PDSA Cycles Research Articles

Improvement in incident resolution time with implementation of an electronic patient management solution at a community oncology practice.

1578 Background: Value-based care models such as the Oncology Care Model incentivize practices to reduce hospitalizations and emergency department (ED) visits. Texas Oncology found that most ED visits occurred during regular business hours. Prolonged patient call back times were consistently rated poorly on satisfaction surveys and often led to ED visits for symptoms that could be managed in our offices. We partnered with Navigating Cancer (NC) to implement an electronic patient management technology solution. Methods: For each of our 200 locations, call volume was estimated based on clinic volume. We then reallocated or hired dedicated triage nurses and operators. Incoming calls were entered into the NC dashboard by operators as incidents which were routed based on symptom priority following system generated prompts. Incident volumes and resolution times were tracked. We instituted PDSA cycles at all locations with a goal of less than 90-minute resolution of symptom-related incidents Utilizing the electronic dashboard allowed us to continue this initiative during the COVID-19 public health emergency as our staff could work remotely. Nurses were able to document if a potential ED visit was avoided. These data points allowed our practice to establish comprehensive and strategic actions plans for quality improvement. Results: We finalized implementation of the system in February of 2020. Total incidents for 2020 were over 1 million, averaging over 5000 per location. Resolution time for all incidents started at 3.2 hours pre-implementation and improved to 2.2 hours in December of 2020. Resolution times for symptom-related incidents started at 2.3 hours pre-implementation and ended at 1.5 hours in December of 2020 with over 60% resolved under one hour. 8% of symptom-related incidents resulted in definite or probable ED avoidances by nursing assessment. Shortness of breath, vomiting, chills, and weakness were the top symptom types addressed for ED avoidances. Conclusions: An electronic patient management solution with PDSA cycles of quality improvement can markedly reduce call back times, especially for symptom related calls. We believe managing symptoms in a timely fashion will lower ED visits and hospitalizations as well as improve patient satisfaction. We will report on these outcomes once available.[Table: see text]

14 Orthopaedic Post-Operative Elective Proforma

Abstract Introduction Post-operative daily reviews are essential for a safer post-op recovery and must recognise, early, potential complications and prevent their advance. The fast turnover of Junior Doctors and often T&O being their first surgical rotation, leads to a decrease in knowledge of which aspects are important to assess in a post-op patient. The aim of this project was to create a proforma that helps in assessing elective post-op patients and reduce mistakes. Method QI methodology was applied and a proforma was created and made available in every set of notes of elective patients. Awareness was raised about the proforma which was done at the time of the induction of the new doctors which corresponded to separate PDSA cycles. Results Following cycle 1, the adhesion was 98%. VTEP, analgesia, Xray reviewed, examinations were documented in 100% of the patients. The PDSA cycle 2 coincided with the new incoming doctors, despite the efforts, there was poor compliance. The notes were reviewed: VTEP, analgesia and examination were not documented, post-op x-rays were reviewed in 60%. Conclusions The PDSA cycle 2 showed how the proforma increases patient safety with good documentation and should continue to be used by the Department.

906 Implementing and Re-Designing A Virtual Fracture Clinic (VFC) During The COVID-19 Pandemic

IntroductionWe have implemented a VFC model during the COVID-19 pandemic to minimise the number of face-to-face consultations and the risk of transmission.MethodThe VFC was implemented and assessed using 3 PDSA cycles. Initially, a paper referral system was introduced along with treatment pathways. Subsequently an electronic referral system was established. The 3rd PDSA cycle involved training A&E staff on referrals and treatment pathways. At each stage the number of VFC referrals and clinic follow-ups were measured. Patient satisfaction was assessed using a telephone survey with a random sample of 30 patients.ResultsThere was a statistically significant reduction in face-to-face follow-ups between pre-VFC (Total:4083, Average:86.87) and post-VFC (Total:713, Average:35.65) p-value<0.0001. There was a statistically significant increase in patient satisfaction after the implementation of the electronic referral system and staff re-training(9.25) compared to paper referrals(8.23), p-value=0.02064.ConclusionsOur study demonstrated that the VFC successfully reduced the number of face-to-face follow-ups while maintaining patient satisfaction. Thus, it is an effective alternative to conventional fracture clinics. A similar model can be introduced at other hospitals to minimise in-person consultations and risk of transmission, while standardising patient care. It has also highlighted the importance of appropriate technological infrastructure, staff training and service evaluation.

Implementation of a Quality Improvement Project to Increase Access to Dietitian Services for Patients With Gastrointestinal Cancer in a Safety-Net Hospital System.

Rates of malnutrition are high in patients with GI cancer, leading to poor outcomes. The aim of our project was to increase the rate of documented dietitian assessment in patients with GI cancer at Parkland Health and Hospital System from 5% to 25%. Three PDSA cycles were conducted after identifying barriers to dietitian services. A registered dietitian was assigned to the GI oncology clinic during the first cycle, an adapted Malnutrition Screening Tool was implemented through the electronic medical record during the second cycle, and clinical staff training was performed during the third cycle. New patients with GI cancer seen by the registered dietitian had weight, Eastern Cooperative Oncology Group performance status, and serum albumin recorded at initial visit and 3-month follow-up. Paired t tests were performed. Emergency department visits and hospital admissions were also recorded during this time. Through these interventions, the percentage of patients with GI cancer with documented assessment by the registered dietitian increased from 5.1% in October 2018 prior to our interventions to 21.8% in July 2019 and has sustained in the 15%-20% range thereafter. From May to July 2019, there were 63 new patients with GI cancer seen by a registered dietitian. No significant difference was observed in average difference in weight and serum albumin level at initial visit and 3-month follow-up. A nutrition-focused quality improvement project led to a more than three-fold increase in the rate of documented dietitian assessment in patients with GI cancer.

A collaborative method for simultaneous operations: case of an eye clinic

The twofolds purpose of this pilot study is first to integrate process mining with Lean Six Sigma (LSS) in a shared resource environment for performing eye surgery operations requiring local anaesthesia and, secondly for the collaboration and measuring performance by utilising the concept of the “Single Minutes’ Exchange of Dies” for quick changeover. A review of articles employing process mining and LSS carried out has identified the gaps in planning an innovative ‘Collaboration Table’ for doctors. The “Plan, Do, Study and Act Cycle (PDSA)” is applied in this pilot case. While different researchers have been working on the application of process mining in finding bottlenecks for improvement and application of LSS, there is a lack of method and tools that integrate and apply these two approaches under the PDSA cycle. The paper provides a new method ‘Collaboration Table’ developed in MS Excel 2019, integrated with the application of process mining and LSS under the overall PDSA improvement methodology.

Screening for Severe Hypogammaglobulinemia in Lung Transplant Recipients

<h3>Purpose</h3> Severe hypogammaglobulinemia (HG), IgG <400 mg/dL, is associated with increased infections and mortality post-lung transplant (LT). Pre- and post-LT screening is recommended, but optimal protocols have not been determined and practices vary between LT centers. We designed and implemented a screening program to detect severe HG in LT recipients. <h3>Methods</h3> We developed and implemented standard pre-/post-LT IgG screening protocols through iterative PDSA cycles starting 1/1/19. We collected pre-/post- IgG levels for LT recipients between 1/1/94-10/15/20 to measure process outcomes and inform future improvements. <h3>Results</h3> Both pre- and post-LT IgG screening increased after screening protocols were implemented (Table). Of 45 patients who underwent LT between 1/1/17-10/15/20 and had pre-LT IgG checked, 0% (0) had severe HG, 11% (5) HG (IgG 400-700 mg/dL), 9% (4) isolated low IgG subclasses, 4% (2) isolated low IgA, and 13% (6) isolated low IgM. All 5 patients with pre-LT HG, 2 with associated low IgA and/or IgM, developed severe or clinically significant HG post-LT requiring IgG Replacement Therapy (IgG-RT). Of 249 patients who underwent LT before 6/30/20 and had post-LT IgG checked, severe HG rates were 17% (8/48), 7% (4/60), 5% (3/56), 14% (8/56), 11% (6/53), 6% (3/48), 3% (1/34), and 3% (1/35) at 0.5, 1, 2, 3, 6, 12, 18, and 24 months. Median [range] time from LT to severe HG onset was 90 [14-730] days. Time from severe HG onset to recovery was 31 [16-184] days in 9 patients whose severe HG resolved without IgG-RT. IgG-RT was started in 28 patients 212 [0-3533] days after LT per immunology recommendation. Pre-LT IgG (r=0.78, p=0) and IgG3 (r=0.82, p=0) correlated with the lowest IgG level post-LT. Pre-LT CD27+ (r=-0.58, p=0.007) and CD27+IgM+IgD+ (r=-0.52, p=0.02) B cells inversely correlated with the lowest IgG level post-LT. <h3>Conclusion</h3> Implementation of standard HG screening protocols increased detection of severe HG post-LT and revealed novel findings regarding the significance of immunologic abnormalities in LT recipients.

105 Beyond the Bleep: Exploring Alternate Methods of Communication in the Multidisciplinary Team to Facilitate Efficient Discharge

Abstract Introduction On the surface discharging a patient seems a simple a simple process, but delays due to coordination and communication in preparing medication, transport and discharge summaries are all to common. This results in delayed discharge, which is unfair on patients and their families, adds to the risk of hospital acquired infection and increases NHS expenditure and bed pressures. This quality improvement project investigates alternate systems for coordinating this process to make it more efficient and easier for the relevant stakeholders, with the added advantage of being “bleep free” as is the Health Secretary’s target for 2021. Method We started with process mapping and summarising the challenges faced by stakeholders in the current system, which uses bleeps for communication across six older people medical wards and ten medical teams. We progressed to iterative PDSA cycles using Medxnote for one medical team across all wards and then Microsoft Teams on one ward with ten medical teams. New process maps for each were created and circulated to stakeholders to explain the roles and responsibilities of each team. Results Both Medxnote and Microsoft teams subjectively made communication easier. However, Medxnote was hampered by the inability to have a three-person conversation and the required use of personal phones. Microsoft teams overcame these obstacles and was able to demonstrate objective improvements with a 42% increase in medication screened before 1 pm and 72% increase in medications prepared on the day of discharge, suggesting better prioritisation. Team feedback was that it decreased workload, made team members more accessible and minimised interruptions to working day. Conclusions The initial PDSA cycle suggests Microsoft teams is a promising tool for improving the discharge process and aiding bleep free communication amongst members of the multidisciplinary team. The next step will be a trial across all wards with all teams.

50 Using A Targeted Teaching Intervention to Drive up the Quality of Discharge Summaries. Shop 75+

Abstract Background Quality improvement project examining discharge communication, and a targeted teaching intervention. Introduction Poor quality, incomplete or missing discharge summaries (DSs) are associated with avoidable/ameliorable adverse events after discharge [1]; preventable readmission [2,3]; failure to implement discharge plans [4]; and medication continuity errors [4,5]. Methods To review the quality of DSs produced, each month forty representative DSs are randomly selected from four clinical areas and qualitatively assessed (total &amp;gt; 1,000, August 2017—to date). Alongside this, in August 2018, incoming foundation doctors were surveyed on perceptions of the purpose/importance of DSs, and training provided on writing them. They were resurveyed after teaching delivery in November 2018 and April 2019. Interventions Data from QI review and survey were used to generate a teaching intervention, in the form of an interactive slide set for delivery in small group settings. This was delivered in weekly mandatory teaching sessions. PDSA cycles were completed for teaching sessions, and the slide set was developed accordingly. Results After the teaching sessions, we noted improvement in satisfaction with training provided on writing DSs (from 24% to 40%), as well as confidence in writing high-quality DSs (from 28% to 100%). We demonstrated increases in responses including the patient as an intended audience for the DS (from 51% to 84%), and rating “patient information in lay terms” of “high importance” (from 41% to 72%). These changes in perceptions were accompanied by improvement in the quality of DSs produced, particularly with respect to the quality of follow-up actions detailed and the quality of patient information provided in lay terminology. The average monthly proportion of DSs achieving a “great score” in these areas increased from 20% and 28% respectively (August 2017—June 2018), to 44% and 71% (August 2018—March 2019). Conclusions These data provide proof-of-principle that targeted teaching, constructed around prior questionnaire surveys, improves awareness of the purpose of DCs and leads to improvement in the quality of DSs produced and enhanced patient safety.

130 Improving Documentation of Bowel Movement on Geriatric Wards

Abstract Introduction Constipation is a widely prevalent issue in older adults that may result in complications such as urinary retention, delirium and bowel obstruction. Previous studies have indicated that while stool charts are well completed by nursing staff, they are infrequently monitored by doctors. This project aimed to improve the documentation of bowel movement by doctors on ward rounds to 85%, by the end of a 3-month period. Methods Formulation of the project was achieved using group work and a fishbone diagram which focussed on how doctors can improve on documenting bowel movements. Baseline data were collected from inpatient notes on weekdays over a three-week period on a geriatric ward in Northern General Hospital, Sheffield. Interventions of posters and stickers of the poo emoji were placed on walls and in inpatient notes respectively as a reminder. Post-intervention data were collected on weekdays over two weeks, and then repeated a month later to assess for a sustained change. Results The data on bowel activity documentation were collected from 28 patients. The baseline data showed that bowel activity was monitored daily on the ward 56.25% of the time. There was a significant increase in documentation of 85.75% following the interventions. The sustainability study showed that bowel activity was documented on the ward 59.09% of the time. Conclusions This study shows how a strong effect on behavioural change can be accomplished through simple interventions such as stickers and posters. As most wards currently still use paper notes, this is a generalisable model that other wards can trial. However, this study also shows the difficulty in maintaining behavioural change over extended periods of time. Further PDSA cycles should examine the reasons behind the difficulty sustaining the change and implement new changes that aim to overcome them.

59 Improving the Identification and Management of Delirium in Older Surgical Patients

Abstract Local Problem A multidisciplinary team comprising a consultant geriatrician and nurse consultant reviews all patients aged ≥70 years who have an emergency laparotomy at Royal Derby Hospital. Anecdotally there is a high incidence of delirium but retrospective casenote audit found only 19% of patients admitted for emergency laparotomy July 2018–July 2019 were identified as having delirium by the surgical team. Method A first PDSA cycle showed that the 4AT was feasible for use by healthcare assistants on the surgical assessment unit (SAU). A second PDSA cycle, described here, sought to develop a rationale for implementation of the 4AT as part of surgical assessment by comparing true prevalence of delirium using 4AT, with the prevalence detected using methods currently mandated by our hospital. All patients aged ≥65 years admitted as part of the surgical pathway had 4AT completed by a member of our improvement team on admission, with daily review until discharge. Results Data were collected for 111 consecutive emergency surgical admissions. Mean (SD) age was 78.3 (7.7) years. Of these, 1 and 3 were categorised as having delirium and dementia respectively using existing hospital screening tools. Using 4AT, 36 (32%) of patients were identified as having delirium. When supplemented by clinical history, true prevalence was 40 (36%). Average (SD) length of stay was 7 (5.6) days for the whole cohort, 10 (6.5) and 5.3 (4.3) days for those with and without delirium respectively. Conclusions 4AT was 92% sensitive for delirium in our cohort. The existing hospital tool was underutilised to the point of being useless. Patients with delirium had a longer length of stay. We have developed a modified 4AT paper tool and training materials and are now piloting routine use in SAU.

145 Improvement of Bowel Monitoring in the Acute Stroke Unit

Abstract Introduction Constipation can lead to complications such as pain, acute kidney injury and delirium. This problem is more apparent in patients who are aphasic or frail, such as those suffering from stroke or have cognitive impairments. However, early recognition and timely prescription of laxatives can help prevent these complications and prevent unnecessary Per-rectal examination and exposure from radiation with abdominal X-rays. Methods This is a Quality Improvement Project that was carried out in the Acute Stroke Unit in Aberdeen Royal infirmary looking at the effectiveness of bowel monitoring and suggesting methods for improvement with the addition of an end-of-bed stool chart. The aims of the stool charts were to aid junior doctors in timely laxative prescription and to guide fluid management. The project was carried out from April to July 2020 using the PDSA cycle and presented to MDT in the ASU. Results show a 100% improvement in bowel monitoring with 67% compliance rate of the new stool charts. A survey was carried out and results show that 90% of the nursing team preferred the new stool chart. In conclusion, I think that the new stool chart serves its purpose in improving patient management amongst junior doctors. It should be implemented as standard care protocol in the acute stroke unit and definitely can be applicable in other wards.

40 Improving Urinary Catheter Documentation and Care in Geriatric Wards

Abstract Introduction NICE guidelines state that urinary catheter insertion, changes and care should be documented. Duration of catheterization is directly linked to the risk of developing a catheter-associated UTI. Furthermore, Public Health England has announced a national aim to reduce the incidence of Gram-negative bacteraemia by 50% by March 2021, and targeting catheters is one of the first steps. Local problem These issues are relevant to the elderly population at Princess Royal University Hospital, where documentation surrounding catheters was found to be inadequate. Despite there being an Electronic Patient Record (EPR) order for catheter insertion and monitoring available, this was not being used. Our primary aim was for all patients to have this order. We also hoped to reduce the weekly rate of catheter days (catheter days per 100 bed days), and improve documentation in clinical notes. Methods We focused on two medical wards and sampled all patients admitted over a period of 4 months who had a catheter at the time of data collection. We identified catheterized patients and whether they had an EPR catheter order on a daily basis. Additional parameters such as indication, insertion date, inserter, and documentation standards were extracted from EPR on a weekly basis. Patients were kept “live” and contributing to catheter day calculations until they were no longer on the ward or if the catheter was removed. Interventions We implemented changes over 2 PDSA cycles. Interventions included the addition of catheter columns to boards and education sessions for doctors and nurses (cycle 1), as well as catheter posters, alert cards, and circulation of emails with guidance to doctors and nursing staff (cycle 2). Results A total of 87 patients were analysed during the project. There was an increase in EPR orders being used, with the 100% target being reached on the final data collection point, and with data showing a significant shift above baseline. Furthermore, there was a decrease in the weekly rate of catheter days, but changes were difficult to sustain. We also saw a general improvement in documentation standards. Conclusion By improving documentation and reducing unnecessary catheterization, we hope to have reduced the overall risk of infection whilst improving patient comfort and experience. Lessons may be transferrable to other trusts.

75 Community Dnacpr Forms: Opening A Can of Worms

Abstract Background There is no national guidance for the transfer of Do Not Attempt Cardio-Pulmonary Resuscitation (DNACPR) decisions between care settings. This issue has been highlighted within our Integrated Care Trust. We reviewed our local process, to improve the transfer of DNACPR decisions between care settings. Method A third PDSA cycle was completed to evaluate intervention. Intervention Frequently asked questions were added to the reverse side of the DNACPR form to improve patient understanding. All patients discharged home were given this updated form during a pilot study. The impact of the intervention was analysed with a follow-up phone call (n = 30) and discussed at a staff focus group. Results No improvement in patient understanding was shown post-intervention, however the intervention was overwhelmingly supported by staff. 60% of patients reported receiving a DNACPR form on discharge and 12% recalled being informed that they would be discharged home with a form. Conclusion Further work is required on the DNACPR pathway across primary and secondary care. The next cycle will involve ensuring that the community form is highlighted in hospital discussions regarding DNACPR decisions.

67 The Evolution of A Frailty Service

Abstract Introduction In September 2017 our frailty service was started within our medium sized DGH in North Wales. Working with our management team we secured a significant clinical resource including: We describe how resources, setting and staffing develop over a 2 year period in order to create a service which meets the needs of the local population. Method The service has been in a constant state of development since it has been in operation, utilising a PDSA model with regular meetings of clinical and managerial staff to analyse performance. Results With each new PDSA cycle the amount of patients reviewed has increased. With the move to AMU we increased the monthly number of patients reviewed from 29 to 172 patients reviewed, 97 of which were discharged directly from the unit. Conclusion Using QI methodology our Frailty Service has improved dramatically since its inception. We will continue to analyse how we work to improve patient outcomes and cost effectiveness.

159 Antibiotic Omissions: A Missed Dose Means A Missed Chance to Save A Life! Is E-Prescribing the Answer?

Abstract Omissions and delay in antimicrobial therapy are common in acute hospitals with an untowrds impact on patient outcomes resulting in harm and prolong stay. We carried out a Quality Improvement Project (QIP) assessing 2 interventions in PDSA cycles to improve situation. This QIP was done in 3 stages and involved about 80 patients over 7 months. We collected data regarding antibiotic omissions on 3 random separate days which gave baseline omission rate. This was 8.5% and quite higher than the national average (5.3%). The reason for the omissions was not documented on the drug kardexes on most occasions. Initial intervention included staff education, verbally and through posters. Post intervention data was collected again on 3 separate days. This showed improvement and the omission rate fell from 8.5% to 5.6%. The percentage of omissions with no code written reduced from 56.25% to 18.18%. The second intervention included participation in EPMA (Electronic prescribing and medicines administration) pilot on the ward. Post EPMA, the omission rate reduced to 4.59%. All omissions had now a code written. The phenomenon of Antibiotic Omissions is an open challenge and its consequences are serious. We can conclude from our study that educational measures though effective are likely to be short-lived.Therefore, it can be asserted that Electronic prescribing is appropriate solution for antibiotic omissions and it also opens up new horizons for patient safety.

100 Frailty Hot Clinics: Rapid Cga and Speciality Diagnostics Reduces Rates of Hospitalisation and Re-Attendance

Abstract Introduction Acute hospitalisation is associated with an increased risk of progressive frailty, morbidity and subsequent institutionalisation. North Middlesex University Hospital is an Acute District General Hospital with over 550 attendances to A&amp;E per day. Comprehensive Geriatric Assessment (CGA) is the gold standard approach for a holistic multi-disciplinary assessment (MDT) of frail patients. A rapid access daily hot clinic service for frail patients opened using quality improvement (QI) methodology to deliver rapid CGA focusing on admission avoidance and early supported discharge. Method 4 PDSA cycles were conducted. A process map identifying key moments in patient care was derived from time studies of the first 10 patients’ journeys. Patients were triaged through the Geriatrician “hotphone” for acute admissions into the Hot Clinic. Dedicated clinic and waiting rooms were placed on the acute frailty unit (Amber) staffed by a dedicated Consultant Geriatrician and Health Care Support Worker working with the Frailty Ward Clerk, Frailty Specialist Nurse, Therapies, specialities in-reach and same-day diagnostics. A shared clerking proforma and subsequent CGA Discharge Summary were completed and emailed to the referrer the same day. Qualitative and Quantitative feedback was gained from referrers, patients and relatives through a structured questionnaire. Metrics were gathered including rate of admissions, re-attendance and use of enhanced community services. Results From the first 48 Hot Clinic patients, there was a low 30-day re-attendance rate (17%—for unrelated reasons), low 30-day re-admission rates (4%) and low Did Not Attend rate (6%) for new referrals and high satisfaction scores for recommending the service (9-10/10) from patients, relatives and referrers. Conclusions Early rapid MDT can reduce re-attendances and re-admissions to hospital in frail patients. A streamlined patient journey can be delivered by frailty-trained staff and in a suitable environment. QI Methodology enables a structured measurable approach to development of the Acute Frailty Pathway.

69 Continuous and Regular Live Feedback is Required to Maintain An Improvement in the Quality of Discharge Summaries. Shop 75 +

Abstract Background This quality improvement project aims to improve communication between secondary and primary care at the time of hospital discharge of older patients. Introduction Discharge summaries (DS) are a key component of communication between secondary and primary care. Poor quality DS are associated with poorer outcomes in terms of adverse events [1], readmissions [2] and medication errors [3]. There is NICE and AMRC guidance on what constitutes a good DS [4, 5]. Method Prospective review of DS from a range of wards was completed in August 2017 against a detailed data tool. A random selection of DS from the same wards was audited monthly from November 2017 onwards. A novel live-feedback system was introduced to the same wards in February 2018 so that the teams completing DS received feedback on how well their summaries complied with the recommendations and what areas needed improvement. A change in staffing lead to a break in the delivery of monthly feedback to the ward teams from April to September 2019 when it was re-commenced. Results In the majority of areas there has been an increase in the quality of the DS from the beginning of the project until March 2019 when the regular feedback interventions were suspended. There was a decrease in the quality of summaries in July and August 2019, followed by an increase as regular feedback interventions recommenced in September 2019. The aggregate results of the four main components of DS (follow-up actions, medicines, clinical summary, and functional assessment), scored “good” in 13% of DS at baseline, 40% in March 2019, 20% in July 2019 and 31% in October 2019. Conclusions The suspension of regular direct interventions resulted in a significant deterioration in the quality of discharge summaries, and this improved quickly after reintroduction of PDSA cycles in key areas. Continuous quality improvement requires uninterrupted focus on regular live feedback.

P0528 / #493: REDUCING DRUG ERRORS IN THE PAEDIATRIC CRITICAL CARE UNIT: A QUALITY IMPROVEMENT PROJECT

Aims & Objectives: Drug errors cause considerable harm to patients. A recent spot-check on our Paediatric Critical Care Unit (PCCU) revealed a culture of under-reporting errors. By increasing the reporting of errors and implementing change following analysis of the type of errors that occurred, we aimed to reduce drug errors in the PCCU by 30% by February 2020. Methods: Using Quality Improvement (QI) methodology we created a driver diagram and process map using members of the multidisciplinary team to better understand the main areas where drug errors could occur. “Plan, Do, Study, Act” (PDSA) cycles were used to develop and improve the reporting tool, frequency and timing of use. Data collected on a weekly basis included: number of errors per active drug prescription; staffing acuity and monthly Datixes. Change ideas included: reintroduction of a prescribing zone and “Dual Prescribing” followed by PDSA cycles to evaluate them. Results: An increase in errors was initially noted, with an average of 1.1 errors per active prescription. By December 2019 this had decreased to an average of 0.28 errors per prescription. Feedback revealed that “Dual Prescribing” of all new prescriptions by the nurse in charge was too time consuming, but was tolerated by the bedside nurse for their individual patient. In times of busyness it was felt that this would be difficult. Conclusions: Reducing drug errors through the use of QI methodology is possible. Further testing and refining of the current change ideas should result in an improved system of prescribing within the PCCU.

PO504a / #1986: IMPROVING COMMUNICATION WITH LIMITED ENGLISH PROFICIENCY FAMILIES IN THE PICU

AIMS & OBJECTIVES: Children and families with Limited English Proficiency (LEP) have been reported to have worse healthcare outcomes as a result of communication barriers. The objective of this quality improvement study was to increase the frequency and quality of communication with LEP families in the PICU through improved access and functionality of video interpreters. METHODS: Interpretation data from our tertiary PICU were obtained and monitored starting in 2019. A key driver diagram was utilized to develop potential interventions. Multiple PDSA cycles were completed to evaluate interventions including providing written instructions on video interpreter use, obtaining new standardized video interpreter devices, designating standard locations and staff education around effective interpretation. Statistical process control was employed to analyze the number of interpretations per LEP patient per day based on hospital billing data. RESULTS: There were 82 encounters requiring interpretation during the study period, with an average of seven LEP families in the PICU on any given day. During the preimplementation phase (September-December 2019), LEP families received an average of 1.5 interpretations per patient day. After implementation (January-May 2020), LEP families received an average of 2.1 interpretations per patient day. CONCLUSIONS: Targeted efforts towards using interpretation services with LEP families can be an effective way to increase frequency of communication. Technology standardization alone did not increase interpreter use, however standardization along with improved accessibility correlated with an increase in interpreter use. This project was limited by a delay in data of interpretations due to billing processing, and disruption of overall patient census during the COVID19 pandemic.

Improving Glycemic Control in Patients With COVID-19 : A Quality Improvement Project

Abstract Background Diabetes has emerged as an important risk factor for severe illness and death from COVID-19. Reports have shown that diabetes is common among patients hospitalized in the United Kingdom with COVID-19 illness. Despite a preponderance of evidence that diabetes is associated with poor COVID-19 outcomes, there is a paucity of information on inpatient glycemic control among patients with diabetes and acute hyperglycemia hospitalized with COVID-19. Aim This quality improvement project was conducted to evaluate the current practice of glycemic management in hospitalized COVID patients and improve the glycemic control in these patients. Method 2 PDSA cycles were conducted with inability to continue further due to reduction in incidence of disease. This involved data collection regarding glycemic control in COVID-19 patients with diabetes on wards, focusing on the referral to DSN(Diabetes Specialist Nurses) , monitoring of blood glucose levels, management in case blood glucose levels were out of range. Data was also collected about the characteristics of patients. Results First PDSA showed that although in most cases, there were timely referrals to DSN in many cases, the monitoring and management of glycemic excursions was suboptimal in all cases. Blood glucose monitoring was also variable. In the second PDSA cycle, awareness sessions were conducted around glycemic management among medical and nursing staff. A two page document based on local guidance and recommendations of Association of British Clinical Diabetologists was prepared, and posted in the ward. It was also discussed in the handovers for wards. Results are shown in attached graph. Discussion In conclusion, awareness exercise and provision of guideline summary led to some improvement in glycemic control of these patients. Further PDSA cycles could not be done due to decrease in number of admissions.