Driver Diagram Research Articles

Increasing the use of anxiolysis and analgesia for paediatric procedures in a community emergency department network: a quality improvement initiative

Prior reports describe the care children receive in community EDs (CEDs) compared with paediatric EDs (PEDs) as uneven. The Emergency Medical Services for Children (EMSC) initiative works to close these...

2042 Implementing the principles of Shared Decision Making into a Hospital at Home service, as part of a wider organisation adoption

Abstract Background NICE (2023) Shared Decisions Making (SDM) Guidelines ensure Health Care professionals work together with a person to reach a decision about care based on their individual preferences, beliefs, and values. Local Problem. We conducted an Audit across our community services to assess NICE SDM, achieving 71% compliance. Results informed the project problem statement “Clinical Teams are not fully compliant to NICE SDM guidelines therefore a shared decision-making approach is not guaranteed”. Methods A fishbone diagram was applied to understand why SDM wasn’t routinely occurring in clinical practice. Our aim is to achieve organisation wide adherence to SDM. We propose a multi modal approach to increasing awareness of SDM across the organisation. We used a driver diagram working backwards from the goal, identifying the drivers and determining the project activities. Interventions Due to the enormity of rolling out a pan-organisational programme we decided to use the Frailty NHS@Home virtual ward to test and learn before greater adoption. We firstly processed mapped how the “What Matters to you?” question is embedded into our Comprehensive Geriatric Assessments. A decision support grid for treatment option decision making was created for dehydration or high risk of dehydration within the NHS@Home service, adapted from Marrin et al (2014). Three options are described underpinned by five questions. Feedback from Patient and public involvement ensured the language was appropriate. After the first PDSA cycle, the tool was reviewed by the project team and two further questions were added, “Did you understand the options which were explained to you?” and “What matters most to you as we decide together how best to treat your dehydration?” Conclusion A re audit and colleague survey will reveal increased knowledge and understanding of the SDM concept. We continually seek Feedback from individuals who use our services for their experience of SDM processes.

Pain-free hospital implementation: a multidimensional intervention to improve pain management at Wallaga University Referral Hospital, Nekemte, Ethiopia

ObjectiveThis quality improvement project is aimed to increase pain free hospital implementation from 21.7 to 80% at Wallaga University Referral Hospital (WURH) from January 1, 2023 to June 30, 2023.MethodsHospital based interventional study was conducted at WURH. The Plan- Do-Study-Act (PDSA) cycle was used to test change ideas. A fishbone diagram and a driver diagram were used to identify root causes and address them. Major interventions included training of health professionals, initiation of pain as fifth vital sign, policy and protocol development, and conducting regular supportive supervision.ResultsUpon completion of the project, overall pain-free hospital implementation increased from baseline 21.7–88.7%. Implementation of pain as 5th the vital sign was increased from 15.4 to 92.3%. Regular audits of pain assessment and management increased from 27.3 to 81.8%. Two standardized treatment protocols or chronic and acute pains were developed from baseline zero. A focal person for Pain-free hospital implementation was assigned. More than 85% of healthcare providers were trained in pain assessment and management.ConclusionCompliance with pain-free hospital implementations was significantly improved in the study area. This was achieved through the application of multidimensional change ideas related to health professionals, standardized guidelines and protocols, supplies, and leadership. Therefore, we recommend providing regular technical updates & conducting a frequent clinical audit on pain management.

Implementation and impact of rapid SARS-CoV-2 point of care test on patient flow in the frailty pathway; A quality improvement approach.

To maintain patient flow during the COVID-19 pandemic, rapid and accurate decisions for the safe triage of geriatrics patients was essential as turnaround times for laboratory testing was ineffective at supporting rapid clinical decision-making for transfer of care. Thus, to mitigate and inform these clinical decisions, a quality improvement collaborative project with the geriatrics and virology department was conducted at the Frailty Assessment Unit (FAU) at Aberdeen Royal Infirmary. The goal was to facilitate patient triage during transfer of care with the introduction of Point of Care testing (POCT). The interventions which resulted in significant improvements were based on the fishbone problem solving approach and the driver diagram with change ideas informing the five Plan, Do, Study and Act (PDSA) cycles. The QI intervention was crucial in supporting clinical staff decision making during transfers for 95% of patients who had been clinically judged as asymptomatic for COVID-19 infection. High staff engagement was observed with 83% of staff suggesting the process map was easy to follow and 92% of clinical staff agreed it contained sufficient information to support the testing process. With POCT introduction, the proportion of patients who were transferred with an early POCT result increased by 20% in the Rosewell House group and by 65% in the community Hospitals group, once governance arrangements were in place. Finally, the considerable uptake of POCT by the ward consequently led to a decrease of up to 86% in the number of samples sent to the laboratory for rapid SARS-CoV-2 testing. The quality improvement project provided a rapid and reliable SARS-CoV-2 triage tool and was effectively integrated into the geriatrics triage algorithm to facilitate patient placement and flow.

Recognise Sepsis in the Emergency Department

Objective: In the UK alone, 245,000 people are affected by sepsis with at least 48,000 people losing their lives in sepsis-related illnesses every year. This is more than breast, bowel and prostate cancer combined. Globally, sepsis claims 11 million lives a year. Yet, for many patients, with early diagnosis it is easily treatable. The UK sepsis trust developed a sepsis screening and action tool which helps clinicians screen for and identify possible sepsis at all levels and across specialities. In the NHS staffing levels vary from junior doctors and trainee advanced care practitioners to registrars and senior consultants which can lead to sepsis being missed at initial presentation. The screening and action tool enables nursing staff at triage to start the tool, if the patient flags up for possible sepsis a Doctor is asked to review the patient and treat with the sepsis 6 action tool. The Emergency department at Royal Derby hospital guidance is to use the sepsis screening and action tool to ensure patients are being picked up early and treated timely and effectively. We conducted a Quality improvement project as an audit showed compliance with the sepsis screening and action tool was 20%. Our problem statement was many patients presenting to RDH ED with suspected sepsis will not be screened for sepsis via the sepsis screening and action tool. This may lead to delays or noncompliance to the sepsis 6 pathway which effectively will lead to morbidities in this patient population. Our rationale for was improving the recognition of sepsis via the standardised sepsis screening and action tool will help raise the awareness and assure early recognition of septic patients amongst healthcare professionals working in the emergency department. Design: We assembled a QI team ranging from nursing staff, doctors, ACP's and Helth care workers. We used four separate PDSA cycles over the course of 9 months. These help form a structured method which is commonly used to test changes as part of an improvement initiative or project. It enabled the team to thoroughly and efficiently test and evaluate your ideas for change and involves four steps. We also used a Driver Diagram to help address and map out the process. Results: At the start of the project the compliance to the sepsis screening and action tool was 20 %, we managed through 4 PDSA cycles to improve the compliance to 60%. We further broke the action tool down to further asses which components to focus on. The components we investigated were One hour antibiotics given, blood cultures taken, target oxygen saturation, blood gas/lactate taken, fluid given, monior input/output chart. Antibiotics given in one hour improved from 82% to 100 %, blood cultures taken from 65% to 95%, target sats and blood gas/lactate level was constant 100% and remained 100%. Although documentation of input/output charting was 10% at the start of the project and 30% at the end. Conclusion: We manged to improve the compliance to the sepsis screening and action tool from 20% to 60%, which in turn improved one hour antibiotics, blood cultures taken, fluids prescribed which effectively improved the identification and treatment of patients with suspected sepsis in our emergency department.

Advancing health equity in improving breast cancer screening with the use of a mobile mammography bus in marginalised population: quality improvement project

BackgroundBreast cancer, the second leading cause of cancer-related deaths in women in the USA, is effectively treated through early detection and screening. This quality improvement (QI) project aimed to improve...

Healthy Aging in Algoma: Tests of Change Program

Introduction: In Algoma District, Ontario, Canada, approximately 25% of the population is 65 years of age and older. The Ontario Provincial Geriatrics Leadership Office (2020) predicts that by 2040 this number will increase to 32% and that 29% of older adults will be living with frailty. In February of 2022, Tests of Change (ToC) Program work commenced to bring an integrated care approach to healthy aging in Algoma. Healthcare member organizations of the Algoma Ontario Health Team (AOHT) and community patient, family, and caregiver advisors identified older adults living with frailty as the target population. A driver diagram of change ideas was conceptualized to support improving care for the identified population. To enact the recommended changes, three priority projects - Outpatient Geriatric Rehabilitation Capacity, Coordinated Access to Geriatric Services and Early Frailty Identification - complement each other with the common purpose of improving early frailty intervention and increasing access to the most appropriate care.
 Aims: The ToC Program entails:
 Embedding a frailty screening tool into electronic medical records for use in primary care;
 Initiating coordinated access to geriatric services leveraging eReferral and a common platform for electronic referral management; and
 Designing an outpatient geriatric rehabilitation program.
 This Program aims to advance the following elements:
 Design upstream engagement strategies (e.g., screening, prevention, disease self-management) for the target population;
 Increase patient access to the appropriate level of care; and
 Transform care coordination, transitions and recovery at home.
 Highlights: The AOHT has engaged partners from across the continuum of care who provide services for frail older adults. Partners include: community support services, home and community care support services, primary care, acute care, specialized geriatric services, and patient advisors. These critical partners assume leadership roles in program design, implementation and evaluation.
 Conclusions: Early frailty identification can improve quality of life, increase intervention success, and delay the need for specialist care. This program is predicated on the establishment of foundational processes enabled by digital tools to identify frailty early, streamline referrals for access to the most appropriate geriatric services, and provide patients with the opportunity to fully participate in interventions such as outpatient geriatric rehabilitation to increase their ability to live independently in the community. By taking an integrated collaborative approach to program planning and execution, overall patient outcomes will be improved.
 Transferability: The WHO Guidelines on Integrated Care for Older People (ICOPE) recommend advancing integrated care through community collaboration, a patient centered approach and supportive leadership. In 2019, the Ontario Health Team (OHT) model was introduced provincially as a way for healthcare providers to partner to deliver coordinated, integrated care. Of significance, several of the 54 approved OHTs have identified older adults living with frailty as a target population. Globally, as older adults are living longer lives, it is anticipated that there will be proportionally more older adults living with frailty. Through collaboration and sharing of the ToC program results, program scalability can be achieved at the OHT level and support the global knowledge base on efforts to strengthen integrated care for older adults.

Improving the Outpatient Pain Management Plan for Patients with Sickle Cell Disease with Electronic Medical Record-Based Pain Action Plans

Background: Patients with sickle cell disease (SCD) experience recurrent vaso-occlusive crises (VOC) as a primary manifestation of their illness. The American Society of Hematology (ASH) best practice guidelines recommend that individuals with SCD have individualized care plans to effectively begin pain management at home prior to presenting to the emergency room. A needs assessment of the comprehensive sickle cell program at Rady Children's Hospital San Diego (RCHSD) identified the need for a standardized approach for the provision of Pain Action Plans (PAP). In 2022, an outpatient PAP Quality Improvement (QI) project was initiated at RCHSD with the global aim to improve outpatient pain management and quality of life for patients with SCD. SMART Aim: Within 6 months (January-June 2023), to increase the proportion of patients with SCD receiving a PAP during a comprehensive clinic visit from 0 to 50%. Methods: The QI project was conducted by an interprofessional team with clinical, QI, and information technology expertise. An initial approach utilizing the Med Action Plan function in EPIC had technical challenges and was not implemented. We identified an existing Epic Asthma Action Plan which could be adapted to a SCD PAP. Meetings with clinical informaticists, pulmonology (consultants), and hematology teams informed the QI tools (process mapping, key driver and Ishikawa diagrams) that we used to design our PDSA cycles. The PAPs were modeled after the existing Asthma Action Plan, with green, yellow, and red zones to indicate different levels of pain management. Patients were given laminated Youth Acute Pain Functional Ability Questionnaire (YAPFAQ) and a comfort measures sheet to complete prior to their visit with the provider to inform the PAP which included pain medication details and supportive care measures for each zone. PAPs were created within the clinic note at comprehensive clinic visits and then provided to the family as a printed letter in person and via MyChart (if activated). Our outcome measure was the percentage of patients who were provided a PAP at their SCD comprehensive clinic visit. Process measures included the percentage of patients who had documentation in the PAP of the YAPFAQ and comfort measures, percentage of patients who had a PAP routed to patient via MyChart, percentage of patients who confirmed receipt of their PAP, percentage of patients who had used their PAP by parental report after one week, and percentage of patients who had used their PAP after 3 months per Epic documentation. Balancing measures were the perceived burden of patient care/documentation for the PAP to be evaluated with pre and post surveys among providers. Results: Interventions were evaluated using PDSA cycles. PDSA Cycle 1 (January-March 2023) included development of the SCD PAP by adapting the existing Asthma Action Plan to a SCD PAP. This included the creation of medication templates, integrating comfort measures and pain triggers, creating EPIC smart phrases to document the YAPFAQ. We educated providers on the SCD PAP and documentation process and worked with the interdisciplinary team including case managers, nurses, child life specialists, and psychologist to incorporate YAPFAQ and comfort measures into the comprehensive clinic visit. PDSA Cycle 2 (April-June 2023) included additional education, training, and targeted e-mail reminders to hematology attendings. From May 2023 to July 2023, 94% percent (13/14) of patients seen at a comprehensive clinic visit received a PAP. One patient had the PAP created but did not receive the printed letter due to time constraints for family. Feedback from families indicated that they felt the PAP was a valuable tool to have at home during VOC, however none had yet utilized it in the week since they were seen in clinic. Early provider feedback has indicated that this functionality is easy to use and efficient during the comprehensive clinic visit. Conclusion: The adaptation of the Asthma Action Plan to the SCD PAP allowed for successful implementation of PAPs for our patients with SCD. Subsequent PDSA cycles will focus on optimizing implementation in the clinic and utilization for pain events. We will evaluate the clinical impact of the PAPs on pain management outcomes.

Promotion of school readiness in home visiting: creating a key driver diagram for continuous quality improvement

ABSTRACT School readiness is a topic of great interest to early childhood and maternal child health initiatives, such as the Maternal, Infant, and Early Childhood Home Visiting (MIECHV) programme. However, there is a lack of information about best practices or strategies in home visiting and their relative effectiveness in improving school readiness, making this topic appropriate for improvement through Continuous Quality Improvement (CQI) methods. In 2022, Alabama developed a Key Driver Diagram (KDD) for improving school readiness efforts within the home visiting programme using synchronous online focus groups as a method of qualitative data collection with early childhood and home visiting experts. Findings from this study include development of a KDD that includes aims, key drivers, and secondary drivers. The KDD represents the first of many steps toward a unified theory of change. Future efforts will include development of a CQI change package and testing change ideas in the field.

Poke Plan: An Initiative to Improve Distraction and Pain Mitigation With Venous Access in Hospitalized Children.

Adequate pain control and anxiety relief during peripheral intravenous cannula (PIV) placement improves patient, parental, and staff satisfaction and reduces health care-induced stress in children. We noted a low rate of analgesic/anxiolysis use (<20%) and child life utilization (3%) in our institution. This quality improvement project was initiated to increase pain mitigation strategies in hospitalized children requiring PIV access. From November 2020 to March 2021, we created a key driver diagram and summarized possible interventions with the aim to increase our use of pain control strategies to >40% and child life utilization to 25%. For 12 months, 8 Plan-Do-Study-Act cycles were conducted focusing on nursing education and training, improved documentation, electronic medical record optimization, easy access to analgesics and anxiolytics, family involvement, and weekly huddles. Our primary measure was the percentage use of pain medications for PIV access. The utilization of PIV experts from the ICU (advanced practice registered nurses and physicians) served as the balancing measure. A total of 883 patient charts were reviewed. The use of topical anesthetics and anxiolytics increased from 16.2% at baseline to 78.9% after the implementation of the quality improvement project. Eighty percent of parents reported their child was kept comfortable during the procedure using pain mitigation and comfort measures. A slight increase from 2% to 5.8% was noted in the utilization of advanced practice registered nurses and intensivists. Implementation of a standardized approach for PIV placement improved team communication and provided better preparation for pain control before needle insertions in hospitalized children.

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.

Patient safety incidents in endoscopy: a human factors analysis of nonprocedural significant harm incidents from the National Reporting and Learning System (NRLS).

Despite advances in understanding and reducing the risk of endoscopic procedures, there is little consideration of the safety of the wider endoscopy service. Patient safety incidents (PSIs) still occur. We sought to identify nonprocedural PSIs (nPSIs) and their causative factors from a human factors perspective and generate ideas for safety improvement. Endoscopy-specific PSI reports were extracted from the National Reporting and Learning System (NRLS). A retrospective, cross-sectional human factors analysis of data was performed. Two independent researchers coded data using a hybrid thematic analysis approach. The Human Factors Analysis and Classification System (HFACS) was used to code contributory factors. Analysis informed creation of driver diagrams and key recommendations for safety improvement in endoscopy. From 2017 to 2019, 1181 endoscopy-specific PSIs of significant harm were reported across England and Wales, with 539 (45.6%) being nPSIs. Five categories accounted for over 80% of all incidents, with "follow-up and surveillance" being the largest (23.4% of all nPSIs). From the free-text incident reports, 487 human factors codes were identified. Decision-based errors were the most common act prior to PSI occurrence. Other frequent preconditions to incidents were focused on environmental factors, particularly overwhelmed resources, patient factors, and ineffective team communication. Lack of staffing, standard operating procedures, effective systems, and clinical pathways were also contributory. Seven key recommendations for improving safety have been made in response to our findings. This was the first national-level human factors analysis of endoscopy-specific PSIs. This work will inform safety improvement strategies and should empower individual services to review their approach to safety.

Reducing missed medications in surgical patients.

Elective surgical patients need accurate drug charts to reduce missed medication doses, decreasing the chance of peri-operative complications. The quality improvement project described in this article used four interventions to improve the percentage of missed medication doses. A driver diagram was produced to interrogate the current pathway which highlighted multiple interventions, including changes to elective pro formas, the initial clerking process and nurse-based prescribing. Once implemented, a plan-do-study-act (PDSA) cycle was completed as per NHS Improvement guidelines. Overall, missed medication dose percentage decreased from 9.8% to 0% after the interventions. Two of these changes have been deemed sustainable and have been integrated into elective patient pathways, improving both patient safety and streamlining surgical elective patient services. This project highlights the importance of prescribing practice in a multidisciplinary team. Simple changes to established systems allow for better patient care, and the authors' project provides evidence that empowering nursing staff to take the lead in the medication management of patients can reduce the likelihood of negative outcomes in a patient's admission.

A quality improvement initiative for neonatal hypoglycemia screening and management in a level III neonatal intensive care unit.

To bring screening and management of neonatal hypoglycemia in alignment with the 2011 AAP hypoglycemia clinical report METHODS: A multidisciplinary team developed a quality improvement initiative for neonatal hypoglycemia in neonates ≥35 weeks gestational age in a Level III neonatal intensive care unit between July 2020 and December 2021. A key driver diagram identified interventions for plan-do-study-act testing with corresponding measures to implement a hypoglycemia management protocol and improve adherence to AAP guidelines. Time to first blood glucose measurement increased from 49.8 to 122.7 min of life and time to first enteral feed decreased from 14.2 to 3.6 h of life. Neonates receiving intravenous dextrose decreased from 97.1 to 24.7% and discharge rates as a mother-neonate dyad increased from 35 to 62.4%. Adherence to the AAP guidelines improved during testing and implementation of a hypoglycemia protocol and was associated with an increased mother-neonate dyad discharge rate.

Discharge Best Practices of High-Risk Infants From Regional Children's Hospital NICUs.

Lack of discharge preparedness after NICU hospitalization is associated with risk of readmission and parental stress. Complex infants cared for at regional children's hospital NICUs would benefit from a systematic approach to transition home. Our objective was to identify potential best practices for NICU discharge and examine priorities for incorporating these best practices in regional children's hospital NICUs. We used techniques from quality improvement, including fish bone and key driver diagrams, yielding 52 potential best practice statements for discharge preparation. Using the modified Delphi method, we surveyed stakeholders on their level of agreement for the statement to be included in the final guideline regarding discharge processes and parental education. Consensus was defined as 85% agreement among respondents. To identify implementation feasibility and understand unit-level priorities, a prioritization and feasibility assessment survey was used to rank the top best practices and performed gap analyses for the first prioritized intervention. Fifty of the 52 statements met the predefined criteria for consensus. The prioritization survey of potential best practice statements named assessment of families' social determinants of health with a standardized tool as the top priority among respondents. Conducting gap analyses enabled an understanding of current practice, barriers, and affordances, allowing for implementation planning. This multicenter and interdisciplinary expert panel reached a consensus on multiple potential best practices for complex discharge preparation from regional children's hospital NICUs. Better support for families navigating the complex NICU discharge process has the potential to improve infant health outcomes.

Neonatal Intensive Care Unit to Home Discharge Communication: A Quality Improvement Project.

We assembled a multidisciplinary team and collected baseline data on discharge communication frequency and quality. We used quality improvement tools to implement a higher-quality system. The outcome measure was the successful delivery of a standardized notification and discharge summary to a PCP. We collected qualitative data through multidisciplinary meetings and direct feedback. The balancing measures comprised additional time spent during the discharge process and relaying erroneous information. We used a run chart to track progress and drive change. Baseline data indicated that 67% of PCPs did not receive notifications before discharge, and when PCPs did receive notifications, the discharge plans were unclear. PCP feedback led to proactive electronic communication and a standardized notification. The key driver diagram allowed the team to design interventions that led to sustainable change. After multiple Plan-Do-Study-Act cycles, delivery of electronic PCP notifications occurred more than 90% of the time. Surveys of pediatricians who received notifications indicated that the notifications were highly valued and aided in the transition of care for these at-risk patients. A multidisciplinary team, including community pediatricians, was key to improving the rate of PCP notification of NICU discharge to more than 90% and transmitting higher-quality information.

Improving the multidisciplinary Team Brief; a trainee led quality improvement project.

Background: The project was developed following the NatSSIPs2 consultation and recent publication to improve patient safety, team working, and efficiency.1 To meet the Team Brief standards and improve their quality we wanted to introduce a formalised approach at the Royal London Hospital. Methods: Quality improvement (QI) methodology was used to guide the project during the ‘CANDLE’ (Curriculum and Delivery Learning Event) regional QI training. A driver diagram was created and stakeholders analysed. The project began in September 2022 with the aim to implement the Team Brief standard by January 2023. Results: A snapshot audit and staff survey were performed in October 2022. Thirteen Team Briefs from a broad range of specialties were audited, and 27 staff members responded to the survey. The results of this were used to define the issues with team brief and to create a multidisciplinary team brief proforma. This was initially trialled over a 2-week period from 16 to 29 November. After the initial trial, the design was refined based on feedback. Well-being was included with individual and team ‘RAG’ (red, amber, green) ratings and inclusion of ‘Greatix’ QR code to encourage reporting of good feedback. Appropriateness of staffing was also recorded. The use of the new proforma was audited between 26 November 2022 and 20 January 2023. Usage was sporadic, only 38% of lists (183/480), except in the orthopaedic trauma theatres where uptake was much higher. The staff in these theatres were interviewed to ascertain why uptake was so good; it was because of nurse in charge adoption. The project was presented at local audit meetings, and a QI celebration event. This led to buy-in from the senior management team. The proforma was reintroduced in February 2023. The project became self-sustaining with recruitment of other members to the QI team and became imbedded in the local culture. Feedback from the most recent theatre audit meeting was excellent. From 20 February to 10 March 2023 the proforma was used in 79.3% (119/150) of main theatre lists. Conclusion: The multidisciplinary Team Brief project has introduced a proforma which has been adopted consistently in theatres and created a self-sustaining change. The proforma includes structured organisational information to improve patient safety and communication but also focusses on team working, psychological safety, and well-being. The CANDLE course for curriculum and delivery of QI supported trainee leadership, teamwork, and delivery of QI. 1.National Safety Standards for Perioperative Care 2. Centre for Perioperative Care. January 2023. Available from https://cpoc.org.uk/sites/cpoc/files/documents/2022-12/CPOC_NatSSIPs2_Summary_2023.pdf (accessed March 2023)

External Service Providers (ESP) Reach-Out Project: How Can Nurses Assist With Improving Patients’ Social, Economic, and Physical Environments?

This project aimed to improve Capital, Coast and Hutt Valley’s cardiology outpatient “nurses” confidence in connecting patients to community support services (Exercise, Food and Nutrition, Medications, Healthy Homes including Power and Gas, Mobility, Social Isolation and Transport) from 46% to 80% by October 2022. The plan-do-study-act (PDSA) cycle is a methodology for rapidly testing change. A baseline of the “nurses” confidence and identification of the types of services needed by patients was established. Follow-up focus group sessions were held with nurses at two hospitals, covering four geographical locations, within the district. The development of a driver diagram translated the high-level improvement goal and identified various causes to help organise the Change Ideas. Not all ideas could be undertaken in the 3-month timeframe. However, Change Idea One—“Help Directory”—was researched and created by the project manager, which is currently a 37-page resource, with seven categories of services, formatted by region (four) that includes links to service providers, referral forms, and printable handouts for patients. The resource was shared with the “nurses” and an incentivised quiz developed to encourage its review. A second anonymous survey was constructed, allowing for a PDSA cycle, to compare confidence levels after having access to the resource. Cardiology outpatient nurses’ level of confidence (quite confident to extremely confident) connecting patients to community support services increased from 46% to 100%. Since completion, the ESP Reach-Out Resource has proven useful to select nurses and, in turn, their patients. The next steps are to escalate to executives within the hospital to seek budget for the development of the resource, including a more environmentally friendly and dynamic resource that is preferably electronic. Once established, it will be promoted within Capital, Coast and Hutt Valley for internal users.

Keep calm and stay warm: a QI project to optimise perioperative temperature control in paediatric anaesthetics at the Evelina London Children’s Hospital

Background: Hypothermia is defined as a core body temperature <36°C.1 Complications of anaesthetic-related heat loss include delayed recovery and increased risk of surgical wound infection.2 Predominantly owing to a smaller weight-to-surface-area ratio,3 this is more common in paediatrics. With ∼45.1%4 of cases involving at least one hypothermic episode, it is vital that body temperature is regularly monitored and corrected throughout the perioperative period. We aimed to increase the percentage of anaesthetic charts with temperatures recorded at the correct time intervals according to the Evelina guidelines for perioperative temperature control by 20% by mid-February 2023. Methods: After an initial shadowing exercise observing temperature recording in practice, we created driver diagrams and completed two PDSA (plan-do-study-act) cycles: 1. a 30-min presentation to key stakeholders on the importance of perioperative temperature control and current local guidelines; 2. we displayed posters containing cycle 1 results and a summarised guideline flowchart. Data were collected over 18 weeks and analysed using descriptive statistics. Results: At baseline, 8.4% of temperature measurements were recorded correctly. After intervention 1, this increased to 8.8% and 13.6% after intervention 2. A 5.2% increase was noted overall. Conclusion: Our results indicate that reminder-based interventions can improve guideline compliance within a short timeframe and at low cost. However, we were unable to reach our aim. A questionnaire distributed to the team revealed that 75% (n=3) felt the interventions provided useful reminders of forgotten information while 56% (n=5) were absent from the presentation. Staff engagement should hence be prioritised in future. Further PDSA cycles may also consider reiterating the guidelines by other means (e.g. attaching reminders to anaesthetic desks). As many commented on paper charts being a hindrance for timely documentation, electronic prompts that indicate when recordings are to be made may also be considered. 1.Hart SR, Bordes B, Hart J, Corsino D, Harmon D. Ochsner J 2011; 11: 259–702.Diaz M, Becker DE. Anesth Prog 2010; 57: 25–333.Nemeth M, Miller C, Bräuer A. Int J Environ Res Public Health 2021; 18: 75414.Görges M, Afshar K, West N, Pi S, Bedford J, Whyte SD, et al. Pediatr Anesth 2019; 29: 27–37

Eliminating Central Line Associated Bloodstream Infections in Pediatric Oncology Patients: A Quality Improvement Effort.

Our SMART aim was to reduce the CLABSI rate by 50% from a baseline of 1.89/1000 central line days to less than 0.9/1000 central line days by December 31, 2021. We created a multidisciplinary team being mindful to identify roles and responsibilities upfront. We developed a key driver diagram and designed and implemented interventions to influence our primary outcome. We implemented interventions and conducted Plan-Do-Study-Act cycles concurrently. We found that performing audits by directly observing tasks rather than auditing documentation resulted in more accurate compliance assessments. As a result, our CLABSI rate improved from 1.89/1000 central line days in 2020 with 11 primary CLABSI to 0.73/1000 central line days in 2021 with four primary CLABSI. Average days between events improved from 30 days in 2020 to 73 days in 2021, and we achieved an unprecedented 542 days CLABSI-free, extending into 2022. Through a multimodal approach and utilizing characteristics of high-reliability organizations, we significantly reduced primary CLABSI, approaching zero in our PHO population and doubling the average days between events. Future efforts will focus on the sustained engagement of all stakeholders and improving our safety culture.