Completed Audit Cycle Research Articles

Development and Implementation of a Venous Thromboembolism Prophylaxis Protocol in the Rehabilitation Setting – A Completed Audit Cycle

Abstract Background 63% of all Venous Thromboembolic disease (VTE) is hospital-acquired, and 70% of hospital-acquired VTE is potentially preventable with appropriate prophylaxis. NICE recommends a VTE risk assessment for all patients admitted to acute hospitals within 24 hours. Validated risk assessment models for acute hospitals enhance provision of thromboprophylaxis, but no such protocols exist for the rehabilitation setting. The aims of this audit were to determine if VTE risk assessments are occurring on admission and during acute illness in rehabilitation wards, to assess the proportion of rehabilitation inpatients receiving VTE prophylaxis, and to develop and pilot a VTE Prophylaxis Protocol. Methods An initial audit was carried out on three rehabilitation wards in May/June 2023. A VTE Prophylaxis Protocol was developed based on the HSE VTE Prevention Program template, incorporated into the admission booklet on 3 pilot wards in February 2024, and practice re-audited in April 2024. Results Pre-intervention, 41 patient records were assessed. 0 patients (0%) had a documented VTE risk assessment on admission, 23(56%) had therapeutic anticoagulation continued, and 3(7%) commenced appropriate VTE prophylaxis on admission. 8 eligible at-risk patients did not receive prophylaxis. Post intervention, all patients (n=25) on the three pilot wards were re-audited. 10 patients (40%) had a documented VTE Risk assessment within 24 hours of admission, 9(36%) had therapeutic anticoagulation continued, and 5(20%) received appropriate VTE prophylaxis on admission (2 without a documented risk assessment). 3 at-risk patients did not receive prophylaxis (1 with a completed risk assessment), and 1 risk-assessed patient inappropriately received prophylaxis. Conclusion Implementation of a VTE Prophylaxis Protocol improved VTE risk assessment in rehabilitation. This small sample however did not demonstrate an association between prophylaxis prescription and use of the protocol. Further education and feedback is required to increase use of the protocol as part of this ongoing quality improvement project.

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.

174 A silver lining: the identification of silver trauma at triage for older persons (>65) presenting to the emergency department

Abstract Background Trauma in patients over 65 (silver trauma), can result in serious injury from lower impact mechanisms. The NOCA Major Trauma report highlights that 58% of major trauma is a result of a fall from 2 metres or less and mortality increases with age and comorbidities. Failure to identify, rapidly assess and treat older persons who have suffered silver trauma results in prolonged emergency department stays with an increase in morbidity and mortality. We therefore, performed a completed audit cycle to assess the identification of Silver Trauma in our emergency department. Methods A focus group involving key stakeholders was established, including Emergency Physicians, nurses and members of the Gerontological Emergency Department Intervention team. An audit assessed patients triaged as ‘major trauma’ from October to December 2022. We established silver trauma guidelines for triage. Teaching sessions on the recognition of silver trauma were provided, daily briefings were given, and information leaflets were placed in all triage areas. A triage discriminator of ‘Silver Trauma’ was introduced to prompt recognition and review by clinicians. A full audit cycle was completed. Results Our initial audit (October to December 2022) revealed 25 patients triaged as ‘Major Trauma’ who were aged over 65. After the completion of the initial audit and implementation of measures, 122 patients were triaged as ‘Silver Trauma’ between January 20th and March 31st. We identified that 59% (N = 72) were due to falls from 2 meters or less. Other mechanisms of injury included unwitnessed fall (21% N = 25), syncope (7% N = 8), fall from height (11% N = 13) and Major Trauma (3% N = 4). Seventy-one (58.19%) were admitted and 51 (41.80%) were discharged home. Conclusion This audit demonstrates that departmental education and implementation of a triage discriminator has significantly improved the recognition of silver trauma within the ED setting.

Assessment of endometrial carcinoma on biopsy as a predictor of final surgical pathology: Are we doing it right? A completed audit cycle and recommendations.

Typing and grading of endometrial carcinomas (ECs) on small biopsy specimens is crucial to determine the need for full surgical staging. Histological subtype and grade are key factors available for risk stratification before surgery. However, this can be diagnostically challenging on small biopsy specimens, especially when morphologic features are subtle or overlapping. The aims of this audit were to assess concordance of endometrial carcinomas on biopsy specimens with hysterectomy specimens and to determine if the immunohistochemistry (IHC) panel being used in our practice was adequately subtyping ECs. The audit was approved by the Clinical Effectiveness Team of the Royal College of Pathologists (UK) as meeting all the criteria and standards set out by the College. Biopsies from 67 cases of EC were compared for histological subtype and grade of endometrioid carcinoma with resection specimens. A re-audit was carried out on 59 cases after implementation of changes recommended by the initial audit. Two of 35 (6%) tumours defined as G1 on biopsy were upgraded (to G2) on final pathology, as was one of 7 (14%) G2 tumours (to G3). One of these cases had solid areas just amounting to more than 6% on resection. In the second case, a comment was made that assessment had been difficult as the specimen was suboptimally fixed, but nuclei appeared atypical. Of seven G2 biopsies, one case was upgraded to grade 3 on final pathology based on proportion of solid areas. Our data show lower rates of discordance as compared to previous studies and on re-audit, the concordance between endometrioid and nonendometrioid serous carcinoma improved with the addition of immunohistochemistry (IHC) for Phosphatase and tensin homolog (PTEN) to biopsies. PTEN IHC can complement other stains and aid in the distinction of grade 3 endometrioid carcinoma from serous carcinoma on endometrial biopsies.

1038 Improving Adherence to Antibiotic Guidelines for the Treatment of Acute Cholecystitis: A Completed Audit Cycle

Abstract Aim Acute cholecystitis (AC) accounts for up to one third of emergency surgical admissions. The initial management of AC includes fluid resuscitation and appropriate antibiotic therapy. The aim of this study is to audit compliance with local microbiology guidelines for the treatment of AC and to develop interventions that improve compliance rates. Method All patients admitted from September to December 2020 with radiologically confirmed AC were included in an initial prospective audit (n=39 patients). Antibiotic prescriptions, patient demographics, presence of fever (>38°C), inflammatory markers and liver function tests were recorded. The results were disseminated, educational material produced, and antibiotic “champions” appointed to improve adherence to antibiotic guidelines. A prospective re-audit was conducted from May to June 2021 to establish the effectiveness of the interventions (n=49 patients). Compliance rates before and after the interventions were compared using a Chi-squared test. Binomial logistic regression was carried out to establish whether any patient demographic or clinical parameters were independent predictors of prescribing behaviour. Results Compliance to antibiotic guidelines for AC significantly improved following the interventions (12.8% vs 57.1%; p<0.001). Age, gender, temperature, inflammatory markers, and liver function tests were comparable in both groups and were not found to be independent predictors of non-compliant antibiotic prescription. Conclusions Adherence to antibiotic guidelines for AC can be improved with educational interventions and the appointment of individuals responsible for ensuring correct prescribing behaviour. Interestingly, patient demographics, signs of sepsis or liver function did not influence prescribing behaviour, suggesting that divergence from antibiotic guidelines may be due to ingrained prescribing dogma.

710 IPC STOCKINGS FOR VTE PREVENTION IN STROKE: BENEFITS OF INTRODUCING ELECTRONIC PRESCRIPTIONS AND WARD ROUND PROMPTS

Abstract Background A fully completed audit cycle, performed by doctors on the Stroke Unit at Royal Lancaster Infirmary (RLI) which is a combined acute and rehabilitation ward in a university teaching hospital. Introduction Deep vein thrombosis (DVT) and pulmonary embolism (PE) are common complications of hemiplegic stroke. Evidence shows that IPCs (intermittent pneumatic compression devices) reduce the risk of DVT. Recent data from SSNAP reports that IPCs are only used in 33% of all stroke patients. We aimed to improve our local standards in the prescription of IPCs for stroke patients within 3 days of admission, thus reducing the incidence of VTE (venous thromboembolism). Methods Data was collected retrospectively from patient records of all stroke patients discharged over a one-month period for each of 2 audit cycles. Prescribing is electronic based at RLI. After the first cycle we initiated a prompt on the electronic VTE pro forma to initiate prescribing. We also changed the prescribing default to regular instead of when required, requiring staff to document when they were not given and the reasons why. Results Between the first and second cycle, completion of VTE proformas improved to 100% and VTE incidence reduced from 7.6% to 0. Overall, there was a large improvement in prescribing IPCs within the first 3 days of admission. 71% of patients reviewed in the second cycle had IPCs prescribed compared to 37% in the first. Conclusion Adherence to local standards in prescribing of IPCs within 3 days of admission markedly improved after the Introduction of electronic ward round prompts and prescriptions and the incidence of VTE decreased to zero. The prescribing prompts encouraged increased documentation of administering of IPCs. There are still some issues concerning documentation and prescribing of anticoagulants which will be tackled by implementing teaching sessions and updating our electronic prescribing prompts.

Retrospective audit of midazolam dose and intravenous sedation record keeping in a primary care oral surgery service

Regular and robust audit of conscious sedation practice is key to the delivery of safe and effective patient care in all clinical settings. Analysis of outcomes will help to highlight any necessary modifications to procedures and techniques. The Intercollegiate Advisory Committee for Sedation in Dentistry (IACSD) states that conscious sedation procedures must be the subject of robust and regular audit in which every member within the team takes part.1 This completed audit cycle highlighted the efficacy of intravenous (IV) midazolam in anxious patients undergoing oral surgical procedures and the suitability for its use in the primary care setting. No patient safety concerns or complications were recorded in this audit and midazolam was administered within the recommended dose range. By the conclusion of two audit cycles, all clinicians providing intravenous sedation within the service were aware of the missing elements in sedation record-keeping and were able to complete accurate contemporaneous records before, during and after conscious sedation, ensuring the continuous delivery of high-quality, safe, and patient-centred care.

325 Improving the Documentation in the Consent Form for Patients Lacking Capacity: A Completed Audit Cycle

Abstract Aim According to GMC guidance, we are bound to discuss with close members of the patients to consider their views and reach the consensus of clinical management when patients lack capacity to make decisions. Our audit aimed to compare the practice of our institution against this guidance and instigate changes as necessary. Method We collected data of 30 randomly selected patients with dementia, undergoing emergency orthopaedic operations, from February to April 2021 in the first cycle. The data were collected from medical notes prospectively. The findings were presented in the local meeting. The implementations involved raising awareness of the GMC guidance among the members of the Trauma & Orthopaedics team by organizing a teaching session, creating posters, and sending an email from the clinical lead to the staff members to highlight the audit result. It was followed by the second audit cycle, which included 40 patients from June to August 2021. Results The first cycle revealed that there was only 36% compliance to the GMC guidance in our department, since only 9 out of the 30 cases had documentation about the discussion with the appropriate family member. The compliance rate of the second cycle (40 patients) saw a huge improvement up to 83%. Conclusions Significant improvement in documentation of the socially and medicolegally important discussion with the close contact of the patient was achieved. This was done by identifying the area which needed improvement and instigating changes in our department. Further audit loops will be conducted in due course to sustain this achievement.

623 Completed Audit Cycle of Indications for Excision of Fibroadenomas At A University Hospital

Abstract Aim This audit looked at indications for excisions of fibroadenomas one year on from the first audit cycle and following intervention of presentation and teaching at local departmental meeting. This audit was motivated by a drive to reduce operations on benign breast conditions including fibroadenoma excisions. ABS (Association of Breast Surgery) guidelines advise excision for fibroepithelial lesions (B3) on biopsy, pain and increasing size. Local consensus is excision of fibroadenomas over 30mm on ultrasound. Method Patients who underwent surgical excisions of fibroadenomas over 6 months at one hospital were analysed for size on ultrasound, biopsy histology and reason for excision, and compared to previous audit results over 24 months. Results Over 6 months, 18 patients underwent excisions. Histology specimens showed 13/18 were fibroadenomas, 4/18 benign phyllodes and 1/18 other benign conditions. This was similar to the previous audit, although there was an increase in the rate of benign phyllodes. Pre-operatively, 11/18 of patients met the ABS criteria for excision (7/11 were B3 lesions, 3/11 for increasing size and 1/11 pain). 11/18 patients met the local criteria. 2/18 patients met neither criteria. This had improved compared to the first audit cycle. Conclusions 88.9% of patients met ABS or local criteria, compared to 83.7% previously, and so this had improved following intervention. One outcome from the first audit cycle was patients need greater reassurance about the benign nature of fibroadenomas to avoid unnecessary morbidity due to surgical procedures, and this appears to have improved on re-audit. Both patients not meeting criteria had histology showing fibroadenomas.

Monitoring side-effects of antipsychotics using the glasgow antipsychotic side-effect scale

AimsAntipsychotic drugs frequently produce side-effects which represent common reasons for noncompliance. National guidelines, published by the National Institute of Care and Health Excellence, the Royal College of Psychiatrists, and the Maudsley Prescribing Guidelines in Psychiatry, stipulate that patients prescribed antipsychotic drugs should be reviewed for side-effects on a weekly basis. This completed audit cycle, conducted on a mixed acute general adult psychiatric ward, examined whether patients were being assessed for side-effects of antipsychotic drugs using a standardised, self-reporting scale – the Glasgow Antipsychotic Side-effect Scale (GASS) – as per national guidelines. As identification of side-effects is important in tailoring treatment to improve compliance, auditing monitoring practice was important in realising these outcomes.MethodRetrospectively, 26 inpatients were identified over a two-month period who were prescribed antipsychotic drugs. Their notes were reviewed for documented weekly GASS scores for the duration of antipsychotic treatment. Initial data demonstrated 0% compliance with guidelines, as no patients completed a weekly GASS. The intervention to improve compliance was a training session for ward staff on implementing the GASS. Data were subsequently collected prospectively over three weeks for 15 patients.ResultSeven patients completed the GASS weekly over three weeks, representing 47% compliance. Two patients (13%) completed two forms, three (20%) completed one form, and three (20%) completed no forms. There was a positive correlation between being offered the GASS and completing it – only one patient declined to complete it and was not offered it during the third week. Of the remaining 14 patients, if the GASS was offered there was 100% rate of completion. Staff did not offer the GASS to every patient each week, which accounted for most cases of non-completion. Some patients with pre-existing symptoms of physical illnesses included these on the GASS, which complicated interpretation. Future interventions could include further staff education, and involving a ward pharmacist to review results during medication reviews to optimise treatment compliance, as no medication changes resulted directly from patients completing the GASS.ConclusionCompliance with completing the GASS weekly improved following staff education, identifying the main factor affecting compliance as staff not offering the GASS to patients. Patients generally engaged well with side-effect monitoring, as most completed the GASS when offered. Further staff education may produce even greater compliance with guidelines, and involving pharmacy staff to review GASS scores and inform medication choices may lead to use of the GASS resulting in more tolerable and effective treatment plans.

945 Re-Audit of Incorrect Tcis; Are We Now Listing the Right Teeth

Abstract Introduction In 2018 in our OMFS out-patients department there were two wrong tooth extraction (WTE) events- at a Clinical Governance meeting we identified that TCI (‘to come in’ forms) were being completed incorrectly; from December 2018 to February 2019 there were 6 separate forms where the teeth listed for extraction was different to the teeth that were planned for extraction. As a result, our first stage audit involved data collection and root cause analysis of the incorrectly completed forms. As a result of the findings of the first stage audit, we decided to implement a change to TCI forms. Aim To assess whether TCI forms were being correctly completed following on change to TCI forms. Data collection Retrospective data collection from September 2019- January 2020 analysing any occurrences of incorrect TCI forms Results No further incidents of incorrect TCI forms since September 2019 and WTE since the last occurrence in 2018. Conclusions Although an incorrect TCI form was not listed as a potential cause for the two WTE events that occurred within the department, incorrect documentation is a known risk factor for WTEs. This completed audit cycle demonstrates successful learning from the WTEs and the implementation of beneficial changes.

An audit of the cervical screening programme in the National Drug Treatment Centre (NDTC).

BackgroundWomen diagnosed with substance use disorders (SUDs) have higher rates of major medical conditions compared to women without SUDs. Cervical cancer is the second leading cause of cancer death in women aged 20–39 years worldwide and women with SUDs have an increased risk of cervical cancer compared to women without SUD. The National Drug Treatment Centre (NDTC) cervical screening programme, derived from the national CervicalCheck programme, offers free cervical screening to patients attending for treatment of SUDs.AimsThis study aimed to audit adherence to the NDTC Cervical Screening guidelines before and after the implementation of an awareness-raising educational intervention.MethodsThe electronic clinical records of women aged between 25 and 60 years attending the lead consultant’s (M.S.) outpatient clinic were reviewed for documentary evidence indicating that information about the cervical screening programme had been discussed. This was completed before and one month after the implementation of an awareness-raising educational intervention.ResultsAll women (n = 46, mean age 36.3 (SD = 6.5) years) had an opioid use disorder; 85% had a benzodiazepine use disorder, and 24% had an alcohol use disorder. Of these, 80% had at least one chronic medical condition, 76% had a psychiatric disorder, and 59% were homeless. Adherence to the NDTC cervical screening guideline, as indicated by documentary evidence in clinical records, was 33% (14/43) at baseline, and rose to 88% (36/41) (p < 0.0001) one month after the intervention.ConclusionsThis completed audit cycle shows that an awareness-raising educational intervention can significantly improve adherence to a cervical screening programme in women with SUDs.

Midface trauma: outpatient follow-up and surgical treatment times

Introduction/aims: Surgical treatment of midface fractures should ideally occur within two weeks of injury, after which bony healing and consolidation makes repair more difficult for the operating surgeon. The OMFS unit at the Royal Surrey County Hospital is the tertiary referral centre for maxillofacial trauma from five regional hospitals. We present a completed audit cycle of midface trauma referrals managed over a one year period. Our standard was that clinical assessment of the midface fracture would take place in a consultant led outpatient clinic within 7 days, and when indicated, surgical fixation would occur within 10 days of referral.

A pilot project on the management of osteoporosis in primary care: results of the audit cycle.

Osteoporosis is a major public health problem with the ageing population in the UK. However, there is no known national algorithm for the management of osteoporosis in primary care. Therefore, a treatment pathway was developed in secondary care for patients in the community. This audit cycle investigates whether patients at a GP practice with a population of 14 000 have been appropriately identified, coded as osteoporosis, treated, and have followed the recommended pathway. A search of the practice clinical system was undertaken for three groups of patients coded as: patients currently on the existing osteoporosis register; patients with a code of 'osteoporosis' or 'fragility fracture' but not prescribed an osteoporosis treatment; and patients currently prescribed an osteoporosis treatment with no coding for 'osteoporosis' or 'fragility fracture'. The words 'osteoporosis', 'fragility fracture', 'QOF', and all individual drug names were used in the search engine. The completed audit cycle shows an increase in the proportion of patients following the local guidelines pathway, from 75% in 2018 to 81% in 2019, emphasising the importance of having a guideline for GPs to follow in order to optimise treatment and prevent future fragility fractures. This is a pilot project to assess the ability to identify patients who have osteoporosis and review their treatment pathway. The results are promising as the analysed data indicate that GP practice lists can be used to identify and treat high-risk patients for osteoporosis and assess the adherence to the pathway. Using the pathway, GPs can more efficiently diagnose and manage patients.

Confidential image transfer: an ethico-legal dilemma

Clinical photographs aid decision-making and represent important medicolegal records. Storage and transfer of images of the facial area must adhere to Caldicott Principles. Outside working hours, clinical photography services are often limited. Our Trust has introduced a Secure Clinical Image Transfer (SCIT) app allowing clinicians to take photographs on personal devices to be securely uploaded to the patient's electronic health record. To evaluate whether clinicians were taking clinical images in an insecure manner, clinicians completed an anonymous questionnaire before and after introduction of the SCIT app. The standard was 100% knowledge of, and adherence to, trust information governance guidelines. Response rate was 100% in both cycles. Introduction of the SCIT app reduced inappropriate clinical photography on personal devices. Our completed audit cycle shows that the SCIT app allows convenient, secure information capture on personal devices and automatic secure synchronisation to trust electronic health records.

Temporal artery biopsy: our experiences and an evidence based approach to case selection

Introduction Temporal artery biopsy remains the gold standard for diagnosing giant cell arteritis (GCA). Following a retrospective audit, we implemented a standardised surgical technique in order to improve diagnostic yield. We present the findings of our completed audit cycle and an electronic referral proforma based on the American College of Rheumatology (ACR) criteria.

Multi-Faceted Intervention to Improve the Antibiotic Prescriptions among Doctors for Acute URI and Acute Diarrhoea Cases: The Green Zone Antibiotic Project.

BackgroundAntimicrobial resistance is a global problem that is perpetuated by the inappropriate use of antibiotics among doctors. This study aims to assess the antibiotic prescription rate for patients with acute upper respiratory infection (URI) and acute diarrhoea.MethodsA completed clinical audit cycle was conducted in 2018 in the busy emergency department of a public hospital in Malaysia. Pre- and post-intervention antibiotic prescription data were collected, and changes were implemented through a multifaceted intervention similar to Thailand’s Antibiotics Smart Use programme.ResultsData from a total of 1,334 pre-intervention and 1,196 post-intervention patients were collected from the hospital’s electronic medical records. The mean (SD) age of participants was 19.88 (17.994) years. The pre-intervention antibiotic prescription rate was 11.2% for acute diarrhoea and 29.1% for acute URI, both of which are above the average national rates. These antibiotic prescription rates significantly reduced post-intervention to 6.2% and 13.7%, respectively, falling below national averages. Antibiotic prescription rate was highest for young children. There were no significant changes in rates of re-attendance or hospital admission following the intervention.ConclusionThe multifaceted intervention, which included continuing medical education, physician reminders and patient awareness, was effective in improving the antibiotic prescription rates for these two conditions.

Extended VTE prophylaxis after colorectal cancer resection: A completed audit cycle

Extended VTE prophylaxis after colorectal cancer resection: A completed audit cycle

Best practice tariff for fragility hip fractures – A completed audit cycle in a district general hospital

Best practice tariff for fragility hip fractures – A completed audit cycle in a district general hospital

Improving breast Q capture rates in reconstructive surgery at the Royal Devon & Exeter NHS foundation trust using iPads: A completed audit cycle

Improving breast Q capture rates in reconstructive surgery at the Royal Devon & Exeter NHS foundation trust using iPads: A completed audit cycle