International Journal of Risk & Safety in Medicine - Volume 33, issue S1

Authors: Okocha, M. | Bruno, P. | Ghandour, O. | Newton, L. | Cook, H. | Slim, N.

Article Type: Editorial

DOI: 10.3233/JRS-227035

Citation: International Journal of Risk & Safety in Medicine, vol. 33, no. S1, pp. S1-S8, 2022

Article Type: Abstract

DOI: 10.3233/JRS-227020

Citation: International Journal of Risk & Safety in Medicine, vol. 33, no. S1, pp. S9-S33, 2022

Authors: Niazi-Ali, Saarah | Bircher, Joanna

Article Type: Research Article

Abstract: BACKGROUND: With the majority of antibiotics being prescribed in primary care it is of utmost importance that antimicrobial stewardship principles are adhered to in order to slow down the incidence of antimicrobial resistance. OBJECTIVE: Broad spectrum antibiotic prescribing is often seen as a proxy marker of increasing resistance within a population and so it is important that they are used sparingly, to avoid drug-resistant bacteria developing. METHOD: In Tameside and Glossop a novel approach, using quality improvement methods, was employed to allow the behaviour change to be sustained for a longer period. Practices submitted monthly broad …spectrum usage data, and if over a set target they were required to submit a “deep dive”. RESULTS: A 10.6% reduction of broad spectrum antibiotic usage was seen over the 2019-20 financial year. CONCLUSION: Over time the number of practices submitting a deep dive reduced and clinicians saw the deep dive as method to peer review their prescribing. Putting the practice staff in control of their own prescribing, allowed for a better method to sustain the improvement. Show more

Keywords: Antimicrobials, broad spectrum antibiotics, quality improvement, antibiotic stewardship

DOI: 10.3233/JRS-227021

Citation: International Journal of Risk & Safety in Medicine, vol. 33, no. S1, pp. S35-S40, 2022

Authors: Choudhury, J. | Perrio, S. | Scobell, M. | Bertram, T. | Gray, A.

Article Type: Research Article

Abstract: BACKGROUND: Healthwatch England estimated emergency readmissions have risen by 22.8% between 2012–13 and 2016–17. Some emergency readmissions could be avoided by providing patients with urgent out of hospital medical care or support. Sovereign Health Network (SHN) comprises of three GP practices, with a combined population of 38,000. OBJECTIVE: We will decrease the number of SHN patients readmitted within 30 days of discharge from Portsmouth Hospitals Trust following a non-elective admission (excluding Emergency Department attendance) by 40–60% by July 2020. METHODS: Four Plan, Do, Study, Act (PDSA) cycles were used to test the administrative and clinical processes. …Our Advanced Nurse Practitioner reviewed all discharge summaries, added alerts to records, and proactively contacted patients either by text, telephone or home visit. RESULTS: 92 patients aged 23 days to 97 years were admitted onto the recent discharge scheme. Half of discharge summaries were received on the day of discharge, whilst 29% of discharge summaries were received more than 24 hours post-discharge, and one was received 11 days post-discharge. Following our interventions, there were 55% less than expected readmissions during the same time period. CONCLUSION: To allow proactive interventions to be instigated in a timely manner, discharge summaries need to be received promptly. The average readmission length of stay following a non-elective admission is seven days. Our proactive interventions saved approximately 102.9 bed days, with potential savings of 1,775 bed days over a year. We feel the results from our model are promising and could be replicated by other Primary Care Networks to result in larger savings in bed days. Show more

Keywords: Discharge summary, post-discharge care, readmission, emergency admission, recent discharge

DOI: 10.3233/JRS-227022

Citation: International Journal of Risk & Safety in Medicine, vol. 33, no. S1, pp. S41-S45, 2022

Authors: Barnes, Eve | Parfit, Caroline

Article Type: Research Article

Abstract: BACKGROUND: This project was undertaken to improve the documentation of Just in Case (JiC) medication in a general practice. The outcome of a Strengths, Weaknesses, Opportunities, Threats (SWOT) analysis highlighted this as an area where awareness within the practice could be improved. OBJECTIVE: A Plan-Do-Study-Act (PDSA) approach was taken to the project and involved collaborative working and data collection from the general practice and relevant care homes. METHOD: JiC medications are used to promptly manage symptoms experienced at the end of a patient’s life and are part of the Gold Standard Framework (2006). RESULTS: …Of the patients registered at the practice with JiC medication, 37.5% were incorrectly documented. This included errors/ inaccuracy with the clinical coding, or the medication. Three patients on practice generated searches had no JiC medication in the care homes, and 4 patients had JiC boxes in the care home that was not identified by the search. CONCLUSION: This evaluation has identified documentation errors and discrepancies between practice and community records of JiC medication. A newly generated practice specific flowchart was created, with an aim of reducing the discrepancies. A guide of how to carry out a QI project like this was created for the RCGP and can be found on their website. A seminar at Bristol, North Somerset, and South Gloucestershire (BNSSG) CCG to present this project took place in 2021. Show more

Keywords: Just in Case (JiC), anticipatory prescribing, community palliative care, Daffodil Care Standards, out of hours, general practice, quality improvement

DOI: 10.3233/JRS-227023

Citation: International Journal of Risk & Safety in Medicine, vol. 33, no. S1, pp. S47-S51, 2022

Authors: Jegatheeswaran, Lavandan | Choi, Byung | Cohn, Martin | Minocha, Amal | Mutengesa, Ernest | Zala, Ashik | Alhilani, Michel

Article Type: Research Article

Abstract: BACKGROUND: During the COVID-19 pandemic, the Hillingdon Hospitals NHS Foundation Trust produced trust guidelines for the initial blood investigation of COVID-19 inpatients. However, insufficient education meant inconsistent adherence to this guidance. OBJECTIVE: To examine whether the implementation of a COVID-19 blood request panel improves adherence to local trust guidelines. METHOD: Between March and April 2020, initial blood investigations performed for positive COVID-19 cases were compared to guidelines. Results were presented locally and a COVID-19 panel was added to the electronic system that provided prompts for appropriate investigations. A re-audit between May and June 2020 was conducted …to assess adherence post-intervention. RESULTS: 383 patients were identified in the initial audit cohort and a sample of 20 patients were re-audited. Adherence to Full Blood Count, Urea and Electrolytes, C-reactive Protein and Liver Function Tests increased to 100% from 99.7% (p = 0.8), 99.2% (p = 0.69), 98.7% (p = 0.61), and 96.6% (p = 0.4) respectively. Coagulation screen adherence increased to 90% from 72.8% (p = 0.09). Appropriate requesting of D dimers increased to 50% from 19.9% (p = 0.001). Inappropriate troponin requesting decreased to 26.3% from 38.9% (p = 0.23). CONCLUSION: A user-friendly COVID-19 panel of investigations resulted in improved adherence to guidelines. Clear communication and education are essential to help alleviate uncertainty during a pandemic. Show more

Keywords: COVID-19, guidelines, evidence-based medicine, care bundles, biomarkers

DOI: 10.3233/JRS-227024

Citation: International Journal of Risk & Safety in Medicine, vol. 33, no. S1, pp. S53-S56, 2022

Authors: Wong, Jeremy J. | Tailor, Bhavesh V. | Chen, Fangyue | Florance, Robert

Article Type: Research Article

Abstract: BACKGROUND: Malnutrition adversely affects clinical outcomes, necessitating a prompt and accurate assessment of nutritional status on admission. A variety of tools exist to aid nutritional assessment, of which the malnutrition universal screening tool (MUST) is recommended, but remains difficult to implement in practice. OBJECTIVE: The aim of this audit was to improve the utilisation of the malnutrition universal screening tool (MUST) in the Acute Medical Unit (AMU) at Queen Elizabeth Hospital, King’s Lynn. Specifically, patients should have a completed and accurate MUST score within 6 hours of arrival to AMU and high-risk patients (MUST score ≥2) should be referred …to dieticians within 48 hours of admission. The first cycle was conducted by March 2019 and the second cycle was completed 1 year later to allow assessment of interventions actioned after the first cycle. METHODS: We conducted a two-cycle audit evaluating the MUST completion and dietician referral rate of high-risk patients (defined as MUST ≥2) on the Acute Medical Unit in a district general hospital, with the standards of 80% and 100% respectively. A questionnaire was distributed after the first cycle exploring nurses’ current experience and competence in using MUST. RESULTS: In the first cycle, MUST scores were calculated correctly in 111/150 patients (74%) and 1/9 (11%) high-risk patients were referred to dieticians. After interventions, MUST scores were calculated correctly in 77/101 patients (76%) and 2/4 high-risk patients (50%) were referred to dieticians. The nurses (n = 19) who took part in the questionnaire felt confident in MUST completion, but the average score in an objective assessment was 67%. CONCLUSIONS: As per the literature, the first cycle demonstrated the under-utilisation of MUST in clinical practice. In response, we proposed additional face-to-face training for existing staff, the inclusion of an e-learning module within the staff’s induction, and provision of ward MUST ‘troubleshooting’ booklets. MUST utilisation rates improved upon re-auditing, but not to target standards. We will need to consider potential barriers to sustainable change and implement interventions such as identification of nursing champions to overcome them. Show more

Keywords: Malnutrition, dietetics, screening, surveys and questionnaires, quality improvement

DOI: 10.3233/JRS-227025

Citation: International Journal of Risk & Safety in Medicine, vol. 33, no. S1, pp. S57-S61, 2022

Authors: Patel, Samit | Utting, Isabel | Ang, Wan Wei | Fautz, Tessa | Radmore, Rebecca | Vourou, Panayiota | Beaumont, Lara | Ryeland, Paula | Lillis, Ashling

Article Type: Research Article

Abstract: BACKGROUND: Discharge summaries (DCS) are vital in facilitating handover to community colleagues. Unfortunately, at Whittington Health, General Practitioners (GPs) found it difficult to identify relevant information in DCS, and use of medical jargon meant patients did not understand details of their admission. With this quality improvement project, the team aimed to improve DCS to enhance patient-centered care. OBJECTIVE: The aim of this quality improvement project (QIP) was to improve the quality of DCS by critiquing the ones produced within our trust and implementing various interventions. METHODS: Multiple Plan-Do-Study-Act (PDSA) cycles were completed. A multi-disciplinary meeting was …conducted to identify the needs of each party in a DCS. A new template was subsequently launched. Teaching was conducted and educational leaflets were disseminated hospital-wide. Quality of written communication was audited quarterly, and evaluated against quality indicators. Problems with DCS were identified via GP and patient feedback, and these became the focus of subsequent PDSA cycles. RESULTS: From March 2019 to February 2020, all the audited categories improved, with an overall improvement from 67% to 92%. We also received positive feedback from GPs. CONCLUSIONS: Quality of DCS can be improved with appropriate interventions, leading to improved patient care. A similar PDSA cycle could be utilized elsewhere to achieve similar results. Show more

Keywords: Discharge summary, quality improvement, PDSA cycle, patient satisfaction, audit

DOI: 10.3233/JRS-227026

Citation: International Journal of Risk & Safety in Medicine, vol. 33, no. S1, pp. S63-S67, 2022

Authors: King, Oliver | Collman, Emily | Evans, Alice | Richards, James | Hughes, Elin | Acquah, Lydia | Parsons, Helen | Morrison, Jo

Article Type: Research Article

Abstract: BACKGROUND: Advance care treatment escalation plans (TEPs) are often lost between healthcare settings, leading to duplication of work and loss of patient autonomy. OBJECTIVE: This quality improvement project reviewed the usage of TEP forms and aimed to improve completeness of documentation and visibility between admissions. METHODS: Over four months we monitored TEP form documentation using a standardised data extraction form. This examined section completion, seniority of documenting clinician and transfer of forms to our hospital electronic patient record (EPRO). We added reminders to computer monitors on wards to improve EPRO upload. RESULTS: Initial data …demonstrated that 95% of patients (n  = 230) had a TEP, with 99% of TEPs recording resuscitation status. However, other sections were not well documented (patient capacity 57% completion and personal priorities 45% completion, respectively). Only 11.9% of TEPs documented consultant involvement. Furthermore, only 44% of TEPs with a do not attempt resuscitation (DNACPR) decision were uploaded. Following this, we added reminders to computer monitors explaining how to upload TEP decisions to EPRO, which increased EPRO uploads to 74%. CONCLUSION: Communication of TEPs needs improving across healthcare settings. This project showed that the use of a physical reminder can greatly improve communication of treatment escalation decisions. Furthermore, this intervention has inspired future projects aiming at making communication more sustainable through the use of discharge summaries. Show more

Keywords: Treatment escalation plans, resuscitation, CPR, communication, advanced care planning

DOI: 10.3233/JRS-227027

Citation: International Journal of Risk & Safety in Medicine, vol. 33, no. S1, pp. S69-S72, 2022

Authors: Slaich, Bhavandeep | Garrett, Frederick

Article Type: Research Article

Abstract: BACKGROUND: The British Thoracic Society (BTS) Acute Non-Invasive Ventilation (NIV) standards state all patients who require acute NIV should be initiated on NIV within two hours of hospital admission. The delivery of acute NIV is a time critical intervention as prompt application of acute NIV substantially reduces mortality for patients with acute hypercapnic respiratory failure. OBJECTIVE: This audit aimed to assess the number of patients for whom there is a delay in the initiation of acute NIV. We also assessed the outcome of admission for patients started on acute NIV. METHODS: Data was collected on patients …admitted to Kings Mill Hospital for acute NIV between 1/2/2019 and 31/3/2019. Awareness and knowledge of acute NIV was highlighted as an area for improvement. E-learning packages on ‘Acute NIV’ were designed and sent to medical-staff. The audit was repeated for patients admitted for acute NIV between 1/2/2020 and 31/3/2020 and analysed using chi-square tests. RESULTS: 25 patients were included in the initial audit and 30 patients in the re-audit. Prior to intervention 31% of patients had a delay in the initiation of acute NIV, which increased to 77% post-intervention (p < 0.0001). Prior to intervention there was a mortality rate of 17% and a mortality rate of 13% post-intervention (p > 0.05). CONCLUSION: Further work is required to ensure the sustained delivery of acute NIV to BTS standards, however variable achievements in the targets does not seem to have a significant adverse effect on patient outcomes. Show more

Keywords: Acute NIV, non-invasive ventilation, patient care

DOI: 10.3233/JRS-227028

Citation: International Journal of Risk & Safety in Medicine, vol. 33, no. S1, pp. S73-S77, 2022

Authors: Turton, Emily | Myles, Liam | Lee, James | Saffin, Victoria | Lawson, Amy

Article Type: Research Article

Abstract: BACKGROUND: In 2011 Mrs A assaulted two people, one who died. In the hours prior to the attack she made multiple attempts to gain help including attending accident and emergency, contact with an inpatient service and the police. Subsequent investigation highlighted that her risk was not well documented or understood. OBJECTIVE: This quality improvement project aimed to improve knowledge and awareness of HCR-20 risk assessments amongst mental health professionals. METHOD: The Quality Improvement approach was taken and various initiatives were introduced to improve knowledge of the location and purpose of the HCR-20 and to ensure that …these risk assessments were regularly updated. RESULTS: The results indicated that knowledge relating to the HCR-20 significantly improved amongst staff and breaches of deadlines for updating these risk assessments dramatically declined after the induction of the interventions. CONCLUSION: Including the ‘risk formulation’ and ‘scenarios’ from the HCR-20 in clients’ crisis plans, introducing training relating to the HCR-20, and including discussions relating to the HCR-20 at the beginning of CPA meetings resulted in improved MDT awareness and knowledge of the HCR-20. A broader understanding and awareness of risk factors enabled the service to move towards a culture of risk being everyone’s business. Show more

Keywords: Forensic psychology, forensic psychiatry, HCR-20, multidisciplinary risk assessment, quality improvement

DOI: 10.3233/JRS-227029

Citation: International Journal of Risk & Safety in Medicine, vol. 33, no. S1, pp. S79-S83, 2022

Authors: Landin, Madeleine | Palmer, Charlotte | Paul, Nadine | Shahrjerdi, Puneh

Article Type: Research Article

Abstract: BACKGROUND: Patients in psychiatric inpatient settings are at increased risk of developing physical health complications due to the structure of inpatient wards, the metabolic side-effects of antipsychotic medications and socioeconomic factors. Robust physical health monitoring and interventions are paramount in reducing this health inequality. OBJECTIVE: To improve the quality of physical health interventions in the ward environment and empower patients to follow healthy lifestyle guidance to reduce their risk of metabolic syndrome. METHODS: Patient weight and waist circumference data were collected at baseline and weekly throughout the 8-week intervention period. A questionnaire was recorded from baseline …to week-5 to assess patient understanding. Two Plan-Do-Study-Act (PDSA) cycles were completed: (1) Series of weekly psychoeducation sessions and group exercise and (2) Implementation of healthy living diaries. RESULTS: Our data did not demonstrate any definitive impact upon the waist circumference and weight of participants. However, analysis of the questionnaires showed a consistent trend in knowledge improvement. CONCLUSION: Whilst our aim of reducing patient weight and waist circumference was not realised, there was a significant impact on participant’s knowledge, demonstrating a subjective benefit of our interventions. Our project also highlighted inconsistencies in physical health measurements and data collection, providing vital information for further quality improvement measures. Show more

Keywords: Physical health, patient education, metabolic risk factors, inpatient psychiatry, forensic psychiatry, intellectual disability psychiatry

DOI: 10.3233/JRS-227030

Citation: International Journal of Risk & Safety in Medicine, vol. 33, no. S1, pp. S85-S90, 2022

Authors: Politis, Anna | Cook, Hannah | Cohen, Hugo M.L. | Pullyblank, Anne

Article Type: Research Article

Abstract: BACKGROUND: The General Medical Council (GMC) states that all intimate examinations should have a chaperone offered. Documentation of chaperone identity, or patient’s refusal, is essential. OBJECTIVE: This project aimed to improve documentation of chaperones during intimate examination of patients based in a Surgical Admissions Unit (SAU) within a large tertiary hospital in the Southwest of the UK. METHODS: A Plan-Do-Study-Act (PDSA) cycle structure was used. Initial data collection and planning occurred in December 2019. Intervention implementation and analysis occurred from January 2020 to March 2021. Intervention 1 involved presenting results at a clinical governance meeting. Intervention …2 was information posters in the SAU and intervention 3 involved training sessions for nursing staff. Intervention 4 was editing the surgical clerking proforma. RESULTS: Prior to interventions, chaperone identity or patient’s refusal was correctly documented only 9.7% (N  = 7 out of 72) of the time. Intervention 1 increased this to 34.6%. Following interventions 3 and 4, correct documentation was 25.0% and 28.6% respectively. After intervention 4 correct documentation was at 59.1%. CONCLUSIONS: Initial documentation of chaperones was poor. Interventions 1 to 3 were successful in educating clinicians how to document accurately, but engaging individuals in person was more successful than passive education through posters. Changing the proforma structure was the most successful intervention. This suggests a visual reminder for clinicians at the point of contact with the patient is the most effective way to encourage correct documentation of chaperones, improving patient care and clinical practice. Show more

Keywords: Documentation, chaperones, intimate examination, surgery, proforma

DOI: 10.3233/JRS-227031

Citation: International Journal of Risk & Safety in Medicine, vol. 33, no. S1, pp. S91-S95, 2022

Authors: Pathan, Aly Zaheer | Barwell, Jennifer | Kastrissianakis, Artemis | Awan, Kiran | Abila, Anie | Lim, Amelia | Wickramasinghe, Rucchira | Pathare, Anuj | Deakin, Susan

Article Type: Research Article

Abstract: BACKGROUND: Since the outbreak of the coronavirus (SARS-Cov-2), wearing personal protective equipment (PPE) has become necessary. Patients’ ability to recognize staff is disrupted impacting on the relationship between healthcare worker and patient. OBJECTIVE: Assess the patients’ perspective of healthcare workers wearing PPE and its effect on communication. METHODS: Admitted Orthopaedic patients during the first wave of SARS-Cov-2 were surveyed about the experience with staff wearing PPE. In response to feedback, individual badges with large pictures and names were introduced to wear over PPE. Patient views and response to the badges was collected from surveying admitted patients. …RESULTS: Patients encountered staff wearing face masks and felt this was appropriate in the context of the pandemic. 44% responded that they would prefer staff wearing badges with names, roles and pictures more visible. Following the introduction of badges, patients were better able to recognize staff roles and remember names. Hospital staff felt this was a positive change to help improve rapport while wearing PPE. CONCLUSION: Wearing PPE affects patients’ ability to recognize individuals in a fast-paced environment such as an acute hospital. Introducing badges was an intervention based on patient feedback and an important adaptation to sustained PPE use to improve the patient’s experience. Show more

Keywords: COVID-19, SARS-Cov-2, PPE, patients’ perception, communication

DOI: 10.3233/JRS-227032

Citation: International Journal of Risk & Safety in Medicine, vol. 33, no. S1, pp. S97-S101, 2022

Authors: Jayaraajan, Keerthanaa | Sivananthan, Ahrabbey | Koomson, Abeku | Ahmad, Aznavar | Haque, Mohammed | Hussain, Mohammod

Article Type: Research Article

Abstract: BACKGROUND: Previous reports have shown that there are long waiting times to commence therapy in the community-based mental health programme, IAPT (Improving Access to Psychological Therapies). OBJECTIVE: This study aimed to explore both causes and potential solutions to alleviate the burden of these waits. METHODS: A Systematic Literature Review (SLR) and Semi-Structured Interviews (SSIs) were conducted to identify causes and effects of these waits. Consequently, meaningful recommendations were made and tested with the aim of improving IAPT’s waiting times. RESULTS: SLR and SSIs revealed high ‘Did Not Attend’ (DNA) rates and a lack of …support between initial appointments as being both a cause and effect of long waits. The identified issues were tackled with the development of an app design. Expert interviews and a mass survey fuelled the iterative process leading to a final prototype. Notable features included: therapist profile page, smart appointment reminders and patient timeline. Positive feedback was received from university students and ICS Digital, with scope to trial the app within Manchester CCG. CONCLUSIONS: In the long run, the app aims to indirectly shorten waiting times by addressing treatment expectations and serving as an IAPT companion along the patient journey, thus reducing anxiety and consequently DNAs. Show more

Keywords: Anxiety, depression, waiting times, CBT, Improving Access to Psychological Therapies (IAPT), non-attendance

DOI: 10.3233/JRS-227033

Citation: International Journal of Risk & Safety in Medicine, vol. 33, no. S1, pp. S103-S110, 2022

Authors: Woolford, Megan | Todd, James

Article Type: Research Article

Abstract: BACKGROUND: The Nightingale North West (NNW) was a UK temporary field hospital set up during the COVID-19 pandemic. Policies and standard operating procedures were undeveloped. Visitors were permitted only in exceptional circumstances, resulting in heightened anxiety for patients and next of kin (NOK). OBJECTIVE: Recognising the importance of effective NOK communication, a quality improvement project (QIP) was undertaken to improve communication between doctors and NOK. METHOD: NOK satisfaction with communication received from doctors (scored 1–5) was the primary outcome measure and data was collected through standardised phone-calls. A wide four point (1–5) variability in satisfaction was …identified. PDSA methodology was used to introduce interventions: (1) ‘Gold standard’ for frequency of NOK updates; (2) Record date of NOK update on the doctors’ list. RESULTS: Early post-intervention data showed reduced variability in satisfaction with 82% of NOK scoring ‘4’ or ‘5’. Process measures demonstrated excellent uptake of interventions. CONCLUSION: Conclusions are limited by the project’s short time-frame but there is a promising role for these interventions in enhancing doctor-NOK communication. Show more

Keywords: Communication, COVID-19, Nightingale Northwest, Quality improvement project, Next-of-kin

DOI: 10.3233/JRS-227034

Citation: International Journal of Risk & Safety in Medicine, vol. 33, no. S1, pp. S111-S115, 2022