Collaborating to DrEaM bigger and better: the challenges in using digital data to drive quality improvement in clinical practice

Abstract

Background: Supporting patients to Drink, Eat and Mobilise (DrEaMing) within 24 h of major surgery is associated with reduced length of hospital stay and late complications.1 This quality metric was assigned a financial incentive in the 2022 NHS England CQUIN scheme with a compliance target of 60–70% for specific surgical patient cohorts. Beyond the CQUIN, we wanted to deliver DrEaMing to all surgical patients and embed a culture change by reinvigorating core concepts of enhanced recovery pathways. Optimal use of our electronic healthcare record, EPIC, was key to our strategy, aiming to provide surgical teams with sustainable real-time data to drive quality improvement (QI) through electronic extraction of CQUIN metrics. Methods: CQUIN specialty data were extracted from EPIC quarterly. Anaesthetic registrars worked as DrEaMing champions alongside clinical nurse specialists (CNS) to facilitate collaborative working within the perioperative team. Key stakeholders were educated on how to record DrEaMing instructions and provision allowing electronic audit of CQUIN compliance with accurate time stamps. A total of 26 ward staff involved in DrEaMing provision on postoperative surgical wards were surveyed on barriers to DrEaMing. Results: EPIC data from 2022–23 showed varying CQUIN compliance rates across surgical specialties. Gynae-oncology documentation of postoperative DrEaMing instructions increased from 0% in April to 100% by January, however, postoperative DrEaMing provision plateaued around 60–70%. Overall CQUIN attainment across the year was <50%. Colorectal CQUIN compliance was limited by poor documentation of postoperative eating instructions and subsequent poor ward eating provision (Fig. 6), reflecting the heterogenous nature of colorectal procedures undertaken and varied recovery approach by teams. Surveys of ward staff across women’s health and colorectal surgery revealed burden of documentation, lack of access to means to document and unclear surgical postoperative instructions were important barriers to ward documentation of DrEaMing provision. Conclusion: DrEaMing compliance using EPIC data extraction at UCLH remains poor, despite motivated staff and a culture of QI, but was significantly higher with manual review of the notes trawl highlighting disparity between clinical practice and use of new EPIC builds. Our aim to make DrEaMing data easily accessible for QI requires further buy-in from surgical teams and engagement with ward staff. Permanent CNS act as pivotal change champions, through education and raising awareness. 1.Oliver CM, Warnakulasuriya S, McGuckin D, et al. Br J Anaesth 2022; 129: 114–26