scholarly journals Escalation of care planning on an older adult inpatient unit during the COVID-19 pandemic

BJPsych Open ◽  
2021 ◽  
Vol 7 (S1) ◽  
pp. S90-S91
Author(s):  
Alexander McDermott ◽  
Jennifer Rankin
Keyword(s):  
Older Adult ◽  
District General Hospital ◽  
Junior Doctors ◽  
Best Interest ◽  
Sustained Improvement ◽  
Difficult Decision ◽  
Care Plans ◽  
Risks And Benefits ◽  
Pdsa Cycle ◽  
Adult Inpatient

AimsInitial planning during the first wave of the COVID-19 pandemic involved difficult decision making for many clinicians. The Older Adult Mental Health Wards in Bridgend were relocated from the district general hospital (Princess of Wales) and merged at Angelton Clinic, an off site separate unit. It was therefore essential that patients had clear escalation of care plans as access to medical input was limited and transfer to hospital potentially not appropriate in the later stages of chronic illness such as dementia.The initial aim of the PDSA cycle was to assess the level of compliance with Do Not Attempt Resuscitation (DNAR) discussions and if appropriate, DNAR documentation. The other aim was to assess the utilisation of Escalation of Care plans.MethodAn audit of patients MDT medical notes on 38 admitted to Angelton clinic was carrired out in March. It was documented if the patient had a clear DNAR or Escalation plan that was easily accessible in the front of the notes. The guidelines compared to were the GMC recommendations that patients 12 months of should have a discussion about risks and benefits associated with Cardiopulmonary Resuscitation. If the patient lacks capacity a best interest decision should be made with nearest relatives. Discussions should also be had with patients and family in in regards to and transfer to a medical ward.Upon completion of the initial PDSA cycle, views were sought from the wider MDT a new escalation of care proforma was designed. This was implemented by education and communication with members of the medical team. This was to be clearly placed in the notes, with the DNAR form if that was appropriate.ResultAll inpatient notes were audited at Angelton Clinic in March 2020. It was found that only 18% of patients had Escalation of Care plans in comparison to 84% of notes which had DNAR forms. Previous escalation of care forms were not being utilised appropriately.Upon implementation of the Escalation of Care proforma, a re-audit of the audit cyle was completed. In July 2020 it was found that 78% of notes had completed Escalation of Care forms with 83% had completed DNAR forms.ConclusionTo enable ongoing sustained improvement, the unit Nurse Practitioner will champion its completion. The audit findings have been shared with the newly rotated junior doctors and proformas were made available on all inpatient wards.

scholarly journals 88 Improving Clinical Effectiveness At Identifying Patients Requiring Advanced Care Plans

2021 ◽  
Vol 50 (Supplement_1) ◽  
pp. i12-i42
Author(s):  
P Nemchand ◽  
D Hassan ◽  
A Steel
Keyword(s):  
Junior Doctor ◽  
Positive Impact ◽  
Clinical Effectiveness ◽  
District General Hospital ◽  
Junior Doctors ◽  
Advanced Care Planning ◽  
Team Members ◽  
Care Plans ◽  
White Boards ◽  
Geriatric Inpatients

Abstract Our project was conducted in a district general hospital across five acute geriatric wards. Our team included consultants, registrars, and ward matrons. The project focused on improvement of care for geriatric inpatients, with moderate to severe frailty. Advanced care planning (ACP) columns are displayed on white boards. They indicate whether ACPs are required/initiated for each patient. When previously utilised, ACPs were initiated for 78% of appropriate patients [1]. Following a change in staff and reduction in awareness/education, the ACP column use reduced with fewer ACPs established. Our goals were to ensure completion of the ACP column, encourage junior doctor/nurse involvement and trigger a greater number of appropriate ACPs initiated Improvement in ACP practice was addressed by daily board round review of appropriate patients for ACP, increasing awareness of ACP triggers and education around discussion content. Interventions consisted of: 1, a flow-chart adjacent to white boards prompting “Do not attempt resuscitation (DNAR)” and ACP processes. This signposted staff to information on ACP triggers and “how to start a conversation”. 2 Involving registrar “champions” on each ward. We explained our intervention to all team members to encourage engagement. Data from the ACP columns were audited prior to intervention, 2 weeks and 6 weeks after intervention. There was a 54% increase in ACP documentation after 6 weeks across the wards. The improvement in the use of the ACP column correlated with a greater number of ACPs initiated. This facilitated an increase in consideration of patient wishes towards the end of life. Increasing use of a daily ACP prompts on board rounds triggers an increase in ACP implementation for appropriate patients. Sustainability was achieved by recruitment of ward “ACP champions”. Junior doctors/matrons were more empowered to discuss ACPs. Results were presented at departmental teaching to reinforce the positive impact of the intervention.

Improving communication lines: quality improvement project moving a department away from outdated paging

BMJ Leader ◽  
2019 ◽  
Vol 4 (1) ◽  
pp. 37-40
Author(s):  
Neil John Jones ◽  
Sachi Shah ◽  
Shibby Robati ◽  
Michael Thilagarajah
Keyword(s):  
Quality Improvement ◽  
Mobile Phone ◽  
Mobile Phones ◽  
Healthcare Professionals ◽  
District General Hospital ◽  
Junior Doctors ◽  
Improvement Project ◽  
Mobile Phone Technology ◽  
Pdsa Cycle ◽  
The Way

IntroductionPaging systems in Hospitals have been established for some time, but they are now outdated and unreliable. This opinion is shared by the UK government, which has given the NHS until 2021 to become free of these technologies. Given this new mandate, we wanted to implement a change in the way other Healthcare Professionals can contact Orthopaedic Senior House Officer Doctors (SHOs), at Darent Valley Hospital, a District General Hospital in Kent, England.MethodsUsing the Plan, Do, Study, Act (PDSA) cycle model for quality improvement projects, the authors demonstrate two successful cycles improving the way in which HCPs can establish communication with Orthopaedic Junior Doctors. PDSA cycle 1 introduced a ward doctor to be stationed on the orthopaedic wards and to carry a mobile phone. The mobile phone worked well, but there were limitations to having to stay on the wards. PDSA cycle 2 introduced mobile phones for all Orthopaedic Doctor Teams. Impact of changes made was measured using staff questionnaires distributed to a range of Healthcare Professionals.ResultsAfter PDSA Cycle 1, 100% of the 36 asked agreed that having a ward doctor had saved time in their day. 72% said they page an Orthopaedic Doctor zero to two times with no reply, compared with 9% before the change was implemented. After PDSA cycle 2, 100% of the 31 asked agreed that using mobile phones was an effective way of communicating with the Orthopaedic Doctors, and 90% said that, on average, they would spend less than 2 min trying to contact an Orthopaedic Doctor, compared with 33% after PDSA cycle 1 intervention.ConclusionThis cycle has clearly improved communication in our orthopaedic department. If used in the right way, mobile phone technology can surely improve our clinical environments.

scholarly journals ‘I’ve got a little list’—the scourge of a surgical junior. A quality improvement project to change the surgical patient list in a district general hospital

2020 ◽  
Vol 9 (2) ◽  
pp. e000829
Author(s):  
Hiba Khan ◽  
Elizabeth Flesher ◽  
James Marshman ◽  
Alexander Harding ◽  
Rob Bethune ◽  
...  
Keyword(s):  
Transition Period ◽  
District General Hospital ◽  
Automated System ◽  
Surgical Patient ◽  
Junior Doctors ◽  
Human Errors ◽  
Improvement Project ◽  
Pdsa Cycle ◽  
Surgical Teams ◽  
System Errors

BackgroundJunior doctors at the Royal Devon and Exeter Hospital spend hours every day creating and updating patient lists for all surgical specialties on Microsoft Excel spreadsheets. This not only consumes time that should be spent on clinical tasks, it allows for human errors, system errors and patient safety concerns. Our aim was to reduce time spent on the list and reduce the chance for error.MethodsWe measured the time junior doctors spent creating and updating the surgical lists for one specialty, and on-call shifts. Our first Plan-Do-Study-Act (PDSA) cycle was to introduce clinical secretaries; this reduced the time spent by ward teams on the list but had no effect on the on-call team. We then worked with the hospital application developer to adapt software currently used to suit all surgical teams. Once completed, this software was rolled out alongside the existing spreadsheet method with a view to a switch after a transition period.ResultsThe introduction of clinical secretaries reduced the time spent on the colorectal surgery list from 99.22 min a day to 43.38 min. The on-call team however did not benefit from this intervention. Following the introduction of the new software, the day on-call team time spent on the list changed from 121 min a day to 4.66 min. The night on-call team time changed from 91 min to 7.38 min.ConclusionReducing the time juniors spend compiling surgical lists has clear benefits to patients with extra time for junior doctors to clerk patients. The use of an automated system removes the chance of error in transcription of blood results. Due to the success of this project, colorectal, upper gastrointestinal, urology, vascular and on-call teams have adopted the new list permanently.

scholarly journals Nursing Home Staff’s Perceptions of Healthcare Decision Making for Unbefriended Residents

2020 ◽  
Vol 4 (Supplement_1) ◽  
pp. 384-384
Author(s):  
Hyejin Kim ◽  
Molly Perkins ◽  
Thaddeus Pope ◽  
Patricia Comer ◽  
Mi-Kyung Song
Keyword(s):  
Decision Making ◽  
Geographic Area ◽  
Care Physician ◽  
Healthcare Decision ◽  
Do Not Resuscitate ◽  
Best Interest ◽  
Care Plans ◽  
Course Of Action ◽  
Healthcare Decision Making ◽  
Facility Level

Abstract ‘Unbefriended’ adults are those who lack decision-making capacity and have no surrogates or advance care plans. Little data exist on nursing homes (NHs)’ healthcare decision-making practices for unbefriended residents. This study aimed to describe NH staff’s perceptions of healthcare decision making on behalf of unbefriended residents. Sixty-six staff including administrators, physicians, nurses, and social workers from three NHs in one geographic area of Georgia, USA participated in a 31-item survey. Their responses were analyzed using descriptive statistics and conventional content analysis. Of 66 participants, eleven had been involved in healthcare decision-making for unbefriended residents. The most common decision was do-not-resuscitate orders. Decisions primarily were made by relying on the resident’s primary care physician and/or discussing within a facility interdisciplinary team. Key considerations in the decision-making process included “evidence that the resident would not have wanted further treatment” and the perception that “further treatment would not be in the resident’s best interest”. Compared with decision making for residents with surrogates, participants perceived decision making for unbefriended residents to be equally-more difficult. Key barriers to making decisions included uncertainty regarding what the resident would have wanted in the given situation and concerns regarding the ethically and legally right course of action. Facilitators (reported by 52 participants) included some information/knowledge about the resident, an understanding regarding decision-making-related law/policy, and facility-level support. The findings highlight the complexity and difficulty of healthcare decision making for unbefriended residents and suggest more discussions among all key stakeholders to develop practical strategies to support decision-making practices in NHs.

scholarly journals 145 Point of care lung ultrasound in patient triage: integration of ultrasound into a streaming pathway for COVID-19

2020 ◽  
Vol 37 (12) ◽  
pp. 839.1-839
Author(s):  
Dominic Craver ◽  
Aminah Ahmad ◽  
Anna Colclough
Keyword(s):  
Point Of Care ◽  
District General Hospital ◽  
Training Programme ◽  
Service Evaluation ◽  
University Hospital ◽  
Junior Doctors ◽  
Point Of Care Ultrasound ◽  
Face To Face ◽  
Point Of Care Diagnostics ◽  
Audit Data

Aims/Objectives/BackgroundRapid risk stratification of patients is vital for Emergency Department (ED) streaming during the COVID-19 pandemic. Ideally, patients should be split into red (suspected/confirmed COVID-19) and green (non COVID-19) zones in order to minimise the risk of patient-to-patient and patient-to-staff transmission. A robust yet rapid streaming system combining clinician impression with point-of-care diagnostics is therefore necessary.Point of care ultrasound (POCUS) findings in COVID-19 have been shown to correlate well with computed tomography (CT) findings, and it therefore has value as a front-door diagnostic tool. At University Hospital Lewisham (a district general hospital in south London), we recognised the value of early POCUS and its potential for use in patient streaming.Methods/DesignWe developed a training programme, ‘POCUS for COVID’ and subsequently integrated POCUS into streaming of our ED patients. The training involved Zoom lectures, a face to face practical, a 10 scan sign off process followed by a final triggered assessment. Patient outcomes were reviewed in conjunction with their scan reports.Results/ConclusionsCurrently, we have 21 ED junior doctors performing ultrasound scans independently, and all patients presenting to our department are scanned either in triage or in the ambulance. A combination of clinical judgement and scan findings are used to stream the patient to an appropriate area.Service evaluation with analysis of audit data has found our streaming to be 94% sensitive and 79% specific as an indicator of COVID 19. Further analysis is ongoing.Here we present both the structure of our training programme and our integrated streaming pathway along with preliminary analysis results.

scholarly journals Reducing the use of high dose antipsychotic medication in acute adult inpatient psychiatric units

BJPsych Open ◽  
2021 ◽  
Vol 7 (S1) ◽  
pp. S341-S341
Author(s):  
Shay-Anne Pantall ◽  
Sarah Warwicker ◽  
Lisa Brownell
Keyword(s):  
Antipsychotic Medication ◽  
Psychiatric Inpatient ◽  
Electronic Prescribing ◽  
Antipsychotic Treatment ◽  
High Dose ◽  
Junior Doctors ◽  
List Type ◽  
Increased Risk ◽  
Adult Inpatient ◽  
Inpatient Units

AimsTo evaluate the use of antipsychotics, and high dose antipsychotic treatment (HDAT) in psychiatric inpatient unitsBackgroundThe Royal College of Psychiatrists published a consensus statement on high dose antipsychotic medication in October 1993. Such treatment carries an increased risk of adverse effects including towards ventricular tachycardia and sudden death.MethodA retrospective case note review of all male patients on acute adult inpatient units in a psychiatric hospital in South Birmingham on a date in June 2018 (n = 45) including review of electronic patient records and prescriptions. This was compared with the results of an earlier study, with identical methods, undertaken in June 2015.Result•In both 2015 and 2018, only a minority of patients (20% and 11% respectively) were informal.•In both 2015 and 2018, the majority of inpatients had a diagnosis of schizophrenia (54% and 67%)•In both 2015 and 2018, 93% inpatients were prescribed antipsychotic medication.•In 2015, 56% patients were prescribed HDAT. This reduced in 2018 to 16%.•This reduction in use of HDAT was almost entirely due to a reduction in the prescription of PRN antipsychotic medication.•In terms of regularly prescribed antipsychotic medication, in both years, the most commonly prescribed drug was flupentixol, with a range of other second generation oral and long acting medications being prescribed, usually at doses within BNF limits.Between the two years, there was a substantial change in the prescribing of PRN antipsychotics. In 2015, 59% individuals were prescribed at least one PRN antipsychotic (27% were prescribed two). In 2018, this reduced to 40% prescribed at least one, and only 2% being prescribed 2 PRN antipsychotics. In both years, oral quetiapine was a common choice (39% patients in 2015 prescribed oral quetiapine, and 34% in 2018). In 2015, 39% patients were prescribed oral or intramuscular aripiprazole, while this reduced to 7% in 2018.ConclusionThe vast majority of psychiatric inpatients were being prescribed antipsychotic medication. Prescription of high dose antipsychotic medication was common in 2015, and this was largely attributable to high levels of prescribing of PRN antipsychotics. Following an educational programme for junior doctors and ward nurses, and the introduction of electronic prescribing, we achieved a significant change in practice, particularly in the prescribing of PRN antipsychotics, which has reduced our patients’ risk of receiving high dose antipsychotic medication.

The Introduction of An Intravenous Fluid Bundle to Improve the Prescribing of Intravenous Fluids Within a District General Hospital (Preprint)

2022 ◽  
Author(s):  
Abdul-Rahman Gomaa ◽  
Sharan Sambhwani ◽  
Jonathan Wilkinson
Keyword(s):  
Point Of Care ◽  
Kidney Injury ◽  
District General Hospital ◽  
Good Clinical Practice ◽  
Point Prevalence ◽  
Grand Round ◽  
Junior Doctors ◽  
Improvement Project ◽  
Increased Risk ◽  
The Impact

BACKGROUND Intravenous (IV) fluids are some of the most commonly prescribed day-to-day drugs. Evidence suggests that such prescriptions are rarely ever done correctly despite the presence of clear guidelines (NICE CG174). This is believed to be due to lack of knowledge and experience, which often breeds confusion and places patients at increased risk of harm. It also incurs avoidable costs to hospitals. OBJECTIVE This quality improvement project (QIP) aims to ensure that IV fluid prescriptions are: safe, appropriate and adhere to evidence-based NICE guidance. The project’s aims will be achieved through implementing multiple interventions that are categorised under: educational, changing prescribing habits and raising awareness. METHODS Review and improve the prescribing process of “IV fluid prescribing” via three simultaneous approaches.  Teaching sessions were delivered to all junior doctors in order to improve knowledge and awareness of appropriate IV fluid prescribing and promote familiarity with the current NICE IV fluid guidelines. This included a ‘feature session’ at our local hospital Grand Round. A point-of-care aide-memoire containing a summary of the information needed for correct prescription was designed and printed. This complimented the teaching sessions and supported good clinical practice. Using serial Plan-Do-Study-Act (PDSA) cycles, a novel “IV fluid bundle” was developed, fine-tuned and trialled on five wards, (three surgical, two medical). The aim of the bundle was to ensure that patients were clinically reviewed in order to assess their volaemic status in order that appropriate IV fluids could then be selected and prescribed safely. The impact of these interventions was assessed on the trial wards via a weekly point prevalence audit of the IV fluid bundles for the duration of the trial. Parameters looked at were: incidence of deranged U&E’s, incidence of AKI and the number of days between the latest U&E’s and the patient’s IV fluid prescription. RESULTS These interventions were assessed on trial wards via a weekly point prevalence audit of the new IV fluid prescription chart (bundle; IFB) for the duration of the trial. Parameters monitored were: incidence of deranged U&E’s, incidence of acute kidney injury (AKI) and the number of days between the latest U&E’s and the patient’s IV fluid prescription. Of all of the patients on the IV fluid bundle, 100% had a documented weight, review of both fluid status and balance. The incidence of deranged U&E’s decreased from 48% to 35%. Incidence of AKI decreased from 24% to 10%. The average number of days between the latest U&E’s and a fluid prescription decreased from 2.2 days to 0.6 day. CONCLUSIONS Prescribing IV fluids is a complex task that requires significant improvement both locally and nationally. With 85% uptake of the IFB, we were able to significantly improve all measured outcomes. Through carefully structured interventions geared towards tackling the confounding issues identified from previous audits and process mapping we have shown that prescribing IV fluids can be made safer.

Development and implementation of a structured leadership programme for junior doctors

BMJ Leader ◽  
2020 ◽  
pp. leader-2020-000281
Author(s):  
Anum Pervez ◽  
Aaisha Saqib ◽  
Sarah Hare
Keyword(s):  
Leadership Skills ◽  
District General Hospital ◽  
Training Programme ◽  
Junior Doctors ◽  
Leadership Roles ◽  
Self Assessment ◽  
Leadership And Management ◽  
Business Cases ◽  
Do So

IntroductionHealthcare performance and quality of care have been shown to improve when clinicians actively participate in leadership roles. However, the training for junior doctors in leadership and management is either not formally provided or requires out of programme training. In this article, we discuss how we devised a leadership training programme for junior doctors at our district general hospital and reflections on how it can be implemented elsewhere.MethodsA junior doctors leadership programme was developed involving workshops and guidance through delivery of quality improvement projects. A precourse and postcourse questionnaire assessing preparedness to lead was given to trainees to assess the effectiveness of the course.ResultsUsing a Likert Scale, trainees provided quantitative self-assessment for precourse and postcourse changes in their leadership skills. There was an overall increase in confidence across key areas such as communication, preparing business cases and understating hierarchies of management teams.DiscussionThe structure of this leadership programme has provided the opportunity to address gaps in leadership skills that trainees encounter, without the need to extend training. This programme is easily reproducible and offers other trusts a guide on how to do so.

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