 formal requests are made of the project team to provide updates
and details of expected completion dates; if these are not forthcoming the project is discontinued
and this is notified to the project team, specialty audit lead, clinical director and general manager.
Audits can be discontinued for a number of reasons, the most common of which is due to a lack of
progress being made. This most commonly arises when junior doctors rotate away from the
specialty or leave the trust without completing the audit, emphasising the importance of having a
senior/substantive lead for each project started.
During the year there have been 38 discontinued audits, compared to 20 in 2012/13 and 21 in
2011/12. The reason for these is as follows:
Reason for discontinued audits
2013/14
2012/13
Included in other audit
5
7
No changes implemented - added to risk register
-
1
21*
3
Priority of department changed - no longer needed
7
6
Unable to collect data
-
4
National audit not applicable or not participating
5
9
TOTAL
38
30
No response to queries / lack of progress
*These 21
audits are split
across all
directorates
with the
exception of
paediatrics
who did not
discontinue
any audits due
to lack of
progress.
2.3 New Developments
Feedback from Clinical Audit Leads
To ensure the ongoing changes made within the Clinical Audit & Effectiveness Department
continue to effectively support the specialty clinical audit leads, the Department undertook a ‘user
survey’ to gain feedback on the audit team, support provided and information and training
provided. 17 (50%) people responded to the questionnaire and the results of this were very
positive with over 82% saying the support they receive from the department is ‘very useful and
constructive’. Unfortunately only 63% said the same of the Audit Leads Committee meetings and
we will look at how we can improve these going forward.
5
Appendix B
We were asked to provide more help with the design of audit proformas using available software,
and to teach staff how to complete [audit registration] forms and develop spreadsheets etc for
inputting data. We have recently implemented new software – Snap - to make audit proformas,
data entry and analysis much easier and this is discussed further in section 2.3 below. Training
has been provided to FY1 and FY2 doctors this year but we recognise the need to extend this to
nursing staff, particularly in midwifery where the number of nurse led audits is highest, to ensure
each project is carried out to its full potential.
Please see Appendix A for the full results from the satisfaction survey.
Snap
The clinical audit department has recently implemented a new piece of software ‘Snap’ to improve
the quality of audits undertaken and enable auditors to collect and analyse audit data via the web
using a number of input devices, from desktop computers to tablets and smart phones.
This will overcome a number of quality concerns that arise in clinical audits at present including
collecting too much / not enough / irrelevant data to compare current practice to guidelines or
standards, and IG risks when patient identifiable data is collected unnecessarily. It will also
remove the need to enter all data collected into another form, such as spreadsheet, to enable
analysis.
The system is currently being set up to administer the trust wide Quality of Information in Health
Records audit, which previously collected data via a questionnaire on Adagio. Although this was
adequate for data collection, the significant time needed to review, interpret and analyse the data
was a huge resource pressure on the department and there was little engagement with the results
at department and ward level. By using the new system data can be entered online in the same
way, but the questionnaires are more intuitive, with questions excluded if they are not applicable
and the reporting, once it has been set up initially, is simple and quick to run whenever needed.
We will also be able to give individual wards access to view their own results on a live basis so
they can take responsibility for addressing any areas of concern and ensuring improvements are
made.
2.4 Risks
National Audits
Last year a new process for the management and review of national audits was introduced and
there has been a significant improvement in the information provided by national audit leads at the
onset of new projects in terms of the data they will be collecting and the expected numbers of
patients involved. However some risk remains in that we are not always successful in obtaining
evidence of the local review and reporting of some national audit reports by the project leads.
There are still 6 audits from the 2012/13 Quality Account list for which the local summary and
evidence of actions/learning remain outstanding, as follows:
Audit
Ref
Project Title
Specialty
2076
National Review of
Asthma Deaths
Respiratory
Dr Mushtaq
Awaiting completion of the National
report summary and ICE score.
2103
Cardiac Rhythm
Management Audit
Cardiology
Pauline
Cherek
Awaiting completion of the National
report summary and ICE score.
2183
Carotid Interventions
Audit (Carotid
Endarterectomy (CEA)
& Carotid Stents)
General
Surgery
Mr McIrvine
National report summary received and
audit scored as ICE 2 – to be presented
at Audit Leads Committee to discuss the
results and action plan.
2200
Bowel Cancer
(NBOCAP) (Patient
Outcome Programme)
Cancer
Services
Mr Bhardwaj
Awaiting completion of the National
report summary and ICE score.
Auditor
6
Comment
Appendix B
2201
Lung Cancer
(LUCADA) (Patient
Outcome Programme)
Cancer
Services
Dr Mushtaq /
Pippa Miles
Awaiting completion of the National
report summary and ICE score.
Resources
The clinical audit department has taken on a number of additional responsibilities in the last few
years with no increase in staff numbers. The key pressure comes from the national audit
programme – before the Quality Account, national audits were undertaken within directorates with
little or no support or involvement from the clinical audit department. Now however we are
required to register all audits on the Quality Account list each year, obtain registration forms to
identify the audit methodology, data to be collected and key staff involved both for data collection
and reporting, provide support during audits, and maintain oversight of their progress until the final
report has been received, reviewed and ICE scored, and action plans are implemented. Some
projects are only a month or two long, but others (for example the National Emergency
Laparotomy Audit – NELA) last for several years with data required to be collected by different
staff groups, all being monitored and supported by one audit facilitator.
The department is now also involved in the national Trauma Audit and Research Network which
collects data on every trauma case in the trust, and supports the Mortality Working Group by
notifying consultants of every patient death, providing medical notes for review and maintaining all
related records.
Furthermore, although the new Snap software will reduce data entry and analysis time for audits,
most of this saving will be made by the clinicians rather than the audit department, and the more
wider reaching projects we become involved in to facilitate the use of Snap, the more pressure
this puts on departmental resources.
It is anticipated that the structure of the department and its roles within the trust may need to be
reviewed over the next year to ensure we continue to be effective in the support and delivery of
high priority clinical audits.
2.5 Going forward
It is anticipated that the changes being made to the reporting to the Quality and Safety Committee
will raise the profile of clinical audit and key outcomes, including ICE 1 audits and resulting action
plans, and provide an effective mechanism for ensuring audits lead to quality improvement where
required.
The department will continue to support audit leads in the development and delivery of the clinical
audit forward plans and in strengthening their links to other governance areas. We are working
towards developing a training programme for audit leads and have already introduced an
information pack for any newly appointed leads to help them understand what is required of them
and how we can help.
Top actions to take forward for 2014-2015




To progress the monitoring of the implementation of action plans arising from clinical
audits.
To develop a training programme for directorate and specialty clinical audit leads.
To progress the use of Snap to drive improvements in the quality of audits undertaken.
To continue to inform the Quality and Safety Committee of non-participation in national
audits and details of any discontinued audits.
My sincere thanks to the audit team for their support and incredibly hard work over the last year.
Angela Eldridge
Clinical Audit & Effectiveness Manager
June 2014
7
Appendix B
3. Clinical Audit & Research Competition
The Clinical Audit and Research Competition saw the presentation of five audit and five research
projects on 8th May n the Lecture Hall of the Philip Farrant Centre. The competition was judged
by Miss Annette Schreiner - Medical Director; Phillipa Wakefield - ITU & Outreach Audit Lead; Dr
Guy Sisson - Consultant Gastroenterologist, Janardan Sofat – Trust Chairman; Dr Muhammad
Javaid – Consultant Nephrologist; Sue Craven – Associate Director or Governance & Head of
Therapies.
All the presentations were of an excellent standard and stimulated an interesting debate and an
opportunity to learn from others work. Prizes in the form of Bluewater vouchers were awarded as
follows:
Audit Competition Winners
 1st prize £200 – WHO Surgical Safety Checklist Compliance of Completion: Closing the
Loop – Dr J Nimick, Dr R Sucharita, Dr S Parmar - Anaesthetics
 2nd prize £100 – A Re-Audit of Vancomycin Prescribing and Monitoring at DVH – James
Hartwell – Pharmacy
 3rd prize £50 – A Sustained Improvement in Emergency Surgical Admissions Documents
– Sarah Wheatstone, Brenda Stacey, Kothandaraman Murali – General Surgery
Runners up £25 each:
 Infection Rates in Parenteral Nutrition Lines – Dr R Pai, Dr G Sisson, L Dempster, J
Wheeler

An audit to determine whether patients newly initiated on new oral anticoagulants are
being counseled at DVH – Gagan Kaler, Chikondi Savieli - Pharmacy
The posters of the top three prize winners in Clinical Audit and Research are on show in the
display cabinets in the Philip Farrant Centre. The Competition this year attracted a full capacity
turnout, with over 120 people attending for at least part of the event. It was as always pleasing to
see a wide variety of different departmental and specialty staff represented.
I would like to thank Mr Jones and Mr Sriprasad for their support and encouragement, Bridget
Fuller of the R&D team; and Jane Beadle, Tracey Fyfe, Anita Gorvan and Jo Summers from the
Clinical Audit team for all their hard work, without whose efforts the event would not have been
possible. Finally we must also thank the Phillip Farrant Education Centre staff for their help and
support.
8
Appendix B
4.
Projects Scored as ICE 1
Projects are scored as an ICE 1 if they show high implications or priority for change or action,
highlight major clinical risk issues or the need for major changes in patient care, or that there have
been major differences in outcomes when comparing current practice to a given set of standards.
Therefore these projects are carefully monitored.
With these projects any action plans need to be implemented and monitored and a re-audit should
be undertaken within 3-6 months. Where this is not possible or where a project is scored as an
ICE 1 again at re-audit a risk assessment is required to be completed to ensure the issue
continues to be monitored through the appropriate risk registers.
In 2013-2014, 22 completed audits were scored as ICE 1, 14 relating to initial audits and 8 reaudits; 6 re-audits are still in progress following previous ICE 1 scores. In addition 7 audits
previously scored as ICE 1 were scored ICE 2 or 3 on re-audit, demonstrating an improvement in
practices from the actions taken. These are all summarised in the tables below and the full
abstracts are shown in Appendix B & C to this report.
Specialty
Audit
Ref
Project Title
14 NEW INITIAL ICE 1 AUDITS – See appendix B for full details
Trauma & Orthopaedics
2327
Audit of Trauma Patient's time to theatre and reasons for delays
Obs & Gynae
2236
Obstructed Labour Delivery
Obs & Gynae
2276
Audit Of Laparoscopic Hysterectomies
Obs & Gynae
2414
Cardiotocograph (CTG) Documentation Audit
Haematology
2138
Sickle Cell Acute Painful Episode Clinical Audit as per NICE
guideline 143
General Surgery
2338
Antibiotic Prescription Audit -General Surgery
A&E
2355
Severe Sepsis - CEM Interim Audit
Risk Management
2417
Audit of Incident Reporting on Datix
Pharmacy
2292
An audit of Vancomycin prescribing at DVH
Urology
2336
A review of the current practice of post first TURBT intravesical
mitomycin
General Surgery
2332
The Management of Severe Acute Pancreatitis at DVH
Nephrology
2288
NHS Kidney Care Acute Kidney Injury Audit
Nutrition & Dietetics
2264
Completion & accuracy of STAMP - Paediatric Nutrition Screening
tool - Willow Ward
Gastroenterology
2369
Parentaral Nutrition Service Review
9
Appendix B
Specialty
Audit Ref
Initial audit
ICE score
Project Title
8 RE-AUDITS SCORING ICE 1 - See appendix C for full details
Diabetes
2121
Foot assessment for Diabetes Patients - Re-audit
1
A&E
2243
Re audit of D Dimer & CTPA for suspected PE in A & E
1
Trauma &
Orthopaedics
2364
Re-audit of Trauma Patient's time to theatre & reasons for
delay
1
General Surgery
2452
Re - audit of Antibiotic prescribing in General Surgery
patients
1
Infection Control
2107
Audit Of Infection Rates In Parenteral Nutrition Lines
(Patient Bacteraemia Arising From Poor Clinical
Management Line Sepsis In Total Parenteral Nutrition)
1
ITU
2169
Re-audit Observations Audit
2
ITU
2413
Re-audit Observation Audit & Fluid
1
General Surgery
2165
Re-audit of Surgical Patients - The first 24 hours
2
Specialty
Audit
Number
Project Title
NEW
Comments
ICE score
7 RE-AUDITS DEMONSTRATING IMPROVED RESULTS (PREVIOUS ICE 1 AUDITS)
Paediatrics
2104
Re-audit Breast
Feeding during stay &
on discharge home
(NICE)
A&E
2115
Reagent Strip
Urinalysis
2
Pharmacy
2207
Re-audit of Oxygen
Prescribing at DVH
2
General
Surgery
2166
Re-audit of Compliance
with NICE CG50
'Acutely Ill Patients'
2
Microbiology
2151
Re-audit of the Impact
of Delayed
Antimicrobial Therapy
in Septic ITU Patients
2
General
Surgery
2425
Re-audit of Surgical
Patients - The first 24
hours
2
10
2
Babies breastfeeding on discharge
increased to 14.4% from 5% at initial
audit. Teaching to continue and infant
feeding guidelines implemented.
46% of pts admitted had urinalysis, up
from 29% at initial audit. Included in
nursing training and to introduce new
protocol to require all pts to have urine
dip.
49% of pts receiving oxygen had
adequate documentation for prescribing,
desired saturation levels and
administration. Training to be given.
Improved documentation of frequency of
observations required from 3.6% to
36.8%. Increase in obs following
increased PAR school noted in 99.7% of
cases, Vs 20% at initial audit. Continue to
reinforce guidelines for staff.
Improvements since initial audit – most
antibiotics fiven <1hr of sepsis from 25%
to 90%; increased blood cultures from
55% to 100%. Reinforce Surviving Sepsis
Campaign.
Pt details recorded improved from 71 –
100%; allergy recording improved 87100%;’ VTE assessment increased 286%; sustained improvements in other
Appendix B
Risk
Management
2439
Re-audit of Incidents
Reported on Datix
3
areas. Emphasise GMC good practice re
medical record keeping, and review and
revise if necessary the admission docs.
The initial audit identified 75% of incidents
reviewed had multiple errors including
incorrect harm levels and being reported
to NRLS without being reviewed.
Following updates to various policies,
Datix system and harm categories the reaudit found only minor issues with 42%.
6 ICE 1 re-audits are still in progress as follows:
National Audit of Dementia 2012 – Elderly care, ref 2142
National Care of the Dying – Cancer Services, ref 2136
Re-Audit of Malnutrition Universal Screening Tool and STAMP – Nutrition & Dietetics, ref 2472
Re-audit a review of current practice of post first intravesical mitomycin C – Urology, ref 2410
Management Of Laparoscopic Hysterectomies Re-Audit – Obs & Gynae, ref 2443
Cardiotocograph (CTG) Documentation Re-Audit – Obs & Gynae, ref 2477
5.
Audit Leads Committee (ALC)
The ALC is chaired by consultant obstetrician Mr Jones and has a membership of representatives
from all directorates and specialties.
Meetings are held on a quarterly basis in March, June, September and December each year.
During the last year the function of the ALC was:





To receive regular updates on current audit activity in each department/specialty,
To monitor the progress of clinical audit forward plans,
To review the ICE 1 reports, monitor risks and facilitate the implementation of
recommendations
To review the NICE quality standards and any audits required
To receive presentations of national audits results scored as ICE 2.
Audit leads are required to regularly attend meetings of the ALC and attendance over the past
year has improved, with 11 specialties/directorates being represented at 3 or 4 of the quarterly
meetings; unfortunately 4 specialties were only represented at one meeting.
Attendance at ALC meetings during 2013/14
Attended 4 / 4 meetings
Attended 3 / 4 meetings
ITU, nutrition & dietetics / therapies, paediatrics, cancer services,
anaesthetics, surgery, O&G
Pharmacy, haematology/pathology, T&O, elderly care
Attended 2 / 4 meetings
Radiology, respiratory, urology
Attended 1 / 4 meetings
Medicine, cardiology, gastroenterology, A&E
11
Appendix B
APPENDIX A
Clinical Audit & Effectiveness Department Service Evaluation Questionnaire & Responses
How can we improve?
Clinical Audit and Effectiveness Department
Please take a moment to help us improve the service that the Department provides to you as Directorate /
Department Audit Lead. When you’re done, please either return the questionnaire in the internal post to the
Audit Department Level 3 Admin Corridor, or email back to [email protected].
Clinical Audit Team
How often do you meet with your audit
facilitator?
35% Monthly or more often
35% Every 1 – 2 months
30% Less often
Is there always someone in the audit department
who can help you when needed?
71% Yes, always
29% Usually
0
Rarely / Never
Departmental Support
Very useful
and
constructive
Adequate
Needs
improvement *
Don’t know
/ Not used
Registering new audits and assisting
with methodologies?
88%
6%
0%
6%
Progressing audits to completion?
82%
12%
0%
6%
Developing action plans for
implementation?
82%
12%
0%
6%
63%
25%
0%
12%
How would you rate the help and support
given by the department in the following
areas:



Thinking now of the quarterly Audit Leads
Committee meetings, how would you rate
their effectiveness?
Information and Training
How would you rate the information provided to you by the
department, in terms of timeliness and usefulness?
53% Very good
35% Good
6% Adequate
6% Needs improvement *
Do you think there should be
annual training / refresher
sessions for audit leads?
88% Yes
12% No
If you ticked ‘needs improvement’ for any of the above, please provide further
details
Need to provide more help with the design of audit proformas using available software.
Any other comments
All members of audit team always very friendly and approachable, a pleasure to work with.
I feel communication is the key, you get out what you put in. I feel very supported and valued by
the department, thank you
Finding time and junior help with audits is my biggest problem
I am very happy with the service I receive
The team are very helpful and supportive. The audit registration forms could however be revised
as this is often off-putting for clinical staff when trying to engage in audits. It would be useful if
there were sessions available to teach staff how to complete the forms and develop spreadsheets
etc for inputting data.
Thank you for your participation!
APPENDIX B
ABSTRACTS FROM ICE 1 INITIAL AUDITS
Audit of Trauma Patient’s time to theatre and reasons for delay
ID 2327
Audit project lead: Dr Andrew Stone, Mr Mike Thilagarajah
Speciality:
Trauma & Orthopaedics
Presented: April 2013
Reasons for Audit:
Clear standards exist regarding maximum acceptable waiting time for operative management for
certain types of limb trauma. In fractured neck of femur there are significant financial incentives for
complying too these standards, which are to become more stringent soon.
Background:
Anecdotally there was concern in the department regarding waiting time for operations in limb
trauma. This can significantly impact patient care, and lead to significant financial losses in
fractured neck of femur patients. Longer waiting times also mean longer hospital stays, with the
associated increased cost and morbidity. The audit was carried out to assess the Trust’s
performance when compared to national and local standards, and also to try and identify factors
leading to delays
Aims & Objectives:
Aim: Improve waiting times in cases of limb trauma requiring operative management
Objectives: Assess waiting times in operative management of limb trauma. Identify factors
causing unnecessary delays. Remove/improve such factors.
Design:
1 month of retrospective data collection (16th February 2012 to 17th March 2012). Trauma book
consulted to identify acute limb trauma admissions. Cases requiring operative management
identified. Time of admission or time of referral to orthopaedic team compared with surgical start
time, waiting time calculated and compared to guidelines. Case notes examined for reasons for
delay in any cases exceeding recommended waiting times. Data was collected in December
2012. 56 patients in total were included. 1 was lost to follow up as notes could not be found to
investigate the reason for delay.
The standards for maximum acceptable waiting times were as follows. Fractured neck of femur:
36 hours (Best Practice Tariff from joint BOA/BGS guidelines. Open fractures: 24 hours (joint
guidelines from BAPRAS/BOA). Dislocations: 24 hours (local guidelines set by the consultant
orthopaedic surgeons). Other injuries: 36 hours (local guidelines set by the consultant orthopaedic
surgeons).
Results:
13/30 Fractured neck of femur patients waited longer than 36 hours for their operation (45%). 2/20
patients with other injuries waited longer than 36 hours (10%). All open fractures and dislocations
were operated on within 24 hours. 15/56 in total exceeded the maximum waiting time (27%).
Of those 15 patients, 1 set of notes was not available, 1 was treated conservatively so this was a
planned delay, and 6 were delayed as they were not medically fit for theatre. The remaining 7
patients had been delayed due to insufficient space on the afternoon trauma list.
Of note, discovered whilst performing the audit, 41% of operations are being carried out on the
CEPOD emergency list during the day on weekends and bank holidays.
Conclusions:
27% of limb trauma not meeting recommended target. 45% of fractured neck of femur patients not
meeting target. 47% of those not meeting the target are due to insufficient space on the current
afternoon trauma list. This is therefore a potentially improvable cause of increased length of
hospital stay and increased morbidity associated with delay in definitive treatment. Also, 41% of
trauma operations are being done on the CEPOD list on a weekend. This is not an appropriate
use of CEPOD, and will have repercussions outside of the orthopaedic department, potentially
delaying emergency general surgical operations.
13
Appendix B
Areas of moderate clinical risk and significance have been identified in this audit
Recommendations/Action plan:
No:
Recommendations:
Action(s) to be taken:
1.
Use of morning elective Sufficient space to be
left on the staff grade
list for trauma
2.
Pre-preparation of a
fractured neck of femur
patient for morning list to
minimise delays
3.
Re-audit
elective lists for trauma
to be added
Night SHO to identify a
suitable patient,
prepare them for
theatre and ask the on
call anaesthetist to
assess the patient
overnight
Evidence
Action:
of
Nominated
lead (s):
Completion Date:
Updated
TheatreMan
lists
Mr
Thilagarajah
January 2013
Documentati
on in patient
notes
Dr Stone
January 2013
Re-audit for the same Re-audit
Dr Stone
time period in 2013, data
and
examining if there presentation
has
been
any
improvement
May 2013
Obstructed Labour Delivery – A Quality Laboratory Review
N2236
Dr Madhavan, Mr Jones, Mr Waterstone
Specialty: Obstetrics & Gynaecology
Presented/Reviewed: O&G meeting 8/11/12
Reason for Audit: Quality Laboratory Case Note Review
Background:
Quality Laboratory (QLab) sessions are run on a 3 monthly rolling programme throughout the
Trust. The programme enables directorates to compare their coded activity to those of their peers.
At the session held on 11th April 2012 the O&G group reviewed code 064, obstructed labour due
to malposition/malpresentation. The data from January to December 2011 showed DVH with a
rate of 7.9% compared to 2.6% peer rate. It was agreed to look at one months data using
December 2011 where the rate was 10.2% to the peer rate of 2.9%.
Objectives:
To assess the accuracy of the Q-Lab data collection process with regards to complication code
064, obstructed labour delivery. To report back the findings at the QLab session scheduled for 8 th
November.
Design:
A retrospective case notes review of all obstructed labour cases for December 2011. Cases
identified from the Q-Lab data.
Results:
43 cases highlighted with a code 064 obstructed labour. The results were as follows:
Spontaneous vaginal delivery = 9, Ventouse = 3, Forceps = 5, Caesarean due to other causes =
14, Caesarean due to obstructed labour = 12.
Conclusions:
The review has highlighted that only 28% of coding was correct & that the DVH Trust rate for 064
obstructed labour complication was standing at 2.76% lower than the peer rate of 2.9.
Recommendations:
To provide the notes for the coding department to review (excluding those 12 cases recorded as
caesarean due to obstructed labour).
To have a nominated Consultant interface for coding issues – Mr Waterstone
To report back the findings at 8th January 2013 QLab session.
14
Appendix B
To re-audit in 3 to 6 months.
Action Plan:
No
:
Recommendation:
Action(s) to be taken:
Evidence of Actions
Nominated
lead(s):
Completion
Date:
1.
To provide the notes
for the coding
department to review
(excluding those 12
cases recorded as
caesarean due to
obstructed labour)
To have a nominated
Consultant interface
for coding issues
To report back the
findings at 8th
January 2013 QLab
session
To re-audit in 3 to 6
months.
Clinical Audit Department
to arrange for the
appropriate notes to be
sent to Coding
Acknowledgment
from the Coding
Dept that the
appropriate notes
have been received
Anita Gorvan
December
2012
To request a volunteer
from the O&G
Consultants
To diarise for the project
to be on the agenda for
the O&G meeting on 8th
January 2013
To update the audit
database with the re-audit
details & allocation of the
project to an O&G doctor
Nominated Lead
contact details
Mr Jones
December
2012
Agenda
Minutes of the
meeting
Mr Jones,
Anita Gorvan
Project registered
with the audit
department
Anita Gorvan,
Mr Jones
January 2013
As soon as
minutes are
available
July 2013
2.
3.
4.
ICE1 – Action Plan Follow Up:
1. The coding manager confirmed that all the required notes had been received & cases reviewed
2. Mr Waterstone agreed to be the nominated Consultant Interface
3. The coding manager provided detailed information for the meeting on how the coding of this
particular procedure had been corrected & what measures had been put in place for the future
4. CHKS updated the meeting on the trend since January 2012 of the volume & rates of
obstructed labour which had reduced significantly. The previous rates were due to the inaccuracy
of the clinical coding rather than clinical care.
Laparoscopic Subtotal Hysterectomies
N2276
Audit project lead: J Taylor, A Üçyiğit, A Montgomery, T Holland, A Lesseps
Speciality: Obstetrics and Gynaecology
Date presented/Reviewed: December 2012
Reasons for Audit:
There has been a gradual switch from subtotal to total hysterectomies in Darent Valley hospital.
Therefore this audit was designed to identify risks with subtotal hysterectomies and provide a
platform for future comparison of both procedures. It also aimed to audit basic WHO checklist
standards as well as basic standards of operative note keeping.
Background:
Concern that best practice is not being followed for gynaecology procedures that presented
important risk management issues. Guidelines: National Patient Safety Alert WHO Checklist,
GMC Good Medical Practice – Surgical Record Keeping.
Aims & Objectives:
To ensure that patients undergoing LASH where given the best treatment from initial assessment
for procedure to follow up after procedure.
Objectives:
 Identify common indications for LASH
 If conservative/medical treatment offered prior to LASH, where appropriate.
 Identify intra-operative and post-operative complication rates
 Assess average length of stay in hospital and overall patient satisfaction
15
Appendix B
Design:
We identified 77 Patients who had a LASH performed between Jan 2010 to July 2012. 11 patients
excluded due to additional procedures requiring an open operation, leaving 66 patients belonging
to 5 consultants.
Standards:
 Conservative/medical treatment offered prior to surgery, where appropriate (100%)
 Documentation of pre-op urinary HCG test (100% of pre-menopausal patients)
 Completion of the WHO surgical checklist (100%)
 Documentation of EBL in operative note (100%)
Results:
The indication for hysterectomy in 98% of patients was due to dysmenorrhoea and menorrhagia.
58 patients were offered conservative management and of those 76% actually trialled. 65% had a
pre-operative scan. No WHO checklist was identified for 3 patients and pregnancy test not
completed on 5 patients of whom one was sterilised. Estimated blood loss (EBL) was not
documented in 12 patient notes. Average theatre time was 90 minutes. Post-op complications in 9
patients, with overall patient satisfaction of 90%.
Conclusions:
The standard of 100% for the WHO checklist and checking the pregnancy status of patients were
not met. This posed major risk management issues, which could be detrimental to patient safety if
actions plans are not put in place. EBL documentation is important and should be documented in
all operation notes as this aids identification of post-op complications. An objective method
requires implementation to correctly assess patient satisfaction.
ICE 1 – Presented at the O&G audit meeting December 2012. This was agreed as having major
risk management issues and immediate action to be undertaken with a plan to re-audit in 3 to 6
months.
The results were reported back to the O&G Directorate at the departmental audit meeting on 9 th
July 2013.
The ICE1 score was agreed. The Department were all in agreement that the requirement to
record data on the WHO checklist was mandatory as is the requirement to record estimated blood
loss in the operation note.
Recommendations:
That the mandatory completion of the WHO surgical checklist is adhered to.
That the mandatory checking of the pregnancy status is adhered to.
That the mandatory recording in operative notes of estimated blood loss is adhered to.
Proposed Action Plan:
To measure again these mandatory requirements by undertaking a further audit (not just the
laparoscopic surgery) & to include the standards from the previous audit.
As the lead for this audit, Mr Lesseps is invited to designate a team of individuals to repeat the
audit, which is to include the above & also the three original standards, as follows:
If indication is menorrhagia, has the patient trialled conservative measures - 100%
(exception/patient choice).
Has an assessment of uterine size been made prior to laparoscopy – 100%.
Has the BMI been calculated prior to offering the procedure – 100%.
An audit date & team is to be established. Timeframe July to December 2013.
N Recommendation:
o
1. Re-audit of the management of
laparoscopic hysterectomies. Audit
to include compliance against the
mandatory completion of the WHO
Action(s) to be
taken:
Evidence of
Actions
Nominated
lead(s):
Completion
Date:
Re-audit date &
team to be
identified.
Project
registered
with the audit
dept.
Mr Lesseps
January 2014
16
Appendix B
surgical check list & recording of
EBL.
Cardiotocograph Documentation Audit
Dr T Aojanepong, Dr G Vivehanantha, Mr A Gupta, Obstetrics & Gynaecology
Date presented: September 2013, O&G Clinical Audit Meeting
N2414
Reasons for Audit: NHSLA (CNST)
Background:
Cardiotocograph (CTG) monitoring is as important part of intrapartum care. Appropriate
documentation and actions are required in the case of an abnormal CTG.
Aims:
To assess the CTG documentation and management plans in abnormal CTG’s in the department
and compare against guidelines.
Design:
A prospective audit carried out between August to September 2013. Assess the documentation at
the start of the CTG, intrapartum events and the end of the CTG. Assess compliance against
Trust guidelines on fetal monitoring and fetal blood sampling. Standards being measured:
Indication for CTG identified, Patient details at the start, Intrapartum event, Documentation in
notes & CTG, Hourly systematic assessment, Actions taken if abnormal CTG, Documentation at
the end of CTG. All required a target of 100% compliance.
Results:
Less than 75% of cases had appropriate documentation on CTG at the start of CTG, intrapartum
and at the end. Similarly, less than 75% of cases had an appropriate documentation in the case
note.
Conclusions:
Poor documentation of CTG on both CTG and cases note. Does not reach CNST level 2
requirement (compliance of 75%).
Recommendations/Action plan:
- Sticker for CTG documentation in the note
- Senior midwife and consultant obstetrician to review the guideline, in particular the
frequency of fresh eyes review and the requirement of hourly fetal heart rate
documentation on CTG
- Re-audit 3 months after the sticker has been implemented
No
Recommendation:
Action(s) to be taken:
Evidence of Actions
Nominate
d lead(s):
Completion
Date:
1
Disseminate results and
recommendation via
maternity newsletter, CTG
meeting , midwifery
meeting and Supervisory
MW.
Liaise with risk
management midwife
Jo
Seymour
Oct –Nov
2013
2
To use stickers for CTG
documentation in the notes
Design and approve the
use of stickers
Ursula
Marsh
December
2013
3
Review the guideline to see
if any changes are
appropriate
Liaise with Ursula Marsh
and obstetric consultant.
To be discussed in labour
ward forum
Audit result has been
disseminated via the
newsletter and email.
CTG meetings take
place every Tuesday
& Friday
Stickers have been
designed and in use
throughout the
directorate
Continuous
monitoring &
intermittent
auscultation guideline
has been agreed at
Ursula
Marsh
Mr.Waterst
one
April 2014
17
Appendix B
Re-audit 3 months after the
use of sticker has been
implemented
To complete audit cycle 3
months after the
implementation of
stickers
Ursula
Marsh
Mr Gupta
April 2014
ICE1 – The project is scheduled for a re-audit before April 2014. The recommendations will be
monitored to ensure changes have been put in place before commencing the re-audit.
A registration form has been provided for the re-audit. An update has also been provided on the
implementations of the recommendations. Action table updated.
Management of an Acute Painful Sickle Cell Episode in Hospital - Implementing NICE
Guidance 143
Ref 2138
Audit Project Lead: Dr Alesia Hunt and Dr Raphael Ezekwesili
Specialty: Haematology
Reason for Audit:
• In June 2012 NICE issued clinical guideline 143.
• Outlines how to manage acute painful sickle cell episode in hospital.
• Audit tool used to collect all acute episodes at DVH from January 2012 to December 2012.
Background:
• Most people affected are African or African-Caribbean origin.
• Although the sickle gene is found in all ethnic groups.
• Estimated between 12,500-15,000 people with sickle cell disease in UK.
• Darent Valley have small number with SCD.
• Acute painful crisis (vaso-occlusive crisis): caused by the sickling of the red blood cells
which causes blockage of the blood vessels and lack of oxygen to the tissue.
• Hypoxia to the tissue can cause pain and tissue infarction.
Design:
• Data collected from paper medical records from patients who had acute painful crisis
between January 2012- November 2012.
• Acute episodes: n=20
• Patients: n=11
Results:
Number of episodes per patient:
10
9
Acute painful episodes
4
the Labour Ward
Forum on 4/4/2014.
Midwife :
Amy McLeod
Kashka Williams
8
7
6
5
4
3
2
1
0
1
2
3
4
5
6
Patie nt ID
7
8
9
10
11
Date of episode:
18
Appendix B
Acute episodes
6
5
4
3
2
1
0
JanuaryFebruary
March
April
May
June
July August
September OctoberNovember
Sex of patients:
Female
Male
45%
55%
Pain Assessment:
• Pain assessed on arrival: 20/20 (100%)
• Pain assessment tool: 8/20 (40%)
• Tool was age appropriate: 8/8 (100%)
• Analgesia within 30 minutes: 11/20 (55%)
– Median: 33 minutes
– Mean: 40 minutes
– iv access difficult to achieve x 2 episodes
Date of acute episode did not affect duration of time to receive analgesia:
Observations taken on arrival:
• BP, hr, RR, Oxygen saturations, temperature: 19/20 (95%)
– 1 patient seen in minors did not have any observations taken on arrival.
• Oxygen given if sats >95%: 6/6 (100%)
19
Appendix B
Analgesia on arrival:
• 18/20 (90%) patients were in moderate-severe pain: 18/18 (100%) were offered a strong
opioid.
• 2/20 (10%) patients were not in severe pain and chose a weak opioid.
• Paracetamol was offered in 11/20 (55%).
• NSAID was offered in 8/20 (40%).
• Pethidine was used 2/20 (10%) because no iv access.
• Laxatives used: 11/20 (55%)
Reassessment of pain:
• Pain was reassessed after 30 minutes: 0/20 (0%)
• Pain was reassessed every 4 hours: 0/20 (0%)
 there was no documented reassessment of pain and no pain charts.
• 2nd bolus of opioid given: 10/18 (55%)
Observations after episodes:
• Observations taken every 60 minutes for the first 6 hours: 0/20 (0%)
• Observations taken every 4 hours: 20/20 (100%)
Conclusions:
• Done well:
– Assessment of pain on arrival.
– Strong opioids offered 1st line.
– Analgesia was given with 30 minutes most of the time.
– Observations on arrival.
– Observations every 4 hours.
• Done poorly:
– Pain tool/scoring system.
– Pain reassessment.
– Adjuvant medication.
– Observations every hour for 6 hours post opioids.
Recommendations:



Use of a printed pain assessment tool and scoring sheet to assess pain objectively and
frequently -> I have redeveloped an existing one from another trust who manage a lot of
sickle cell patients.
Teaching annually for A&E and CDU medical staff and nurses regarding SCD -> I have
made a presentation which can be given to these groups.
Develop trust guidelines and make available to all staff -> I have developed these and
given them to the Haematology team to review.
ICE 1
No
Recommendation:
Action(s) to be taken:
Evidence of Actions
Nominate
d lead(s):
Completion
Date:
Design a pain
assessment tool
Dr Hunt has
redeveloped an
existing tool from
another trust who
manage a lot of sickle
cell patients -copy in
project files
Dr
Ezekwesili
1.
Use of a printed pain
assessment tool and
scoring sheet to assess
pain objectively and
frequently
Presentation to be drawn
up
Dr Hunt has made a
presentation
which
can be given to these
groups
-copy
in
project files
Not specified
but as ICE 1
need
evidence of
implementati
on within 3-6
months
Not specified
but as ICE 1
need
evidence of
implementati
on within 3-6
2.
Teaching annually for A&E
and CDU medical staff and
nurses regarding SCD
20
Dr
Ezekwesili
Appendix B
months
3.
Develop trust guidelines
and make available to all
staff
Guidelines to be agreed
Dr
Hunt
has
developed guidelines
and given them to the
Haematology team to
review
-copy
in
project files
Dr
Ezekwesili
Not specified
but as ICE 1
need
evidence of
implementati
on within 3-6
months
Antibiotic Prescription Audit –General Surgery
Ref 2338
Audit project joint leads:
Dr Ashwin Kumaria, Dr Sheena Ramyead, Mr Bhardwaj
Speciality: General Surgery
Date presented: February 13 2013
Reasons for Audit:
To assess the extent to which the surgical teams are following the local antibiotic guidelines.
Background:
The trust’s guidelines on Abx prescription are clear and prescription of antibiotics, ubiquitous.
Audit was undertaken as deviations from the guidelines were noted.
Aims & Objectives:
To what extent are we following guidelines when prescribing antibiotics?
Objectives – to ensure that antibiotic prescription is in accordance with trust guidelines vis-à-vis
documentation of choice of antibiotic, duration, allergies, indication.
Design:
Trust antibiotic guidelines available on Adagio were audited. A point prevalence study was
conducted looking at all general surgery inpatients including outliers.
Results:
Twenty one out of 53 general surgical inpatients were taking antibiotics.
With 100% being the standard:




62% had indications for the antibiotics documented on the drug chart
67% had the duration documented on the drug chart
86% had the allergies documented on drug chart
Only 67% were on the appropriate choice of antibiotics
Conclusions:
 Our current practice is strong in terms of documentation of patients’ allergies however,
there is much scope for improvement in documentation of indications and duration of
antibiotics on drug chart.
 Deviation from current antibiotic guidelines where appropriate, must be documented in the
‘additional information’ box on the drug chart
ICE 1
No:
Recommendation:
Action(s) to be taken:
Evidence of
Actions
Nominated
lead(s):
Completion
Date:
1.
Documenting review date /
duration / indications.
Avoid deviation from
guidelines re: choice of
ABx. Exceptions - e.g.
micro advice, medics
advice.
Deviation from current
antibiotic guidelines where
Disseminate outcomes
of this audit to surgical,
medical and pharmacy
staff
Minutes
of
meeting,
attendance log
(pharmacy staff
were invited to,
and attended
the
presentation at
the
surgical
Dr Ashwin
Kumaria &
Dr Sheena
Ramyead
February
2013
21
Appendix B
2.
3.
appropriate, must be
documented in the
‘additional information’ box
on the drug chart
Prepare a short
presentation for the surgical
audit meeting to clarify the
prescription standards
required and to announce
the intended follow up audit
Conduct a follow up reaudit, to include collecting
additional data on who has
completed the prescription
meeting)
Dr Ashwin Kumaria to
present @ surgical
audit
meeting
on
13/03/13
Dr Kumaria to conduct
a snapshot re-audit with
results to be presented
at April audit meeting
Copy of
agenda,
minutes
Mr Murali,
Dr Kumaria
March
2013
Audit abstract,
meeting
agenda &
minutes
Dr Ashwin
Kumaria
April 2013
Severe Sepsis and Septic Shock –CEM Interim Audit
Ref 2355
Auditors: Dr O Siddique (CT1 Anaesthetics), Dr R Suleman (Consultant ED/Intensive Care)
Specialty: Emergency Medicine
Date presented: July 2013
Reason for Audit:
Royal college of Emergency Medicine standards
Background:
To improve the efficiency and delivery of treating patients with Sepsis and septic shock in the first
4 hours in ED
Aims & Objectives:
Are the guidelines for early directed goal therapy for sepsis and septic shock being adhered to?
To improve patient safety by effective treatment and escalation in these types of patients.
Design:
The standards were measured against guidelines and care bundles from the ‘surviving sepsis’
campaign. Inclusion criteria – 24 case notes of patients with severe sepsis (septic patients with
organ dysfunction) from 6th October to 8th October over the age of 18 fitting the criteria on the front
sheet (A&E cascard).
Results:
Out of 997 cascards screened over the four day period, 57 patients were SIRS positive with 51 of
those being Sepsis positive while 26 were found to have severe sepsis. 24 case notes were
reviewed for audit as two sets of notes were not available.
The vital signs were documented in 66% (16/24) of cases (CEM standard 95%)
High flow oxygen was administered in 58% (14/24) of cases (CEM standard 95%)
Serum Lactate measurements were obtained prior to leaving ED in 46% (11/24) of cases (CEM
standard 95%)
Blood cultures were obtained prior to leaving ED in 50% (12/24) of cases (CEM standard 95%)
IV fluids given within 1hr – 29% (7/24) (CEM standards 75%)
IV fluids given within 2hrs – 50% (12/24) (CEM standards 90%)
IV fluids given before leaving ED – 75% (18/24) (CEM standards 100%)
IV antibiotics given before 1hr – 0% (0/24) (CEM standards 50%)
IV antibiotics given before 2hrs – 46% (11/24) (CEM standards 90%)
IV antibiotics given before leaving ED – 79% (19/24) (CEM standards 90%)
Urine output measurements were recorded in just 17% of patients (4/24) (CEM standards 90%)
Conclusions:
Poor results in adhering and applying the surviving sepsis care bundle in our patients were seen
throughout. Particularly in early administration of antibiotics, fluid resuscitation, obtaining blood
cultures and recording urine output measurements. These all can be improved and need to be
addressed however there are many factors affecting the implementation of these specific care
points. In ED the diagnosis may be problematic early on, and many of the presentations may be
atypical/non specific. Biomarkers are often not available until at least a few hours after admission
therefore delaying diagnosis.
ICE score: 1
Action Plan:
22
Appendix B
No:
Recommendation:
Action(s) to be taken:
Evidence of Actions
Nominated
lead(s):
Completion
Date:
1.
Education and training of
all staff in the recognition
and early treatment of
septic patients
Audit findings
presented in the audit
meeting
Audit meeting
agenda and minutes
R Suleman
26/07/2013
2.
Posters
around
the
department with clear flow
charts/guidelines
when
encountering
septic
patients
New sepsis proforma
devised, copies printed
and laminated. Copies
placed in appropriate
areas of the ED
Copies of proforma
in appropriate places
R Suleman
3 September
2013
3.
A septic shock/SIRS
proforma printed out for
A&E clerking upon
identifying septic patients
on triage
Involving a senior A&E
doctor in triaging allowing
earlier oxygen, IV fluid, IV
antibiotic administration
Proforma emailed to
appropriate personnel
to be added to intranet,
iSoft and eCAS
Laminated copy of
proforma placed in
triage/ assessment
cubicle.
R Suleman
3 September
2013
Sepsis teaching
delivered to junior
doctors soon after their
induction (27th August
2013
SHO teaching
programme
4.
Audit of Incidents Reported on Datix
Audit project lead: Angela Eldridge, Clinical Audit Manager
Audit Ref 2417
September 2013
Reasons for Audit:
To repeat the audit carried out by PWC earlier this year on the accuracy of incidents reported on
the DATIX system.
Background:
An initial audit carried out by PWC highlighted a number of inconsistencies in the reporting of
incidents, including incorrect harm levels and incident categories.
Aims & Objectives:
The purpose of the re-audit was to clarify whether the quality of reporting had improved now that
online reporting has been rolled out across the trust, and if necessary, to identify any further
changes or guidance needed. The re-audit seeks to clarify whether harm levels and incident
categories have been correctly recorded in line with guidance available, and all appropriate cases
reported to the National Reporting and Learning System (NRLS) as per applicable trust guidelines
and policies.
Design:
Per the Incident Reporting Policy Ref CG001:
The grading of harm caused by incidents should comply with the DVH Datix Incident Severity
Guide (April 2013) which supersedes the incident grading table in Appendix 5 of the policy.
All patient safety related incidents should be reported to the NRLS each month.
A sample of 20 incidents were reviewed, selected from all patient related incidents reported on the
DATIX system between 1 April and 28 August 2013; 4 were selected from each harm category
(no, low, moderate, severe and death). All cases were compared to patient medical notes to
verify the date and nature of the incident and harm level.
Results:
Although only 20 incidents were reviewed some had multiple errors, each of which are recorded
separately below:
OK
Category
error
Reported to Incident
NRLS in error incorrectly
23
Harm
level Non
incorrect
compliance
Other
(see
notes below)
Appendix B
or not yet reported but
reviewed
not removed
5
1
6
2*
with Pressure
Ulcer Policy
3**
6***
5****
Notes
* One incident of a 3rd degree tear was reported in error due to an error on the Euroking system;
one entry was duplicated as 2 people reported the same pressure ulcer on the same day.
** Two relate to grade 3 pressure ulcers classed as severe harm not moderate as per severity
guide, 1 related to trauma case bought to DVH in error but still appropriately treated – potential
near miss or no harm but reported as moderate. All 3 cases were reviewed by the governance
department.
*** Community acquired pressure ulcers not reported to NRLS as required by the Pressure Ulcer
Prevention and Management Policy and Guidelines Ref PCD070 (section 7.2).
**** 5 'other' points were noted during the review not directly related to the objectives but which
raised concerns, as follows:
 The policy says incidents should be reported each month to the NRLS; the sample
showed time scales of between 7-73 days and some were not yet reported. However
delays may be appropriate if a case is awaiting completion of a RCA or other investigation.
A further review of all cases (provided for sample selection) showed 21% of no harm, 10%
of low harm, and 13% of moderate harm cases were awaiting governance review. The
percentages of severe harm cases awaiting review (50%) relate mainly to cases under
further investigation or RCA.
 All maternity incidents are reviewed by maternity and not the governance department.
Upon further review it was also noted that all 3rd degree tears (38 in review period) were
reported as either no harm (6 cases) or low harm (32 cases) which is inconsistent with the
Incident Severity Guide.
 One case found a patient admitted with a grade 4 pressure ulcer where the CDU
Admission Pathway states pressure areas "healthy".
 There is no guidance for the harm level attributable to missed fractures (one case of
missed #NOF)
 One death not shown as a SUI and nearly 2 months since record last updated.
Conclusions:
Further guidance is required in terms of time scales and criteria for reporting to the NRLS, eg
whether they should be reported within a specified time or after review by governance
department/completion of RCA or investigation, community acquired pressure ulcers, etc. There
also needs to be more timely review of cases by the governance department to ensure incidents
are reported consistently. Furthermore the reporting requirements of community acquired
pressure ulcers differs between the Incident Reporting Policy and the Pressure Ulcer Policy; this
needs to be rectified.
N
o:
1.
2.
3.
Recommendations/Action plan:
Recommendation:
Action(s) to be taken:
Determine time scales for
governance review and
reporting to NRLS, for no,
low and moderate harm
incidents
Determine criteria for
reporting severe harm and
death incidents to NRLS –
before/after conclusion of
RCA.
Fix the bug in the DATIX
system which allows cases
to be reported to the NRLS
without governance
department review
Evidence of Actions
Nominated Completion
lead(s):
Date:
Once agreed, policy /
guidelines to be
updated
Updated
documentation
Michael
Brand
Once agreed, policy /
guidelines to be
updated
Updated
documentation
Michael
Brand
Unable to send
incidents to NRLS
without governance
review completed
Michael
Brand &
Gurinder
Singh
Update system
24
Completed
September
2013
Completed
September
2013
Appendix B
4.
5.
Pressure Ulcer Policy
and/or Incident Reporting
Policy to be amended to
correctly reflect the Trust
requirements for reporting
community acquired
pressure ulcers to the
NRLS.
Review the consistency of
reporting of maternity
related incidents as not
reviewed by governance
department
6.
To review and agree harm
category to be used for 3rd
degree tears.
7.
CDU department to be
made aware of case where
pressure ulcer missed, with
further training provided if
necessary
Determine whether
other Trusts report
community acquired
pressure ulcers as well
as trust acquired ones.
Once agreed, policy /
guidelines updated
Audit to be repeated
for wider sample of
maternity related
incidents to ensure
same criteria is being
applied
To be discussed at
O&G governance
meeting to reach
agreement.
TV nurse to share with
CDU and assess need
for further training
Updated
documentation (v3)
Michael
Brand
Completed
September
2013
Audit abstract etc
Michael
Brand
Completed
September
2013
- Minutes of meeting.
- Inclusion on incident
severity guide.
Michael
Brand, Jo
Seymour,
Sue Craven
TVN
Completed
September
2013
ICE score: 1
A high number of errors were found with only 25% of incidents reviewed being free from errors.
Although the implications of most errors are not fundamental to patient care or clinical risk, it is
considered a reputational risk as the correct reporting of clinical incidents and risk forms a
reporting mechanism to external bodies and is a fundamental requirement of the Trust.
It is understood that records submitted to the NRLS can be re-submitted so errors can be
corrected upon completion of RCA's, and the actions required to address the problems are all
fairly straight forward to implement, some of which were completed at the time of the audit. A reaudit is to be undertaken in November of September and October incidents.
An Audit of Vancomycin Prescribing at Darent Valley Hospital
Audit Ref E2292
Audit project lead: David Russell
Speciality:
Pharmacy
Date presented/Reviewed: March 2013
Reasons for Audit:
Assessing compliance with Trust Antimicrobial Policy on vancomycin prescribing.
Background:
Vancomycin infusion has always been used on Intensive Treatment Unit (ITU) at Darent Valley
Hospital. However in April 2012, after an internal review, it was decided that the use of
daptomycin should be reduced and vancomycin should be used on general wards as the
glycopeptide of choice. It is because of this recent change to using vancomycin throughout the
hospital, rather than just on ITU, that the use of vancomycin is being audited. Vancomycin needs
careful monitoring, incorrect dosing of vancomycin can cause nephrotoxicity and ototoxicity or
lack of efficacy.
Aims & Objectives:
To assess the extent to which the Trust Policy for prescribing of intravenous vancomycin are
being followed at Darent Valley Hospital and what measures can be put in place to help ensure
they are. With regards to whether; the weights of patients prescribed vancomycin is documented
in notes or drug chart, patients are receiving the correct loading dose for vancomycin according to
body weight, the blood tests are scheduled and done at the appropriate time, the appropriate
maintenance dose is prescribed and the doses are given at appropriate times.
25
Appendix B
Design:
The guidelines used were the Dartford and Gravesham Trust Antibiotic Policy - Vancomycin
prescribing dated july 2012. The standards were:
1.) That the patients weight has been documented in 100% of patients prescribed vancomycin.
2.) That the loading dose of vancomycin has been adjusted according to the patients weight in
100% of patients.
3.) That the blood level monitoring is done 30 minutes before the fourth dose of vancomycin is
due and the time the blood level is taken is recorded in 100% of patients.
4.) That an appropriate maintenance dose is prescribed in 100% of patients.
5.) That the doses are given at the appropriate time in 100% of patients.
The patients included were all patients prescribed IV vancomycin between November and
January. Forty patients were identified and the lead auditor collected the data from these patients.
Results:
55% of patients had their weight documented when prescribed vancomycin. 73% of patients
received the correct loading dose of vancomycin. Monitoring of patients was done correctly in
63% of patients. The appropriate maintenance dose of vancomycin was prescribed in 77% of
patients. Doses were given at appropriate times in 60% of patients. Only 23% of patients’
prescriptions complied with every standard set.
Conclusions:
The objective of this audit was to assess whether Trust guidelines for vancomycin prescribing
were followed correctly. The data shows that it isn’t and changes need to be made to enforce this.
ICE 1
N
o:
Recommendation:
Action(s) to be taken:
Evidence of
Actions
Nominated
lead(s):
Completio
n Date:
1.
Reinforce education on
vancomycin, creatinine
clearance and trust
guidelines.
IV presentation
update/ induction
agenda
1. Susan
Boorman
2. Njavwa
Simwanza
3. Rakhee
Patel
4. Alison
Williams
March 2013
2.
Increase awareness of
need for monitoring
vancomycin.
1. Include subjects in
IV talk for junior
doctors.
2. Include subjects in
IV talk for nurses.
3. Include subjects in
induction talk for
Pharmacists.
4. Include subjects in
update talks for
Pharmacy
technicians.
1. Poster
2. Trial vancomycin
reminder stickers.
1. David
Russell
2. David
Russell
April 2013
3.
Reinforce the correct
prescribing of vancomycin.
Copy of poster in
file. Feedback from
nurses about
stickers-the sticker
trial was
unsuccessful & will
not be
implemented
Changes to the
guidelines.
1. Rakhee
Patel
July 2013
4.
Involve labs in reporting –
highlight high results to
doctors and pharmacy
Levels done out of hours
and at weekends to be
highlighted by pathology to
doctors and nursing staff
for handovers
Present to
5.
6.
1. Make clarifications to
the antibiotic guidelines
to make it more
accessible.
Antimicrobial
stewardship group to
speak to biochemistry
Pathology/ward
staff/antimicrobial
stewardship group to
action
Present to
Now reported back
to the ward
Minutes, agendas
26
April 2013
Pathology/ward
staff/antimicrobi
al stewardship
group to action
01/05/2013
1. David
Sept 2013
Appendix B
7.
pharmacy/antimicrobial
stewardship
group/pharmacy risk
group/medical and surgical
audit meetings
Re-audit once action plan
implemented
pharmacy/antimicrobial
stewardship
group/pharmacy risk
group/medical and
surgical audit meetings
Russell
2. Rakhee
Patel
A REVIEW OF THE CURRENT PRACTICE OF POST FIRST TURBT INTRAVESICAL
MITOMYCIN C
ID: 2336
Audit project lead: W.Mahmalji, F.Khan, F.Anjum, S.Sriprasad, I Dickinson, S.Madaan (Lead)
Speciality: Urology
Date presented/Reviewed: April-2013
Reasons for Audit:
The British Association of Urological Surgeons (BAUS) and European Association of Urology
(EAU) recommend that intravesical Mitomycin C (MMC) should be given within 6 hours of primary
Transurethral Resection of Bladder Tumour (TURBT). This was not being carried out at DVH and
MMC administration times seemed prolonged.
Background:
The audit was performed as DVH did not appear to comply with national and international
guidelines. Taking into account that this procedure is a very common and malignant,
administrating MMC <6h can reduce tumour re-occurrence rates by 40%.
Aims & Objectives:
The aim of this audit was to analyse the administration times of MMC following primary TURBT,
looking at reasons for possible delays. The objective was to ensure that patients were receiving
acceptable standards of care post primary TURBT and that we were doing everything possible to
reduce tumour re-occurrence rates.
Design:
Retrospective notes analysis was performed. All patients that had a primary TURBT within the
last 12 months were identified. MMC administration times, documentation, reasons for delay and
omission were all analysed. The sample size was set at 50.
Results:
Of the 25 patients 12 had MMC requested, 2 patients did not get it for reasons not documented.
Both these patients had tumour re-occurrence (Unacceptable). Of the patients that did receive
MMC the administration time was >15h (Unacceptable). The remaining 13 patients did not have
MMC requested 4 of these patients should have had it. The same operator omitted MMC with no
documented reason. Overall 6/25 patients who should have had MMC did not receive it, 5/6 had
tumour re-occurrence (Unacceptable).
Conclusions:
MMC administration post primary TURBT at DVH is delayed and inappropriately omitted and this
is resulting in tumour reoccurrence. The audit objectives have been met and reasons for the
results include:
• Lack of Places to give
• Lack of Trained Staff
• Difficult Prescription Methods
• Delayed Dispensing
Recommendations/Action plan:
No: Recommendations:
1.
MMC should be given
immediately post primary
Action(s) to be taken:
Facilities provided to
give MMC in theatre
27
Evidence
Action:
of Nominated
lead (s):
All urologists
and nursing
S.Madaan
W.Mahmalji
Completion
Date:
Re-audit after
changes made:
Appendix B
TURBT in theatre or
recovery and it is the
responsibility of the
operating surgeon to give
it.
and recovery
staff to be
trained in
MMC
administration
and handling.
September
2013
ICE score: 1
Management of Severe Acute Pancreatitis at DVH
Ref 2332
Dr Simran Grewal, Ms Sarah Wheatsone, Dr Ronald Cheung, Dr Raisa Ahmed, Mr Jacek
Adamek
Speciality: Surgery
Date presented: 9th July 2013
Reasons for audit:
It had been noticed in our monthly departmental mortality and morbidity meetings that we had a
preserved increase in severe pancreatitis deaths and wanted to analyse our management of
these patients.
Aims and objectives
To compare our management of pancreatitis with those audit standards in the British Society of
Gastroenterology Acute pancreatitis management guidelines
Specific objectives
1. Assess the % of patients who get an US of the gallbladder within 24 hours (target = 100%)
2. Assess the % of patients who have ERCP within 72 hours if they fulfil the required criteria
(target = 100%)
3. Assess the % of patients with biliary pancreatitis who undergo definitive management of
gallstones during the same hospital admission unless a clear plan has been made within
the next two weeks.
4. Analyse the % of patients with severe acute pancreatitis who are managed in a HDU/ITU
with full monitoring and systems support (target = 100%)
5. To find what proportion of patients have undetermined aetiology.
6. Furthermore in the predicted severe cases (Glasgow Score 3 or greater) we analysed their
clinical course in depth with regards to their acute management, ITU involvement and
eventual outcome.
7. We also compared the DVH predicted severity scoring system against the Glasgow score
to see if there was a discrepancy.
Design
Retrospective analysis of 33 inpatients admitted with acute pancreatitis in between 12/6/12 to
17/10/12. 3 patients excluded due to incorrect coding on discharge summary. Audited against
BSG guidelines for acute pancreatitis.
Results
 80% of patients did not get an USS within 24 hours
 0% of patients who fulfil the criteria for urgent ERCP actually have one within 72hours.
 93% of patients with gallstone aetiology did not have conclusive treatment in two weeks,
which contributed to a high readmission rate.
 When patients predicted severity was high, they were under investigated, not admitted to
HDU/ITU early on, and became cardiovascularly compromised
 40% of patients admitted with pancreatitis did not have a confirmed aetiology (guidelines
state not more than 20% should be labelled idiopathic)
 The scoring sheet on our local DVH pancreatitis protocol is not the recognised published
Glasgow Score; it inflates the score and therefore identifies too many patients as predicted
severe pancreatitis.
 Overall mortality rate was 10%, comparable with expected rate in guidelines.
Conclusions
28
Appendix B
The objectives were met. It appears we are failing to meet the guidelines across the board from
thoroughly investigating and diagnosing aetiology, to managing the severe cases of pancreatitis,
to providing definitive management
ICE 1
ACTION PLAN
No
:
Recommendation:
Action(s) to be taken:
Evidence of Actions
Nominated
lead(s):
Completion
Date:
1.
Change the scoring
system used at DVH
to the recognised
Glasgow score.
Draw up draft replacement DVH
guidelines. Discuss with Dr
Gonzalez, sponsor of current
guidelines. Reach agreement
on new DVH pro-forma and
guidelines.
Publishing of new
guidelines on DVH
intranet ‘Adagio’.
Clinical
records
committee minutes
Grewal,
Wheatston
e
1 October
2013
2.
Amend current DVH
guidelines to reflect
national
British
Society
of
Gastroenterology
guidelines
Draw up draft replacement DVH
guidelines. Discuss with Dr
Gonzalez, sponsor of current
guidelines. Reach agreement
on new DVH pro-forma and
guidelines.
Publishing of new
guidelines on DVH
intranet ‘Adagio’.
Clinical
records
committee minutes
Grewal,
Wheatston
e
1 October
2013
3.
Discuss
with
radiology and agree
an action plan to
prioritise
USS
in
pancreatitis patients.
Increase the number
of gallstone mildmoderate pancreatitis
patients
having
cholecystectomy
within one week.
Discuss with critical
care department
Discuss
with
radiology
department.
Present @ radiology audit
meeting?
Re-audit
Minutes
of
meeting/discussion
Adamek
1 October
2013
Discussed at departmental
audit meeting to highlight issue.
Re-audit
Reduction
in
the
number of patients
waiting >1 wk for
cholecystectomy
Completed
Discussed
in
July
meeting.
Awareness of current patient
care not meeting best practise
guidelines.
Adamek,
Wheatston
e
1 October
2013
Develop a follow up
plan for patients with
undetermined
aetiology.
Re-audit within six
months
Discuss with gastroenterology
to decide who best to follow
patients up.
Re-audit
Minutes
of
meeting/discussion
with CC
Correspondence
Record of agreed plan
Wheatston
e
1 October
2013
Wheatston
e
1 January
2014
4.
5.
6.
7.
The Management of Acute Kidney Injury (AKI), Darent Valley Hospital
Audit Ref 2288
Audit project lead: Dr. Muhammad Javaid (Consultant), Dr. Rudresh Shukla (F1 doctor)
Speciality: Nephrology
Date presented: 7th March, 2013
Reasons for Audit:
Re-audit to look at changes in management of Acute Kidney Injury (AKI) at DVH following the pilot
audit done in 2012 - ICE score of 1 (Ref 2067). This data set is also part of a national audit on
AKI.
Background:
AKI complicates 7% of all hospital admissions and 30% of ITU admissions according to latest
NCEPOD report. It also found only 50% cases were appropriately managed and 43% involved
unacceptable delays in identifying AKI. The management of AKI at DVH was previously audited in
2012 and highlighted that not all cases were managed optimally, potentially leading to increased
length of stay and increased cost.
29
Appendix B
Aims & Objectives:
With NICE guidance for AKI due in late 2013, NHS Kidney Care undertook this audit – with DVH
being one of 47 trusts taking part nationally. The aim was to study if adopting London AKI network
guidelines, education of junior doctors via teaching sessions and grand round presentations on
AKI have improved our management of patients with AKI.
Design:
This retrospective 5 month (Aug-Dec, 2012) audit looked at patients specifically with AKI stage 3
as defined by Kidney Disease Improving Global Outcomes (KDIGO) i.e. creatinine > 354 or 3
times greater than baseline if less than 354. Creatinine levels were checked for past 3 months for
baseline and each patient was included only once in the audit. Out of the 167 cases, 114 were
confirmed as AKI 3, other cases with Chronic Kidney Disease (CKD) and End stage renal failure
(ESRF) were excluded. Patient notes, Telepath and PACS were used to collect data.
The standards audited included:
• All patients with AKI 3 should have:
1. All admission investigations i.e. senior review within 12 hours, urine dip and USS if
indicated
2. If a senior clinician indicated USS or obstruction was indicated as a possible
cause, this should be done within 24 hours.
3. Medication review and discussion with nephrologist.
4. Quick transfer to ITU/Kings if accepted.
5. Documented cause(s) for AKI 3
Results:
1. 95% (108/114) patients had a senior review within 12 hours (69% in pilot audit)
& 33% (38/114) patients had a urine dip done (71% in pilot audit).
2. USS was indicated for 55% (63/114) patients (35.7% in pilot). 31% (19/63) patients
had an USS done within 24 hours of being clinically indicated.
3. 78% (66/114) had medication reviewed and 35% (40/114) were discussed with
renal specialist.
4. The average transfer time to Kings College Hospital was 78 hrs and ITU was 9 hrs.
5. 99% (113/114) cases had a documented cause for AKI 3.
6. 34% (26/114) patients died in the same admission.
Conclusions:
 AKI 3 is associated with a high percentage mortality. 1 in 3 patients with AKI3 passed
away.
 Senior clinicians are reviewing more patients but less numbers are receiving a urine dip on
diagnosis of AKI 3 compared with the previous audit.
 Few patients are having an USS done within 24 hours of being clinically indicated.
 Transfer of sick patients to a tertiary centre is taking more than 3 days after being
accepted.
 Nearly all patients with AKI3 have a documented cause for the same.
ICE score: 1
Risk assessment was agreed but deferred until the national report is published by NHS Kidney
Care to compare DVH with other trusts.
Despite action plans being implemented from the previous audit (ref 2067) such as teaching
sessions for junior doctors, adopting London AKI Network (AKIN) guidelines and making them
readily available on ADAGIO, the above data suggests we are still unable to manage AKI
appropriately.
Due to this, an ALERT system was setup in March 2013 that has enabled Nephrology consultants
to review new cases of AKI3 on a daily basis, even prior to a formal referral being made. We are
hopeful that this, in addition to the below action plans, will enable us to achieve an appropriately
manage AKI3 as a trust.
30
Appendix B
N
o:
Recommendation:
Action(s) to be taken:
Evidence of Actions
Nominated
lead(s):
Completion
Date:
1.
Educate staff about
the findings of the
audit for the
importance of Urine
dip, USS and quick
transfer to tertiary
centres.
A daily alert of
patients developing
AKI 3 to the
nephrology team
Presentations for A&E
department, medical and
surgical directorates,
radiology department,
management team.
Audit presentation at
March medical audit
meeting. Presentation
forwarded to appropriate
individuals.
Dr.
Rudresh
Shukla
07/3/13
Alert system was put in
place for the same on 1st
March, 2013
Alert system was put in
place for the same on 1st
March, 2013
ongoing
3.
Compare AKI3 data
from DVH with
national data
DVH data has been
submitted by Jane Beadle
to NHS Kidney Care
4.
Raise awareness of
the importance of
carrying out urine
dips in A&E
NHS kidney care will be
publishing data from 47
trusts across England in
future.
Disseminate results to A&E
and seek agreement for a
re-audit of Ref 2115 –
reagent strip urinalysis for
acute admissions via A&E
Dr.
Muhamma
d Javaid
Dr. Paul
Murray
Dr.
Muhamma
d Javaid
Jane
Beadle
14/3/13 –
action plan
for ref 2115
updated
with new
re-audit
date
5.
Re-audit to
commence in
March 2014
2.
Jane Beadle discussed
this with Dr. Suleman on
13/3/13 and re-audit has
been brought forward to
Aug 2013. AKI3
presentation was
forwarded to Dr. Suleman
on 14/3/13
November
2013
Dr.
Muhamma
d Javaid
Audit of completion and accuracy of STAMP (Paediatric Nutrition Screening Tool) on
Willow Ward at Darent Valley Hospital
Audit Ref 2264
Audit project lead: Suzanne Bloohn, Paediatric Dietitian; Jo Wheeler, Chief Dietitian; Dr Kulkarni,
Consultant Paediatrician
Speciality: Nutrition and dietetics
Date presented/Reviewed: November 2013
Reasons for Audit:
Paediatric dietetic department initiative
Background:
STAMP (Screening Tool for the Assessment of Malnutrition in Paediatrics) is the paediatric
equivalent of MUST (Malnutrition Screening Tool) and it is Trust guidelines to carry out STAMP
within 24 hours of admission of a patient to Willow Ward.
Aims & Objectives:
To ascertain if paediatric nursing staff are following guidelines to nutritionally screen Willow
patients within 24 hours of admission and if so, whether they are doing so accurately.
Design:
Standards to be audited:
1. 100% of patients admitted to Willow ward should be nutrition screened using the STAMP tool
within 24 hours of admission
2. 100% of STAMP screening completed must be done accurately
Sampling/method: Nursing notes for inpatients on Willow ward were reviewed during the morning
or afternoon for STAMP tool completion and accuracy once a month for 6 months between
September 2012 and April 2013 inclusive. The number of patients reviewed for STAMP screening
on each day depended on the number of in-patients on the ward at that particular time.
31
Appendix B

The following data was collected from the total number of patients reviewed: % of STAMP
forms in the nursing notes; % of STAMP forms used; % screened within 24hrs; % Step 1
completed; % STEP 2 completed; % STEP 3 completed; % risk score completed; %
accurate STEP 3; % accurate risk score; % signed and dated; % with patient details.
 Of the number of STAMP forms used the following data was collected: % screened within
24hrs; % Step 1 completed; % STEP 2 completed; % STEP 3 completed; % risk score
completed; % accurate STEP 3; % accurate risk score; % signed and dated; % with
patient details
Results:
A total of 92 patient admissions were audited across the 6 months from which sampling was
completed. There was variance within the data, however, this was not analysed but a total for
each data set obtained.
Looking at completion: 74% of total patients had a STAMP form in the notes with 85% of these
actually used i.e. only 63% of total patients had a used STAMP form. 69% of used forms were
completed within 24 hours of admission (only 43% of total patients were screened within standard
time) and 86% of used forms had patient details filled in, while only 51% of used forms were
signed and dated. 54% of total patients had a completed Step 1, 53 % total a completed Step 2,
25% total a completed Step 3 and 27% a completed risk score. Of the actual STAMP forms used,
86% of used forms had a completed Step 1, 84% had a completed Step 2 and only 40% had a
completed Step 3 and 43% a completed risk score.
Looking at accuracy: of Step 3 completed, 87% were accurate; of risk score completed 76% were
accurate. This translates into 22% of total patients with an accurate Step 3 completed and 22% of
total with an accurate risk score.
Conclusions:
Less than half of patients audited on Willow ward were nutrition screened within 24 hours of
admission, falling very short of the standard set of all patients. When the nutrition screening is
undertaken, Steps 1 & 2 of the STAMP form are twice as likely to be completed than the more
complicated Step 3 and risk score. However, when Step 3 and the risk score are completed,
these have a higher percentage of accuracy although still not meeting the standard of 100%
accuracy. It is likely that when a STAMP form is being completed, the main barrier to completing
Step 3, which is needed to complete a risk score, is the difficultly in obtaining a height or length for
a child or infant due to clinical condition at the time. It is clear that staff on Willow ward are not
meeting the required standards for nutrition screening and accuracy of such.
Recommendations/Action plan:
ICE score: 1
N
o:
Recommendation:
Action(s) to be taken:
Evidence of Actions
Nominated
lead(s):
Completion
Date:
1
Present results to
paediatric medical
staff
Present results to
ward staff
Audit lead dietitian to
present findings to
paediatric medical staff
Audit results to be
presented to senior and
band 6 nursing staff during
department meeting,
development training and
Nurses study day
All paediatric medical staff
to be aware of use of
STAMP
STAMP audit presented to
consultants and medical
staff on 29.11.13
Presentation of audit
results to nursing staff
Paediatric
dietitians
Completed
November
29th 2013
April 2014
Date TBC
Raised awareness and
interest from paediatric
medical staff via wall
display for ward
Raised awareness and
interest from relevant
management via wall
display for ward
Improvement in STAMP
completion – meeting
standard
Paediatric
dietitians
April 14
Paediatric
dietitians
April 14
Paediatric
dietitians
Regular
dates
through
year
2
3
Support from
paediatric medical
staff
4
Support from
relevant
management
Relevant management to
be aware of use of STAMP
5
Regular STAMP
training and
assessment
Paediatric dietitians to hold
regular STAMP training
sessions, include in nurses’
annual preceptorship talk
32
Paediatric
dietitians
Appendix B
6
Willow referral to
Dietitians to include
STAMP score
Willow ward staff to be
informed that referrals to
dietitians must include an
accurate STAMP score
Ward staff informed that
STAMP is part of referral
criteria. Included on Willow
ward notices
Paediatric
dietitians
Completed
September
2013
7
STAMP form to be
included in
admission pack
printed off from
PAS
Include growth
chart in medical
notes for each
patient
PAS system to be set up
so STAMP form is included
in admissions pack
Already actioned –
STAMP form is now part of
admissions pack
Willow staff
Completed
November
2013
Nursing staff to include
appropriate age and
gender growth chart in
each patient’s medical
notes
Dietitians to train nursing
staff in how to take proxy
height and length
measurements. SB to
check with Amanda
Russell if these are
recorded in A&E and if so
how this information can be
communicated to the ward
All paediatric medical
notes to contain an
appropriate growth chart
Willow
ward staff
Completed
January
2014
Achieving standard for
Willow STAMP
Paediatric
dietitians
April 2014
8
9
Accurate proxy
height and length
measurements to
be included in
STAMP training to
enable completion
of Step 3 and risk
score
Parentaral Nutrition (PN) Service Review
ID: 2369
Audit project lead: Guy Sisson Gastro Consultant & Gill Murray-Ashby Nutrition Nurse Specialist
Speciality: Nutrition
Date presented/Reviewed: Feb 2014
Reasons for Audit:
Review PN practice within DVH of adult Patients to ensure NICE guidelines are adhered to.
Background:
Areas of the NICE guidelines are not being followed, which is affecting best practice, increasing
the risk of infection, poor nutritional intake and increased hospital stay.
Aims & Objectives:
Aim: Improve best practice for all adult PN patients within DVH in a designated area/ward. All
trained staff who will be nursing patients with PN to undergo PN training and have passed PN
competence. Develop a PN care bundle.
Objectives: All patients requiring PN are referred to the Nutrition Team, correct documentation
filled in as per PN care bundle, plan of care documented by patients’ medical team, correct PN
bloods requested as per NICE guidelines.
Design:
All patients who had PN from 2012 - 2013 in all only 87 patients set of notes were available to
audit. Data performer developed from NICE guidelines for best practice and DVH PN policy, audit
commenced in May – September 2013. All PN patients’ case notes were reviewed individually by
Nutrition Nurse Specialist then updated the information on to data performer.
Results:
All results should be 100% as per NICE Guidelines. Blood results as follows: UE=98%, Mg=80%,
LFT=84%, Ca=77%, CRP=95%, Copper=6%, MCV=74%, Ferritin=8%, Glucose=99%,
Phos=84%, INR=94%, Alb=82%, Zinc=58%, FBC=98%, Iron=8%, B12=3%
88% had no plan documented in patient’s notes
13% of PN commenced at weekend
71% of PN commenced out of hours
63% of PN commenced without Nutrition team input
33
Appendix B
83% had no reason documented why PN was commenced
Conclusions:
Objectives of PN Audit not met as shown in results full review of PN practice at DVH
Recommendations/Action plan:
No: Recommendations:
Action(s) to be taken:
Evidence of Nominated
Action:
lead (s):
Completion
Date:
Update
training
registration
Nutrition
Nurse
Specialist
March 2014
On
PAS
under
Nutrition
Bloods
Dr Sisson &
Jo Wheeler
March 2014
Nutrition
Nurse
Specialist
March 2014
1.
Education of Trained Staff
2.
Correct bloods for PN
patients pre, peri and post
PN
Develop teaching pack
and competency for
Trained Staff dealing
with PN patients
PN bloods placed in to
categories relevant to
PN
3.
Correct
documentation
relevant for PN monitoring
Develop
Bundle
PN
Care
ICE: 1
34
Appendix B
APPENDIX C
ABSTRACTS FROM ICE 1 INITIAL AUDITS
Foot Assessment For Diabetic Patients Re-Audit
Dr M Ismail, Fiona Sylvester, Diabetes, General Medicine
N.2121
July 2012
Reason For Audit: Re-audit ICE1, NICE
Background:
Diabetes is known to cause ulceration of the feet due to its damaging effects on blood vessels
and nerves. Patients’ feet require regular assessment as recommended by NICE guidelines.
Patients with diabetes admitted to hospital are at a high risk of foot ulceration particularly pressure
ulcers on the heels. When a patient with diabetes is admitted to hospital, a foot assessment
should be undertaken within 24 hours and the risk for ulceration classified.
The purpose of this audit was to determine how many patients with diabetes had had a foot
assessment within 24 hours of their admission to Darent Valley Hospital.
The length of hospital stay for patients with diabetes foot problems is 13 days longer than for
people with diabetes who do not have foot problems.
A previous audit was undertaken in October 2010 and found that the Trust was not achieving
100% compliance rate with undertaking foot assessments.
Method:
A retrospective study of all current inpatients with diabetes on a particular day was undertaken to
see if their feet had been examined and their risk of ulceration classified within 24 hours of their
admission. Data collection period 10th January 2012.
Results:
Of the 59 patients surveyed, 20% had had a foot assessment within 24 hours.
Low Risk
Medium Risk
High Risk
Not Recorded
6
1
3
49
10.1%
1.7%
5.1%
83.1%
Active Foot Pathology
14
23.7%
Conclusions:
Although the previous audits recommendations were implemented this unfortunately has not
resulted in meeting 100% compliance of undertaking foot assessments for patients with diabetes.
Recommendations:
To raise awareness among hospital staff in order to improve this aspect of care.
Action Plan:
A separate page to be included in the Medical Admissions Pathway as this is currently not
automated.
Workshops to continue for medical staff covering foot assessments & other aspects of diabetes
inpatient care.
Implement previous unmet plans from previous audits.
ICE1 – Dr Ismail confirmed the ICE score. As this is a repeat ICE 2 score, a risk assessment has
been undertaken.
Evaluation of Computerised Tomography of Pulmonary Artery (CTPA) Requests in Patients
with Suspected Pulmonary Embolism Attending the Emergency Department at Darent
Valley Hospital
Ref 2243
Dr R Suleman, Dr Y Deylamipour, Dr T Tavakkoli
35
Appendix C
Background and reasons for audit:
Pulmonary embolism is a highly prevalent condition, usually requiring hospitalization and
sometimes leading to recurrence and death. A district general hospital with catchment population
of 200,000 may expect to diagnose 50 cases of pulmonary embolism. Some of these become
apparent during autopsy. On the other hand, an autopsy in patients diagnosed with PE failed to
confirm the diagnosis in 63% of cases. This indicates that PE is both over diagnosed and under
diagnosed in clinical practise. Patients with suspected PE should be managed with a diagnostic
strategy that includes clinical probability assessment in combination with a D-dimer test.
Guidelines suggest a pathway for diagnosis based on stratifying patients into low, medium or high
risk based on their clinical risk factors, and the presence of an alternative clinical explanation for
the symptoms (Appendix 1). In combination with a negative D-dimer result, a PE can be
confidently excluded in a patient who is low risk clinically, removing the need for further imaging.
There is a significant role for imaging tests in diagnosing pulmonary embolism. Computerised
Tomography of Pulmonary Artery (CTPA) is now the recommended and imaging test of choice
because of its high sensitivity and specificity in patients with high risk and those low risk patients
with a positive D-dimer result. However, there has always been a growing concern over the fact
that one third of Emergency Department CT and nuclear imaging is potentially avoidable if
emergency department personnel were less aggressive in ordering the tests for low-risk patients.
This is important in view of unwanted exposure to radiation and limited resources. It is
recommended that all patients undergoing CTPA for suspected PE have their clinical probability
assessed and documented. Also as a part of this project we re-audited two previous D-dimer
audits (E1086 and E1491) in order to ensure that there has been improvement in practice.
Aims and objectives:
In view of the importance of this issue we carried out an audit based on CTPA requests from the
emergency department at Darent Valley Hospital. Our aim was to find out:
1) Total number of CTPA requests and classify with demographic parameter
2) Assessment of pulmonary embolism probability in each patient based on BTS guidelines
3) Accuracy and time of management
4) Total number unnecessary CTPA’s
Design:
We retrospectively evaluated all CTPA requests from the Emergency Department at Darent Valley
hospital over course of 12 months, commencing 1st June 2011 (until 31st May 2012). The
radiology department performed a total of 539 CTPA’s for suspected PE. Out of those, 43 CTPA
scans were requested by the A&E department. 39 cases were reviewed (4 were taken out of the
study due to unavailability of notes).
The clinical probability of PE in patients assessed by looking at the history notes, nursing
documentation of vital signs, ECG interpretations, CXR reports from PACS system, records of
blood gases and pathology results (including D-dimer) was identified.
Results:
Our cohort group consisted of 21 male and 18 female patients with an age range of 24 to 85
(mean of 57.2 and median of 56). From those who had a positive scan 45% presented with
shortness of breath, 36% tachycardia, 78% chest pain (only 10% pleuretic in nature) and 0% with
Haemoptysis.
All 39 patients had a valid ECG and chest x-ray done at presentation to A&E. Of these 39
patients, 28 were classified as low or intermediate risk patients for PE (71.6%) while 11 (28.2%)
were high risk.
A total of 11 out of 39 CTPA requests were reported positive (28%) out of which 6 were high risk,
5 were intermediate risk and none were in the low risk group. The mean time of CTPA to be
requested was 220 minutes (161) with a range of 11 to 690 minutes. {SD=71.3} Mean time of
CTPA to be done from the time of request was 148 minutes (65.8) with a range of 1 to 1091
minutes. {SD=54.7} Mean time of CTPA to be reported from the time it was done was 84.08
minutes (76.8) with a range of 21 to 358 minutes. {SD=40.2}.
Among 28 patients with low and intermediate risk probability, 9 (32%) patients did not have a Ddimer test performed. The CTPA scans in this group of patients were all negative for PE
36
Appendix C
confirming that up to fifth of the CTPA requests (9 out of total of 39) by the Emergency
Department could have been avoided.
26 out of 39 patients had a D-dimer test requested. Among those, 7 were done for patients with a
high probability of PE. This highlights that up to 27% (7 out of 26) of D-dimer requests for
suspected PE could have been avoided.
Conclusion:
Out of 28 patients with low or intermediate risk for PE, 9 patients (32%) underwent a CTPA
without a D-dimer test. The CTPA scans in this group of patients were all negative for PE
confirming that 20.5% (9 out of total of 39) of CTPA scans requested by the Emergency
Department might be preventable.
Moreover, this study revealed that some D-dimer requests were preventable as well; D-dimer
requests could be considered unwanted if the patient is high risk. Overall, this comprises of 27%
of D-dimer requests which could be avoided. This suggests that, regardless of 2 previous Audits
on D-dimer requests, doctors in the ED are still not adhering to D-dimer request protocols and
there is still a significant amount of unnecessary requests from A&E.
Finally, unless contraindicated, Heparin should be started in cases who are at high risk for PE and
for those at a low risk who had a positive D-dimer whilst waiting for results of investigations. This
study shows that only 36% of patients who were high risk or were low risk with positive D-dimer
were Heparinised before CTPA was requested.
Action plan:
In order to prevent unnecessary D-dimer and CTPA scans in the Emergency Department we
designed, and recommended the use of a pro forma as a guide for all doctors for any patients
suspected of PE/DVT. Using this, all junior doctors could assess the clinical probability of their
patients before requesting any investigation. It should be printed and used for any patient
suspected of PE/DVT, and for all D-dimer and CTPA requests filling this form should be
mandatory. Obviously, by starting to use a new pro forma there is no need to fill and send the
previous D-dimer audit form. This can contribute to reducing the amount of D-dimer requests and
also unwanted CTPA scans. Furthermore, high risk patient can benefit from treatment before
undertaking any further tests.
ICE 1
Re-Audit of time to theatre in trauma cases
ID: 2364
Audit project lead: Dr Andrew Stone, Mr Michael Thilagarajah
Speciality: Trauma & Orthopaedics
Date presented/Reviewed: June 2013
Reasons for Audit:
Clear standards exist regarding maximum acceptable waiting time for operative management for
certain types of limb trauma. In fractured neck of femur there are significant financial incentives for
complying too these standards, which will become more stringent soon.
Background:
Anecdotally there was concern in the department regarding waiting time for operations in limb
trauma. This can significantly impact patient care, and lead to significant financial losses in
fractured neck of femur patients. Longer waiting times also mean longer hospital stays, with the
associated increased cost and morbidity.
An audit was carried out to assess the Trust’s
performance when compared to national and local standards, and also to try and identify factors
leading to delays. Since the previous audit which was ICE scored as 1, there have been changes
in practice: Thursday and Friday morning Middle Grade Elective lists now have space for a
trauma case; on the Wednesday and Thursday night shifts, if there is an eligible fractured neck of
femur case for the following morning, the patient is identified, prepared for theatre by the
orthopaedic SHO and reviewed by the overnight anaesthetic team, so as to avoid delays in the
morning. This is a re-audit to see if any improvement has been made since the last audit and
subsequent changes in practice
Aims & Objectives:
37
Appendix C
Aim- Improve waiting times in cases of limb trauma requiring operative management
Objectives – Assess waiting times in operative management of limb trauma. Identify factors
causing unnecessary delays. Remove/improve such factors. Examine whether any improvement
since the previous audit. Assess the reliance of the Orthopaedic department on the CEPOD list,
particularly on the weekend
Design:
1 month of retrospective data collection (17th March 2013 to 16th February 2013). Trauma book
consulted to identify acute limb trauma admissions. Cases requiring operative management
identified. Time of admission or time of referral to orthopaedic team compared with surgical start
time, waiting time calculated and compared to guidelines. Casenotes examined for reasons for
delay in any cases exceeding recommended waiting times. Data was collected in May 2013. 60
patients in total were included.
The standards for maximum acceptable waiting times were as follows. Fractured neck of femur:
36 hours (Best Practice Tariff from joint BOA/BGS guidelines. Open fractures: 24 hours (joint
guidelines from BAPRAS/BOA). Dislocations: 24 hours (local guidelines set by the consultant
orthopaedic surgeons). Other injuries: 36 hours (local guidelines set by the consultant orthopaedic
surgeons).
The type of operating list that the case was performed on was also noted from Theatre Man
(elective/trauma/CEPOD)
Results:
10/31 Fractured Neck of Femur patients were not operated on within 36 hours (32% compared to
43% previously).
8/20 other injuries were not operated on within 36 hours (40% compared to 10% previously)
All open fractures/dislocations were operated on within 24 hours (9/9)
Of the 18 patients breaching the standards set, 9 had a clinical reason for the delay, 9 were
delayed due to no space on the operating list. This corresponds to 6/31 fractured necks of femur
patients (19% compared to 20% previously) and 3/20 other injury patients (15% compared to 5%
previously)
26/60 operated on CEPOD (43% compared to 45% previously)
21/60 operated on CEPOD over the weekend (35% compared to 41% previously)
Conclusions:
Although small improvement in the proportion of fractured necks of femurs breaching the
standards set, this shift in priority towards those patients has led to a larger increase in other
cases breaching the standards. This is likely due to the longer theatre time (both anaesthetic and
surgical) in the fractured neck of femur cases. There has also been a slight improvement in the
CEPOD usage, particularly on the weekend. This is likely due to the use of the Thursday and
Friday elective lists, reducing the backlog on the weekend.
Recommendations/Action plan:
No:
Recommendations:
Action(s) to be taken:
1.
Fractured
necks
of
femurs to be first on the
list
SHOs to be made aware
of correct order
Evidence of
Action:
Audit
Presentation
2.
Improve
trauma
list
efficiency
More
trauma
lists,
whether in the week or at
weekends
Review of trauma list
efficiency
Discuss with executives
Present
review
Minutes
3.
38
Nominated
lead (s):
Andrew
Stone
Hannah
Rogers
Mr
Thilagarajah
Completion
Date:
Done at time of
presentation
On-going
July 2013
Appendix C
4.
Increase awareness of
36
hour
operative
window
in
fractured
necks of femurs
Alterations to the neck of
femur proforma
Updated
proforma
Mr
Thilagarajah
July 13
ICE score: 2
Mr Thilagarajah confirmed that he has now spoken to Mr Moftah & Alex Tan (3) and highlighted
the need for more Trauma lists this is now being reviewed. He has also updated the NOF
proforma (4) addressing the 36 hr awareness. The updated proforma is now being used. A reaudit will be carried out in 1yr to show compliance – July 14.
Re-Audit of Antibiotic Prescribing in General Surgery Inpatients
Audit Project Leads: Mr Murali, Dr Lizzy Tuckwell, Dr Alice Michell
Ref 2452
Reasons for Audit
ICE1 Re-Audit
Background
Previous audit graded as ICE1 (Ref 2338) and showed the department not performing to the
standards expected.
Aim
Are we following antimicrobial guidance in accordance with trust policy?
Objectives
To ensure that infections are being treated appropriately
To ensure documentation is accurate and detailed
Design
A point in time review of inpatient drug charts was undertaken over 4 days throughout October
and November of surgical inpatients . The charts of those patients on antibiotics were then
evaluated to assess whether allergy documented, signature and bleep documented, indication
documented, whether this was the guideline antibiotic according to trust policy, duration was
documented and if there were any omissions in drug administration and finally if a probiotic had
been prescribed. In total 50 inpatient charts were reviewed with the target standard 100% for all
objectives except omissions which was 0%.
Results
We achieved our target (100%) for allergy documentation, signature on the chart and omissions
(0%). 82% of charts had an indication documented. 68% of antibiotic prescriptions were in line
with trust guidance. 38% of charts had a bleep number documented. A stop or review date was
written in 38% of charts and 28% of patients were prescribed an oral probiotic.
Conclusions
One of the main key points following the audit were that whilst the documentation of allergy and
signature achieved the target, the overall documentation of indication, duration, bleep number
was below our trust’s standards.
Recommendations and Action Plan
No:
Recommendation:
1.
Educate new trainees
and existing doctors on
the
trust
policy
‘Antibiotics of Choice’
Action(s) to be taken:
5. Ensure all doctors
have a hard copy
of the guideline
6. Show staff where
to
find
the
39
Evidence of Actions
Nominated
lead(s):
Completion
Date:
Agenda / minutes of
induction
Dr
Tuckwell,
Dr Michell
October
2013
Appendix C
2.
3.
Re-enforce the need for
bleep as well as
signature on charts
Re-audit once action
plan implemented
guidelines on the
intranet
Disseminate
audit
results
to
whole
department
Minutes of surgical
audit
meeting
October 2013
Registration form
Dr
Tuckwell,
Dr Michell
October
2013
March 2014
ICE 1
Infection Rates in Parenteral Nutrition Lines
N2107
Dr Pai, Dr Sisson, General Medicine, Linda Dempster, Infection Control
January 2014
Presented: Adult Medicine & Surgical Clinical Audit Meetings, October & November 2013.
Reasons for Audit:
A previous audit in 2010 showed a high rate of infection in those who had central lines for
parenteral nutrition. This was an ICE1 audit and was placed on the risk register.
Background:
Anecdotal evidence showed that there were higher-than-normal rates of infection in lines used for
parenteral nutrition. The audit was carried out to find out exact rates of infection of central lines
used for total parenteral nutrition (TPN) and to find out adherence to local and national guidelines.
Aims and Objectives:
Aim: To find out what the infection rates are and improve rates of documentation regarding care
on the wards
Objectives:
- Ensure that the aseptic insertion technique is being followed
- Ensure timely removal of the line if parenteral nutrition is no longer required
- Ensure only single lumen lines are inserted when the sole indication is PN
- Find out which bacteria are responsible for infections
- Audit daily documentation regarding care and condition of the line
Design:
A whole year’s worth of PN patients were audited. A list of patients who had parenteral nutrition in
2012 was supplied by the dieticians (n=108). Out of these patients, case notes were retrieved for
86 patients. Each set of notes was studied for documentation of insertion, type of line, reason for
insertion, date of removal, reason for removal and positive blood cultures.
Results:
In the 86 patients, a total of 118 lines, including hickman lines and PICC lines were used for PN,
with a total of 1002 catheter days. 10 infections were identified in 6 patients, 7 proven catheter
associated blood stream infections, and 3 catheter suspected blood stream infections. 5 were
from single lumen, 2 from multi-lumen lines, 1 from a hickman line, and 2 from unknown types of
central lines (type of line was not documented at time of insertion). All positive blood cultures were
coagulase negative staphylococcus. Mean length of stay of the line was 8 days and mean length
of time on PN was 13 days.
39% of patients did not have sufficient documentation in the medical notes regarding aseptic
insertion of the line. None of the wards had any documentation regarding the ongoing care of the
line, either from nursing or doctors notes. At least 17 multi-lumen lines were inserted when the
sole indication for the central line was PN.
Conclusion:
There is a high rate of infection in parenteral nutrition lines despite following Matching Michigan
guidelines. There is a poor rate of ongoing documentation regarding care of the line on the
wards, and there is poor documentation regarding the type of the line and insertion of the line in
the medical notes.
40
Appendix C
Inappropriate lines are being used when the sole indication is PN. The cost of a catheter related
blood stream infection is costed conservatively at £5000.
Action Plan:
N
o
Recommendation:
Action(s) to be
taken:
Evidence of Actions
Nominated
lead(s):
Completion Date:
1
.
Introduce a ‘PN pack’ or
form for ongoing care and
documentation of the line
Addition of discussion
regarding the pack on
the agenda
Guy Sisson
31/03/2014
2
.
Educate staff on the wards
regarding accessing the
line aseptically and
highlight the importance of
reviewing the line daily
Discussion between
the nutrition team
and the risk team
regarding the
introduction of the
pack
Covered in IV Study
days.
Saving Lives Audits
Lead
Infection
Control Lead
Complete and
Ongoing
3
.
Inform junior doctors of the
policy to take blood cultures
from
the
line
and
peripherally
Include in F1/F2/CT
teaching
Blood Culture training
included on Infection
Control teaching.
Representatives of
company supplying
blood culture packs
have and continue to
facilitate ward based
training.
Blood Culture policy
updated to Reflect
this.
Lead
infection
Control
Nurse.
Complete and
Ongoing
4
.
Re-audit rates of infection
in PN lines
5
.
An Infection Control nurse
to be a member of the
weekly
Multi-disciplinary
Nutrition ward rounds.
Re-Audit once
recommendations
have been
implemented.
 Nominate a
member of the
team as main
Nutrition link.
 Commence
attendance.
Band 7 Nurse
regularly attends
rounds when service
needs allow.
Infection
Control
Team
Lead Control
Nurse
A re-audit is to be
undertaken
before 30/6/2014
Lead
Infection
Control
Nurse
12/2/2014
ICE1 – Contact early May for an update on the implementation of the recommendations. A reaudit is to be undertaken before August 2014
Dr Sisson emailed that the ICE1 reflects the significant impact this project has on patient care.
Observation Audit 2012
Ref 2169
Audit Leads:
Phillipa Wakefield - ITU Audit Nurse, Tara Laybourne - Matron &
The Critical Care Outreach Team
Speciality:
Outreach
Reason for Audit:
Network Initiative and Re Audit
Audit Completed:
November 2012
Review Date:
November 2013
Aims and Objectives:
The aim of the audit was to establish Trust compliance in according with NICE CG50 and Local
Policy. This was a re-audit which is carried out annually by the Outreach Nurses in the Kent and
Medway Critical Care Network.
As per the Trust “Adult Vital Sign and Fluid Chart” (PAR Scoring) Policy a complete set of
observations (vital signs) must be recorded each time a patient has observations taken. This
41
Appendix C
score includes the patients urine output, therefore any patient who has a fluid balance in progress
MUST have a urine output measured. This audit therefore also aims to measure the
documentation within the fluid charts and compliance with the trust policy.
Method
All adult in-patient areas in the Trust were included in the audit. Out-patient areas and A+E were
excluded as the criteria for inclusion was a hospital stay of greater than 12 hours. All observation
charts were examined and the percentage of compliance calculated and compared to previous
audits. All elements in each section must have been present to achieve compliance. In total 340
temperature, pulse and respiratory (TPR) charts were reviewed during the same week in
November 2012 across all sites.
Of the 340 patients with TPR charts a total of 100 fluid charts were also found to have been
completed and therefore subsequently audited.
Results of Observation Audit
Recording of Observations: TPR charts were checked to establish whether pulse, blood
pressure, temperature, oxygen saturations, respiratory rate and AVPU were recorded within the
last 12 hours. Results show 96%-98% (95-98%) compliance in this section.
Frequency and appropriateness of observations: The frequency of observations was thought to be
appropriate for 89% (96%) of patients and 89% (91%) of patients last set of observations were a
full set. 88% (96%) of the patients had observations recorded as being done before 9am.
Demographics: Patient identification, date/time and nurses initials must all be present. 57%
(57%) of charts had patients’ name and unit number completed. 80% (75%) of charts were
initialled and 74% (69%) had year, date and time completed.
Oxygen: 96% (95%) had Fio2 recorded in the last 12 hours. This could have been documented
as room air or percentage of oxygen.
PAR Score: 97% (97%) had a correct AVPU incorporated into the PAR score. 96% (96%) of
patients had been PAR scored in the last 12 hours.
Conclusion of Observation Audit
50% of the results were the same in comparison to last year. 25% were worse, including obs not
done before 9am, of the PAR scores completed in the last 12 hours, less were correct than last
year. The last set of observations was not a complete set and the frequency of obs was not
appropriate in more cases. However there was improvement with the recording of the year, date
and time, temperature in the last 12 hours, fio2 in the last 12 hours and the observations being
initialled.
The overall compliance Trust wide in observation recording still does not meet NICE (CG50)
guidance of 100%. Despite the ongoing recommendations in place within the trust, this years
audit highlighted some areas where compliance was down from the previous year.
It is essential to complete demographics on patient’s documentation as this allows the appropriate
care to be delivered to the right patient; however there was minimal improvement in this area. It
also means that patient notes & records can be filed accurately. At times notes can become
separated & if patient demographics are incomplete individual charts/pages are not able to be
filed accurately.
Results of Fluid Audit
Demographics: 99% of charts had the patients’ name documented, however only 13% had the
patients unit number recorded, and only 25% had the patients NHS number recorded.
Fluid Balance – Input: Only 58% of the input section of the fluid charts were fully completed, 32%
had infrequent documentation and 10% had no documentation at all, therefore falling short of the
minimum policy requirement of 4 hourly documentation.
42
Appendix C
Fluid Balance – Output: Only 45% of the output section of the charts were fully completed; 32%
had infrequent documentation and 23% had no documentation at all, therefore falling short of the
minimum policy requirement of 4 hourly documentation.
Total Fluid Balances: Only 5% of charts had a total running balance documented
24 hr Fluid Balance: Only 9% of charts had the previous 24hr fluid balance recorded
Fluid Balance Aim: No charts (0%) had the fluid balance aim for the next 24hrs!
Nil by Mouth: Only 23% of the charts had the nil by mouth section completed
Conclusion of Fluid Audit
The results clearly demonstrate poor and in some areas non-compliance to the Trust Adult Vital
Sign and Fluid Chart (PAR scoring) Policy.
The lack of recognition of the importance of fluid balance as part of the PAR score clearly has an
impact on the nurses correctly PAR scoring the patient and furthermore, it has a direct implication
for patient safety. Deteriorating patients are not being escalated as per the PAR algorithm in a
timely manner due to incorrect PAR scores.
This leads to an increased risk in patients deteriorating which could clearly have a compounding
effect on length of hospital stay and patient outcome and cost implications for the trust. The
recording of patient identifiable information was very poor on the fluid charts.
Recommendations for Observation & Fluid Audit
1. All Staff to adhere to the deteriorating patient escalation algorithm as they have a duty of
Care for their acts and omissions.
2. Promote HDU, Deteriorating Patient and ALERT Courses.
3. Ensure mandatory attendance of timely Resuscitation Training.
4. Collaboration and improvement in Site Team/Outreach working to identify and manage
critically ill patients 24 hours a day.
5. MET call will be monitored to ensure compliance with trust policy
6. Fluid charts to be included in all future Annual Network Audits in order to establish overall
PAR accuracy in the Trust
7. Greater awareness to be highlighted to all medical staff to improve adherence to the Policy
8. Documentation of daily aim for 24hr fluid balance
9. Increase our recognition via Governance structure on lack of adherence to policy on
observations and fluid charting
10. ITU chart to be trialled on chestnut ward and fed back if the “tool” makes a difference to
completion
11. Matrons to be sent a copy of the business case Tara made for scales
12. Review Vital Signs Policy
13. NHS number to be pre printed fluid charts from PAS
14. PAS observation chart needs removing or updating as current version is incorrect
ICE Score: 1
Re-audit due: November 2013
Observation & Fluid Audit 2013
Audit Id Number: 2413
Audit Leads:
Phillipa Wakefield - ITU Audit Nurse, Tara Laybourne - Matron &
The Critical Care Outreach Team
Speciality:
Outreach
Reason for Audit:
Network Initiative and Re Audit
Audit Completed:
November 2013
Review Date:
November 2014
Aims and Objectives:
43
Appendix C
The aim of the audit was to establish Trust compliance in according with NICE CG50 and Local
Policy. This was a re-audit which is carried out annually by the Outreach Nurses in the Kent and
Medway Critical Care Network.
As per the Trust “Adult Vital Sign and Fluid Chart” (PAR Scoring) Policy a complete set of
observations (vital signs) must be recorded each time a patient has observations taken. This
score includes the patients urine output, therefore any patient who has a fluid balance in progress
MUST have a urine output measured. This audit therefore also aims to measure the
documentation within the fluid charts and compliance with the trust policy.
Method
All adult in-patient areas in the Trust were included in the audit. Out-patient areas and A+E were
excluded as the criteria for inclusion was a hospital stay of greater than 12 hours. All observation
charts were examined and the percentage of compliance calculated and compared to previous
audits. All elements in each section must have been present to achieve compliance. In total 371
(340) temperature, pulse and respiratory (TPR) charts were reviewed during the same week in
November 2012.
Of the 371 patients with TPR charts a total of 119 (100) fluid charts were also found to have been
in place and therefore subsequently audited.
Results of Observation Audit
NB: Results are shown as: 2013 - **%, 2012 – (**%), 2011 – (**%)
Recording of Observations: TPR charts were checked to establish whether pulse, blood
pressure, temperature, oxygen saturations, respiratory rate and AVPU were recorded within the
last 12 hours. Results show 91%-94% (96%-98%) (95%-98%) compliance in this section.
Frequency and appropriateness of observations: The frequency of observations was thought to be
appropriate for 89% (89%) (96%) of patients and 82% (89%) (91%) of patients last set of
observations were a full set. 89% (88%) (96%) of the patients had observations recorded as
being done before 9am.
Demographics: Patient identification, date/time and nurses initials must all be present. 51%
(57%) (57%) of charts had patients’ name and unit number completed. 80% (80%) (75%) of
charts were initialled and 71% (74%) (69%) had year, date and time completed.
Oxygen: 92% (96%) (95%) had Fio2 recorded in the last 12 hours. This could have been
documented as room air or percentage of oxygen.
PAR Score: 94% (97%) (97%) had a correct AVPU incorporated into the PAR score. 92% (96%)
(96%) of patients had been PAR scored in the last 12 hours. Of these only 63% (86%) (94%)
were actually correctly calculated and therefore reflective of the patient’s condition at that time.
The reason for 63% accuracy is due to the fact that urine output was either being measured
incorrectly or not at all.
Conclusion of Observation Audit
Despite the importance given to this and a comprehensive action plan in light of the poor
compliance following last year’s audit, the results again this year are very disappointing. The only
improvement on last years results were of 1% in the patients observations being recorded before
9am.
Results of Fluid Audit
Demographics: Are the patients full details documented? 82% (13%)
Full date and current ward documented? 88%
Fluid Balance – Input: Fluid Input at least 4hrly? 38% (58%)
Fluid Balance – Output: Fluid Output at least 4hrly? 34% (45%)
Total fluid balance – 18% (5%)
Previous 24hr balance – 20% (9%)
44
Appendix C
Fluid Balance Aim: Only 2% (0%) of the charts had the fluid balance aim for the next 24hrs
Nil by Mouth: Only 24% (23%) of the charts had the nil by mouth section completed
Conclusion of Fluid Audit
The results again this year clearly demonstrate poor compliance, and in some areas worse
compliance with the Trust Adult Vital Sign and Fluid Chart (PAR scoring) Policy compared to last
year. The only significant improvement in compliance is within the patient demographics
completion. This year we audited a new area of compliance within demographics (documentation
of the full date and current ward). Compliance in this area was 88% however we cannot compare
this to last year.
The lack of recognition of the importance of fluid balance as part of the PAR score clearly has an
impact on the nurses correctly PAR scoring the patient and furthermore, it has a direct implication
for patient safety. Deteriorating patients are not being escalated as per the PAR algorithm in a
timely manner due to incorrect PAR scores.
This leads to an increased risk in patients deteriorating which could clearly have a compounding
effect on length of hospital stay and patient outcome and cost implications for the trust.
Recommendations for Observation & Fluid Audit
1. Present audit results at Clinical Nurse Board.
2. Present results at Ward Sisters meeting.
3. Matrons to meet with ward sisters to discuss individual results and develop an action plan
specific to the needs of individual’s area. (instruction from Kate King)
4. A period of time, no longer than six weeks, will be established for implementation of the
action plan, after which a further audit will be undertaken by your Matron. (Kate Kings
expectation is that performance in relation to this aspect of care will be compliant with the
existing standard by the end of the period )
5. Local audits to be carried out using the same tool as used for the annual audit.
6. Matron and Ward Sister of each area to meet with Kate King to discuss any lack of
improvement and further action, if improvement is not evidenced.
7. The GM of the area will be kept fully informed of the results of the audit, action plans and
outcomes by the Matron.
8. Implementation of a new ward Observation and Fluid chart know as the “Heidi chart”
(Heidi Greeves)
9. Vital Pac system to be considered as part of the IT bids for this year.
ICE Score: 1
Recommendations and Action Plan
Recommendation
Action
By whom
By when
1. Present results at Clinical
Nurse board.
Present results at Clinical
Nurse board
Tara Laybourne
9th Jan 2014 - Done
2. Present results at Ward
Sisters meeting.
Present results at Ward Sisters
meeting.
Tara Laybourne
Jan 2014 - Done
3. Matrons to meet with ward
sisters to discuss individual
results and develop an action
plan specific to the needs of
individual’s area. (instruction
from Kate King)
Discuss individual results and
develop an action plan specific
to the needs of individual’s
area.
Matrons & Ward
Sisters
By end Feb 2014
4. A period of time, no longer
than six weeks, will be
established for implementation
of the action plan, after which a
further audit will be
undertaken.
Further audit will be undertaken
(Kate Kings expectation is that
performance in relation to this
aspect of care will be compliant
with the existing standard by
the end of the period)
Matrons & Ward
Sisters
Full implementation
and re audit to be
completed for all
areas by end April
14.
45
Appendix C
5. Local audits to be carried
out using the same tool as
used for the annual audit.
Observation and fluid audit
tools to be emailed to all
Matrons & Ward Sisters
(including Judith Fell at Queen
Marys)
Phillipa Wakefield
14th Jan 2014 Done
6. Matron and Ward Sister of
each area to meet with Kate
King to discuss any lack of
improvement and further
action, if improvement is not
evidenced.
Matron and Ward Sisters to
meet with Kate King following
when local audits have been
done and results are available
Matrons & Ward
Sisters
By end April 2014
7. The GM of the area will be
kept fully informed of the
results of the audit, action
plans and outcomes by the
Matron.
Matron and Ward Sisters to
regularly update the GM
Matron & Ward
Sisters
End April 2014
8. Implementation of a new
ward Observation and Fluid
chart know as the “Heidi chart”
(Heidi Greeves)
1. Formulate new Obs & Fluid
chart
2. Implement new Obs & Fluid
chart trust wide
1. Heidi Geeves
March 2014
2. ??????
April 2014
9. Vital Pac system to be
considered as part of the IT
bids for this year.
Include in the IT bid for 2014
Tara Laybourne
January 2014 Done
Re-Audit of Acute Surgical Admissions Documents
Audit Ref 2165
Audit project lead: Ms S Wheatstone, Ms B Stacey, Mr K Murali
Speciality: General Surgery
Date presented/Reviewed: February 2013
Reasons for Audit:
Re-audit as recommended in of ‘Re-Audit of Surgical patient – The first 24 hours’ Ref 2165, ICE 2
November 2011.
Background:
After introducing an acute general surgical admissions proforma in 2011, an improvement was
previously found in accuracy of some documentation, but some key data was routinely missing
from patients’ notes. This has implications for accurate medical record keeping, and CQUIN
funding for the Trust.
Aims & Objectives:
The aim is to re-audit how accurate and complete our admissions data collection is using our
improved surgical admissions proforma. In particular we are focusing on the parts with poor
completion previously in November 2011 such as recording VTE risk assessment, and patient
identifying details on each page and also examining if we have sustained improvement from the
first audit in April 2011 prior to introducing a surgical admissions proforma.
Design:
We undertook a case note analysis of all acute surgical admissions on 7 days in Dec 2012. We
identified 57 case notes where the admissions proforma had been used and examined them at
the time of the post-take ward round. We excluded patients seen as ward referrals and patients
not admitted as in neither case would the admissions document be used. Notes were audited
against minimum documentation criterion from the GMC, RCSEng and as used in the previous
audit.
Results:
46
Appendix C
Only 4% of notes had patient identifying information on every page. This has reduced from 19% in
November 2011 and 98% in April 2011 before the proforma was introduced. Completion of the
VTE assessment form has increased from 2% (April 2011) to 12% (Nov 2011) to 45% (Dec 2012),
appropriate prescription of VTE prophylaxis has decreased from 98% (April 2011)to 89% (Nov
2011) to 87% (Dec 2012). Prescription of a patient’s normal medication has improved from 57%
(Nov 2011) to 94% (Dec 2012). Blood results are documented in 70% of notes (Dec 2012).
Observation frequency is requested in 33% of patients (Dec 2012). Handover sheet completion
has remained good with differential diagnosis in 94% (April 201),92% (Nov 2011) and 91% (Dec
2012) and management plan in 92% (April 2011) 98% (Nov 2011) and 91% (Dec 2012). Allergy
information on the drug chart has remained fairly static (87% April 2011, 88% Nov 2011, 86% Dec
2012). Over 98% (Dec 2012) of patients have a differential diagnosis and a management plan, up
from originally 88% (April 2011).
Conclusions:
Currently, we are not meeting basic requirements in accurate record keeping. 96% of patients’
notes contain pages with inadequate identifying details on; this is below the expected standards.
CQUIN funding for VTE prophylaxis is based on 95% completion of assessment forms,
prescriptions and discharge summary data. We are not currently meeting targets for assessment
forms and prescriptions at the time of the post-take ward round. Prescription of normal
medications has improved after a prompt on the admissions proforma. There is already a prompt
for VTE prophylaxis. Junior doctors are reluctant to request observation frequency, perhaps due
to unfamiliarity with this.
Recommendations / Action plan
ICE1
No:
Recommendation:
1.
Consider availability of
patient ID labels in A&E.
Consider admissions
document generated on
patient centre and printed
with details already
present.
Education of junior
doctors of CQUIN targets
and implications for not
meeting them.
Education of all
department of duties in
GMC ‘Good Medical
Practice’ regarding
medical record keeping.
Education of junior
doctors in observation
frequency. Review
admissions document and
revise as required.
Quality of Information
Audit:
Junior doctors should
participate in quality of
information audit.
2.
3.
4.
5.
Action(s)
taken:
to
be
Evidence of
Actions
Nominated
lead(s):
Completion
Date:
Discuss at
medical records
committee
meeting.
Presence of
labels/document
on patient centre.
B Stacey
April 2013
Discuss at
departmental audit
meeting.
Minutes of Audit
S
Wheatstone
April 2013
Discuss at
departmental audit
meeting, as part of
presentation of this
audit.
Discuss at audit
meeting.
PowerPoint audit
presentation
S
Wheatstone
February
2013
Minutes of audit
meeting.
S
Wheatstone
April 2013
Remind junior
doctors at audit
meeting
Increase in doctors
performing quality
of information
audit
S
Wheatstone
June 2013
47
Appendix C