WHERE THIS HAPPENED: King's College Hospital NHS Foundation Trust
Incorrectly directing hospital patients to their general practitioner (GP) when they require a Statement of Fitness to Work or ‘Fit Note’ delays the patient providing their employer with the required medical evidence of their health condition. If a GP appointment is for the sole aim of obtaining a Fit Note, this is a waste of an appointment for both the patient and the GP. Furthermore, the relevant discharge paperwork may not have reached the GP, resulting in further delays. Given the current strain on GP appointments, reducing wastage and duplication of work wherever possible is a priority.
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WHERE THIS HAPPENED: North Bristol NHS Trust
Certain cardiac conditions can limit patients’ ability to drive. It remains the doctors' responsibility to advise patients of any driving restrictions and is particularly important after certain diagnoses or procedures. We identified that the quality of documented advice was variable and frequently no written driving advice was recorded on discharge. It was apparent that there was a lack of awareness and knowledge of the current Driving and Vehicle Licensing Agency (DVLA) guidance among junior doctors.
We therefore designed a quality improvement project using Plan–Do–Study–Act (PDSA) methodology to improve the provision of driving advice on discharge from a cardiology ward by focusing on staff education. After collecting baseline data, we created a template with cardiologyspecific DVLA advice. During the second PDSA cycle, we improved the electronic template and also introduced a hard copy on the ward. During the third PDSA cycle, we incorporated information on DVLA guidance in the specialty induction session. We also evaluated junior doctors’ confidence of providing driving advice before and after this intervention.
Baseline measurements showed that 10% (9/92) of all discharge summaries included driving advice. This improved to 49% (34/69) after the third PDSA cycle. Importantly, after receiving information on driving advice in the induction, junior doctors felt more confident in providing driving advice to cardiology patients on discharge. In conclusion, the provision of driving advice on discharge is an important element of patient safety. However, clinicians’ knowledge and awareness of current DVLA guidance is often limited. We demonstrated a significant increase in the provision of driving advice by introducing a standardised template.
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Are they high on steroids? Tailored interventions help improve screening for steroid-induced hyperglycaemia in hospitalised patients
WHERE THIS HAPPENED - Heart of England NHS Foundation Trust, Birmingham NHS Foundation Trust, University of Birmingham Queen Elizabeth Hospital Birmingham
Steroid-induced hyperglycaemia (SIH) is a common adverse effect in patients both with and without diabetes. This project aimed to improve the screening and diagnosis of SIH by improving the knowledge of healthcare professionals who contribute to the management of SIH in hospitalised patients. Monitoring and diagnosis of SIH were measured in areas of high steroid use in our hospital from May 2016 to January 2017. Several interventions were implemented to improve knowledge and screening for SIH including a staff education programme for nurses, healthcare assistants and doctors.
The Trust guidelines for SIH management were updated based on feedback from staff. The changes to the guideline included shortening the document from 14 to 4 pages, incorporating a flowchart summarising the management of SIH and publishing the guideline on the Trust intranet. A questionnaire based on the recommendations of the Joint British Diabetes Societies for SIH was used to assess the change in knowledge pre-intervention and post-intervention.
Results showed an increase in junior doctors’ knowledge of this topic. Although there was an initial improvement in screening for SIH, this returned to near baseline by the end of the study. This study highlights that screening for SIH can be improved by increasing the knowledge of healthcare staff. However, there is a need for ongoing interventions to sustain this change.
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WHERE THIS HAPPENED: Homerton University Hospital NHS Foundation Trust
Hydroxyurea is the gold standard treatment for prevention of vaso-occlusive crises in patients with sickle-cell anaemia. It has a narrow therapeutic index and dangerous side effects including cytopenias. There is high variation in dose–response across the population. Therefore, a robust outpatient monitoring programme is crucial to ensure efficacy and safety of treatment. However, there has historically been difficulty engaging the target population in regular laboratory test monitoring programmes. This project aimed to ensure that all patients on hydroxyurea had routine blood tests at least once every 2 months which were reviewed and acted upon within the 3-year project life cycle.
A specialist haematology nurse prescriber clinic service was introduced, first informally, and then formally to take blood tests, alter medication dosing, prescribe it and then write a clinic letter. The mean number of tests per patient per year rose from 0.21 at baseline to 9.05 after 2 years of the formal nurse prescriber clinic. This led to an associated increase in dose changes from 0.23 to 1.45 per patient per year. This improved the number of patients on the optimum dose of hydroxyurea.
Furthermore, due to increased confidence in the outpatient monitoring, the total number of people being prescribed hydroxyurea increased from 26 to 42. Restriction of prescriptions to only those enrolled in the service has prevented unmonitored patients being at risk of the potential toxicities associated with doses that are too high. The introduction of a formal nurseled clinic has improved the safety, efficacy and compliance and increased the number of patients on the gold standard preventative treatment for vaso-occlusive crises in sicklecell anaemia.
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WHERE THIS HAPPENED - Royal Bournemouth HospitaL
The colorectal services at The Royal Bournemouth Hospital needed to adapt to meet the extra demand on fast-track patient referrals to the outpatient department, as a consequence of the changes in the National Institute for Health and Care Excellence (NICE) guidance on cancer referrals in June 2015. Learning from other units, a telephone assessment clinic (TAC) triaging patients straight to colonoscopy was trialled. A Plan–Do–Study–Act (PDSA) methodology was used. A baseline study showed that fast-track colorectal patients referred from their general practitioner (GP) were taking on average 30 days until they received their colonoscopy.
This quality improvement project focused on sending fast-track colorectal GP referrals through a straight-to-colonoscopy TAC. The results of this intervention showed an improvement from GP referral to colonoscopy. Both PDSA cycle 1 and PDSA cycle 2 showed an average of 24 days. This reduction of 6 days was a promising improvement in a 62-day patient pathway, so funds were accessed to invest in a temporary full-time TAC nurse appointment to allow more data to be collected. PDSA cycle 3 showed a reduction of the average from referral to colonoscopy to 19 days and a reduction in the variation. This outcome will be sustainable, as the TAC role is now a permanent position.
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WHERE THIS HAPPENED - Royal United Hospital NHS Foundation Trust, Bath
The Royal United Hospital, NHS Foundation Trust, Bath, (RUH) is a busy district general hospital, providing secondary healthcare for 500000 people across the South-West of England. The surgical take is busy and varied. Two consultant-led, post-take ward rounds take place each day in the surgical assessment unit (SAU), a 19-bed admissions unit that takes direct admissions from general practitioners and the emergency department. The bays are overseen by a ward manager (senior nurse), and three to five staff nurses with an equal number of healthcare assistants.
The daily ward rounds include the team of junior doctors on the take that day, as well as a senior SAU nurse. Because of the fast-paced nature of the ward information may not be documented or communicated effectively, and this can impact on patient safety. There is also a degree of variability in the way the ward round is conducted, depending on the lead consultant for that round.
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WHERE THIS HAPPENED - Royal Cornwall Hospital
The handover of large numbers of medical patients, during on call periods when staffing levels are reduced, is a challenge for all acute medical services. At the Royal Cornwall Hospital, a large district general hospital, we identified that foundation doctors were reviewing medical inpatients during weekend on call periods with limited written handover information. We chose to address this problem by developing an intervention, a weekend handover sticker, and piloting it. We used the review of documentation to measure improvement and feedback from users to assess the processes involved. Use of the weekend handover form improved the written communication between weekday and weekend teams.
The number of weekend plans documented in the notes increased from 15% to 84%and the provision of a patient summary within the last 7 days increased from 26% to 94%. The feedback from users confirmed it was a useful intervention and 100% (15/15) of doctors and nurses responded positively to the question “Do you think the weekend sticker should be introduced and used at the weekend for all medical patients?”
The feedback also identified concerns regarding additional workload for weekday ward staff and this has led to ongoing work to try and ensure that the weekend handover form continues to be used effectively to maintain an improved level of written handover information for on call staff. While we have not included a direct measure of patient care, we hope that by improving the quality of written handover information we are acting to ensure patient information is shared effectively, with likely positive impact on patient care.
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Improving the patient booking service to reduce the number of missed appointments at East London NHS Foundation Trust Community Musculoskeletal Physiotherapy Service
WHERE THIS HAPPENED - Royal London Hospital, London, East London NHS Foundation Trust
In the East London National Health Service (NHS) Foundation Trust (ELFT) Community Musculoskeletal (MSK) Physiotherapy Service, a large proportion of appointments were recorded to have not been attended by patients. The service offers approximately 21 000 appointments per year, thus averaging 400 patients per week, with each appointment lasting 30min. Baseline data identified that 23.76% of newly referred patients did not attend their first appointment and 23.74% of current patients failed to attend their follow-up appointment. The National Schedule of Reference Costs1 reports the cost of non-specialist MSK rehabilitation at £187/patient. Therefore, an average of 96 patients (~24%) per week not attending their appointment equates to a financial loss of approximately £18 000/week for this service.
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Improving the ability to review preoperative radiographs intraoperatively in trauma and orthopaedic theatres at Lancashire teaching hospitals
WHERE THIS HAPPENED: Royal Preston Hospital
The ability to review preoperative radiographs during trauma and orthopaedic surgery is essential for the surgeon to provide optimum treatment to the patient. However, due to current information technology (IT) systems, screen-savers frequently interrupt the ability to review images and theatre staff are not routinely available to deactivate the screen-saver. This prolongs theatre time for the patient and affects the quality of care provided. The aim of this quality improvement project was to improve the availability of radiographs for the surgeon to review intraoperatively.
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Reducing DNACPR complaints to zero: designing and implementing a treatment escalation plan using quality improvement methodology
WHERE THIS HAPPENED: Weston General Hospital, Weston-super-Mare
Do Not Attempt Resuscitation (DNAR) decisions have traditionally formed the basis of ceiling of care discussions. However, poor quality discussions can lead to high patient and relative dissatisfaction, generating hospital complaints. Treatment escalation plans (TEPs) aim to highlight the wider remit of treatment options with a focus on effective communication. We aimed to improve TEP discussions and documentation at Weston General Hospital by introducing a standardised form.
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WHERE THIS HAPPENED: Sandwell and West Birmingham Hospitals NHS Trust, Heart of England NHS Foundation Trust
The West Midlands Adult Cystic Fibrosis (CF) Centre based at Birmingham Heartlands Hospital provides care for adults with CF in the West Midlands. People with CF are prone to pulmonary exacerbations, which often require inpatient admission for intravenous antibiotics. We observed that the admission process was efficient during working hours (9:00–17:00, Monday–Friday) when the CF team are routinely available, but out-of-working hours, there were delays in these patients being clerked and receiving their first antibiotic dose. We were concerned that this was resulting in quality and potential safety issues by causing delays in starting treatment and prolonging hospital inpatient stays. We therefore undertook a quality improvement project (QIP) aimed at addressing these issues. An initial survey showed median time to clerk of 5 hours, with 60% of patients missing their first dose of antibiotics and mean length of stay of 16 days.
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Improving MRCP PACES pass rates through the introduction of a regional multifaceted support framework
WHERE THIS HAPPENED: Heart of England NHS Foundation Trust, Lewisham and Greenwich NHS Trust, University Hospitals Coventry and Warwickshire NHS Trust
Practical Assessment of Clinical Examination Skills (PACES) constitutes the final part of the mandatory Royal College of Physicians exam series for progression to higher specialty training. Pass rates were lower for core medical trainees (CMTs) in Coventry and Warwickshire in comparison to other regions within the West Midlands and nationally.
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WHERE THIS HAPPENED: NHS Lothian, Edinburgh
Electronic patient records have been used by general practitioners (GPs) for some time, but up until recently details of these records were not routinely accessible in secondary care in Scotland. Patients with an existing care plan or anticipatory care plan (ACP) in place previously had documents shared with out of hours (OOH) services, but there was no reliable way of sharing this information with secondary care.
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WHERE THIS HAPPENED: Royal Free London NHS Foundation Trust, University College London Hospitals NHS Foundation Trust
Patient experience is one of the three pillars of quality in healthcare.1 2 If healthcare organisations are to improve the quality of care they provide; then efforts to improve their patients’ experience must be integral to any quality improvement plan.
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WHERE THIS HAPPENED: Aneurin Bevan University Health Board
Although the National Health Service is one of the great concepts of the twentieth century, as we move into the twenty-first century expectations and demands are increasing. The patients’ experience of their encounters with the National Health Service is becoming increasingly important. Wait times are recognised as being a source of patient dissatisfaction in healthcare. Bleustein et al1 found that every aspect of the patient experience correlated negatively with longer wait times. In their study of patients undergoing total knee arthroplasty surgery, Lizaur-Utrilla et al2 found that a waiting time longer than 6months negatively influenced postoperative satisfaction, as well as patient-related outcome at 1year following surgery.
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WHERE THIS HAPPENED: Taunton and Somerset Foundation Trust
Taunton and Somerset NHS Foundation Trust have helped develop a vital signs application that alerts staff to a patient’s deteriorating condition before it becomes life-threatening.
The global digital exemplar trust worked in partnership with clinical technology specialist IMS Maxims on the design and functionality of its latest app, which can be accessed from anywhere in the hospital.
Michael Thick, chief clinical information officer and chief medical officer at IMS Maxims said it addresses a common pitfall of existing clinical apps – alert fatigue, where users become so used to receiving notifications from an application that they become inclined to ignore them or turn them off.
“The Maxims solution gives staff tailored alert support, avoiding the send-to-all approach of other solutions”, Thick said.
“The 24/7 monitoring system and vital decision support make it quicker and easier for staff to observe a patient’s condition and prevent them from getting any worse.”
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WHERE THIS HAPPENED: Ashford and St. Peter's Hospitals NHS Foundation Trust
Medicines reconciliation is integral to patient safety, symptom control and reducing patient anxiety. During a 3-month period on the respiratory ward at St. Peter's Hospital, 54% of drug charts were not reconciled with pre-admission medicines at the point of discharge for admissions up to 17 days. Only 18% were reconciled within 24 hours of admission. 50% of drug charts were missing 0-2 pre-admission medicines and 50% were missing 3-5 pre-admission medicines. The most common medicines that were not reconciled included topical applications which included eye, ear, nasal and skin applications (14%); vitamins i.e. vitamin B12 and thiamine, analgesia, PRN inhalers (11% individually); antidepressants and lipid regulators (6% individually); amongst a range of other medications including antiplatelets, calcium channel blockers, ACE inhibitors and diuretics.
Two interventions were carried out to improve the rate of medicines reconciliation onto hospital drug charts with pre-admission medicines. These were: 1) a green sticker placed in the medical notes by the pharmacist when drug charts were incomplete, which required a date and signature from the doctor when the drug chart had been reconciled 2) the placing of the loose medicines reconciliation record (a list of pre-admission medicines retrieved from a reliable source usually by the pharmacist) to the front of the drug chart. These measures were designed to alert the doctors that the drug chart was incomplete.
After 2 PDSA cycles, the results showed positive outcomes. In 75% of the cases where the interventions were used, medicines reconciliation was complete at the point of discharge with 34% of drug charts reconciled within 24 hours of admission. Of the 25% of drug charts that were not reconciled despite the use of the interventions, 100% of them were missing 0-2 medicines however 0% were missing 3-5 medicines. This highlights that the interventions were effective in improving the rates of medicines reconciliation.
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WHERE THIS HAPPENED: East London NHS Foundation Trust
Cost effective care requires comprehensive person-centred formulation of solutions. The East London NHS Foundation Trust Community Health Services in Newham have piloted models of Integrated Care called ‘Virtual Wards’ which aim to keep people living with multiple long-term conditions, well at home by minimising system complexity. These Virtual Wards comprise Interdisciplinary Teams (IDTs) with a General Practitioner (GP) seconded to provide leadership. Historically assessments have been dominated by biomedical approaches with disability emphasised over personal aspirations and ability. New professional skills are needed to organise information from diverse approaches into a common framework, which can enable agreed goals of care to be delivered collaboratively. From June 2014 to January 2016 we aimed to improve the documentation of person-centred goals of care in 100% of our assessments. Change ideas were tested and team development addressed to improve documentation of aspirations for care for people being referred and if achieved, then to test ideas to improve coproduction of care. Change ideas included Enhanced Clinical Supervision (ECS) by a GP with additional expert skills; Flash Teaching (FT) defined as five-minute weekly discussion on topics generated from the case-mix to develop a shared understanding of Integrated Care; Structured Formulation using a novel, quick, integrated assessment framework called the Handy Approach (HA) with the hand as a memory prompt to bring the personal together with the mental, social and physical domains and finally we tested focusing on ‘Team Primacy’ (mutual regard within the team) to embed behaviour change. 181 cases were tracked and documentation of personal aspirations for care by case showed: ECS 0/21 (0%); FT 5/50 (10%); ECS/FT plus the HA 35/83 (42%); Team Primacy plus ECS/FT/HA 27/27 (100%). By January 2016 prompted by using the Handy Approach in a highly functional team, all members of the IDT consistently documented personal aspirations.
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WHERE THIS HAPPENED: Chelsea & Westminster Hospital NHS Trust
Dehydration is a growing problem among elderly patients in hospital wards. Incidents such as those raised in the Francis Report highlight a problem that may not have been sufficiently addressed by current schemes. This improvement project aimed to identify the barriers faced by staff in improving oral hydration and to design and implement an effective solution. A 33 patient pilot study carried out at Chelsea & Westminster Hospital NHS Trust, United Kingdom, revealed that a significant proportion of patients were reported to be dehydrated on admission, with few having their hydration needs addressed. Staff cited time pressures and unclear task responsibility as the major barriers. The intervention was a Hydration Sticker education scheme. These stickers were placed on patient cups, notes and beside areas as a visual prompt for staff and family members to encourage the patient to drink. The intervention was implemented on the Acute Assessment Unit and Stroke ward through a poster campaign. The Hydration Stickers scheme resulted in a 6.5-fold increase in patients’ hydration needs being assessed and addressed. Coupled with the low implementation cost and ease of use, Hydration Stickers may be a simple, effective, transferable and sustainable solution to the problem of dehydration among elderly inpatients.
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A Multifaceted Quality Improvement Programme to Improve Acute Kidney Injury Care and Outcomes in a Large Teaching Hospital
WHERE THIS HAPPENED: Central Manchester University Hospitals NHS Foundation Trust
Acute kidney injury (AKI) is now widely recognised as a serious health care issue, occurring in up to 25% of hospital in-patients, often with worsening of outcomes. There have been several reports of substandard care in AKI. This quality improvement (QI) programme aimed to improve AKI care and outcomes in a large teaching hospital.
Areas of documented poor AKI care were identified and specific improvement activities implemented through sequential Plan-Do-Study-Act (PDSA) cycles. An electronic alert system (e-alert) for AKI was developed, a Priority Care Checklist (PCC) was tested with the aid of specialist nurses whilst targeted education activities were carried out and data on care processes and outcomes monitored.
The e-alert had a sensitivity of 99% for the detection of new cases of AKI. Key aspects of the PCC saw significant improvements in their attainment: Detection of AKI within 24 hours from 53% to 100%, fluid assessment from 42% to 90%, drug review 48% to 95% and adherence to nine key aspects of care from 40% to 90%. There was a significant reduction in variability of delivered AKI care. AKI incidence reduced from 9% of all hospitalisations at baseline to 6.5% (28% reduction), AKI related length of stay reduced from 22.1 days to 17 days (23% reduction) and time to recovery (AKI days) 15.5 to 9.8 days (36% reduction). AKI related deaths also showed a trend towards reduction, from an average of 38 deaths to 34 (10.5%). The number of cases of hospital acquired AKI were reduced by 28% from 120 to 86 per month.
This study demonstrates significant improvements related to a QI programme combining e-alerts, a checklist implemented by a nurse and education in improving key processes of care. This resulted in sustained improvement in key patient outcomes.
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