Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Download oral presentations
Transcript
SHARING NOTABLE PRACTICE Holiday Inn, Carburton Street, London 12 June 2013 - Abstract Book – Sharing Good Practice June 2013 SHARING NOTABLE PRACTICE 12 June 2013, Holiday Inn, Carburton Street, London Programme th 0930 Registration 1000 Welcome , Introduction & Chair Dr Aileen Sced, Consultant Anaesthetist FPD/Assoc DME, Portsmouth Hospitals NHS Trust 1005 Emergency Medical Services at the London Olympics, Dr David Zideman, Clinical Lead, Emergency Medical Services, LOCOG. Quality Improvement projects of Educational Innovation 1030 Delivering a trainee centred interactive educational programme, Dr Sarah Hoye, Huddersfield Royal Infirmary 1045 Blended approach to foundation trainee preparation for the ARCP process, Dr Bridget Langham & Mrs Heidi Breed, East Midlands LETB 1100 Exploring medical students perceptions on preparedness for becoming a first year graduate doctor after undertaking a prolonged assistantship, Dr Sarah Jayne Kingdon, Sheffield Medical School 1115 A questionnaire based survey of junior doctors’ knowledge of incident reporting and risk, Dr Elizabeth Mathew, Russells Hall Hospital, Dudley 1130-1200 Coffee & Poster Session - Judges: Dr David Zideman, Dr Clare van Hamel & Dr Claire Mallinson Plenary Chair: Dr Rebecca Aspinall, Consultant Anaesthetist, University Hospitals, Bristol Quality Improvement projects of Educational Innovation 1200 Introducing coaching training in a large foundation school, Prof Paul Baker and Dr Joanne Curran, North Western Deanery 1215 Four day shadowing program for F1 doctors: a blended approach, Mrs Andrea Fox-Hiley, Mrs Margaret Ward and Dr Catherine Dickinson, St James’ University Hospital, Leeds 1230 1245 Tackling bullying in the foundation years: why it’s better to prepare and prevent than repair and repent, Dr Lois Haruna and Dr Shaarifa Raza, North Middx University Hospital Trainees improving care through leadership and education (TICkLE), Dr Christopher Cousins and Dr Zeeshan Malik, Salford Royal NHS Foundation Trust 1300-1400 Lunch & Poster Viewing Plenary Chair: Dr Clare van Hamel, FSD, Severn Deanery/UKFPO Clinical Advisor 1400-1425 Lessons Learnt, Building a safer Foundation, Dr Maria Ahmed, Imperial College 1425-1430 Careers Planning: a national perspective, Dr Melanie Jones, Co-Chair of the Careers Planning Group & Ms Joanne Marvell, National Specialty Recruitment Manager, HEE Breakout sessions 1435-1514 1 – QI Clinical (1) & QI Process (2 Groups – 3 Oral presentations 10 mins each + 3 mins discussion) 1514-1534 Tea 1534-1613 2 – QI Clinical (2) & Careers (2 Groups – 3 Oral presentations 10 mins each + 3 mins discussion) 1618 Careers initiative for Trainees, Better Training Better Care 1620 Poster Prize and short synopsis by winners -2- Sharing Good Practice June 2013 1628 Wrap-Up & Close BREAKOUT SESSION DETAILS: QI Clinical 1 – Oxford Chair: Dr Claire van Hamel, FSD, Severn Deanery/UKFPO Clinical Advisor 1435 1448 A solution to F1 induced malnutrition, Dr James Cheaveau, Royal United Hospital Bath Improving the safety and efficiency of IV fluid prescribing for adults on medical and surgical wards, Dr Emma Tenison, Dr Katherine Leonard, Dr Andrew Cumpstey, Dr Sarah de Courcy, Dr Alison Foster, Dr Hannah Mackinnon, Dr Kirsty Nelson-Smith, Dr Sophie Walter and Dr Hazel Yilmaz, Musgrove Park Hospital, Taunton 1501 Analysis of the implementation of breast multi-disciplinary team decisions at a district general hospital, Dr Alexander Bates, Cheltenham General Hospital QI Process – Cambridge Chair: Dr Claire Mallinson, Chair NACT UK 1435 Shared experiences of Quality Improvement for Foundation trainees, Dr Benjamin Plumb and Dr Katherine Finucane, Southmead Hospital, Bristol and Dr Joanne Watson, Musgrove Park Hospital, Taunton PRIMO: the use of risk monitoring tools to promote a safer working environment, Dr Phyllis Mezue and Dr Nicole McGrath, Lincoln County Hospital 1501 1510-1530 TEA QI Clinical 2 - Cambridge Chair: Dr Ratan Alexander, PG Clinical Tutor & FPTD, Worcs Royal Hospital 1534 1547 1600 Dementia: junior doctors championing change, Dr Catherine Pye, Kingston Hospital Change from the bottom up, Dr Asher Steene, Luton & Dunstable Hospital Documentation of DVLA driving advice following new medical diagnoses , Dr Claire Cameron, Bristol Royal Infirmary QI Careers – Oxford Chair: Dr Rebecca Aspinall, Consultant Anaesthetist, University Hospitals, Bristol Supervised learning events – trainees’ perspective, Dr Sapna Patel, King’s College Hospital 1534 London 1547 Embedding careers education in the U/G medical curriculum: an overview of current practice, Mr Michael Wilson, Newcastle University Preparing F2s for specialty interviews and selection centres, Ms Lisa Stone, South Thames 1600 Foundation School POSTER PRESENTATIONS: - 37 in total selected 1. Hospital Antibiotic Prudent Prescribing Indicator Audit (HAPPI), Dr Yvonne Tin, Dr Karen Pond and Dr Robert Penders, Gloucestershire Royal Hospital 2. Assessing the assessments: trainee and trainer opinions of foundation programme supervised learning events in a district general hospital, Dr Saurabh Singh, Dr Vishal Vyas, Mr Louis Savage and Mr Martin Klein, Barnet and Chase Farm Hospitals NHS Trust 3. Invasive medical procedure skills amongst foundation year doctors – a questionnaire study, Dr Chung Thom Lim, Dr Victoria Gibbs and Dr Chung Sim Lim, Barts and the London Hospital 4. Do not attempt resuscitation (DNAR) orders: a dying skill? Dr Katy Hosie and Dr Kate Spencer, Weston General Hospital 5. Foundation doctor audits: a missed opportunity? Dr Milan Makwana, Mr Louis Savage, Dr Saurabh Singh and Mr Martin Klein, Barnet and Chase Farm Hospitals NHS Trust 6. Local audit of escalation plans and DNACPR orders for acute medical admissions in accordance with 2012 NCEPOD guidelines, Dr Lorna Starsmore, Gloucester Royal Hospital -3- Sharing Good Practice June 2013 7. 8. Prevent the three year progression from erectile dysfunction of myocardial infarction, Dr Laura Backhouse, Gloucester Royal Hospital An innovative approach to teaching guidelines and research, Dr Craig Montgomery, Dr Laura Norris, Dr Stephen Keddie, and Dr Mark Piper, Education Department Northumbria Healthcare 9. 10. Are we following the NCEPOD recommendations for emergency surgery in elderly patients? Dr Yuka Ikegaya and Mr Jamshed Shabbir, University Hospitals Bristol Audit of overnight red blood cell transfusion, Dr Sarah Mabbutt and Dr Amy Gray, Weston General Hospital 11. Development of a regional formative prescribing assessment for doctors, Mrs Gail 12. Fleming, Mrs Siobhan Burke-Adams, Dr Jane Allen and Mr Marc Terry, KSS Deanery Death certification: re-audit on practice at the Royal Bolton Hospital, Dr Anli Yue Zhou and Dr David Bisset, Royal Bolton Hospital 13. Peripheral Venous Cannula insertion audit December 2013, Musgrove Park Hospital: do foundation doctors follow guidelines? Dr Helen Casey, Dr Claire SpoltonDean, and Ms Julie Roberts, Musgrove Park Hospital, Taunton 14. Is the time for the hospital bleep system now over? Assessing mobile phone usage for work purposes amongst new junior doctors, Dr Vishal Vyas, Dr Tami Benzaken and Mr Benjamin Stubbs, Barnet and Chase Farm Hospitals NHS Trust 15. 16. 17. 18. 19. 20. 21. Confusion Assessment Method (CAM-ICU): a quality improvement project in progress, Dr Alessandra Glover, Bristol NHS Trust Improving the management of Acute Kidney Injury (AKI) at Kings Mill Hospital: Introduction of the DONUT care bundle, Dr Anisha Bhagwanani, Dr Rory Carpenter, Dr Aqeelah Yusuf and Dr Simon Stinchcombe, King’s Mill Hospital, Sutton in Ashfield Virtual Interactive Teaching and Learning (VITAL) for Doctors, Dr Rebecca Igbokwe, S Potter and M Thomas, Heartlands Hospital, Birmingham Using simulation-based teaching to deliver core medical emergency topics of the foundation programme to trainees in a district general hospital (DGH), Dr Prashant Kumar, Dr Sarah Miller, Dr Claire Smith, Dr Thomas Cullen and Mrs Ruth Edwards, Milton Keynes Hospital Safe Handover: safe patients – the electronic handover system, Dr Alex Till and Dr Hanish Sall, Northampton General Hospital Engaging juniors – reforming our adult non-elective admissions pro forma, Dr Hanish Sall and Dr Alex Till, Northampton General Hospital Safe removal of radiologically inserted drains: what a junior doctors should know Dr Renukha Govinda Rajoo and Dr Tom Gordon, St Peter’s Hospital, Chertsey 22. 23. Improving Peripheral Arterial Disease Management through use of the audit cycle, Dr Tom Heaton, Manchester Royal Infirmary Stick with it: improving antibiotic documentation, Dr Hannah Collins, North Bristol NHS Trust 24. Errors in drug prescription and administration – a survey of clinical year medical students in St Georges University of London, Dr Smiley Crane, Dr Abdulsatar Ravalia and Dr Philip Sedgwick, Darent Valley Hospital, Dartford 25. The use of abdominal x-rays as first line imaging and their diagnostic yield: an audit at a London District General Teaching Hospital, Miss Mahbuba Choudhury and Dr Saiji Nageshwaran, Croydon University Hospital 26. 27. Sharing good practice to improve junior doctor weekend handover and patient safety, Dr Joanne Lee, Royal United Hospital, Bath Are we scanning enough heads? Audit of CT scanning in children presenting with head injuries, Dr Catherine Lewis, Dr M Fernando, Dr N Hussain and Dr G Worthington, Yeovil District Hospital -4- Sharing Good Practice June 2013 28. 29. Sepsis quality improvement project: making a change to improve recognition and management of sepsis, Dr John Sykes and Dr James Peters, North Bristol NHS Trust Improving patient safety and junior doctor confidence on consultant ward rounds using a simple checklist. A foundation year 1 quality improvement project, Dr Charlie Andrews, North Bristol NHS Trust 30. 31. 32. 33. 34. 35. 36. 37. Inter-professional simulation-based education for foundation doctors, Dr Mithun Biswas, Dr Claire McHale, Dr Alistair Ross and Dr Shumontha Dev, Guy’s and St Thomas’ NHS Foundation Trust Undergraduate simulation-based teaching by Foundation Programme doctors, Dr Mithun Biswas, Dr Claire McHale and Dr Shumontha Dev, Guy’s and St Thomas; NHS Foundation Trust Chelsea and Westminster Hospital at Night Audit, Dr Rebecca Spruce, Dr Anna Warrington and Dr Alice Moran, Chelsea and Westminster Hospital Change in practice: troponin ordering, Dr Helen McDill and Dr James Varley, Imperial College, London A junior doctor initiative to improve consent in ENT surgery, Dr Mazin Alsaffar, Mr Alex Gan, Mr Glen Watson, Dr Meena Beena and Mr Anu Daudia, Royal Blackburn Hospital Clinical induction workshop for foundation trainees in psychiatry, Dr Antonina Ingrassia, Oxleas NHS Foundation Trust The dilemmas of a rota: google’s solution, Dr Jibran Qureshi and Dr Samuel Trowbridge, St Helier Hospital, Surrey The hunger games: our fight to reduce nil by mouth times for gastroscopy, Dr Simon Huf, Dr Ariadne Strong, Dr Rachel Cave, Dr Din Sumathipala, Dr Sorayya Alam and Dr James Robinson, North Bristol NHS Trust -5- Sharing Good Practice June 2013 ORAL PRESENTATIONS Delivering a trainee centred interactive educational programme, Dr Sarah Hoye, Huddersfield Royal Infirmary Background Calderdale & Huddersfield NHS Trust inspires to improve Medical Education. Since August 2012 a new format has been trialled for the mandatory Foundation Year One weekly teaching sessions. The ambition was to deliver a “trainee centred interactive educational programme”, which combines the following: 1. Clearly defined aims of each session 2. Most effective educational methodology 3. Most effective facilitator 4. Feedback & evaluation / revision 5. Encourage reflection The “How to treat……..” series was implemented with the hope that simple measures could create a learning environment suited to the Adult Learning Style, and prompt a selfdirected approach at the end of each week. “Simulation Summer” is also planned to reinforce learning with practical hands-on experience later this year. Methods Preparatory work by the FTPD (provision of relevant curriculum competences) given to the ‘expert’ (facilitator) assists compilation of a maximum of ten learning outcomes, extra reading material plus revision quiz. The sessions’ format proceeds as follows in a rollover pattern: - Quiz performed (self-test) (5 mins) – led by last week’s rostered FY1 - Rostered FY1 teaches back topic (15 mins) & gives out quiz answers - Expert (who is running whole session) then does “How to treat……..” (30mins) - Expert highlights ≤10 learning outcomes - Next rostered FY1 collects Quiz questions & answers (to be utilised following week) - Learning outcomes, further reading and relevant curriculum emailed to all FY1s to upload into e-portfolio library - Expert completes “Developing the clinical teacher” assessment for FY1 Results The Foundation Year 1 teaching programme was well praised and described by all as dynamic.” Deanery Quality Report Sept 2012 -6- Sharing Good Practice June 2013 Blended approach to foundation trainee preparation for the ARCP process, Dr Bridget Langham, Mrs Heidi Breed, Dr Nick Spittle and Dr Rob Gregory, East Midlands LETB Background The introduction of the ARCP process for all Foundation Trainees, whilst not intending to impact on the number progressing to sign off, alters the way outcomes are recorded. In particular, if a trainee has insufficient evidence for sign off at the time of the ARCP an outcome 5 is recorded. We wish to ensure all trainees are aware of the changes by using a blended method of communication. Methods We recognise different learning styles and have used this to develop three tools in addition to the information provided by UKFPO. The tools are: A self-directed interactive PowerPoint presentation with both visual and audio information to describe the ARCP process on the Virtual Learning Environment. A PowerPoint presentation for all Foundation Training Programme Directors to deliver to all foundation trainees. A Frequently Asked Questions resource on the ARCP process. Results The ARCP process has not commenced, but we anticipate that by using this approach we will minimise the number of outcome 5’s awarded. Key Messages When introducing a new process, consider the likely impact on the end user (foundation trainees), in this case the awarding of an outcome 5, and develop a plan to minimise any adverse effect. -7- Sharing Good Practice June 2013 Exploring medical students’ perceptions on preparedness for becoming a first year graduate doctor after undertaking a prolonged assistantship, Dr Sarah Jayne Kingdon, Dr Elewys Lightman, Mr Andrew Hill and Dr Michael Nelson, London Deanery Background Adequate preparation is essential for a smooth transition from medical student to junior doctor1. The GMC2 expects students to have undertaken a period of ‘shadowing’ Foundation trainees. Sheffield Medical School responded to this by initiating a six week student assistantship following finals. This qualitative study aims to explore the perceptions of students on their preparedness for clinical practice following the assistantship. Methods Students undertaking the assistantship completed a questionnaire regarding their anxieties towards FY1. Subjects were purposefully sampled and 20 underwent semi-structured interviews. Interviews were transcribed verbatim and thematic analysis conducted. Results The majority described a positive experience, felt they were given appropriate responsibilities and were well integrated into their teams. The most commonly reported anxieties included risk of causing harm, prescribing errors, overwhelming workload and doubts concerning competence. In terms of the assistantship, discussion centred around: learning goals, supervision, prescribing, and acute management. Key messages • Assistantships improved students' sense of preparedness for FY1 training. • Graduated and supervised stepwise allocation of responsibility is superior to the current ‘jump’. • To maximise the benefit of the placement students should create reflexive goals. • Teaching sessions must be tailored around topics that cause most anxiety, particularly prescribing and the acute patient. • A national programme allowing students to undertake assistantship in their prospective job should be implemented. References 1) Matheson, C., Matheson, D, 2009. How well prepared are medical students for their first year as doctors? The views of consultants and specialist registrars in two teaching hospitals. Postgraduate Medical Journal. 85, 582-9 2) General Medical Counsel. Tomorrows Doctors. London GMC 2003 -8- Sharing Good Practice June 2013 A questionnaire based survey of junior doctors’ knowledge of incident reporting and risk, Dr Elizabeth Mathew, Mr R McCulloch and Mr A Marsh, Russells Hall Hospital, Dudley Background A publication from the Department of Health in 2000 reported that 10% of all patient contact results in harm to either the patient or the health professional1. Half of these incidents are preventable1. Therefore all doctors should be aware of critical incidents in order to prevent them and take appropriate action if they occur. At induction all foundation year one and year two doctors at Russell’s Hall Hospital (Dudley) received an information booklet and lecture on the subject; this required their signature to confirm reading and understanding. Methods The juniors were assessed for knowledge and awareness of incident reporting and risk by completion of a ten question questionnaire. Questions included whether they had received formal training on the subject and assessed knowledge of critical incidents, risk management and reporting. Results 77% of the cohort responded. The mean mark for the questionnaire was 69%. Marks ranged from 44-89%. 70% stated they had not received formal training. The most common questions answered incorrectly were regarding never events and defining risk. Key Messages The range of scores indicates there are significant numbers of the cohort with poor awareness that needs improvement. An online learning module, mandatory for all doctors, is currently being developed, with re-audit thereafter. References 1. Department of Health. An organisation with a memory: Report of an expert group on learning from adverse events in the NHS chaired by the Chief Medical Officer. Crownright. Department of Health. HMSO. 2000. URL:http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/docume nts/digitalasset/ dh_4065086.pdf (accessed 14 March 2012) -9- Sharing Good Practice June 2013 Introducing Coaching Training in a large Foundation School, Prof Paul Baker, Miss Claire Flint, Dr Sarita Bhat and Dr Jo Curran, North Western Deanery Background Whether for careers guidance or performance issues, coaching is increasingly accepted as part of medical training. We explore how training for trainers in coaching can be rolled out in a large Foundation School of 1100 trainees. Methods Training events were run for Foundation trainers in the North Western Deanery, aiming to aid detection and assistance of trainees in career or performance difficulty. Evaluation was by questionnaire after each course. Six months after training, qualitative feedback was invited from delegates, in particular around utilisation and efficacy of the techniques. Results Immediate evaluation by delegates was overwhelming favourable. Feedback after six months indicated many trainers had used the techniques learnt in self-management. A smaller proportion had used the techniques for trainees in difficulty, with good results. Key messages Coaching training for Foundation trainers is well received. We used the model training internal coaches from the organisation, mindful of the role of credibility and rolemodelling in medical training. Given the small proportion of trainees who run into difficulties, having a small trained-up faculty in each programme may be the best model. ‘Level 3’ and even ‘level 4’ efficacy may be demonstrable. Such training is also a valuable personal development tool - 10 - Sharing Good Practice June 2013 Four Day Shadowing Program for F1 Doctors: a blended approach, Mrs Andrea Fox-Hiley, Mrs Margaret Ward, Miss Sarah Kaufmann and Dr Catherine Dickinson Background In March 2012 Medical Education England supported the adoption of “Shadowing for Appointees to Foundation Year 1Guidance Notes” (1) which required that all new Foundation programme appointees should undertake a period of shadowing immediately before they take up their F1 post. Methods The Department of Medical Education at Leeds Teaching Hospitals NHS Trust developed a four day programme which adopts a blended learning approach. The key non ward based elements of the programme were delivered in two days and are; an e-learning clinical induction programme, a ward based “freeze frame” simulation, competency assessments and ward experience. The individual components of the programme were evaluated using immediate post simulation interviews and on-line questionnaires. Results Qualitative data obtained from the one hundred Foundation year trainees interviewed post “freeze Frame” scenarios was overwhelmingly positive. Participants felt the session contained a high level of clinical relevance, realistic and challenging nature of scenarios, importance of prioritization skills, opportunity to review prescribing skills and document familiarization. On-line evaluation of the whole four day program revealed that 13% of FY1’s evaluated the four days as excellent, 68% good, and 18% average. Key Message A blended approach to induction was identified as excellent preparation for becoming a foundation doctor, providing the knowledge and skills to ensure delivery of safe, high quality patient care, it is also an effective and efficient way of delivering the program. This approach also helped participants identify potential learning needs in the transition from student to junior doctors References (1) Workforce Availability Policy and Programme Implementation Group. Shadowing for appointees to foundation year 1 guidance notes. Workforce Availability Policy and Programme Implementation Group. 2012 - 11 - Sharing Good Practice June 2013 Tackling Bullying in the Foundation Years: why it’s better to prepare and prevent than repair and repent, Dr Shaarifa Raza, Dr Lois Haruna and Mr Wai Yoong, North Middlesex University Hospital Background GMC Survey revealed that bullying is most rife amongst Foundation Year trainees, leading to sick leave absences and poor productivity. The Northwick Park Report and Bristol Heart Inquiry have also implicated undermining as a factor in patient safety. The aim of this workshop was to: - explore definitions of bullying - discuss cases of undermining - understand how bullying affects patient safety - advise trainees how to avoid bullying and promote assertiveness against undermining Methods The authors facilitated an open forum which enabled doctors to share their personal experiences. Audiovisual material highlighted how undermining behaviour may manifest and equipped trainees with practical tips on how to recognize and handle bullying. Results (preliminary) Of the 20 juniors who attended the first workshop, 30% had personal experience of bullying and 90% had witnessed bullying of a colleague. Mean satisfaction score was 8/10 and would recommend the workshop. All delegates found individual narratives from videos discussions (re-enacting real life scenarios) “powerful” and would use the practical tips recommended. Key Messages - Early recognition and action against bullying - Zero tolerance culture: non acceptance of training via humiliation ethos - Coping mechanism for “victims” and awareness of support structures - 12 - Sharing Good Practice June 2013 Trainees Improving Care through Leadership and Education (TICkLE), Dr Emma Donaldson, Dr Sara Barton, Dr Christopher Cousins and Dr Zeeshan Malik, Salford Royal NHS Foundation Trust Background Trainees Improving Care through Leadership and Education (TICkLE) was started to enable junior doctors rotating through Salford Royal NHS Foundation Trust to contribute effectively to patient safety and quality improvement work. Our ambition is to maximise engagement between trainees and the Trust and to build trainees’ skills in Quality Improvement (QI) and Clinical Leadership. Methods We are building a robust framework of QI education, support and opportunities for sharing with peers and senior colleagues to achieve our goal. Results We have established a TICKLE committee that reports to Trust Executive Quality and Safety Committee giving trainees a voice at senior level in the organisation, building sustainability and accountability into the project. We host alternate monthly Patient Safety evening meetings with excellent feedback from the first three – they include Serious Incident reports and trainee presentations for discussion, We have launched an intranet page with message board to promote trainee collaboration on Patient Safety projects and allow publication of meeting records. We have also arranged teaching programs of QI skills and Clinical Leadership for Foundation trainees and are running drop-in support sessions for Audit and QI projects. Conclusion TICkLE has engaged trainees and the Trust, to allow trainees to improve patient safety. - 13 - Sharing Good Practice June 2013 A Solution to F1 induced malnutrition, Dr James Cheaveau and Dr Daniel Liu, Royal United Hospital Bath Background Decisions on whether acute surgical patients can eat and drink are often neglected on the post-take ward round (PTWR). Responsibility then lies with the F1 and they are often cautious due to a lack of understanding, making the patient NBM. Unnecessary NBM decisions have been shown to impact patient recovery. Method A retrospective audit of nutritional decisions was carried out of every acute surgical patient (43) in 1 week. The decision and the reasons were documented, and the patients were followed up to determine the time spent NBM, and whether or not it was appropriate. Results 51% of patients had a decision regarding eating and drinking made by a senior on the PTWR. For 49% of patients, no decision was made. 8% were left NBM on average for 16hrs for no reason at all. There was particular room for improvement regarding scans with patients being needlessly made NBM. There were no guidelines available to clarify this. Key Messages The PTWR document has been changed so that there is an obvious area to document decisions. Intranet guidelines are now available to clarify decisions regarding scans. This simple solutions should help patients avoid patient being unnecessarily made NBM and therefore improve patient care. - 14 - Sharing Good Practice June 2013 Improving the safety and efficiency of IV fluid prescribing for adults on medical and surgical wards, Dr Emma Tenison, Dr Andrew Cumpstey, Dr Sarah de Courcy, Dr Alison Foster, Dr Katherine Leonard, Dr Hannah Mackinnon, Dr Kirsty Nelson-Smith, Dr Sophie Walter and Dr Hazel Yilmaz, Musgrove Park Hospital, Taunton Background Intravenous fluid prescribing can cause significant iatrogenic morbidity, yet this task generally falls to foundation doctors, and often for patients not under their regular care when ‘on-call’. Methods On-call foundation doctors were surveyed to determine the time spent prescribing fluids and the parameters used to determine fluid choice. A sample of medical and surgical prescriptions were evaluated for their appropriateness. Using Plan-Do-Study-Act cycles1 we will develop a tool to improve the safety and efficiency of fluid prescribing and encourage day-teams to prescribe the majority of routine fluids for their patients. We will measure whether the changes result in an improvement. Results On-call doctors are regularly asked to prescribe fluids that could have been prescribed (55% of cases, n=45) or stopped (22%, n=45) by day-teams and their approach to assessing fluid-status is variable. Inappropriate prescription of electrolytes is common: excess sodium in 83% and insufficient potassium in 85% (n=46). Key Messages There is a need to standardise fluid-status assessment, reduce the number of out-of-hours fluid prescriptions, stop intravenous fluids when not required and facilitate the on-call doctor in their decision-making process. Re-designing the fluid prescription chart (to include evidence-based guidance and up-to-date patient-specific clinical information) should achieve this. References Langley GL, Nolan KM, Nolan TW, Norman CL, Provost LP (2009). The Improvement Guide: A Practical Approach to Enhancing Organizational Performance (2nd Edition). Jossey Bass, San Francisco. - 15 - Sharing Good Practice June 2013 Analysis of the implementation of breast multi-disciplinary team decisions at a district general hospital, Dr Alexander Baters, Mr Angus McNair, Miss Donna Egbeare, Mr Charlie Chan and Mr James Bristol, Gloucester Royal Hospital Introduction Multidisciplinary teams (MDT) are an essential part of cancer care in the United Kingdom. Evidence suggests that MDT decisions often need revising. In breast cancer, one study investigated MDT implementation rates in Bristol and identified 6.9% decisions that were subsequently changed.1 The aim of this audit is to compare MDT decision implementation rates in Cheltenham to this standard and to identify factors that may affect this rate. Methods All patients discussed at Cheltenham MDT meetings in April 2011 were included. Decisions were identified and compared to the treatment patients received. Case notes were examined where decisions were not implemented to identify reasons. Logistic regression was then used to identify any association between implementation rates and other factors. Results 63 decisions proceeded for analysis. 7 (11.1%, 95% CI 3.1-19.1) decisions were not implemented. Of these, 6 were because of patient choice, 1 was because of new information being obtained post MDT. Of decisions not implemented due to patient choice, all involved choice of surgery. No association was demonstrated between implementation rates and lead surgeon and age, P=0.45 and P=0.99 respectively. Key Messages Implementation of breast MDT decision making in Cheltenham General Hospital is in line with published standards. The MDT should more closely consider patients’ views to improve this further. - 16 - Sharing Good Practice June 2013 Lessons learnt from 3 years of Foundation Q1 projects, Dr Benjamin Plumb and Dr Katherine Finucane, Southmead Hospital, Bristol Background North Bristol Trust runs one of the first Foundation QI programs. After 3 years we present our top tips for those embarking on QI. Methods We use IHI methodology to adapt; we have developed workable solutions to problems encountered over the years. Results Problems encountered Projects dwindle once trainees rotate Solutions developed F1s who stay on as F2s are recruited to be facilitators. Similar problems year on year F1s are offered to take up successful projects to work from where teams left off. Facilitators not trained in QI methodology Facilitators and Trainees learn together in a stepwise approach at monthly evening meetings from QI experts in the Trust with guidance from us. Facilitators too busy Each team has 3-4 facilitators which includes Consultants, senior trainees, nurses and F2s to provide a skills and specialty mix. Management and financial restraints The Trust Board supports us and attends our annual presentation event. A multiprofessional, flexible faculty helps to navigate obstacles. Attendance at meetings Meetings are short and focused on shortterm goals. Beer and pizza is provided! Key Messages Education of QI methodology to trainees and facilitators. Using a multi-specialty faculty, including F2s who have completed projects. Continuity of projects, using the same facilitators and encouraging trainees to develop successful projects. - 17 - Sharing Good Practice June 2013 Year on Year Improving the Foundation Doctors’ Quality Improvement Training at Musgrove Park Hospital, Taunton, Dr Joanne Watson, Dr Michael Walburn, Dr Stephen Harris and Dr Jason Loius, Musgrove Park Hospital, Taunton Background In 2010 we established a practical quality improvement programme for F1 doctors which enables some of the brightest people in the hospital to improve the system within which they work during their first year in the NHS. Since starting this work we have involved all 32 F1s at Musgrove Park and expanded the model to include FY2 doctors. Methods Using the Salisbury District Hospital model, we piloted an F1 service improvement project with 11 volunteers in 2010. With their success, QI became part of FY1 formal training programme with the opportunity for all FY1s to work on projects of their choosing. 4 projects were selected with 3 of them making permanent changes to the system. Similar programmes have run yearly since. Results FY1 work is now continued as spread and sustainability projects by the FY1(2)s staying another year. New to Musgrove FY2s have the opportunity to work through an FY2 setting up an innovation forum to support their ideas. 14 poster presentations at regional, national and international meetings with 4 prizes speaks to the high quality of work, with survey data reporting that this work is highly recommended by F1s. Key messages Knowing about QI is not enough, FY1&2s must do - 18 - Sharing Good Practice June 2013 PRIMO: The use of risk monitoring tools to promote a safer working environment, Dr Phyllis Mezue and Dr Nicole McGrath, Lincoln County Hospital Background PRIMO (Proactive Risk Monitoring in Healthcare) was set up to identify and address risks to patient safety. Following the success of a pilot programme in 2010, this project has been extended to include Lincoln County Hospital with the following aims: i) To understand and identify processes that adversely affect patient safety ii) To encourage and enable staff to actively promote a safer working environment Methods The project was led by junior doctors. We identified key problem areas through narratives and these became the themes of a monthly questionnaire sent out to staff. Areas of improvement highlighted were divided into longer and shorter term action plans. “Easy wins” were identified within the shorter term action plans and involved implementation of immediate changes to improve safety. The effectiveness of these changes was assessed in the ongoing questionnaires. Results Areas of improvement highlighted included communication, teamwork and insufficient equipment. We addressed these by educating staff through a series of junior doctor led presentations, organising and funding equipment and these significantly improved results within the questionnaires. Key Messages A safer working environment is an easily attainable goal and the project emphasises the use of simple measures such as education to achieve this. Reference The Health Foundation. PRIMO. http://www.health.org.uk/areas-ofwork/programmes/primo/ - 19 - Sharing Good Practice June 2013 Dementia: Junior doctors championing change, Dr Catherine Pye, Dr Louise Mellor, Dr Laura Tucker, Dr Josie Day and Dr Chooi Lee, Kingston Hospital Background Many of the 800,000 people with dementia in the UK are not formally diagnosed, so are unaware of available support1. Previous audit showed that older patients in Kingston hospital were not routinely assessed for cognitive function; none were referred for specialist diagnosis. Methods Foundation Year One doctors drove the achievement of National Dementia CQUIN targets and implemented lasting changes in senior doctors’ awareness, attitudes and behaviour. Specific measures included: Junior doctor dementia champions role-modelled behaviour, e.g. routine memory screening, use of the ‘Dementia and Delirium Diagnostic Assessment’, and specialist referral FY1 doctors performed monthly audits; wards and firms were bench-marked against each other and informed of progress. Results 96% (176/184) were asked the national memory screening question 97% (179/184) had validated memory assessment 100% (40/40) of patients with cognitive impairment without a prior diagnosis of dementia had been investigated and diagnosed with delirium (5/40), and/or dementia/suspected dementia (35/40) with appropriate onward referral. Key messages By role-modelling, FY1 doctors successfully produced long-lasting positive changes in dementia awareness, attitudes, and behaviour amongst senior colleagues. FY1 doctors successfully achieved the National dementia CQUIN targets, 3 months early. FY1/2 dementia champions improved dementia care by implementing the ‘forgetme-not’ scheme of excellent dementia care. References 1. Dementia 2012: A national challenge, March 2012, Lakey L, available from: http://www.alzheimers.org.uk/site/scripts/documents_info.php?documentID=341 - 20 - Sharing Good Practice June 2013 Change from the bottom up, Dr Asher Steene, Luton and Dunstable Hospital Background Luton is a tertiary centre for obesity surgery for 2 million people. After discharge when complications arise patients often present to their district general hospital who are not familiar in the management of these complex patients. Following a patient death we designed a comprehensive safety system to ensure patients with problems after surgery come back to Luton for their care. Methods Working in the Obesity Multi disciplinary team we worked to modify existing staff roles, IT resources and patient information material to provide a 24 hour support network. Results We created a 24 hour, consultant led telephone advice service for patients and doctors augmented by custom discharge letters and a credit card information/safety leaflet for patients. This is supported by the development of a decision support algorithm for telephone triage my non-medical staff. Elements of this program, including generic information cards are being offered to other surgical units in the UK. Key Messages Changes to services in the UK can be led by an FY1. Such change can be implemented within a year spent in one hospital trust. These service changes can be achieved within existing structures and budgets. Finally a personal (patient) tragedy can inspire positive change. - 21 - Sharing Good Practice June 2013 Documentation of DVLA Driving Advice Following New Medical Diagnoses, Dr Claire Cameron, Dr Georgina Fremlin and Dr Jessica Triay, Bristol Royal Infirmary Background It is a doctor's ethical and legal duty of care to inform patients of driving restrictions resulting from new diagnoses. It is good practice that this information is communicated to the patients' primary care provider. These requirements are frequently overlooked in a busy hospital environment. Previous studies confirm that doctors’ knowledge of DVLA regulations is poor1. Our aim was to assess and improve (1) doctor’s knowledge, (2) number of patients correctly advised, (3) communication of advice with primary care. Methods Doctors throughout the trust received a questionnaire assessing knowledge of driving regulations. Retrospective audit of documented advice within notes and dischargesummaries led to a ‘plan-do-study-act’ (PDSA) cycle of quality improvement (QI). Interventions included education, email alerts and quick-reference intranet guidelines. Two weeks after each intervention, discharge-summaries were assessed. Results Questionnaires confirmed poor knowledge. Out of 200 patient records, only 32.5% of notes and 12.5% of corresponding discharge-summaries documented advice. PDSA data collection suggested 20-25 patients/week required driving advice. The number of patients receiving documented advice rose from 4% to 16% over three cycles. Key Messages Regular small interventions that increased awareness have already influenced our practice. Future QI measures work towards a compulsory driving advice alert on edischarge summaries. References 1. A Frampton “Who can drive home from the emergency department? A Questionnaire based study of emergency physicians’ knowledge of DVLA guideline” Emerg Med J 2003 - 22 - Sharing Good Practice June 2013 Supervised Learning Events – trainees’ perspective, Dr Sapna Patel and Dr Christopher O’Dowd-Booth, King’s College Hospital, London Background Supervised Learning Events (SLE) are essential to clinical training, encompassing supervised consultations, case discussions and clinical assessments. The design has evolved from a formal scored exercise, into a discussion providing constructive feedback. The objective is to highlight areas of strength, as well as difficulty, providing a direction for improvement. The aim of our study is to assess the effectiveness of training events and to evaluate their perceived usefulness from a trainee’s viewpoint. Methods A questionnaire was sent to 20 foundation trainees, asking for their anonymous evaluation of the current system of assessment. Results 40% of trainees value SLEs, 50% of which felt as though they are being formally assessed. 45% felt that adequate time was an important factor, with 25% critical of the time allotted. 40% noticed significant variability between trainers, rising to 85% dissatisfaction with the level of feedback and only 15% receiving feedback during the assessment. Key Messages A vital improvement required is that of assessor education and training. Trainees’ experiences demonstrate time constraints, along with varied levels of training between assessors, which have a negative impact upon the effectiveness of these assessments. These factors prevent adequate constructive feedback, and hence the progression desired by both trainers and trainees alike. - 23 - Sharing Good Practice June 2013 Embedding Careers Education in the Undergraduate Medical Curriculum: an overview of current practice, Mr Michael Wilson, Newcastle University Careers Service Background Career guidance for medical students received increased attention with higher tuition fees and the changing medical workforce. Oversubscriptions in foundation and competition for specialty necessitates medical students and foundation doctors to be career ‘aware.’ Tomorrow’s Doctors (2009) requires Medical Schools to provide a careers strategy. To get a picture of current delivery models, the Medical Careers Adviser Network chose to research careers education in the medical curriculum. Methods A qualitative survey was distributed via Surveymonkey to medical schools throughout the UK in 2012. Clinical and career contacts were targeted to provide comprehensive feedback on current delivery models, predicting demand and resource implications. Results 19 of the medical schools responded giving details of their current practices. All medical schools had some element of careers delivery although there was great variation. Almost all respondents felt that the need for careers advice would increase and this would have significant resource implications. Key Messages Careers education within the curriculum remains patchy across medical schools Strong partnerships are developing with Medical Schools and Postgraduate Deaneries Overwhelmingly there is a view that careers advice needs will increase. Medical Schools and Postgraduate Deaneries should share best practice to ensure equity to medical students in ‘career preparedness’ References General Medical Council, Tomorrow’s Doctors 2009. - 24 - Sharing Good Practice June 2013 Preparing F2s for Specialty Interviews and Selection Games, Ms Lisa Stone, HE KSS Background Junior doctors are extremely anxious about assessment centre interviews1. In 2012 the careers team at the South Thames Foundation School (STFS) produced a package of downloadable material for running a session to help F2s prepare for specialty interviews and selection centres. Methods The package includes PowerPoint slides, a session plan and specific question sets for a variety of specialties to be delivered by senior clinicians and careers advisers. The team also produced four short videos of F2s that had been successful at interview, giving advice on what they did to prepare. The information was reinforced by emailing a series of targeted ‘countdown’ messages during the two-month period prior to applications. The messages were configured so that they are easy to read on a smart phone and have been published on the STFS website: http://www.stfs.org.uk/doctor/foundationdoctors/careers-countdown Results The package has been published: http://www.stfs.org.uk/doctor/careersguidance/preparing-specialty-applications-and-selection-centres. Positive feedback has been received from senior clinicians, careers advisers and F2s. The Mersey Deanery has used the package. Key Messages Important to provide the material for senior clinicians to encourage them to provide appropriate mock interview sessions. Reminding F2s of the timetable for recruitment and getting them to do some early preparation is key. 1 BMJ Careers 2011, Applying for Specialty Training: http://careers.bmj.com/careers/advice/viewarticle.html?id=20002942 (accessed 5th March 2013). - 25 - Sharing Good Practice June 2013 Hospital Antibiotic Prudent Prescribing Indicator Audit (HAPPI Audit), Dr Yvonne Tin, Dr Karen Pond and Dr Robert Penders, Gloucestershire Royal Hospital Background An audit looking at adherence to trust guidelines1 in antibiotic prescribing at Gloucestershire Royal Hospital (GRH). Aim: to prevent antibiotic related illnesses2, increased resistant organisms, increased expenditure and risk of adverse effects. Methods Three cycles and two interventions (email and teaching), looking at documentation (allergy - drug and reaction, review/stop date, indication for treatment and appropriate antibiotic and route) of antibiotic prescribing of up to 10 drug charts on three wards. Standards were set at 100%. An online survey created investigating why doctors do not complete the drug chart. It included four designs of a modified drug chart and respondents chose the one they were most likely to complete. Results Documentation of allergy box improved (68% to 93%). Review/stop date improved from 32% to 67%. Indication improved from 52% to 70%. Appropriate antibiotic and route were well documented with 100% achieved on cycle 3. Survey - 86 respondents - reasons of poor documentation attributed to ‘lack of time’, ‘unknown indication/duration’ or ‘other’. Key Messages Documentation and awareness improved through education. The trust drug chart has been modified according to results of the survey. An e-learning microteach is being created and monthly results of the HAPPI audit are circulated to all prescribers. References 1. Antibiotic Stop/Review Date and Indication Policy, GHNHSFT February 2011 2. Pépin et al Clin. Inf. Diseases 2005;41:1254-1260 - 26 - Sharing Good Practice June 2013 Assessing the Assessments: Trainee and Trainer opinions of Foundation Programme Supervised Learning Events in a District General Hospital, Dr Saurabh Single, Dr Vishal Vyas, Dr Louis Savage and Dr Martin Klein, Barnet and Chase Farm Hospitals NHS Trust Background The purpose of this study was to ascertain trainee and trainer perceptions of Supervised Learning Events (SLEs), in a busy District General Hospital. Methods A questionnaire sought responses on trainee and trainer understanding of miniCEX, DOPS and CBD; their attitudes towards SLEs, including education value, practical applicability and free-text comments. Results 70 responses were received; 44 F1/F2 doctors and 26 trainers. Most responders agreed/strongly agreed that they understood and knew how to complete; CBD (94%), DOPS (88%), mini-CEX (87%). 45% perceived SLEs to be primarily about assessment. The CBD was perceived to be the most useful SLE (3.1/5), mini-CEX (2.7/5) and then DOPS (2.6/5).The most common free-text feedback was that SLEs could become a “tick box exercise”. Key Messages The majority of trainees and trainers understand and know how to complete Foundation Programme SLEs. Most trainees and trainers find the CBD the most educationally useful SLE. The miniCEX was considered the least useful, with trainers particularly unsure as to how these should be completed. Free-text comments showed that there is a common perception of SLEs as a “tick-box exercise”. Trainers should be aware of the findings of this study to ensure maximal educational benefit is achieved when completing SLEs. - 27 - Sharing Good Practice June 2013 Invasive Medical Procedure Skills Amongst Foundation Year Doctors – a questionnaire survey, Dr Chung Thong Lim and Dr Victoria Gibbs, Barts and the London Hospital Background Invasive medical procedures do not form part of the core curriculum for the Foundation Year (FY) doctors but nevertheless, some of the trainees have the opportunity to perform and learn them at this stage. This questionnaire survey aimed to investigate if the current FY trainees have performed several invasive procedures and their level of confidence. Methods Questionnaire study. Results 103 FY trainees responded to the survey. The percentage of trainees who have performed these skills and their average level of confidence (in a scale of 1 to 5) were as followed: intubation (34%,1); chest drain (34%,1); central line (27%,1); femoral line (26%,1); peripheral line (28%,1); lumbar puncture (68%,3); ascitic tap (61%,3). Only 25% of the trainees have attended structured training courses on these skills and 73% found them very useful. All the trainees agreed that these courses should be available for all the FY doctors. 92% believe that these courses are most beneficial during the FY1 training. Key Messages Most FY trainees have low confidence and exposure to these invasive procedures. Structured courses should be made available to the FY doctors for the benefit of their trainings and to increase their level of confidence and quality of patient care. - 28 - Sharing Good Practice June 2013 Do Not Attempt Resuscitation (DNAR) orders: a dying skill? Dr Katy Hosie and Dr Kate Spencer, Weston General Hospital Background CPR is inappropriately administered to elderly patients where it is seldom successful. This is primarily due to lack of initial resuscitation assessment. Inappropriate resuscitation attempts and subsequent patient morbidity can impose a substantial strain on hospital and NHS resources. Furthermore, patient autonomy is unfairly compromised by a reluctance to engage patients in the decision making. Methods In April 2012, sixty-five patient notes from a DGH were retrospectively reviewed for evidence of decision making and documentation surrounding resuscitation status. The aims were to highlight short fallings and raise awareness amongst staff and patients. Results 37% of patients had a resuscitation status documented. Of these, just 27% were documented as per national guidelines. Documentation regarding rationale for decision making and discussion with patients was poor. Consultant review and communication with nursing staff were also insufficient. Key Messages The discussion about resuscitation should occur in a timely fashion and be respectful of patient autonomy. Lack of inter-professional communication is a problem and further steps are required to promote better clinical practice. We believe a big push is needed to improve education of junior doctors and senior medical students about the processes involved and their role as intermediaries between patients and senior colleagues making the ultimate decisions. - 29 - Sharing Good Practice June 2013 Foundation Doctor Audits: a missed opportunity? Dr Milan Makwana, Mr Louis Savage, Dr Saurabh Singh and Mr Martin Klein, Barnet and Chase Farm Hospitals NHS Trust Background The purpose was to assess the effectiveness of mandatory Foundation doctor audits, and their place in a broader clinical governance framework. Methods A retrospective review was conducted of training records of all Foundation Trainees in our trust between 2011-2012 to establish if a clinical audit project had been completed. This was correlated with Clinical Governance Department records to see if audits were registered, supervised and presented appropriately. We also reviewed whether audits were conducted as part of a clinical audit cycle. Results All 99 doctors had completed one or more clinical audits during their Foundation Training. Of these audits, only 29 (30%) had been registered with the Clinical Governance Office. All of the 29 audits were overseen by an appropriate Consultant. Only 14 (50%) of the 29 were recorded as being presented. Prospectively logged audits showed that only 1 was being due to be re-audited. Key Messages Junior doctor audits in our trust are mainly conducted outside of a regulated governance framework. Important audit outcomes are not being collected, monitored or disseminated appropriately. In addition, junior doctor audits are neither selected nor supervised appropriately, meaning that valuable opportunities for improving clinical standards and providing training opportunities are being missed. - 30 - Sharing Good Practice June 2013 Local audit of escalation plans and DNACPR orders for acute medical admissions in accordance with 2012 NCEPOD guidelines, Dr Lorna Starsmore, Gloucester Royal Hospital Background The recently published NCEPOD report ‘Time to Intervene’1 highlights a number of recommendations, including that CPR decisions must be considered and clearly documented for all acute medical admissions. It is also made clear that best practice dictates consultant involvement in all cases where Do-Not-Attempt-CPR orders are believed appropriate. Methods Appropriate patients on the acute medical admission ward were identified and a prospective collection of data from patient notes was conducted. Completion of the trust escalation policy paperwork and evidence of Do-Not-Attempt-Resuscitation orders was sought at the initial consultant review. Escalation plans were recorded as absent or if present the level of escalation believed appropriate. Results Of 109 analysed patient notes only 23% had escalation plans documented, the majority of which were DNACPR and not for referral to Department of Critical Care. It was also found that only 5 out of the 21 escalation policies had been discussed with the patient or next-of-kin. Key messages It is vitally important that decisions regarding escalation planning and resuscitation are made, where possible, in a timely and considerate manner by senior doctors. Given the increasing publicity2,3,4 surrounding this topic it remains best practice to discuss DNACPR decisions with patients or next-of-kin. 1) G.P. Findlay, H. Shotton, K. Kelly, M. Mason, Time to Intervene? A review of patients who underwent cardiopulmonary resuscitation as a result of an inpatient cardiorespiratory arrest, National Confidential Enquiry into Patient Outcome and Death (2012) 2) BBC News. Addenbrooke’s resuscitation policy scrutinised in High Court, BBC News. 5/11/12. http://www.bbc.co.uk/news/uk-england-cambridgeshire20205925. Accessed 11/11/12. 3) N. Triggle. NHS ‘too quick to resuscitate acutely ill people’, BBC News. 01/06/12. http://www.bbc.co.uk/news/health-18278110. Accessed 11/11/12. C.Dyer. Patient had DNR notice “put in her notes without her knowledge”. British Medical Journal 2012;345:e7503. Prevent the 3 year progression from erectile dysfunction to myocardial infarction, Dr Laura Backhouse, Gloucester Royal Hospital - 31 - Sharing Good Practice June 2013 Prevent the 3 year progression from erectile dysfunction to myocardial infarction Dr Laura Backhouse, Gloucester Royal Hospital Background Erectile dysfunction (ED) is common. It can be part of a generalised vascular disorder and an early warning symptom of cardiovascular disease. Men may experience ED on average 38months before the onset of angina.1 By performing a thorough cardiovascular assessment at initial patient presentation, the risks of developing cardiovascular disease can be reduced.2 This audit compared current practice in an urban GP surgery to gold standards.3,4 Method Retrospective point prevalence audit captured 154 patients over a 5 year period. Minimum investigations required at initial presentation were recorded and compared to the international guidelines.3,4 Results The majority of patients had the appropriate physical examinations within 6 months of presentation. No waist circumferences were measured. Serum lipids (72%) and fasting glucose (75%) were recorded. Few (12%) had a testosterone level checked. Cardiovascular risk scores were documented in only 24% of cases. However half of these patients had greater than 20% probability of a future cardiovascular event within 10 years. Key Messages ‘A man with ED is a cardiac patient until proven otherwise.’5 Measure serum testosterone to exclude hypogonadism (a reversible ED cause). Waist circumference is a more accurate indicator of fat distribution than the BMI. Central adiposity increases the risk of developing diabetes and cardiovascular disease.6 References 1. Montorsi F, Briganti A, Salonia A et al. Erectile dysfunction prevalence, time of onset and association with risk factors in 300 consecutive patients with angina chest pain and angiographically documented coronary artery disease Eur Urol 2003;44:360-5 2. Cottrell A, Gillatt D. Early detection of erectile dysfunction may prevent CVD. The Practitioner. Jan 2008; 252 (1702):21-26 3. Hackett G et al. British Society for Sexual Medicine Guidelines on the Management of Erectile Dysfunction. BSSM 2007. Available from: http://www.bssm.org.uk/downloads/BSSM_ED_Management_Guidelines_2009.p df (accessed: September 2012). 4. European Association of Urology. Guidelines on Male Sexual Dysfunction: Erectile dysfunction and premature ejaculation. EAU 2012. Available from: http://www.uroweb.org/gls/pdf/13_Male%20Sexual%20Dysfunction_LR%20II.p df (accessed: September 2012). - 32 - Sharing Good Practice June 2013 5. Jackson G, RC Rosen, RA Kloner, JB Kostis, The second Princeton consensus on sexual dysfunction and cardiac risk: new guidelines for sexual medicine. J Sex Med 2006;3:28-36; discussion 36. Cut the Waist. The importance of waist circumference, a marker of high risk internal fat. http://www.cutthewaist.com/importance.html (accessed: September 2012). - 33 - Sharing Good Practice June 2013 An innovative approach to teaching guidelines and research, Dr Craig Montgomery, Dr Laura Norris, Dr Stephen Keddie, Dr Kate Allen and Dr Mark Piper, Northumbria Healthcare NHS Foundation Trust Background In our departmental experience engaging Foundation Doctors with teaching on guidelines and research has proved challenging and consequentially we developed an innovative and interactive teaching approach to address this. Methods 12 foundation doctors were taken for a 3 hour session on research and guidelines mapping to section 6.2 of the Foundation Programme curriculum, with a clinical focus on resuscitation and death. A pre-intervention confidence questionnaire was completed on arrival, followed by two exercises, firstly a literature review of different styles of articles and secondly clinical simulation, relating to resuscitation decisions. A post-intervention questionnaire was then completed and the results were statistically analysed and graphically represented by the participants to show the effectiveness of the session. Results The intervention data demonstrated improved confidence in all domains. The session evaluation scored 4.2 for ‘relevance to needs’ on a 5 point scale and free text comments included “normally I find literature dull, but it was really useful to get some resuscitation facts to use in real discussions” and “useful to do practical exercises using data, as it is not something we do often”. Key messages Engaging students through active involvement in clinical simulation and their own statistical analysis improves student satisfaction with teaching on research and guidelines. - 34 - Sharing Good Practice June 2013 Are we following the NCEPOD recommendations for emergency surgery in elderly patients? Dr Yuka Ikegaya and Mr Jamshed Shabbit, University Hospitals Bristol Background A National Confidential Enquiry of Patient Outcome and Death (NCEPOD) report1 in 2010 highlighted the failure of the NHS in providing good quality clinical care for elderly patients undergoing emergency surgery. This report produced important guidelines aimed at improving the emergency pre-operative and post-operative care of elderly patients. Methods This audit compared the care given to 22 patients over the age of 80 who had undergone emergency general surgery (excluding trauma and orthopaedics, urology and vascular) in the Bristol Royal Infirmary between January and September 2012 to the NCEPOD guidelines. Results Of the 11 processes audited, the trust was not compliant in 4 of the recommended guidelines. Most notably, none of the patients received the recommended routine input from the Care of the Elderly team (COE), despite over 67% of all post-operative complications resulting from medical illnesses and two thirds of recorded deaths secondary to medical causes. Key Messages There is a clear need to increase the daily input from the COE team in managing acutely ill elderly surgical patients with scope to introduce a local trust protocol triggering appropriate referral of patients to COE from general surgery. 1. Wilkinson K, Martin IC, Gough MJ, Stewart JAD, Lucas SB, Freeth H, Bull B, Mason M. Elective & Emergency Surgery in the Elderly: An Age Old Problem (2010). London: NCEPOD; 2010 November [cited 2012 November 14]. Available from http://www.ncepod.org.uk/2010eese.htm - 35 - Sharing Good Practice June 2013 Audit of Overnight Red Blood Cell Transfusion, Weston General Hospital (WGH), Dr Sarah Mabbutt, Dr Philip Robson and Miss Louise Jefferies, Weston General Hospital Background The Serious Hazards Of Transfusion report, 2005, recommends that transfusion at night (20.00-0800 hours) is inherently unsafe and should be avoided unless clinically essential (1). The aim of this audit was to establish the number and appropriateness of overnight red blood cell (RBC) transfusions at WGH. Criteria for appropriate overnight RBC transfusion were a) active bleeding or haemolysis at the time of transfusion, b) low haemoglobin level giving significant symptoms (2). Methods Case notes for patients who received an overnight transfusion between 1st and 14th March 2012 were searched for documentation regarding the reason for transfusion. Results There were 27 RBC transfusion episodes, 32% of all episodes, during overnight hours. 1 case was excluded. 31% (n=8) of overnight transfusions satisfied the standards, whilst in 62% (n=16) there was no acute clinical need for transfusion overnight. 8% (n=2) required transfusion for next-day discharge. Key messages This highlighted the need for further education for doctors and nurses regarding the hazards of overnight transfusion. To encourage thought on this issue, a new transfusion prescription proforma was developed with a tick box for whether each unit prescribed needed transfusion out-of-hours. A re-audit will occur in May 2013 to ensure the situation has improved. References 1. Serious Hazards of Transfusion Steering Group. SHOT Annual Report 2005. UK; November 2006. 2. Comparative Audit of Overnight Red Blood Cell Transfusion Project Group. National Comparative Audit of Overnight Red Blood Cell Transfusion. UK; January 2008. - 36 - Sharing Good Practice June 2013 Development of a regional formative prescribing assessment for doctors, Mrs Gail Fleming, Mrs Siobhan Burke-Adams, Dr Jane Allen and Mr Marc Terry, HE KSS Background Internal surveys identified marked differences in prescribing training and assessments for foundation doctors in Kent, Surrey and Sussex. A multiprofessional Doctors’ Prescribing Assessment Group (DPAG) was formed and developed a regional prescribing assessment for formative evaluation of doctors’ prescribing skills. The project aimed to identify weak prescribers and target their specific prescribing training needs locally. Method The prescribing assessment was undertaken by 422 Year 1 Foundation doctors during their induction period in 10 Trusts in July 2012. EQUIP1 study findings influenced some key medications chosen for assessment e.g. analgesics, and antibacterials. Feedback was obtained from trainees and prescribing leads. Results 74% of trainees achieved a mean score of 19/ 32 or higher. 38% made at least one error judged to have the potential to cause serious harm. The performance of candidates varied when analysed according to trust and past medical school. Key Messages: In addition to generic prescribing knowledge, the regional assessment focuses on the ability to use and write local drug charts taking into account local guidelines. It has been used to highlight areas of further training required for both cohorts and individuals and thereby improve both patient and foundation doctor safety. References 1.General Medical Council. An in depth investigation into causes of prescribing errors by foundation trainees in relation to their medical education. EQUIP study. December 2009 - 37 - Sharing Good Practice June 2013 Death Certification: Re-audit on practice at the Royal Bolton Hospital, Dr Anli Yue Zhou and Dr David Bisset, Royal Bolton Hospital Background Death certification is a legal document that registers deaths and allows and epidemiological studies. Previous audits have shown that <60% of death certificates meet the minimum standard.1 This re-audit compares the quality of death certification at the Royal Bolton Hospital with previous audit data from 2011. Method A retrospective audit of death certificates between august and October 2012 was done. Guidelines from the Office of National Statistics were used as the gold standard. Results were grouped into: 1. logical certificates completed appropriately, 2. logical certificates containing incomplete data, 3. inappropriate use of part II, 4. Illogical or inappropriately completed certificates. Results A total of 189 death certificates were reviewed. Fifty three percent were logical and appropriate, however near 20% of death certificates were illogical or used part II inappropriately. Consultants filled in the most death certificates and foundation year 2 doctors demonstrated the worst profile. Key Messages 1. Death certification at RBH is on a par with other institutions 2. Approximately half the forms are completed correctly and completely 3. A further 41% contain minor errors or omissions 4. All grades of staff submitted appropriate and inappropriate certificates 5.Improvement in inappropriate death certificates since 2011 - 38 - Sharing Good Practice June 2013 Peripheral Venous Cannula Insertion Audit December 2012, Musgrove Park Hospital. Do foundation doctors follow guidelines? Dr Helen Casey, Dr Claire Spolton-Dean and Ms Julie Roberts, Musgrove Park Hospital, Taunton Background Peripheral venous cannula (PVC) insertion technique by foundation doctors (FDs) was audited. The aim was to assess compliance with trust and national infection control guidelines. This subject was chosen due to the frequency of cannula insertion and the risk of infection if not inserted correctly. Method A random sample of 42 FDs were included in this audit, representing 64% of the FD at Musgrove Park Hospital. Each FD was asked to fill in an anonymous questionnaire based on the trust PVC policy1. Question data was collated, given a score and converted to a percentage. Results Twelve standards showed compliance of less than 80%; Only 30% FDs used needle-free connectors. 54% of respondents repalpated the skin following disinfection, only 35% wore sterile gloves. 48% complied with recommended times for skin disinfection. Documentation of insertion covered five areas with compliance ranging from 4860%. 70% of respondents used as aseptic non-touch technique with 72% always wearing gloves. Key messages Further training for foundation doctors is needed on aseptic non-touch technique when inserting PVCs. Availability of equipment on trollies and knowledge of equipment use needs improving. Current intervention A teaching video is being designed and filmed to highlight correct insertion technique and documentation. Reference Roberts J. (2012) Guideline for the Management of Peripheral Vascular Cannula in Adults. Musgorve Park Hospital, UK - 39 - Sharing Good Practice June 2013 Is the time for the hospital bleep system now over? Assessing mobile phone usage for work purposes amongst new junior doctors, Dr Vishal Vyas, Dr Tami Benzaken and Mr Benjamin Stubbs, Barnet and Chase Farm Hospitals NHS Trust Background Mobile phone usage for work purposes amongst doctors is commonplace yet there is very little published data assessing use amongst new FY1 doctors and investigating junior doctor attitudes towards mobile phone usage for work purposes. Methods An audit of mobile phone usage amongst new surgical FY1 (n=6) doctors was performed during August 2012, using itemised phone bills to determine duration and percentage of work related calls. A survey was also undertaken of junior doctors (n=21) to assess attitudes to the use of mobile phones for work purposes. Results 21% of total mobile phone usage amongst surgical FY1 doctors was for work purposes. 86% of junior doctors surveyed use their mobile phone for work purposes with 67% using it several times a day, 75% preferring/strongly preferring to use a mobile phone over a bleep and 81% agreeing/strongly agreeing that replacing the current bleep system with mobile phones would be a more efficient way of contacting colleagues. Key Messages The vast majority of junior doctors use their mobile phone for work purposes. A sizeable proportion of total mobile phone use is for work purposes. Most junior doctors would prefer to use mobile phones over the current bleep system to contact colleagues. - 40 - Sharing Good Practice June 2013 Confusion Assessment Method (CAM-ICU); a quality improvement project in progress, Dr Alessandra Glover and Dr Fiona McVey, Southmead Hospital, Bristol Background 2013 Journal of Critical Care Medicine guidelines recommend that ICU patients be routinely screened for delirium.1 ICU delirium can occur in up to 80% of ICU admissions, is under-diagnosed and has negative medical and psychological implications for its sufferers.2 It can result in prolonged admission, respiratory wean and possible long-term cognitive dysfunction. Delirium should be prevented and treated for patient medical and psychological well-being. Methods Confusion Assessment Method-ICU (CAM-ICU) is an internationally accepted screening tool for ICU delirium. All nursing staff and junior doctors in the ICU were taught in small groups about delirium and how to use the CAM-ICU. A scorecard, crib sheet and information booklet were developed, in line with patient demand. Incidence of delirium was recorded with a view to developing a unit treatment protocol. Results 30% of patients admitted to our ICU have developed delirium during their admission. The main challenge of implementation has been human factors, with staff rejecting more paperwork, however culture is changing with senior support and the information booklet is nearing completion. Key messages 1. ICU delirium is common, under-diagnosed and can easily be screened for using the CAM-ICU. 2. Its negative consequences warrant active address through medical and psychological support. 1 Clinical Practice Guidelines for the Management of Pain, Agitation, and Delirium in Adult Patients in the Intensive Care Unit. Barr J et al. Crit Care Med. 2013;41(1):278-280. 2 Pharmacological and Nonpharmacological Management of Delirium in Critically Ill Patients. Hipp et al. Neurotherapeutics. 2012 January; 9(1): 158–175. - 41 - Sharing Good Practice June 2013 Improving the management of Acute Kidney Injury (AKI) at Kings Mill Hospital: Introduction of the DONUT care bundle, Dr Anisha Bhagwanani, Dr Rory Carpenter, dr Aqeelah Yusuf and Dr Simon Stinchcombe, King’s Mill Hospital, Sutton in Ashfield Background The NCEPOD report (2009) on AKI found 20% of post-admission AKIs were avoidable and only 50% of AKI care was considered “good” [1]. The DONUT bundle comprises of six interventions aimed at improving the management of AKI. Methods Data was collected prospectively using the biochemistry eAlert system, identifying 50 patients with Stage 1 AKI over a 2 week period. Data was collected 24 hours after the eAlert using a standardised proforma. After data analysis, a DONUT sticker was introduced on the Emergency Admissions Unit, providing an efficient method of recording interventions in the notes. Education sessions outlining the DONUT bundle and stickers were delivered via Foundation Program teaching, along with summary flash cards. A re-audit assessed these interventions. Results Of the initial cohort (n=50), only 8% were fully compliant. Following introduction of the education programme and AKI sticker, re-audit showed a rise in full compliance to 17% (n=42). Only 7% of cases used the AKI sticker but with 100% compliance in these cases. Key Messages AKI management is sub-standard. An educational program and the use of a simple sticker can improve management. Further education regarding AKI is needed and work is ongoing to improve compliance with sticker use. References 1. National Confidential Enquiry Into Patient Outcome and Death: Adding Insult To Injury (2009). Accessed online at: http://www.ncepod.org.uk/2009report1/Downloads/AKI_summary.pdf - 42 - Sharing Good Practice June 2013 Virtual Interactive Teaching and Learning (VITAL) for Doctors, Dr Rebecca Igbokwe, S Potter and M Thomas, Heartlands Hospital, Birmingham Background The transition from student to doctor is a critical period with potential implications for patient safety.2 VITAL is an innovative online programme that aims to enhance this transition promoting excellence in care. Phase 1 consists of key modules relevant to F1’s. Phase 2 consists of ‘speciality’ F2 modules. Methods VITAL presents defined learning outcomes, ‘Quick Guides’ and podcasts designed to allow flexible access, promoting ‘Just in time learning’. Assessments test and develop knowledge; have been used to reward excellence and identified doctors potentially requiring additional support. We designed a multifactorial intervention, using a Before and After study. An intervention group of F1s had access to VITAL from July 2012 with the control group having access four months later. Three assessments were carried out at intervals We are evaluating perceptions of VITAL through questionnaires and focus groups. Results There was no statistical difference in baseline scores between groups. At the second assessment scores showed moderate divergence. (p<0.01). Results of feedback will also be presented. Key messages VITAL can enhance knowledge in patient safety. Although e- learning will never replace all face-face teaching, VITAL allows long term, iterative assessment of knowledge and can be sustainable and adaptable to patient needs References Young J.Q. ’’July Effect”: Impact of the Academic Year-End Changeover on patient outcomes. A Systematic Review. Annals Intern Med. Sept 2011 Sep 6;155(5):309-15 1 - 43 - Sharing Good Practice June 2013 Using simulation-based teaching to deliver core medical emergency topics of the foundation programme to trainees in a district general hospital (DGH), Dr Prashant Kumar, Dr Sarah Miller, Dr Claire Smith, Dr Thomas Cullen and Mrs Ruth Edwards, Milton Keynes Hospital Background Simulation-based teaching is an effective tool to supplement exposure to acute medical emergencies and improve confidence of foundation trainees. Whilst widely available in teaching hospitals, routine use of simulation to help trainees complete foundation programme competencies is often lacking in DGHs. Methods We therefore constructed a regional four-session ‘Acute Medical Emergencies’ simulation-based course, with eight places allocated on a first-come-first-serve basis. We developed scenarios that link with the ‘Good Clinical Care’ & ‘Recognition and Management of the Acutely Ill Patient’ aspects of the foundation curriculum. Each session included a presentation, high-fidelity simulated scenario and debrief meeting. Candidates scored their knowledge, confidence, teamwork and leadership skills using a 110 rated scale (1=very poor, 10=excellent), both pre- and post-course. Results We found universal increases in all domains when comparing pre- and post-course scores, with a 3.5-point increase in candidates’ knowledge of the core topics and a 3.75-point increase in a their confidence to manage the acutely ill patient. Key Messages Simulation-based teaching is an effective modality to deliver aspects of the foundation curriculum to trainees. Where possible, simulation should be incorporated into local foundation teaching programmes to ensure all trainees are given equal opportunity to reach their required competencies. - 44 - Sharing Good Practice June 2013 Safe Handover: Safe Patients – The Electronic Handover System, Dr Hanish Sall and Dr Alex Till, Northampton General Hospital Background Effective handover is the duty of every doctor, yet due to human factors of poor communication and systemic error it is a perilous procedure and a major preventable cause of patient harm. Improving our Electronic Handover System (EHS) was vital to improve out of hours handover of care. Methods Based on the SBAR communication tool pre-entered sub-headings improved the quality of handover by providing a standardized proforma for doctors completing handover. Potential sources of miscommunication were removed; accountability for handovers provided, patient risk assessment re-classified and prompts for verbal handover added to aid escalation of care for unwell patients. Results The quality of information handed over improved by an average of 30%. 5 out of 7 subheadings achieved 80% compliance, the remainder achieved 64% and 74%. 87% of doctors surveyed felt there was a reduction in patient safety risk. 80% felt it increased continuity of care out of hours. Key Messages Our new EHS, as Lord Francis recommends, is designed to include prompts and defaults which contribute to safe and accurate recording of information. It acts as a sustainable safeguard to out of hours patient care. - 45 - Sharing Good Practice June 2013 Engaging Juniors – Reforming our Adult Non-Elective Admissions Proforma, Dr Hanish Sall and Dr Alex Till, Northampton General Hospital Background Leadership and management in the NHS must exist at all levels, from the board to the ward. Actively pursuing this as foundation year doctors we aimed to reform our adult non-elective admissions proforma to provide a thorough assessment for all speciality admissions, increase the quality of care provided and meet financial targets. Methods Specialist input from consultants, resuscitation officers, infection control, pharmacy, porters etc. alongside frontline nursing and medical staff was sought to consider key improvements. NICE, DoH guidance and CQUIN payments were studied and considered. Results Multiple quality improvement measures were implemented. Treatment escalation plans, senior staff countersignatures and communication of the diagnosis and management plan were incorporated to safeguard patient care. Venous Thromboembolism and Dementia assessments were simplified and located to maximise compliance. Nursing assessments, infection control measures and transfer checklists were initiated. Health prevention and promotion was encouraged through alcohol and tobacco cessation advice and referral. Key Messages Junior doctors must be encouraged to utilise their inherent leadership qualities and frontline knowledge on the strengths and weaknesses of existing services to enhance the service provided by their trust. A clear, logical and considered admissions proforma, suitable for all specialties, is vital to ensure quality care. - 46 - Sharing Good Practice June 2013 Chest and ascitic drain removal in the wards: What do we know as junior doctors? Dr Renukha Govinda Rajoo and Dr Tom Gordon, St Peter’s Hospital, Chertsey Background Junior doctors are often asked to perform tasks that are new to them. Working on a radiology rotation, we often receive requests from doctors in the wards for chest/ascitic drain removal as many are unaware of the different chest drains used in the trust and correct removal technique. If not remove correctly, these drains can cause serious injury to patients as well as become source of infection to the patient. Methods We designed a simple guide on the different drains inserted in the department and correct removal technique as part of a patient safety and quality improvement project. These guides are easily attached to patient’s notes for reference and A4 sized poster can be placed in treatment rooms in every ward. We have booked teaching sessions to evaluate our work with a simple multiple choice questionnaire before and after teaching. These questionnaires evaluate experience, confidence and knowledge with drain removal. Results This is a work in progress, we plan to demonstrate the results of our efforts at this conference. We anticipate a positive outcome. Key Messages Safe chest drain removal technique is an important aspect of patient safety. This can be taught through simple posters and teaching sessions. References Walker J (2007)Patient preparation for safe removal of surgical drains. Nursing standards .21,49,39-41. Date of acceptance May 25 2007 Royal Marsden Hospital Manual of Clinical Nursing Procedures. Eighth Edition. Chapter10: Respiratory Care. Chapter 19: Wound management. Boston Scientific User Manual for Flexima Biliary Catheter System - 47 - Sharing Good Practice June 2013 Improving Peripheral Arterial Disease Management Through Use of the Audit Cycle, Dr Thomas Heaton, Manchester Royal Infirmary Background Patients with Peripheral Arterial Disease (PAD) are at high risk of having both fatal and non-fatal cardiovascular events. It is therefore important to optimise secondary prevention treatment for cardiovascular disease to minimise this risk. Methods An initial audit was conducted at a general practice surgery, evaluating the management of three important factors: antiplatelet therapy, blood pressure and serum cholesterol. The results of the audit were presented to the practice staff alongside education about PAD management. To improve patient care, patients were contacted for optimisation of treatment and a repeat audit was undertaken to assess the effectiveness of these interventions. Results A total of 40 patients were included in the initial audit. The optimisation of these important factors was improved by the implementation of these changes. Appropriate antiplatelet therapy increased from 78.4% to 87.1%, attainment of blood pressure targets increased from 86.5% to 90.3%, and cholesterol targets improved from 70.3% to 87.1%. Key Messages The risk of cardiovascular events is increased in PAD and as such management of CVD risk factors is important. Implementation of the audit cycle with simple interventions can help improve the care provided to patients. - 48 - Sharing Good Practice June 2013 Stick With It: Improving Antibiotic Documentation, Dr James Hamill, Graham Wilson, Joanna Mort, Rebecca Mairs, Alexandra Turner, Hannah Trewin, Hannah Collins and Hannah Morley, North Bristol NHS Trust Background Antibiotic prescribing in North Bristol Trust is a common task for foundation doctors and trust-wide e-guidelines facilitate safe prescribing. Documentation of dose/route/duration/indication can prevent patients receiving inappropriate prescriptions which can have hazardous effects on their care and contribute to antibiotic resistance. Methods We based our methodology on a Plan/Do/Study/Act model with the aim to improve documentation, communication and patient safety. Patients receiving antibiotics on medical wards were selected. Foundation doctors were given two minutes to find documentation of the intended route/duration/ indication of antibiotics in medical notes. Thirty-three percent specified all three criteria. We implemented peer-to-peer education and introduced an eye-catching sticker recording this information to insert into the notes when a new antibiotic was prescribed. Results Data collection has found an increase in documentation of intended route/duration/indication of antibiotics. We have re-designed the sticker based on feedback from doctors using it. The stickers have provided an educative tool to improve antibiotic prescribing. Key Messages This F1 driven project highlights the importance of documentation in medical notes to maintain good standards of care. Inappropriate antibiotic prescribing is harmful to patients. Implementing aide memoires such as the antibiotic sticker is one way of improving patient safety. - 49 - Sharing Good Practice June 2013 Errors in Drug Prescription and Administration – a Survey of Clinical Year Medical Students in St George’s University of London, Dr Smiley Crane, Dr Abdulsatar Ravalia and Dr Philip Sedgwick, Darent Valley Hospital, Dartford Background A recent GMC1,2 review on GP prescribing found errors in one in six prescriptions. Complex ways in which drugs are annotated contribute to drug errors. There have been moves to standardise drug infusion concentrations in UK critical care units3,4. A compulsory prescribing skills assessment for medical students has been proposed5. We therefore undertook a survey of medical students to gauge their understanding of commonly used drug concentrations. Methods A ten question pharmacology quiz was emailed to all clinical year students (F=final year, P= penultimate year, T=first clinical year) at St George’s University, London. Questions included: 2 simple unit conversions, 1 percentage solution, 4 unit/ml solutions and 3 ratio solutions (p = 0.05). Results 105 students responded (T: 33; P: 31; F: 41). Scores: simple unit conversions: 68.9-100% (T: 69.7-93.9; P: 87.1-100; F: 78.0-100); percentage concentration: 60.6-71% (T: 60.6; P: 71.0; F: 65.9); concentration/ml solution conversions: 48.5-100% (T: 48.5-100; P: 67.7100; F: 78.0-100); ratio calculations: 21.2-74.2% (T: 21.2-42.4; P: 35.5-74.2; F: 26.873.2). Key Messages Despite score improvement as year of study progressed, results suggest a lack of fundamental knowledge of drug calculations, further compounded by confusing methods of noting drug concentration. A standardized method of annotating drug concentration, with improved education, would reduce drug errors. References (1) GMC. Investigating the practice and courses of prescribing errors in general practice. The Practice Study. GMC, 2012. Chapter 10.3, p.166. Available from: http://www.gmcuk.org/Investigating_the_prevalence_and_causes_of_prescribing_ errors_in_general_practice___The_PRACtICe_study_Reoprt_May_2012_48605085.pdf [Accessed 1st March 2012]. (2) BBC news. GPs 'making too many errors prescribing drugs' [internet] 2012. Available from: http://www.bbc.co.uk/news/health-17911049 [Accessed 1st March 2012]. (3) Borthwick M et al. Towards standardisation of drug infusion concentrations in UK critical care units. The Intensive Care Society, 2009. P197-200. Available from: http://journal.ics.ac.uk/pdf/1003197.pdf [Accessed 8th March 2012]. (4) Intensive Care Society. Medication Concentrations in Critical Care Areas. ICS 2012. Available at: http://www.ics.ac.uk/professional/standards_safety_quality/standards_ and_guidelines/concentration_guidance [Accessed 1st March 2012]. (5) The British Pharmacological Society. The Prescribing Skills Assessment [internet] 2013. Available from: http://www.bps.ac.uk/details/pageContent/884555/Prescribing_ Skills_Assessment.html?cat=bps12cb1b3ea72 [Accessed 1st March 2012]. - 50 - Sharing Good Practice June 2013 The use of Abdominal X-rays as first line imaging and their diagnostic yield: an audit at a London District General Teaching Hospital, Miss Mahbuba Choudhury and Dr Saiji Nageshwaran, Croydon University Hospital Background Abdominal X-rays (AXR) are an aid in managing acute conditions and their use should be determined by clinical need. We aimed to assess the appropriateness of their use and their diagnostic yield. Methods All AXR requests made in December 2013 were identified at a London teaching hospital. Reasons for the requests were recorded and assessed for appropriateness. Appropriateness was judged using RCR guidelines. A target of 80% appropriateness was used. Discharge summaries were reviewed to assess whether the imaging was of any diagnostic merit. Results 582 AXRs were conducted in one month. 18.9% were for ‘abdominal pain’. Other requests included ‘renal stones/colic’, ‘perforation’, ‘obstruction’ and ‘foreign body’. 33.3% were deemed an inappropriate use of AXRs. 16.8% reported abnormal findings. 13.4% of total requests were of diagnostic merit. 41(52.6%) and 37(9.5%) of appropriate and inappropriate requests, respectively, were clinically useful. Key Messages This audit suggests AXRs are over requested and of limited clinical benefit. Inappropriate requests also had poor diagnostic yield. Resource constraints and patient harm should be central in ensuring guidance is adhered to. We implemented an educational intervention at this institution to increase clinicians’ awareness of the indications for AXR and aim to re-audit in one month. - 51 - Sharing Good Practice June 2013 Sharing good practice to improve junior doctor weekend handover and patient safety, Dr Joanne Lee, Caitlin Bowden, Naomi Cornish, Mark Dahill, Priya Deol, Alan Jardine, Claudia Mische, Philippa Mourant, Tristan Page, Victoria Sanders and Rob Bethune, Royal United Hospital Bath Background Although the importance of good communication and handovers for safe clinical care of hospital patients is widely recognised (1, 2, 3), the RCP found that many hospital doctors are dissatisfied with the standard of handovers (4). We felt that the weekend handover at our trust was sub-optimal. Method A group of seven junior doctors at the Royal United Hospital in Bath utilised the ‘Plan Do Study Act’(PDSA) methodology to analyse and improve the weekend handover system. The Model for Improvement was used; handover sheets from a subset of wards were assessed to observe direct effects of staged interventions and allow small-scale testing prior to widespread implementation of intranet-based weekend handover proformas. Evaluation of the handover sheets is ongoing using a predesignated scoring system. Results Through a series of PDSA cycles the overall quality scoring improved from 60% to 92%. Interventions to improve task prioritisation and handover sheet accessibility are ongoing. Key Messages Junior doctors are ideally placed to see potentially poor systems that effect patient care. By sharing our findings with colleagues and continuously improving weekend handover we have successfully altered a potentially harmful system to a safer, more efficient and more accepted handover. References 1. Safe Handover: Safe Patients. Guidance on clinical handover for clinicians and managers. British Medical Association, 2004. 2. Metz D, Chard D, Rhodes J et al. Continuity of Care for Medical Inpatients:standards of good practice. Royal College of Physicians, 2004. 3. Safe Handover: Guidance from the Working Time Directive Working Party. The Royal College of Surgeons 2007. 4. A Scoping Project: Handover - the need and the best practice. Royal College Physicians 2010 - 52 - Sharing Good Practice June 2013 Are we scanning enough heads? Audit of CT scanning in children presenting with head injuries, Dr Catherine Lewis, Dr M Fernando, Dr N Hussain and Dr G Worthington, Yeovil District Hospital Background The audit was carried out following observation of the variation in management of children with head injuries and whether CT scanning was requested. There were also two different sets of local guidelines in use by different departments related to imaging of paediatric head injuries. Methods Standards for CT head scanning were derived from NICE guidelines1 and a data collection tool developed. 100 cases of children presenting to Yeovil District Hospital with a head injury were identified and their notes retrospectively assessed to identify whether a CT scan was indicated or carried out. Results 38 of the 100 children were identified as needing a CT head based on NICE criteria. Of those, 17 (45%) had a CT head scan. Following analysis of the results of the audit, consultations were carried out between the Paediatric, Radiology and Emergency departments of Yeovil District Hospital and local guidelines for imaging in head injuries were re-written and published on the local intranet. Key messages Children with head injuries were not having CT scans where these were clinically indicated. New local guidelines were developed with the aim of ensuring head CTs are carried out when they are appropriate. A re-audit will shortly be carried out. References 1. NICE (September 2007). Clinical Guideline 56: Head injury: Triage, assessment and early management of head injury in children and adults - 53 - Sharing Good Practice June 2013 Sepsis Quality Improvement Project: making a change to improve recognition and management of sepsis, Dr John Sykes, Dr James Peters, Oliver Pearce, Alex Gray, Elizabeth Ivey, Iram Parwaiz, Fionnuala Ryan, Anni Dong, Laura Corbett, Kyron Chambers, Benjamin Plumb, Alan Howe and David Higgie, North Bristol NHS Trust Background Maximising chances of a positive outcome from sepsis requires early recognition and treatment.1,2. Delivering this requires increased awareness in all the multidisciplinary team. This is a foundation year 1 led quality improvement project aiming to improve recognition and treatment of sepsis at our Trust. Methods An initial audit involved checking notes on AMU for a week to assess detection and treatment of sepsis. A questionnaire assessed junior doctor and other healthcare professional knowledge before and after teaching sessions. We used the intervention of a ‘sepsis sticker’ alongside multimodal teaching sessions to a wide range of hospital staff. We have completed our 8th PDSA cycle using the sticker and plan to re-audit notes on AMU. Results 17% of F1s correctly identified sepsis 6 compared to 100% after a teaching session. The initial audit showed only 27% of those with sepsis were correctly recognised and none had sepsis 6 as per guidelines. Our latest PDSA cycle shows 86% of ward admissions using the ‘sepsis sticker’. We expect our re-audit in 2 weeks to show better detection and treatment. Key Messages The intervention of a ‘sepsis sticker’ alongside multimodal teaching sessions and awareness campaigns aids better recognition and management of sepsis. References 1. Linde-Zwirble WT, Angus DC: Severe sepsis epidemiology: Sampling, selection, and society. Crit Care 2004; 8:222–226 2. Dellinger RP et al. (2012) Surviving Sepsis Campaign: International Guidelines for Management of Severe Sepsis and Septic Shock: 2012. Crit. Care Med. Journal 41:2:580-637 - 54 - Sharing Good Practice June 2013 Improving patient safety and junior doctor confident on consultant ward rounds using a simple checklist. A foundation Year 1 Quality Improvement project, Dr Charlie Andrews, Dr J Barrowman, Dr A Dewar, Dr J Eddington, Dr M Jenkins, Dr G Kirby, Dr C Murray and Dr L Walsh, North Bristol NHS Trust Background Consultant ward rounds are a key aspect of inpatient care. Numerous areas of patient care need to be addressed during this encounter and invariably certain areas are missed. Methods We observed ward rounds on 4 different wards at North Bristol Trust and used the Caldwell checklist to identify the most commonly missed areas. We also questioned junior doctors to ascertain their level of confidence in issues such as DNAR status and management plans following consultant ward rounds. Results The results highlighted areas of patient care which were infrequently addressed on the ward round. We also found that following ward rounds, junior doctors were not always confident of management plans and DNAR status for the patients under their care. We therefore designed a small checklist sticker to act as a reminder to ensure that these areas are addressed on every consultant ward round and that there is an opportunity for action plans to be communicated effectively to all members of the medical team on the ward round. Key Messages Initial trials suggest that coverage of these issues is improved by using the sticker. Using PDSA cycles, we have been refining our checklist and aim to use it on a greater number of wards. - 55 - Sharing Good Practice June 2013 Interprofessional simulation-based education for foundation doctors, Dr Mithun Biswas, Dr Claire McHale, Dr Alastair Ross and Dr Shumontha, Guy’s and St Thomas’ NHS Foundation Trust Background Simulation is recognised as an important modality in medical education to develop technical and non-technical skills (NTS). It is used extensively to promote interprofessionalism to allow individuals to “learn with, from, and about each other”.3 Methods We present results from an interprofessional high fidelity simulation course with a focus on both clinical and NTS. Scenarios were followed by structured reflective debriefs. Foundation year doctors (n= 49, 19 male, 39 female) and preceptorship nurses (n=42, 3 male, 39 female) completed pre- and post-course questionnaires of open and closed 7 item likert scale responses. Results Analysis of pre- and post responses showed significant mean score improvement for both doctors and nurses on an integrated clinical and NTS self assessment rating scale of areas including leadership, communication and management of emergency clinical situations (n=93; t =3.44; df 92; p<0.001). No significant differences were observed between groups (p<0.001). There was a non significant improvement in female scores compared to males. The course met the stated aims and objectives (mean 6.02), was felt that to enhance multidisciplinary team working (mean 6.08) and would impact on patient safety (mean 6.09). Key Messages Our findings highlight the value of interprofessional education. Responses reflect increased confidence in important technical and NTS areas - 56 - Sharing Good Practice June 2013 Undergraduate simulation-based teaching by Foundation Programme doctors, Dr Mithun Biswas, Dr Claire McHale, and Dr Shumontha, Guy’s and St Thomas’ NHS Foundation Trust Background Teaching is a key competency of the Foundation Programme curriculum,4 however providing opportunities may be limited, due to time pressures on clinical and educational training experiences.5,6 An initiative at Guy’s and St Thomas’ NHS Foundation Trust requires involvement of Foundation Year 2 doctors as faculty in undergraduate simulation-based teaching. Their role includes facilitating scenarios and debriefing, with the stated aim to develop skills, attitudes, behaviours and practices of competent teachers. Methods Foundation doctors participate in a half-day training course as preparation and are required to be part of faculty for one teaching session. To explore perceptions of the programme, anonymous questionnaires were completed by Foundation doctors. Opinions of the training given, their overall involvement in teaching and whether they planned future involvement were sought. Results Preliminary results suggest a pre-training course met the stated aims, providing adequate preparation to become faculty. Most participants felt their role was important, however not all felt encouraged or confident to participate in debriefing. Involvement was perceived as both important clinically and in developing interest in clinical teaching. Key Messages We present an opportunity to allow foundation doctors to provide regular, formal, structured - 57 - Sharing Good Practice June 2013 Chelsea and Westminster Hospital at Night Audit, Dr Rebecca Spruce, A Warrington, K Maham, A Moran, G Axelsson and G Davies, Chelsea and Westminster Hospital Background The ‘Hospital at Night’ system at Chelsea and Westminster Hospital refers urgent jobs via bleep whilst routine jobs are written in ward books. An audit analysed both the quality of patient identification in these books and the appropriateness of tasks with a view to improving patient safety. Methods Data collected 4-10/02/2013. Adequate patient identification was considered to be 3 pieces of identifiable information (name, hospital number, and DOB). Jobs were analysed for appropriateness of task and adequacy of handover. Results 340 jobs were analysed - 54% of patient identification was adequate, with ward variation of 39%. In 20% identification was by bed number alone. 87% of tasks were suitable for day teams. Only 2 of 116 reviews were escalated although 25% had CEWS (Chelsea Early Warning Score) >1; 33% handovers consisted of a single observation. We are re-designing the book layout based upon SBAR with guidance on adequate completion, in addition to creating an electronic format. Key Messages Patient identification and handover information is critical. Patient identification was inadequate in around 50% cases. Reviews were not escalated according to guidance and handover information was consistently insufficient. Results of re-audit after implementation of plans above will be available shortly. - 58 - Sharing Good Practice June 2013 Change in practice: Troponin ordering, Dr Helen McDill and Dr James Varley, Charing Cross Hospital, London Background The ESC recently changed guidelines on the definition of MI to include any troponin value above the 99th percentile with no inclusion of coeffiencent of variation. We audited how these changes would affect our local population and whether troponin testing is in accordance with NICE guidelines. Methods All acute admissions with chest pain or features suggestive of MI for 10 days were compiled. We retrospectively collected patient demographics, presenting complaint, medical history, ECG, admission and 12 hour troponin, investigations and final diagnosis. For every patient we calculated the NICE pre-test probability score of CAD. Results 171 troponins were done. All positive troponins (19) had abnormal ECG’s and > 1 risk factors as defined by NICE. 22% of troponins ordered were in < 50 year-olds, normal ECG and no risk factors – all were negative and arguably unnecessary. If patients were risk stratified and these tests avoided, £13,500 could be saved. Key Message New ESC guidelines would mean an increase of 27.7% in diagnosis of acute MI with more investigation, medication, hospital stay and with no proof of increased survival based on treating this cohort in this manner. Following introduction of a chest pain pathway at WMUH, re-audit demonstrated a 50% reduction of unnecessary troponin ordering. - 59 - Sharing Good Practice June 2013 A Junior Doctor initiative to improve consent in ENT surgery, Dr Mazin Alsaffar, Mr Alex Gan, Mr Glex Watson, Dr Meena Beena and Mr Anu Daudia, Royal Blackburn Hospital Background Royal College of Surgeons (RCS) and GMC have strict guidelines that emphasise the need to provide adequate information to patients and good record keeping. We developed printed stickers listing complications for ENT surgical procedures (in accordance to ENTUK standards) and subsequently auditing its use in our outpatient department. Methods First cycle Audit: Fifty random operations selected over a 2-week period and analyzed the consent forms. Key problem identified: Complications listed in procedures were not standardised or compliant with ENT-UK standards. Printed stickers were then introduced and subsequently re-audited fifty random operations over a four week period. Standards: All consent forms should have printed sticker. This represents 100% compliance with ENT UK standards. Results After introducing printed stickers, our second audit cycle showed that stickers were used in 76% of consent forms. Where stickers have been used, this has ensured complete documentation of risk in a standardised manner. Reasons for not achieving 100% compliance may be due to availability of stickers and will be highlighted in the next audit meeting. Key Messages Record keeping during consenting is important, particularly for medical legal aspects. Using printed stickers minimises error, standardises consent documentation and avoid legibility issues. - 60 - Sharing Good Practice June 2013 Clinical induction workshop for foundation trainees in psychiatry, Dr Antonina Ingrassia, Oxleas NHS Foundation Trust Background (context setting including why the innovation/development was introduced) Whilst there isn’t a specific curriculum for psychiatry within foundation training, it is clear that placements in psychiatry offer a valuable opportunity to meet several of the competencies outlined in the syllabus. “Commencing training in psychiatry can be daunting for new core trainees” (The Competency Checklist for Psychiatry 2012): the same can be said for all trainees that are new to psychiatry. Recommendations from the South Thames Foundation School Psychiatry Placement Survey in 2011 also highlight that the process of induction should include training on risk assessment and that trainee should have access to psychiatry specific teaching, including using simulation approaches. Methods Using the template provided in The Competency Checklist for Psychiatry- Trainer handbook (2012) we have been running clinical induction workshops (December 2012 and April 2013), as part of the general induction process, for all the Foundation Trainees joining the Trust (4 F2 posts in the Trust). The workshop has OSCE style stations where trainees go through a set scenario or a task with a role player (where appropriate) and in the presence of a trainer. All trainees are given feedback on their performance individually by the trainer at the end of the scenarios and a group feedback session with trainees, trainers and role players is held at the end. The scenarios focus on: Clinical history Mental state examination Risk assessment and management Safe prescribing Written communication Results Trainees have reported high levels of satisfaction and commented on the usefulness of these sessions for clinical practice, patient safety and their own confidence in approaching a new specialty. Key Messages Clinical induction, focused on the acquisition of valuable clinical skills, is crucial to patient safety and well received by foundation trainees. References The Competency Checklist for Psychiatry – trainee handbook 2012 The Competency Checklist for Psychiatry – trainer hand book 2012 South Thames Foundation School Psychiatry Placement Survey 2011 - 61 - Sharing Good Practice June 2013 The dilemmas of a rota: google’s solution, Dr Jibran Qureshi, Dr Samual Trowbridge and Dr Ravindran Karthigan, St Helier Hospital, Surrey Background Trainees frequently require study leave to supplement their training. Out of hours on-call rotas tend to omit these leave periods and are not updated to reflect swaps in on-call duties. Unexpectedly reduced medical staffing levels can result, which may cause confusion and compromise patient care. Google online spreadsheets allows the development of customised rotas which are team specific, remotely accessed and edited by any device with an internet connection and web browser. Method A surgical team consisting of 3 FY1s, a FY2, and SHO trialled the system. The surgical rota was copied into a Google spreadsheet. Subsequently modified to contain team specific rota information including all forms of leave. A link was emailed allowing remote rota access and editing. Result Appropriate staffing levels were maintained on the ward at all times. All forms of leave were accommodated for. Morale was boosted, and colleagues felt well supported. Key Messages A team specific rota documents all leave whilst ensuring adequate ward staffing levels. Remote access facilitates ease of use. Differing privacy levels ensure document security. Real-time updates provide an accurate representation of staffing levels, vital for service managers - 62 - Sharing Good Practice June 2013 The Hunger Games: our fight to reduce nil by mouth times for gastroscopy, Dr Simon Huf, Dr Ariadne Strong, Dr Rachel Cave, Dr Din Sumathipala, Dr Sorayya Alam and Dr James Robinson, North Bristol NHS Trust Background Evidence suggests that patients who are kept nil by mouth (NBM) for greater than 6 hours for solids and 2 hours for clear fluids experience adverse outcomes. This project aims to reduce the number of patients awaiting emergency endoscopy who are kept NBM for greater than 6 hours to <10%. Method This quality improvement project implements ‘Plan Do Check Act’ (PDCA) methodology. In our first PDCA cycle we prospectively collected data for two weeks in the endoscopy department. Patients on the emergency gastroscopy list were asked when they last had food or clear fluids. Results Gastroscopy patients are NBM for an average of 15.5 hours (range 6 to 24 hours). 90% of patients are NBM for more than 6 hours. Only 30% received clear fluids until 2 hours prior to their procedure. After two cycles post intervention, we were able to significantly reduce the NBM time. Key Messages This project identifies an important patient safety issue. To address this, we have designed a protocol to record and reduce NBM times. Subsequently we have re-audited and implemented PDCA cycles. This protocol could be applied to all patients kept NBM for gastroscopy. - 63 -
