Audit Cycle Research Articles

1912 Reviewing the effect of COVID pandemic on changing clinical practice of administrating Zoledronic Acid to hip fracture patients

Abstract Introduction Reduction in outpatient appointments during the COVID-19 pandemic and patient concern surrounding risk of contracting COVID-19 by attending day-case settings, resulted in delayed or cancelled medical treatments including Zoledronic Acid infusions as management for Osteoporosis. This, alongside recent research concluding that these treatments can be given safely as early as 1-2 weeks post-fracture, lead to the adaptation of protocol at Hull University Teaching Hospitals Trust in 2021, to provide rapid loading of Cholecalciferol over 6 days, prior to administration of Zoledronic Acid on day 7. However, some concerns remain surrounding the potential interference with bone remodelling and healing. This completed audit cycle evaluates the logistics and safety of this new protocol. Methods All patients over 60, admitted with neck of femur fracture who received Zoledronic Acid infusion as inpatient or outpatient in 2019 and 2021 were included in the initial and repeat audit respectively. Electronic records for the following 12 months were analysed evaluating for further fragility fracture and mortality rate. Results There was an increase in patients receiving Zoledronic Acid as an inpatient treatment from 21% in the initial audit to 97% in the repeat audit. There was a slight increase in mortality rate at one year from 14% to 19%. The percentage of a further fragility fracture within one year, remained stable at 7%. Conclusion The increase in inpatient infusions suggests more patients with significant frailty who would otherwise not have been able to attend outpatient settings, have been able to receive treatment. The mortality results reflect this frailer audit population. The absence of a substantial increase in the rate of further fragility fracture at one year; supports the earlier administration of Zoledronic Acid as a management protocol.

Data quality assessment of the Enhanced Gonococcal Antimicrobial Surveillance Programme (EGASP), Thailand, 2015-2021.

Quality assessments of gonococcal surveillance data are critical to improve data validity and to enhance the value of surveillance findings. Detecting data errors by systematic audits identifies areas for quality improvement. We designed and implemented an internal audit process to evaluate the accuracy and completeness of surveillance data for the Thailand Enhanced Gonococcal Antimicrobial Surveillance Programme (EGASP). We conducted a data quality audit of source records by comparison with the data stored in the EGASP database for five audit cycles from 2015-2021. Ten percent of culture-confirmed cases of Neisseria gonorrhoeae were randomly sampled along with any cases identified with elevated antimicrobial susceptibility testing results and cases with repeat infections. Incorrect and incomplete data were investigated, and corrective action and preventive actions (CAPA) were implemented. Accuracy was defined as the percentage of identical data in both the source records and the database. Completeness was defined as the percentage of non-missing data from either the source document or the database. Statistical analyses were performed using the t-test and the Fisher's exact test. We sampled and reviewed 70, 162, 85, 68, and 46 EGASP records during the five audit cycles. Overall accuracy and completeness in the five audit cycles ranged from 93.6% to 99.4% and 95.0% to 99.9%, respectively. Overall, completeness was significantly higher than accuracy (p = 0.017). For each laboratory and clinical data element, concordance was >85% in all audit cycles except for two laboratory data elements in two audit cycles. These elements significantly improved following identification and CAPA implementation. We found a high level of data accuracy and completeness in the five audit cycles. The implementation of the audit process identified areas for improvement. Systematic quality assessments of laboratory and clinical data ensure high quality EGASP surveillance data to monitor for antimicrobial resistant Neisseria gonorrhoeae in Thailand.

Infection Prevention Control: First Cycle Audit Regarding Safe Fitting and Removal of Personal Protective Equipment among Health-Care Workers in Infectious Diseases Wards at Soba University Hospital

In the recent years the frequency of health emergences increased highlighted the importance of infection prevention control (IPC) measures especially personal protective equipment (PPE). This study assessed the compliance of the healthcare providers at Soba university hospital to IPC\PPE and assessed the effectiveness of the IPC training center at the hospital. This descriptive cross-sectional, hospital-based study, used self-administered questionnaire to gather the data, and statistical program for social science (SPSS) version 28 to analyze it, frequency tables were used to show the results. The overall knowledge of healthcare providers was good, but only 69.6% agreed that they changed gloves between patients. They mentioned reasons for their poor adherence to PPE: PPE interference with work (69.6%), brought discomfort to the patient (50%), brought discomfort to them (47.8%). This result dictated the effectiveness of theoretical part of the training while the practical and supervision section needs improvement.

Improvement in Diabetic Patient’s Compliance: A Clinical Audit in Accordance with NICE Guidelines

Management of diabetes mainly depends on adherence to the prescribed medicine; however, majority of patients fails to cope with their diabetes management plans due to reasons such as high cost of medication, their side effects, and limited knowledge or understanding of the disease. Medication adherence was accessed in this audit among diabetic patients at the Outpatient department (OPD), Divisional Headquarters (DHQ) Teaching Hospital Mirpur, Azad Jammu and Kashmir (AJK), Pakistan, which focuses on alignment with National Institute for Health and Care Excellence (NICE) guidelines. Adherence was evaluated using a collection of the combination of prospective and retrospective data, through investigation from the patients and review of the records. On 2nd cycle of follow-up, a marked improvement in patients’ adherence to medication, HBA1c levels, smoking cessation and complication rate. Upon 2nd cycle of audit, study also showed a better control on reason of non-compliance to treatment. The cause for non-compliance due to cost issue and lack of understanding was 45% initially, that later shortened to 1% while due to forgetfulness, it also lessened to 1%. We also had a sufficient improvement in follow up visits and sugar monitoring of patients and overall adherence rate was improved. Significant gaps were revealed in the findings by comparing with NICE guidelines, which give emphasis on regular monitoring and focused care of patients. This audit recommends interventions such as education sessions for patients, consultations through tele consults, and regular medical reviews to improve adherence and optimize diabetic care outcomes.

Mewujudkan sistem penjaminan mutu internal berkelanjutan melalui pendampingan audit mutu internal

The Internal Quality Assurance System is a reference for universities to better manage and organize higher education, prepare students to compete at the global level, and make a greater contribution to the local community. Bumi Sebalo Management Academy Bengkayang faces challenges in implementing the Internal Quality Assurance System, such as a lack of understanding of the Internal Quality Assurance System concept, limited human resources and infrastructure, low commitment to quality culture, and not yet having a certified internal auditor. The purpose of this community service assistance is to support the implementation of the Internal Quality Assurance System through the second cycle of Internal Quality Audit using a Participatory Action Research approach consisting of the identification/assessment stage, planning, program design, implementation, and monitoring, and evaluation. As a result, Bumi Sebalo Management Academy Bengkayang successfully implemented the control cycle and can continue to the Internal Quality Assurance System improvement cycle. This is evidenced by the support of the Organizing Board, college management, the involvement of the entire academic community, and the preparation of the second cycle Internal Quality Audit report. Internal Quality Audit assistance is very useful in realizing a sustainable Internal Quality Assurance System at Bumi Sebalo Management Academy Bengkayang

Advancements in computer-aided audit technologies: Impact on loan asset quality in banking

The banking sector continually adapts to technological advancements, and computer-aided audit technologies (CAATs) play a pivotal role in enhancing operational efficiency and risk management. This study explores the impact of CAATs on loan asset quality in banking, investigating how these technologies contribute to the identification, assessment, and mitigation of risks associated with loan portfolios. The research delves into the integration of advanced data analytics, artificial intelligence, and machine learning within audit processes, examining their effectiveness in evaluating loan asset quality. Through a comprehensive review of case studies and industry-specific implementations, the study aims to elucidate the practical implications and outcomes of deploying CAATs in banking audits. Key focus areas include the ability of CAATs to detect early warning signs of potential credit risks, assess the accuracy of loan data, and streamline audit workflows. The study also evaluates the role of these technologies in enhancing regulatory compliance, reducing audit cycle times, and improving the overall reliability of financial reporting related to loan portfolios. By understanding the impact of CAATs on loan asset quality, this research contributes valuable insights to banking professionals, auditors, and policymakers seeking to harness the benefits of technological advancements in ensuring the integrity and stability of loan portfolios within the financial landscape.

Clinical audit: principles and practice

Clinical audit is a quality improvement process that seeks to improve patient care and outcomes through systematic review of care against explicit criteria and the review of change. Aspects of the structure, process and outcome of care are selected and systematically evaluated against explicit and specific criteria. Where indicated, changes are implemented at an individual, team or service level and further monitoring is used to confirm the improvement in healthcare delivery. It is one of the six pillars of clinical governance. Clinical audit involves evaluating three key areas of healthcare delivery: structure, process and outcomes. Clinical audit became mandatory for all clinicians in the United Kingdome in 1990 as a contractual obligation, and it has fuelled evidence-based medicine. The five stages of audit are identification of an audit topic, setting standards, data collection, data analysis, and implementation of changes if necessary. Closing the audit cycle by re-auditing to reassess if implemented changes have had led to improvements. Audit could be indicated for quality assurance against local or national guidelines or because of recent adverse events or patient complaints. It should be specific, measurable, achievable, realistic (or relevant), and time bound. If no guidelines available, adoption of self-constructed standards will be necessary. Once completed, it should be shared with all stakeholders, including clinicians and management. Implementation of changes is essential, although it can be difficult. It needs a buy in and enthusiasm of all. Audit is now an important part of modern clinical practice. It drives improvement and effectiveness culture, and it is a duty we owe to our patients.

Experiences of University College Hospital, Ibadan surgical residents in audit and research

An online monthly seminar was started in April 2021 for surgical residents at the College of Medicine University of Ibadan by a faculty of alumni based in the United Kingdom. The surgical residents felt the seminars will make them better clinicians, fill gaps in their training and find out about Gold Standards of care. Moodle learning management system was used to manage course materials, communication, feedback, online surveys, and interaction with trainees. Seventy-two residents registered, but only about 30 were core attendees. All recorded lectures were placed on You Tube https://www.youtube.com/playlist?list=PLXzLiMlwy2sjLAacZLav58h7aj7qXZaWZ. Topics were multispecialty and determined by the residents. At the same time, an audit-and-research group (ARG) was formed, with eight residents joining. This number has risen to 14. The ARG was a response to a survey assessing residents’ experiences in research and audit. Thirty-seven surgical residents, with an average age of 34.3 years, completed the questionnaire. Forty-three per cent were senior residents and 84% were males. Forty-three percent were general surgery residents, 16% orthopaedics and 11% in urology, 8% in neurosurgery and 8% in paediatric surgery, The rest were from plastic, ENT and cardiothoracic surgery. The median number of years from graduation was 9 years with an inter-quartile range of 7–11 years. Sixty-five per cent of residents had not done any audit since graduation, and only 24% had completed an audit cycle. All residents agreed that surgeons should do audits, and all agreed that it was good for clinical practice. Ninety-five per cent agreed that surgeons should do a least an audit annually, however, only 68% of residents indicated that they would like to do an audit. Eighty-one per cent of residents had never presented an audit or research work, oral or poster, at a national or international meeting, and 65% have never been an author in a peer-reviewed article. Ninety-seven per cent indicated that they would like to take part in a study. The six top reasons given for poor audit and research outputs by the residents were (multiple answers allowed): Not knowing where to start by 60% of surgical residents No support for it by 46% No source of funding by 38% Audit and research is not a culture in their environment by 38% No opportunities by 24%. No suitable role models by 16% After completion of training, 76% of residents indicated that they wanted to work in a teaching hospital. In two and half years since its formation, the ARG has completed a qualitative study on clinical learning environments (OP05) and an audit on the use of WHO surgical safety checklists in theatre (OP06). These were supervised by both a local faculty and a UK-based alumnus. These have generated two oral and one poster presentations at international conferences.

A Clinical Audit of Operation Notes Documentation and the Impact of Introducing an Improved Proforma: An Audit Cycle.

Introduction Accurate and comprehensive documentation of surgical procedures is vital in healthcare for both medical and legal purposes. This audit assessed adherence to international guidelines for operative note documentation in a general surgery department and the impact of introducingeducational initiatives and an enhanced proforma. Methods A retrospective audit of 100 operative notes was conducted in April 2023, followed by a prospective re-audit of another 100 notes in October-November 2023. A checklist based on Royal College of Surgeons (RCS) guidelines assessed 20 parameters. An improved proformaand an awareness session for surgeons were implemented between audits. Data analysis utilized the IBM SPSS Statistics for Windows, Version 26.0 (Released 2019; IBM Corp., Armonk, New York, United States). A paired-sample t-test was used, and a p-value < 0.001 was considered statistically significant. Results The initial audit revealed discrepancies in documentation, with missing information on deep vein thrombosis (DVT) prophylaxis, elective/emergency settings, anticipated blood loss, closure technique specifics, and prosthesis/mesh details. Legibility was satisfactory in 88% of notes. After implementing the proformaand awareness session, significant improvements were observed in all parameters, with documentation rates exceeding 91%. Overall documentation completeness increased from 65.2% to 95.2%. Results of the paired-sample t-test indicated a significant difference before and after the introduction of the new proforma(Mean (M)= 65.2, standard deviation (SD) = 34.3 versus M= 95.2, SD= 4.3) with a p-value of 0.0005. Conclusion Regular audits, surgeon education, and standardized proformas are essential for maintaining high standards in operative note documentation, contributing to improved patient care and safety.

Improving access to patient information leaflets utilising QR codes in patients undergoing emergency appendicectomy.

Abstract Background Informed consent is a cornerstone of ethical surgical practise. Patients undergoing emergency surgery have reduced time to consider their options when compared to the elective setting. Therefore, improving informed consent in this setting is critical. We aim to increase the provision of a pre-operative patient information leaflet (PIL) for patients undergoing an emergency appendicectomy by 50% over two audit cycles. Methods The same methodology were used for both cycles of this audit. Patients were identified through histopathology lists over a two week period. Medical notes were reviewed for documentation of provision of trust approved patient information leaflets. A QR code for an electronic version of the information leaflet was added to emergency clinic rooms, doctors handover rooms and the SHO on call bleep between audit periods. Results Empirical results from two audit cycles revealed that introduction of a QR code increased uptake from 0% of patients receiving the recommended appendicectomy leaflet, to 58%, achieving our aim. Conclusion The QR code provided a useful transportable resource, which was utilised by doctors. This provides scope for progression in provision of leaflet for other surgical issues, both in inpatient and outpatient settings, through utilisation of a QR code.

Structured, nurse-led ward rounds to improve interprofessional communication and optimize care of vascular surgery patients: a best practice implementation project.

Ward rounds are crucial inpatient activities during which patients' conditions are discussed. Team-based models such as nurse-led ward rounds (NLWRs) have been conceptualized and trialled, with positive results. An evidence-based quality improvement pilot project to introduce NLWRs was implemented at a cardiovascular medical-surgical unit in a Singapore tertiary hospital. The JBI Evidence Implementation Framework was used to guide the project. The evidence-based NLWR format incorporated stakeholder feedback on NLWR frequency, preparation, coordination, and content. Baseline and 6-month post-implementation audits were carried out. The 4 audit criteria improved from baseline, reaching 100% compliance for criteria 1, 2, and 3 associated with interprofessional communication and collaboration. An improvement from baseline (30% to 46.7%) was also observed for criterion 4 on patient involvement during medical ward rounds. Moreover, there were improvements in clinical outcome data such as patient hospitalization length, "best medical therapy" rates, and inpatient complications. A statistically significant improvement in nurses' confidence to lead discussions during medical rounds was also observed ( p = 0.026). This project promoted greater compliance with NLWR criteria through audit and feedback cycles and the contextualization of implementation strategies. A well-supported program that prepares nurses for interprofessional communication also improves nurses' confidence in team communication, bolstering their ability to provide high-quality patient care.

Facility-Based Audit System With Integrated Community Engagement to Improve Maternal and Perinatal Health Outcomes in Rural Pakistan: Protocol for a Mixed Methods Implementation Study.

Maternal and newborn mortality in Pakistan remains as a major public health challenge. Pakistan faces significant infrastructure challenges and inadequate access to quality health care, exacerbated by sociocultural factors. Facility-based audit systems coupled with community engagement are key elements in achieving improved health system performance. We describe an implementation approach adapted from the World Health Organization audit cycle in real-world settings, with a plan to scale-up through mixed methods evaluation plan. This study aims to implement a locally acceptable and relevant audit system and evaluate its feasibility within the rural health system of Pakistan for scale-up. The implementation of the audit system comprises six phases: (1) identify facility and community leadership through consultative meetings with government district health offices, (2) establish the audit committee under the supervision of district health officer, (3) initiate audit with ongoing community engagement, (4) train the audit committee members, (5) launch the World Health Organization audit cycle (monthly meetings), and (6) quarterly review and refresher training. Data from all deliveries, live births, maternal deaths, maternal near misses, stillbirths, and neonatal deaths will be identified and recorded from four sources: (1) secondary-level care rural health facilities, (2) lady health workers' registers, (3) community representatives, and (4) project routine survey team. Concurrent quantitative and qualitative data will be drawn from case assessments, process analysis, and recommendations as components of iterative improvement cycles during the project. Outcomes will be the geographic distribution of mortality to measure the reach, proportion of facilities initiated to implement an audit system for measuring the adoption, proportion of audit committees with community representation, and proportion of audit committee members' sharing feedback regularly to measure acceptability and feasibility. In addition, outcomes of effectiveness will be measured based on data recording and reporting trends, identified modifiable factors for mortality and morbidity as underpinned by the Three Delays framework. Qualitative data will be analyzed based on perceived facilitators, barriers, and lessons learned for policy implications. Results will be summarized in frequencies and percentages and triangulated by the project team. Data will be analyzed using Stata (version 16; StataCorp) and NVivo (Lumivero) software. The study will be implemented for 20 months, followed by an additional 4-month period for follow-up. Initial results will be presented to the district health office and the District Health Program Management Team Meeting in the districts. This study will generate evidence about the feasibility and potential scale-up of a facility-based mortality audit system with integrated community engagement in rural Pakistan. Audit committees will complete the feedback loop linking health care providers, community representatives, and district health officials (policy makers). This implementation approach will serve decision makers in improving maternal and perinatal health outcomes. DERR1-10.2196/49578.

Suspected Cauda Equina Syndrome: Can the Presence of an Orthopaedic Doctor in the Emergency Department Reduce Waiting Times for MRI Scans and Inpatient Stays?

Introduction Cauda equina syndrome (CES) is a very rare but devastating surgical emergency that can lead to permanent bowel, bladder or sexual dysfunction and lower limb paralysis. Although it is a clinical syndrome, an MRI scan is a critical diagnostic investigation for these patients and should be done as soon as possible. Our hospital is a district general hospital with no spinal services on site. There is a protocol in place for the management of these patients locally with MRI scanning during daytime hours. However, if the patient presents after 8 pm, they are discussed with the tertiary spinal centre, which then advises if the patient requires transfer overnight for urgent scanning.Considering an MRI scan is a critical diagnostic step for these patients,we introduced a role for an orthopaedic doctor in the Emergency Department (ED) to assess all of these patientsbefore collecting data for the second cycle. The aim of this audit was to see the effect of having an orthopaedic doctor in the ED for the assessment of these patients and its impact on waiting times and admission rates. Methods A closed-loop audit cycle was done looking into all referrals to trauma and orthopaedics with acute back pain and suspected CES in a district general hospital with no spinal services on site. The first cycle was between September 30, 2020, and May 31, 2021, and included 93 patients in total. Following this, a role for an orthopaedic doctor in ED was introduced from December 1, 2021, to January 31, 2022, for assessment of these patients. Data was then collected retrospectively for all patients referred during this period (n=36). Data was extracted from all relevant clinical systems including electronic patient record (EPR), Patient Pass (Patient Pass Ltd, Greater Manchester, England), which is the system used to digitally communicate with regional spinal services, and PACS (picture archiving and communication systems). The data was collated on a Microsoft Excel spreadsheet (Microsoft Corporation, Redmond, Washinton, United States) and analysed. Results Data were collected for a total of 36 patients in the second cycle following the introduction of an orthopaedic doctor in the ED. The age of patients referred was 30-89 yearswith a mean age of 51; 44.4% were male (n=16) and 55.5% female (n=20). All the patients who were referred received their MRI scan and report within 24 hours of presentation to the ED. In the first cycle of the audit, the mean waiting time for an MRI scan had been 12.5 hours, which was reduced to eight hours following the introduction of an orthopaedic doctor in the ED during daytime hours. This was stratified further according to the time patients presented to the hospital. From 8 am to 4 pm, the mean waiting time for an MRI scan was 9.5 hours pre-intervention and 5.5 hours after. From 4 pm to 12 am, the mean waiting timewas 18 hours before and 13 hours after, and from 12 am to 8 am, the waiting time for scans improved from 8.5 hours to 6.5 hours. The number of patients discharged on the same day greatly improved from 29% (n=27) in the initial study to 58% (n=21). This decreased unnecessary inpatient stays from 71% (n=66) to 42% (n=15). Conclusion This study showed that an orthopaedic doctor in the ED for the acute assessment of patients referred with possible CES is an effective way of improving their management. This decreases waiting times for MRI scans and therefore allows the patient to be managed more efficiently.

A Clinical Audit of Orthopaedic Clinical Documentation of Acute Ankle Fractures: A Quality Improvement Project.

Background Orthopaedic ankle fractures are common injuries that require careful assessment, management, and documentation to ensure optimal patient outcomes. Proper documentation plays a critical role in facilitating communication among healthcare professionals, ensuring accurate diagnosis, treatment planning, and monitoring patient progress. Moreover, it is essential for medico-legal purposes and quality improvement initiatives. This article presents a comprehensive clinical audit aimed at evaluating the quality of orthopaedic ankle fracture documentation within a healthcare setting. The aim of this project was to assess the quality and accuracy of ankle fracture documentation within a single centreagainst the audit standards set by the British Orthopaedic Association (BOA) and the National Institute for Health and Care Excellence (NICE). Methods The study was a closed-loop audit utilising both retrospective and prospective analysis of ankle fracture clerking documentation performed by members of the trauma and orthopaedics team. Two audit cycles were completed in total; the first cycle was carried out in January 2020 where data were collected retrospectively from all orthopaedic admissions of ankle fractures. This was then re-audited against the BOA and NICE guidelines and presented to the local clinical governance meeting. A targeted educational intervention was then implemented with the goal of educating and reinforcing to key team members the documentation standards and the importance of accurate clerking documentation. The second cycle was carried out during July 2020 prospectively. All data were collected and collated with a total of nine data parameters analysed. Patients were included if they were skeletally mature and presented with closed malleolar and syndesmotic ankle injuries. Excluded patients were those who presented with open fractures, pilon fractures, and/or were skeletally immature. Data were then re-presented at the clinical governance meeting. Results A total of 23 patients were identified in the initial audit cycle and 22 patients in re-audit. On admission, it was found that 86% of patients presenting with ankle fractures had adequate documentation of their injury mechanism, which subsequently improved to 100% following the intervention. Similarly, there was a 71% improvement in precise documentation of clinical findings of ankle fractures. There was a marked improvement in the consistency of examination findings as well, with over 30% improvement in the rate of documentation for sensation status, skin integrity, circulation, and motor function. Results also revealed a 71% improvement in the documentation rates of vascular examinations where a Doppler ultrasound was used or pulses named in the documentation. Conclusion Through a targeted educational scheme focussing on the proposed documentation guidelines, we noted a significant improvement in documentation standards and accuracy of ankle fractures in the trauma and orthopaedic department. With ongoing educational input and reinforcement, team members can be supported to maintain a high level of documentation that meets all available standards, which will ultimately lead to improved patient care.

HPB O08 Championing benign biliary patients in Emergency General Surgery: A 3 year quality improvement project

Abstract Background A biliary quality improvement project (QuIP) was established in 2019 following 3 audit cycles highlighting delays to laparoscopic cholecystectomy (Lap-C) in patients with gallstone pancreatitis. Limited theatre space and other urgent care priorities hindered efforts to meet other biliary key performance indicator targets between 2015 and 2019. The last phase of the QuIP has introduced a dedicated consultant lead biliary service, a live biliary patient tracking system, increased in-patient Lap-C, implementation of ambulatory pathways and a patient centred integrated care approach. Methods Prospectively collected data from a live biliary tracking system was compared with retrospective audit data from 2015-2019. Key performance indicators were; average time to Lap-C, rate of Lap-C with-in 2 weeks following pancreatitis, inpatient Lap-C rate and out-patient appointments saved. Results 523 patients were managed through inpatient and ambulatory biliary pathways from November 2021-June 2023. 2 week Lap-C post pancreatitis improved from 27% to 79% (43% as inpatients) with average time to Lap-C improving from 68 days to 13 days. 191 outpatient appointments were saved by counselling and pre-assessing patients for Lap-C as inpatients, saving £22920 in outpatient costs. In-patient Lap-C rate improved from 2% to 19% for fit and consenting patients. Conclusions A higher quality of care can be achieved for biliary patients through; effective patient prioritisation, increasing inpatient Lap-C, the establishment of ambulatory pathways and a robust outpatient tracking system.

DELIVERING SUSTAINABLE CHANGE OF POSTOPERATIVE CARE DOCUMENTATION PRACTICES IN SPINAL SURGERY THROUGH QUALITY IMPROVEMENT FRAMEWORKS

AbstractINTRODUCTIONIn the NHS the structure of a “regular healthcare team” is no longer the case. The NHS is facing a workforce crisis where cross-covering of ward-based health professionals is at an all-time high, this includes nurses, doctors, therapists, pharmacists and clerks. Comprehensive post-operative care documentation is essential to maintain patient safety, reduce information clarification requests, delays in rehabilitation, treatment, and investigations. The value of complete surgical registry data is emerging, and in the UK this has recently become mandated, but the completeness of post-operative care documentation is not held to the same importance, and at present there is no published standard. This project summarises a 4-stage approach, including 6 audit cycles, &gt;400 reviewed operation notes, over a 5 year period.OBJECTIVETo deliver a sustainable change in post operative care documentation practices through quality improvement frameworks.METHODSStage 1: Characterise the problem and increase engagement through: SMART aims, process mapping, hybrid action-effect and driver diagram and stakeholder analysis. Multi disciplinary stakeholders were involved in achieving a consensus of evidence-based auditable criteria. Stage 2: Baseline audit to assess current practice. Stage 3: Intervention planning by stakeholders. Stage 4: Longitudinal monitoring through run charts and iterative refinement.RESULTSStage 1: Process mapping identified numerous downstream effects of the absence of critical information from operation notes, and the action-effect diagram highlighted the multiple unnecessary mitigating actions performed by ward staff. An MDT consensus was achieved on 15 essential criteria for complete documentation, including important negative fields. Interest-influence matrix identified stakeholder groups with high influence but low interest who needed engagement to deliver change. Stage 2: Baseline audit demonstrated unexpectedly poor documentation: &gt;75% compliance in 4 criteria, and &lt;50% compliance in 10 criteria, which elevated the interest of key stakeholders. Stage 3: A post-operative care template based on the 15 criteria was embedded within the existing IT software. It allowed use of existing operative templates, with a non-overwriting suffix requiring only two mouse clicks. Stage 4: Re-audit at 3 and 12 months showed improved and sustained compliance. At 24 months compliance had declined. Questionnaire of template usage identified problems of criteria response options, and lack of awareness of template by newly appointed staff. Template update improved compliance over the next 6 months (&gt;75% compliance in 11 criteria). Finally, a further reaudit conducted 12 months after the template update (5 years post baseline audit) showed a sustained improvement in compliance (&gt;75% compliance in 13 criteria).CONCLUSIONSSimple innovation through quality improvement frameworks has changed documentation practices by 1) achieving a consensus from stakeholders, 2) a “shock and awe” moment to highlight existing poor documentation and increase engagement 3) implementing change which fit easily into existing systems, 4) respecting autonomy rather than enforcing change and 5) longitudinal monitoring using run charts and an iterative process to ensure the template remains fit for purpose. This model has now successfully been translated to other subspecialities within the orthopaedic department.Declaration of Interest(b) declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported:I declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research project.

A Good Medical Practice of the Patients' Right to Information: An Audit Cycle of Patient Understanding and Satisfaction With Information Provided to Patients With Acute Pancreatitis.

Introduction Acute pancreatitis (AP),characterized by the inflammation of the pancreas, is a common acute surgical conditionaccounting for approximately 3% of all surgical admissions with abdominal pain and has an incidence of approximately 56 cases per 100,000 population every year. The General Medical Council (GMC), National Institute for Health and Care Excellence (NICE), andRoyal College of Nursing best practice guidelines recommend that such patients and their family membersshould be provided with both verbal and written information about acute pancreatitis and its management in a way that they can understand.The aim of this audit cycle was to find out the compliance with information provided to patients with acute pancreatitis as perthe GMC good medical practice and NICE guidelines and assess their satisfaction. Method A closed-loop audit consisting of two cycles was carried out. Thirty patients who were admitted to the department of general surgery with acute pancreatitis were provided with a questionnaire containing 11 questions asking about the information provided to them about their condition by healthcare professionals; then, interventions were carried out in the form of developing patientinformation leaflets (PILs) and encouraging healthcare professionals to distribute them and provide information to the patients and theirfamily members. Results Overall, improvements were seen in all aspects of the information being provided to patients, and particularly, more than 100% improvement was seen inpatientsatisfaction related to the information provided to them in the second cycle after the implementation of interventions. Conclusions This study concludes that patients should be given all the information they require in accordance with their right to information, in line with GMC best practice, NICE, and Royal College of Nursing best practice guidelines. A very effective way to improve the health outcomes and satisfaction of patients is to give them access to a patient information leaflet, which canallowpatients to consider their options and understand what can happen during treatment, especially when doctors have limited time to carry out detailed discussions with the patient.

A Clinical Audit of Mental State Examination Documentation Among Psychiatric Residents in a Tertiary Care Hospital

Introduction: Modern psychiatry uses Mental State Examination (MSE) as a tool for collecting data and assisting a psychiatrist in developing patient’s working psychiatric diagnosis. There are currently no national criteria on a definitive format of MSE, nor do the bulk of psychiatry training programs insist upon it. However, to ensure proper documentation of MSE results, following a structured format is needed, ensuring that all relevant components of the examination are covered. For this, we conducted this clinical audit regarding proper MSE documentation within the Psychiatry department of a tertiary care hospital. Methods: The study was conducted in the Department of Psychiatry, Civil Hospital Karachi between 15-02-2023 till 15- 04-2023 after approval by Head of Department. A standardized MSE format consisting of 11 parameters of psychiatric analysis was prepared according to British Medical Journal (BMJ) and Oxford University Press guidelines. The parameters incorporated appropriate date, time, and signature of the examining doctor, in addition to proper documentation of appearance, behavior, speech, mood and affect, suicidal and homicidal risk, thought process, perception, cognition (Orientation, attention, concentration, memory and abstract thinking), insight, judgement, and event notes/progress notes sections. The study was divided into two cycles. A retrospective analysis to detect the shortcomings of MSE documentation was done (sample size n=30), followed by a second cycle, in which a standardized MSE template was provided to all psychiatric residents to examine patients prospectively for the next 4 weeks. Data was analyzed using SPSS software to compare the improved changes in MSE documentation. Results: The result showed that all 11 parameters were recorded correctly, however certain sub-parameters were recorded poorly. The least recorded parameters were date of examination (53.3%), Physical stigmata (43.3%), psychomotor retardation (16.7%), and signs of Extrapyramidal symptoms (10.0%), speech assessment (46.7%), suicidal risk (20.0%), and homicidal risk (13.3%), perception assessment [Illusion (16.7%), depersonalization (13.3%), derealization (16.7%) and memory assessment. Documentation of event notes/progress notes was also recorded poorly (33.3%)]. There was an overall improvement in the documentation pattern of all the 11 parameters of MSE during the second audit cycle. The parameters and sub-parameters with an improvement included physical stigmata (66.7%), psychomotor retardation (76.7%), signs of Extrapyramidal symptoms (83.3%), speech assessment (90.0%), suicidal risk (83.3 %%), homicidal risk (83.3%), perception assessment [Illusion (86.7%), depersonalization (86.7%), derealization (80.0%)] and memory assessment. Patient’s name and registration number were perfectly recorded with a percentage of 100% in the first audit cycle, however it declined to 86.7% in the second cycle. There were also marginal improvements in documentation of date of examination and examining doctor’s name. Conclusion: The introduction of an MSE format and consultant supervision of records improved the standard of MSE recording as well as basic medico-legal requirements by psychiatric trainees

Adherence of Radiological Investigation Requests from Medical Wards, to Royal College of Radiologists’ Guidelines

Background: Radiological investigation requests get rejected by vetting radiologists, if they do not adhere to Royal College of Radiologists (RCR) guidelines and Ionizing Radiation (Medical Exposure) Regulations - IR(ME)R 2017 guidelines. This leads to significant delays for all three parties involved: the requesting clinician, the radiologist who vets the investigation, and the patient whose management is affected. Hence radiological investigation requests, which are the main means of communication between the referring clinician and the radiologist, should be appropriately filled in to facilitate the justification process and to optimize patient management. Aims/purpose: To evaluate the adherence of radiological investigation requests of inpatients from medical wards at University Hospitals of Leicester, to RCR guidelines and identify improvement areas, thereby reducing preventable patient delays. Methods: Data from 500 investigation requests of adult inpatients for common modalities of imaging (CT, X-Ray, and MRI) from medical wards at University Hospitals of Leicester were collected across two audit cycles, omitting any patient-identifiable information, and were analyzed for their completeness and adherence to RCR protocols. Results: Based on the analysis, inadequacies of imaging requests were identified, both in completion and adherence to RCR guidelines. In the initial audit cycle, even though more than 90% of the 250 investigation requests analysed contained clinical history, the name of requesting clinician and the question to be answered, only 64% of the investigation requests contained clinical examination or relevant investigation findings. In comparison to more than 94% of MRI and X-Ray requests, only 68.6% of CT requests adhered to RCR and IR(ME)R 2017 guidelines. In order to raise awareness and educate, the audit findings and recommendations were presented in a local medical teaching session within the hospital, and the same was propagated among medical doctors, through an online flyer. During the re-audit, another 250 radiological investigation requests were evaluated, where 73.3% of the requests included relevant clinical examination and/or investigation results and 76% of the CT requests adhered to iRefer guidelines for indication. Conclusion: Radiological investigation requests get rejected if it does not adhere to RCR guidelines for completeness (1) or indication (in compliance with IR(ME)R 2017)(3). This in turn results in delays in patient management. This could be minimized by increasing awareness about the above guidelines and the need for adhering to the same, thereby making sure all the necessary details are filled in and the investigation being requested is appropriate for the clinical indication. Keywords: Radiology, Audit, Medicine.

Management of displaced supracondylar fractures in children and adherence to the BOAST guideline- experience in a District General Hospital, UK

BackgroundSupracondylar fracture is the most common elbow fracture in children. These fractures can be associated with significant complications, including nerve injury, vascular compromise, compartment syndrome and clinical deformity. The British Orthopaedic Association Standards for Trauma (BOAST) provide clear and comprehensive guidance for managing the supracondylar fracture. AimsWe reviewed the management of displaced (Gartland type 2 and 3) supracondylar fractures and adherence to BOAST guidelines between 1st audit and re-audit following the introduction of supracondylar assessment proforma. MethodsWe retrospectively analysed the adherence to BOAST guidelines for 103 patients operated between 2014 and 2020. Documentation of vascular status and individual nerve functions were assessed during presentation to the emergency department, immediately before surgery, and postoperatively before discharge from the hospital. We also reviewed the documentation of the K-wire's size utilised for fixation, the medial wire fixation technique, and post-fixation stability during the operation. A new supracondylar fracture assessment proforma was designed and implemented after the 1st audit as part of the quality improvement measure. During the second stage of the audit cycle, we reviewed 22 patients and used the same methodology as the first audit to analyse the data. ResultsResults: We found significant improvements in the documentation of capillary refill time from 65 % to 95.5 % (p = 0.0038), radial pulse from 59.2 % to 95.5 % (p = 0.0009), and documentation of individual nerve function from 37.9 % to 72.7 % (p = 0.0040) in the emergency department during 2nd stage of the audit cycle. Individual nerve function documentation by the operating team immediately before surgery changed from 42.7 % to 50 %. The use of 2 mm K-wires improved from 53.3 % to 89.5 % (p = 0.0037) Documentation of medial wire fixation technique and post-fixation stability increased to 100 % from 82.9 % to 89.5 % from 42.7 % (p = 0.0002), respectively. Postoperatively, we noted improvement in both radial pulse and capillary refill time documentation from 27.2 % to 54.2 % (p = 0.0216) and the individual nerve function from 9.7 % to 50 % (p = 0.00005). ConclusionPoor adherence in stage 1 of the audit cycle to BOAST standards was significantly improved in stage 2 (Re-audit) after introducing a simple supracondylar fracture assessment proforma and focussed educational sessions.