Implementation Of Proforma Research Articles

647 VTE Prophylaxis Protocol Compliance Post Elective Lower Limb Arthroplasty

Abstract Aim Venous thromboembolism (VTE) is a common post-operative complication, and it is essential for surgical departments to ensure adequate prophylaxis is provided. A single centre DGH introduced a new proforma to be filled out at the time of operation. This audit aims to evaluate compliance with the proforma and its correlation to prophylactic prescription and postoperative VTE rates. Method A retrospective study was conducted for 524 patients undergoing elective lower limb arthroplasty between August 2020 and August 2022. Clinical notes were reviewed for of a) presence and completeness of proforma and b) clear documentation of prophylaxis. 30-day post-operative re-admission rates, associated complications, incidence of VTE, and deaths within 90 days of surgery were also reviewed. Results 335 patients underwent an elective lower limb arthroplasty after the proforma was implemented in August 2021 of which 321 (95.8%) had the proforma in their clinical care forms. Of these, 56/321 (17.4%) forms were filled. All patients had documented VTE prophylaxis prescriptions and 438/524 (83.6%) were clearly described/'complete'. Of those incomplete, 74/86 (86%) were recorded after August 2021. There was 1 confirmed incidence of VTE within 30 days which occurred after proforma implementation. 9/18 surgeons (50%) practiced completing the proforma but 0/18 used it consistently. Conclusions There was poor compliance with the proforma but low incidence of VTE rates. Overall, the proforma did not affect VTE rates. In fact, there is the impression that reliance on the proforma worsened quality of documentation of VTE prescription required in operation notes. This suggests implementation of this proforma was negative.

Improving Orthopedic Documentation Using Post-Operative Note Proformas: A Quality Improvement Study.

Accurate medical documentation is important in the perioperative period, ensuring the safe transfer of information between teams involved in the surgical patient's care. This has been highlighted by multiple standards of care guidelines within the United Kingdom. The use of standardized pre-templated documents has displayed significant success in minimizing errors during the admission and operative stages. The aim of this study is to evaluate whether a similar proforma for the post-operative stage is successful in orthopedic patients. A retrospective review of 25 consecutive orthopedic elective patients was conducted during the first cycle. Exclusion criteria included patients who were under 16, day case procedures, and admission due to trauma. The second cycle consisted of a prospective review of 25 patients a month following the implementation of the new proforma. Both cycles were scored against 10 inclusion parameters as outlined by national guidelines. Implementation of the proforma resulted in a significant improvement in post-operative note compliance. A total of six parameters showed a statistically significant improvement (p<0.05). This included wound assessment (58.3%-100%, p<0.001), post-operative imaging (37.5%-92%, p<0.001), neurovascular assessment (83.3%-100%, p=0.017), National Early Warning Score (25.0%-100%, p<0.001), venous thromboembolism prophylaxis (29.2%-96.0%, p<0.001), and antibiotic administration (4.2%-84.0%, p<0.001). Monitoring of important clinical parameters significantly improved following the implementation of the post-operative proforma. These results will hopefully cause the introduction of other proformas in other surgical specialties and other units.

Implementation of physical examination pro forma – a complete audit cycle

AimsAim of this audit is to achieve and maintain 100% compliance in physical examination on admission.BackgroundConducting physical examination on admission is a mandatory requirement and is monitored by the Mental Health Commission during yearly inspections. A report published by Inspectorate of the Mental Health Commission recently in 2019 identifies a gap in physical health monitoring. We conducted a complete audit cycle in an inner city hospital psychiatric ward to monitor compliance with physical examination on admission.MethodWe based the audit on Judgment Support Framework (JSF) version 5 standards. A retrospective review of all of the patient's medical records was carried out. 13 medical records were reviewed in the first cycle. The results of the first cycle were presented to the Multi Disciplinary Team (MDT) members, including the Non-Consultant Hospital Doctors (NCHD). Physical health policy was reviewed, in consultation with the committee and Clinical Director, a Physical Examination pro-forma (colour coded) was developed and implemented. It was based on the National Guidelines and the JSF ver.5. All members of the MDT and NCHDs were briefed on the pro forma introduced. A repeat audit cycle was conducted of all patients admitted after first audit cycle. Data were collected using a simple audit tool indicating if physical examination was conducted or refused.ResultA total of 22 medical records were audited. 13 medical records in the first cycle indicted only 3 patients had physical examination on admission. However, prior to admission a total of six patients had physical exam in the Emergency Department (ED). Upon implementation of the pro forma, 9 medical records of all patients admitted post-first cycle were audited. A total of 7 patients had physical examination on admission to the ward. Two patients refused physical examination and this was clearly documented. One patient had physical examination completed in ED. All newly admitted patients had physical examination completed or the reason why it wasn't completed documented clearly.ConclusionPhysical examination pro forma was successfully implemented, raising current compliance to a 100%, with a significant improvement from 23% compliance in the first cycle. Existing pro forma is helpful as a reminder to NCHDs. Colour coding of pro forma improves accessibility and distinguishability during the process of admission and auditing. Physical examination pro forma will be audited every 6 monthly.

An audit to identify adherence of laparoscopic appendicectomy operation notes to Royal College of Surgeons Good Surgical Practice standards

Appendicitis is the most common abdominal emergency in England accounting for 40,000 admissions per year. The Good Surgical Practice guideline by Royal College of Surgeons England (RCSEng) defines criteria detailing what constitutes a safe and comprehensive operation note. High-quality operation notes enable continuity of care and safe post-operative management. (1) Assess whether laparoscopic appendicectomy operation notes are adherent to RCSEng criteria. (2) Implement an operation note proforma to improve adherence. (3) Re-audit to assess effectiveness of operation note proforma. A retrospective audit was performed measuring compliance of laparoscopic appendicectomy notes to RCSEng criteria over a 4-month period at a central London tertiary care centre. A laparoscopic appendicectomy operation note proforma was designed and implemented. Compliance to RCSEng criteria was then re-audited against RCSEng criteria, and statistical analysis performed to assess the significance of changes to compliance. The average compliance with the RCSEng guidelines after the first cycle retrospectively was 56.1%. The average compliance after implementation of the proforma was 98.2%, with above 80% of operation notes satisfying all RSCEng criteria. This was a significant 42.1% (p<0.0001) increase in average compliance. The implementation of the proforma reduced the amount of hand-written information, saving time and improving legibility of the operation notes. The implementation of an operation note proforma has the ability to significantly improve operation note quality. This simple and effective intervention to improve operation note quality has the potential to improve post-operative safety and continuity of care post laparoscopic appendicectomy.

The surgical admission proforma: the impact on quality and completeness of surgical admission documentation.

Inadequate medical documentation has been associated with a higher rate of adverse events and may have medicolegal consequences. An accurate admission note is critical as it is frequently referred to during inpatient stay, particularly when the patient is acutely unwell and during handover of care. We set out to implement a surgical admission proforma and evaluate its impact on the quality of acute surgical admission notes. A standardised, structured admission proforma for use with all emergency general surgery patients in a busy model 3 hospital was designed and implemented. Previously, all admission notes were performed freehand. The quality and completeness of admission notes was evaluated both before and after implementation of the proforma over two separate 4-week periods by assessing documentation across 19 criteria. Two hundred and fifty-one admission notes before proforma implementation and 273 admission notes after implementation were assessed. Proforma uptake was 97%. Documentation improved in all 19 criteria, with statistical significance achieved in 17 of these. These include past medical history, medication lists, allergy status, physical examination findings, blood results, vital signs and management plan. The proforma showed evidence of improved communication with both nursing staff and senior colleagues. The surgical admission proforma has significantly improved the quality and completeness of admission documentation, ensuring improved patient safety and efficiency of care. Structured admission proformas have a positive impact on patient outcomes, doctors' performance, hospital efficiency, communication and audit quality control, thus providing multiple clear benefits in comparison to freehand admission notes.

Can the completeness of radiological cancer staging reports be improved using proforma reporting? A prospective multicentre non-blinded interventional study across 21 centres in the UK

ObjectivesFollowing a diagnosis of cancer, the detailed assessment of prognostic stage by radiology is a crucial determinant of initial therapeutic strategy offered to patients. Pretherapeutic stage by imaging is known...

Intervention to improve management of acute hepatitis C infection in a UK sexual health clinic.

A case note review was conducted for all newly-diagnosed acute hepatitis C virus (HCV)-infected patients attending our sexual health clinic pre- and post-implementation of an HCV clinic proforma between January 2010 and September 2016. In total, 87 patient notes were included (40 pre-intervention, 47 post-intervention) of whom 81 were HIV-positive. Data were collected regarding documentation of the following: baseline investigations, four-weekly HCV viral load monitoring, risk assessment, partner notification, advice given and Public Health England (PHE) notification. Appropriate baseline investigations, four-weekly monitoring of HCV viral loads, risk assessment and advice documentation all improved in the post-intervention group when compared to pre-intervention. PHE notification and partner notification remained below the national standard post-intervention, with educational measures among relevant staff implemented accordingly. This audit demonstrates improvement across several key areas post clinic proforma implementation.

Completeness in clerking: The surgical admissions proforma.

BackgroundThe accessibility of surgical patient data is a key safety concern, and relies on efficient clerking and handovers. This project assessed whether the introduction of a surgical clerking proforma improved the recording of patient information in the surgical admissions unit (SAU) at Northwick Park Hospital.Materials and methodsExisting patient notes were assessed on content and ease of access, using two independent surveys conducted over a 5-day period. The first survey audited patient notes before (n = 28) and after (n = 23) the introduction of the proforma. It assessed whether key patient details were documented, in line with the 17 criteria set out in the Guidelines for Clinicians on Medical Records and Notes by The Royal College of Surgeons in England. The second survey questioned healthcare professionals before (n = 25) and after (n = 17) proforma implementation on the accessibility of patient data and coherency of patient notes.Results5 of the 17 criteria showed significant differences post proforma implementation. Of these differences, the recording of height and occupation was most notable (p < 0.01). Medication history, weight and investigations also showed significant increases in documentation (p < 0.05). In all 3 questions asked to healthcare professionals, fewer healthcare professionals were required to revisit archived notes following proforma implementation (p < 0.05).ConclusionOur study illustrates that a comprehensive surgical clerking proforma improves patient data documentation and saves healthcare professionals' time compared to the freehand clerking method. The implications of such work are far reaching, and if well implemented could allow a new reliable platform for further clinical audits.

Improving quality of medical admission clerking and validation of medical assessment proforma, complete audit cycle1

Deficiencies in medical clerking could have significant impacts on patient-centred care, medico-legal issues and accuracy of medical coding. The latter could have various disadvantages of false underestimation of complexity of a patient's conditions, inaccurate mortality statistics as well as inadequate financial reimbursement to individual medical units in the era of activity-based funding. We aimed to find areas of deficiency in documentation in acute medical admissions and intervene to improve those deficiencies. We planned to complete an audit cycle. Review of guidelines and legislations relevant to medical documentation was conducted to establish a gold standard, which resulted in creation of a questionnaire as audit tool. The answers to the questions were among Yes/No/Not applicable. Ninety case notes were audited against the questionnaire by an auditor and areas of deficiencies were identified. To address those deficiencies using the above-mentioned standards, a Medical Assessment Proforma was constructed and implemented for a prospective trial of 3 months. As a secondary measure and to facilitate clinical handover among all disciplines, a section for ISBAR handover was added to the front page of the proforma. The staff got educated regarding the new proforma. At the end of the trial period, using the original audit tool, another audit was conducted on 90 patients to assess thoroughness of documentation on the new proforma. The results were analysed using a Chi-squared test; the significant level was taken as P < 0.05. The implementation of the admission proforma led to statistically significant improvement in details of the clerking in the following areas: None of the items were more accurately documented prior to implementation of the proforma. There was a 100% compliance with documenting ISBAR handover section on the front cover of the proforma which is expected to improve structured clinical handover. Utilizing a standard medical admission proforma significantly improved overall documentation on admission to the acute medical unit. This is expected to enhance the quality of patient care, decrease medico-legal risks to medical patients, generate more accurate funding for medical units and decrease the risk arising from coding errors.

PTU-287 Abdominal paracentesis – improving practice with a multi-disciplinary proforma

Introduction Abdominal paracentesis is a common procedure performed both on Gastroenterology wards and as a day procedure. Although Foundation Doctors and Core Medical Trainees do not have to be independent at this procedure for satisfactory progression of training, 1,2 it is an important part of any Gastroenterology rotation. Furthermore it is an essential sign-off for CCT in General Internal Medicine. Within the Core Medical Training curriculum it is identified as a “potentially life-threatening” procedure. 2 We sought to assess trainees’ attitudes to the procedure and implement a proforma to help improve both confidence in performing the procedure and documentation. Method Foundation doctors and Core Medical Trainees were surveyed about their attitudes towards abdominal paracentesis both before and after the implementation of a multi-disciplinary proforma. The survey consisted of four questions with free text responses: trainees’ confidence in performing the procedure, common worries about the procedure, what has previously gone wrong and whether a proforma would be useful. Documentation of important steps in the procedure and results were audited both before and after implementation of the proforma. Results Only 25 percent of respondents were confident in performing abdominal paracentesis independently and 67 percent of respondents felt a proforma would be useful. Common areas of uncertainty were surrounding bleeding risk and regimes of albumin replacement. Documentation of many key steps in the process of abdominal paracentesis was poor; following the introduction of the proforma documentation rates hit 100% for steps including informed written consent, number of passes to insert the drain and assessment of bleeding risk. The proforma was well received with 100% of respondents, both medical and nursing colleagues, agreeing it was a useful addition. Conclusion Introduction of a simple, multi-disciplinary proforma has improved documentation in abdominal paracentesis. In addition, it clearly sets out best practice and addresses many of the concerns identified by junior doctors. Disclosure of interest None Declared. References UK Foundation Programme Training Curriculum file:///home/chronos/u9d51564d35947b93f52a5afa31247c656f09b206/Downloads/Fp_Curriculum_2012_updated_for_2014_WEB_FINAL.pdf Specialty Training Curriculum for Core Medical Training, JRCPTB http://www.mrcpuk.org/sites/default/files/documents/2009-CMT-Curriculum

Towards a Risk Governance Culture in Flood Policy—Findings from the Implementation of the “Floods Directive” in Germany

The European Directive on the Assessment and Management of Flood Risks is likely to cause changes to flood policy in Germany and other member states. With its risk governance approach, it introduces a holistic and catchment-oriented flood risk management and tries to overcome shortcomings of the past, such as the event-driven construction of mainly structural measures. However, there is leeway for interpretation in implementing the directive. The present paper gives an overview on the implementation of the floods directive in Germany and is divided into two qualitative empirical case studies. Case Study I investigates the level of acceptance of the floods directive among decision-makers in the German part of the Rhine river basin. Findings show that the federal states respond differently to the impulse given by the floods directive. Whereas some decision-makers opt for a pro-forma implementation, others take it as a starting point to systematically improve their flood policy. Case Study II presents recommendations for a successful implementation of flood risk management plans that have been developed within a project for the water authority in Bavaria and might be interesting for other federal/member states. For a participation of the interested parties on the level of shared decision-making, the planning process has to work on sub-management-plan level (15–20 communities). The water resources authority has to adopt a multi-faceted role (expert, responsible or interested party depending on the discussed topics).

Does the Introduction of a COPD Pro-Forma Improve the Standards of Care Delivered by Junior Doctors in the Emergency Department

ABSTRACTAim: To determine if pro-forma based management improves standards of care delivered by junior doctors in chronic obstructive pulmonary disease (COPD) patients in the Emergency Department (ED). Introduction: National COPD audits have found large variations in ED standards of care compared to guidelines. They concluded that the publication of guidelines itself does not translate to an improvement in care. Method: A pro-forma based on the British Thoracic Society Guidelines on COPD, 1997, NICE Guidelines CG12, 2004 and Non Invasive Ventilation (NIV), 2002 was devised and implemented following targeted education. Data were collected pre and post pro-forma implementation and analysed. The primary end point was categorisation of respiratory failure as it was felt that this concept was fundamental in COPD management. Secondary endpoints included the administration of controlled oxygen, repeat blood gases and appropriate referral for NIV. Results: There were a total of 55 patients in each group. The correct categorisation of respiratory failure improved significantly from 4% in the pre- compared to 89% (p < 0.0001) in the post-intervention group. Similarly the administration of controlled oxygen (47% compared to 92%, p < 0.0001), repeat arterial blood gases (50% compared to 83%, p = 0.0098), and appropriate referral for NIV (33% compared to 100%, p = 0.0023) showed significant improvement after the pro-forma was introduced. Conclusion: Pro-forma aided management significantly improves the standards of care in COPD patients in the ED.

Decision support and disease management: a logic engineering approach.

This paper describes the development and application of PROforma, a unified technology for clinical decision support and disease management. Work leading to the implementation of PROforma has been carried out in a series of projects funded by European agencies over the past 13 years. The work has been based on logic engineering, a distinct design and development methodology that combines concepts from knowledge engineering, logic programming, and software engineering. Several of the projects have used the approach to demonstrate a wide range of applications in primary and specialist care and clinical research. Concurrent academic research projects have provided a sound theoretical basis for the safety-critical elements of the methodology. The principal technical results of the work are the PROforma logic language for defining clinical processes and an associated suite of software tools for delivering applications, such as decision support and disease management procedures. The language supports four standard objects (decisions, plans, actions, and enquiries), each of which has an intuitive meaning with well-understood logical semantics. The development toolset includes a powerful visual programming environment for composing applications from these standard components, for verifying consistency and completeness of the resulting specification and for delivering stand-alone or embeddable applications. Tools and applications that have resulted from the work are described and illustrated, with examples from specialist cancer care and primary care. The results of a number of evaluation activities are included to illustrate the utility of the technology.