Post-intervention Audit Research Articles

Engaging the cancer care team in advance care planning.

14 Background: Engagement of oncologists and their care team is essential to ensure advance care planning (ACP) occurs for cancer patients. However, numerous barriers to ACP exists, including the availability of trained staff with competence and confidence to have discussions with patients as well as resources to ensure ACP is effectively and efficiently integrated into the oncology practice. Methods: A baseline audit to determine the presence of documented ACP discussions for patients with metastatic cancer was conducted, followed by a quality improvement program with subsequent reassessment. The baseline audit identified only 20% (10/50) compliance with documentation of such discussions. Subsequently, we joined the Michigan Oncology Quality Consortium’s (MOQC) ACP Collaborative where the care team (MA, RN, PA, MD) were taught how to request and complete a durable power of attorney, conduct ACP conversations, and document pertinent information in a standard EHR location. Results: A one-year post-intervention audit found that 80% (40/50) of patients with metastatic cancer had an ACP documented in their record - a four fold improvement. A post-implementation staff survey noted that the team improved their understanding of both the legal issues and importance of asking about advance directives as well as using the designated chart location to document. 100% of staff agreed or strongly agreed with the statement “I understand the importance of asking patients about advanced directives”. Staff gained confidence in how to talk to patients about advance directives again with 100% of staff agreeing or strongly agreeing with the statement,” I feel more confident now in how to talk to a patient about advanced directives”. Conclusions: It is critical that all members of the oncology care team understand the importance of ACP and that staff feel confident in how to have discussions with patients. While physician/patient discussion is both necessary and expected, patients often discuss their wishes and fears with others in the practice. It is critical that all members of the team understand the importance of and opportunities where they can both support patients’ wishes and direct patients to their oncologist if necessary for further discussion.

Implementation of safe sleep practices in the neonatal intensive care unit.

To increase the percentage of eligible infants engaging in safe sleep practices (SSP) in two level III neonatal intensive care units (NICUs) in the Boston, Massachusetts area. On the basis of eligibility criteria (⩾34 weeks or ⩾1800 g without acute medical conditions), all infants were eligible for two sleep practices: SSP or NICU therapeutic positioning (NTP) depending on their gestational age, weight, clinical illness and need for therapeutic interventions. Compliance with SSP was defined as: (1) supine positioning, (2) in a flat crib with no incline, (3) without positioning devices and (4) without toys, comforters or fluffy blankets. NTP comprised usual NICU care. Nursing education was comprised of a web-based learning module and in-person teaching sessions with a study team member. Double-sided crib cards (SSP one side and NTP on the other) were attached to the bedside of every infant. Pre- and postintervention audits of all infants were carried out at both study sites. We compared compliance across all time points using generalized estimating equations to account for correlated data (SAS v9.3, Cary, NC, USA). Of 755 cases, 395 (52.3%) were assessed to be eligible for SSP. From the pre- to post-intervention period, there was a significant improvement in overall compliance with SSP (25.9 to 79.7%; P-value<0.001). Adherence to each component of SSP also improved significantly following the intervention. Safe infant sleep practices can be integrated into the routine care of preterm infants in the NICU. Modeling SSP to families far in advance of hospital discharge may improve adherence to SSP at home and reduce the risk of sleep-related morbidity and mortality in this vulnerable population of infants.

The effect of teaching on the completeness of the anesthesia record charts for obstetric subarachnoid blocks in a low resource area hospital

Background: Spinal anesthesia is a widely practiced anesthetic technique for cesarean delivery. Record charting and keeping during obstetric spinal anesthesia demand accuracy and completeness for patient's safety, medico-legal and research purposes. This study was conducted to evaluate the effect of teaching on improving audit of the anesthetic record charts for spinal anesthesia in obstetrics. Materials and Methods: We retrospectively reviewed 100 anesthetic charts for spinal anesthesia in the obstetric theatre of our hospital. This was followed by a lecture given by a consultant anesthetist on the importance of the anesthesia record keeping with emphasis on obstetric spinal anesthesia. Immediately after the lecture, post teaching intervention audit of 400 anesthetic charts for obstetric spinal anesthesia in four consecutive periods of 100 charts each were done. Data collected were analyzed with SPSS version 16.0. Results: A total of 500 anesthetic record charts were studied. Average percentage completion of anesthetic charts before the lecture (pre-intervention); first, second, third and fourth audit (post-intervention) were 56.1%, 70.1%, 78.1%, 81.3% and 87.7%, respectively. The level of improvement in the filling of the charts pre- and post-teaching intervention in the elective cases (54.72 vs. 83.69) and emergency cases (48.67 vs. 82.27) were statistically significant respectively (P Conclusion: There was a significant improvement in the adequacy of documentation of anesthetic record chart for obstetric spinal anesthesia after a teaching intervention.

Monitoring of physical health parameters for inpatients on a child and adolescent mental health unit receiving regular antipsychotic therapy.

Physical health monitoring of patients receiving antipsychotics is vital. Overall it is estimated that individuals suffering with conditions like schizophrenia have a 20% shorter life expectancy than the average population, moreover antipsychotic use has been linked to a number of conditions including diabetes, obesity, and cardiovascular disease.[1–4]The severity of possible adverse effects to antipsychotics in adults has raised awareness of the importance of monitoring physical health in this population. However, there is little literature available as to the adverse effects of these medications in the child and adolescent community, which make physical health monitoring in this predominantly antipsychotic naïve population even more important.An expert group meeting in the UK has laid down recommendations in regards to screening and management of adult patients receiving antipsychotics, however no specific guidelines have been put in place for the child and adolescent age group.[5]The aim of this audit was to establish whether in-patients receiving antipsychotics had the following investigations pre-treatment and 12 weeks after treatment initiation: body mass index, hip-waist circumference, blood pressure, ECG, urea and electrolytes, full blood count, lipid profile, random glucose level, liver function test, and prolactin. This is in addition to a pre-treatment VTE risk assessment. These standards were derived from local trust guidelines, NICE guidelines on schizophrenia [6] and The Maudsley Prescribing Guidelines.[7]We retrospectively reviewed 39 electronic case notes in total, of which 24 cases were post intervention. Intervention included the use of a prompting tool. This tool was filed in the physical health files of all patients receiving antipsychotics which was intended as a reminder to doctors regarding their patient's need for physical health monitoring. Professionals involved in the monitoring of such parameters were educated in the importance and purpose of its use. Following this intervention re-audit occurred after 6 and 16 months of the initial audit to establish whether the use of the prompting tool caused any significant change in clinical practice.Overall performance in monitoring physical health parameters was initially poor, however we were able to demonstrate that with the help of a single prompt sheet there was a significant improvement following post intervention audit for the majority of parameters being monitored.

Organizational interventions in response to duty hour reforms.

BackgroundChanges in resident duty hours in Europe and North America have had a major impact on the internal organizational dynamics of health care organizations. This paper examines, and assesses the impact of, organizational interventions that were a direct response to these duty hour reforms.MethodsThe academic literature was searched through the SCOPUS database using the search terms “resident duty hours” and “European Working Time Directive,” together with terms related to organizational factors. The search was limited to English-language literature published between January 2003 and January 2012. Studies were included if they reported an organizational intervention and measured an organizational outcome.ResultsTwenty-five articles were included from the United States (n = 18), the United Kingdom (n = 5), Hong Kong (n = 1), and Australia (n = 1). They all described single-site projects; the majority used post-intervention surveys (n = 15) and audit techniques (n = 4). The studies assessed organizational measures, including relationships among staff, work satisfaction, continuity of care, workflow, compliance, workload, and cost. Interventions included using new technologies to improve handovers and communications, changing staff mixes, and introducing new shift structures, all of which had varying effects on the organizational measures listed previously.ConclusionsLittle research has assessed the organizational impact of duty hour reforms; however, the literature reviewed demonstrates that many organizations are using new technologies, new personnel, and revised and innovative shift structures to compensate for reduced resident coverage and to decrease the risk of limited continuity of care. Future research in this area should focus on both micro (e.g., use of technology, shift changes, staff mix) and macro (e.g., culture, leadership support) organizational aspects to aid in our understanding of how best to respond to these duty hour reforms.

Oral oncolytics: Patient-monitoring improvements in private practice.

215 Background: The use of oral oncolytics is becoming more common. These drugs have their own unique challenges in managing patient initiation, monitoring side effects and adherence. Methods: We conducted a baseline chart audit of patients prescribed oral oncolytics in our private oncology practice followed by a quality improvement program and subsequent reassessment. Information obtained included: prescription date, actual start date and any documented problems with the oral therapy. The baseline audit included patients from may of 2011 to July 2013. Subsequently we joined the Michigan oncology quality consortium’s oral chemotherapy collaborative and initiated the following: office procedures for identification of all patients on oral therapy, use of the Edmonton Symptoms assessment system (ESAS), and a self-care management education program including patient self-monitoring of symptoms with recommended initial treatments. A postintervention audit was conducted from August 2013 to March 2014. Results: We identified 25 patients in the first time period and 13 in the second. In the first time period we found only 13 of the 25 patients had an actual start date documented, and of these 13, 10 had a &gt;/=4 week delay prior to starting therapy, with 3/13 having a 2-4 week delay prior to start of therapy. 12 of the 25 patients discontinued their drug within the first month due to side effects without consulting their physician. After participating in the quality initiative, we identified only one patient without a documented start date, only 1/13 that had a &gt; 4 week delay from prescription date to starting the drug, with 12/13 having a less than 2 week lapse. We also found that there were no patients who discontinued the drug and only one dose reduction as directed by the physician. Conclusions: The introduction of new office procedures to easily identify all patients on oral therapy and improved patient management of symptoms at home with the use of self-care guidelines, and in the office with use of ESAS contributed to greater adherence to oral chemotherapy regimens.

Improving documentation of quality measures in the electronic health record.

Oncology quality measures provide an important tool to evaluate care received by cancer patients. These measures are frequently addressed by oncology nurse practitioners (NPs). NP documentation of quality oncology practice initiative (QOPI) measures in the electronic health record (EHR) is evaluated in this study. NP documentation of specific QOPI measures before and after an educational intervention (EI) was evaluated. EHR shortcuts, called "SmartPhrases," were used to increase efficiency in documentation of these measures. Preintervention chart audits found compliance <80% in the multiple measurement areas. Following the EI, NPs surveyed identified greater understanding of QOPI measures and an interest in using "SmartPhrases" to aid in measure documentation. The postintervention audit demonstrated improvement in all areas addressed during the EI noting the use of "SmartPhrases" based on descriptive findings. NPs play a significant role in providing quality care for oncology patients. By increasing knowledge related to the documentation of quality measures and providing tools to increase the efficiency associated with their documentation, a positive impact can be made in efforts to promote quality patient care.

Application of the WHO surgical safety checklist outside the operating theatre: medicine can learn from surgery

Safety checklists in medicine are designed to identify a potential error before it results in harm to a patient. The World Health Organization (WHO) safety checklist was widely implemented in surgical practice in the UK after significant reductions in death, and peri-operative complications were achieved in eight countries worldwide in the 'Safe Surgery Saves Lives' campaign of 2008. Nevertheless, use of the checklist for invasive medical procedures is not yet routine. Such procedures are becoming ever more complex, necessitating multidisciplinary team management and involving higher-risk patients, with the need for general anaesthesia on occasion. As a result, the potential for error increases and the need for a safety checklist has become more apparent. Such a checklist can be modified to provide a framework for specialty-specific safety checks, enhanced team-working and communication for invasive medical procedures. Following an audit of use of the WHO checklist in 20 cases under general anaesthesia in our quaternary referral cardiac catheterisation laboratory, we discovered use of this safety tool was poor (performed/documented: sign in 30%/40%, time out 10%/15%, sign out 10%/15%) and we identified two 'near miss' incidents within the audit period. We then developed and implemented a modified WHO checklist for the specific challenges faced in the cardiac catheterisation laboratory. Following a staff education programme, a subsequent audit of 34 cases demonstrated improvement in all sections (performed/documented: sign in 91.2%/82.4%, time out 85.3%/76.5%, sign out 73.5%/64.7%) with no patient safety incidents during the post-intervention audit period. Well-designed, procedural checklists may well prove to be of benefit in other areas of interventional medicine.

Urinary Tract Infections: Leading Initiatives in Selecting Empiric Outpatient Treatment (UTILISE).

Overuse of fluoroquinolone antibiotics is associated with outbreaks of methicillin-resistant Staphylococcus aureus and of Clostridium difficile-associated diarrhea and increasing resistance in gram-negative organisms. Over the past decade, resistance of Escherichia coli to ciprofloxacin has increased in the Regina Qu'Appelle Health Region. In August 2011, an exploratory audit of the Regina General Hospital (RGH) emergency department showed that 20% of new antibiotic orders were for fluoroquinolones, and 60% of these new fluoroquinolone orders were for ciprofloxacin. It was postulated that ciprofloxacin was predominantly prescribed for outpatients with urinary tract infection. To develop, implement, and evaluate a best-practice algorithm for the empiric treatment of uncomplicated urinary tract infection in the RGH emergency department, as part of an educational initiative for emergency physicians. A literature review was conducted and local antibiogram data were analyzed to establish a best-practice algorithm for treatment of uncomplicated urinary tract infection in outpatients seen in the emergency department. A chart review was conducted from January to March 2011 to establish a baseline of empiric antibiotic use. An educational strategy targeting emergency physicians described changes in antibiotic resistance patterns in the health region, principles of antimicrobial stewardship, drivers of resistance, and the results of a literature review of best practice for urinary tract infection in outpatients. A post-intervention audit was conducted from January to March 2012 to determine changes in practice. Comparison of results from the post-intervention audit with baseline data showed that adherence to best practice increased significantly, from 41% (39/96) before the intervention to 66% (50/76) after the intervention (odds ratio [OR] 2.81, 95% confidence interval [CI] 1.51-5.25; p < 0.001). There was also a significant change in overall antibiotic selection (OR 0.25, 95% CI 0.11-0.58; p < 0.001). Further analysis suggested that this significant change was driven by a decrease in use of ciprofloxacin, from 32% (31/96) to 11% (8/76). Creation of a best-practice algorithm and education focused on emergency physicians significantly increased adherence to best practice and optimized antibiotic prescribing for outpatients with uncomplicated urinary tract infection by limiting overuse of fluoroquinolones, primarily ciprofloxacin.

G219(P) Improving the use of Phlebotomy Services in A Paediatric Inpatient setting

ContextA Children’s Hospital offers a twice daily phlebotomy service on the General Paediatric ward. At the start of this project, if the phlebotomists were unsuccessful in obtaining a blood sample,...

Audit and Feedback-Focused approach to Evidence-based Care in Treating patients with pneumonia in hospital (AFFECT Study)

Pneumonia is the eighth leading cause of death in Canada. Use of guideline-concordant therapy tempers the development of resistance, decreases health care costs, and reduces morbidity and mortality. The purpose of this study was to optimize the treatment of patients with pneumonia under hospitalist care by focusing on best practice and local antibiogram data. The objectives were to collaborate with a hospitalist representative to optimize in-hospital treatment of patients with community-acquired, hospital-acquired, and health care-associated pneumonia; to complete a baseline audit to determine the proportion of antibiotic orders adhering to the strategy; to present the strategy and baseline audit findings to the hospitalists; to perform a post-intervention audit, with comparison to baseline, and to present results to the hospitalists; to expedite de-escalation to a narrower-spectrum antibiotic; to expedite parenteral-to-oral step-down therapy and promote appropriate duration of therapy; and to determine if a pneumonia scoring system was used. An audit and feedback intervention focusing on pre- and post-intervention retrospective chart audits was completed. Review of pneumonia guidelines and the local antibiogram assisted in identifying the study strategy. A presentation to the hospitalists outlined antimicrobial stewardship principles and described the findings of the baseline audit. Pre- and post-intervention audit results were compared. Local best-practice treatment algorithms were developed for community-acquired pneumonia and for hospital-acquired and health care-associated pneumonia. The pre-intervention audit covered the period December 2011 to January 2012, with subsequent education and audit results presented to the hospitalists in November 2012. The post-intervention audit covered the period December 2012 to January 2013. Adherence to the treatment algorithms increased from 10% (2/21) in the pre-intervention audit to 38% (5/13) in the post-intervention audit. There was a trend to reduced duration of therapy in the post-intervention group. An audit and feedback intervention related to hospitalists' prescribing for pneumonia increased adherence to local best practice.

Improving the use of phlebotomy services in a paediatric inpatient setting.

The aim of this project was to improve the use of the current Paediatric Phlebotomy service. The main problem identified was the lack of a system to notify medical teams of unsuccessful blood requests. A phlebotomy process map was constructed to help analyse reasons why failure to notify occurred. Pre and post intervention audits were conducted using the number of unsuccessful blood requests notified as a baseline measurement. The initial intervention was modified based on feedback during the process. A 44% improvement in the number of unsuccessful blood requests notified and a potential cost savings of £6240 was demonstrated in the post-intervention audit. Further work is required as to whether these improvements can be increased, sustained and be cost effective.

Hand hygiene in the nursery during diaper changing

This project aimed to improve hand hygiene practice during diaper changing among nurses working in the nursery. This project was conducted in one of the nurseries in a 935-bed acute care hospital with a sample of 15 nurses. A pre- and post-intervention audit was conducted utilising the Joanna Briggs Institute Practical Application of Clinical Evidence System and Getting Research into Practice module. A revised written workflow, which specified the occasions and process for hand hygiene during diaper changing, was introduced. Modifications to the baby bassinets and nursery were made after barriers to good hand hygiene were identified. The project was carried out over 4 months, from March to June 2011. The post-intervention audit results show an improvement in performing hand washing after changing diapers (20%) and performing the correct steps of hand rubbing (25%). However, the compliance rates decreased for the other criteria that measured whether hand rubbing or hand washing was performed prior to contacting the infant and after wrapping the infant, and whether hand washing was performed correctly. The improvement in compliance with hand washing--the main focus of the new workflow--after changing diapers was especially significant. The results indicated that having a workflow on the occasions and process for hand hygiene during diaper changing was useful in standardising practice. Pre- and post-implementation audits were effective methods for evaluating the effect of translating evidence into practice. However, this project had limited success in improving compliance with hand hygiene. This suggested that more effort is needed to reinforce the importance of hand hygiene and compliance to the proposed workflow. In addition, this project showed that for change to take place successfully, environmental modifications, increased awareness and adequate communication to every staff member are essential.

Intravenous fluid use in the acutely unwell adult medical inpatient: improving practice through a clinical audit process

Our Trust developed a clinical guideline to improve the prescribing and use of intravenous (IV) fluids based on the British consensus guidelines on IV fluid therapy for adult surgical patients. We audited the effect of targeted interventions to improve performance against this guideline. There were 53 IV fluid prescription charts in the pre-intervention audit and 48 in the post-intervention audit. Data was collected on the seven local practice standards ('local gold standards') in the clinical guideline; compliance with all of them was necessary to meet the IV fluid prescribing bundle of care. The proportion of prescriptions which met the IV fluid prescribing bundle of care increased (3.8% to 22.9% [p=0.004]) and the legibility of the IV fluid prescription increased (28.3% to 56.3% [p=0.004]). We have shown that the process of prescribing, administering and monitoring IV fluid use can be significantly improved through a range of targeted multi-disciplinary interventions.

Impact of a structured template and staff training on compliance and quality of clinical handover

IntroductionChange in junior doctors working pattern has brought effective and safe clinical handover into a central role to ensure the patient safety and high quality care. We investigated whether the compliance and quality of clinical handover could be improved through the use of a standardised and structured handover template. MethodsA computerised template was developed in accordance with handover guidelines provided by the Royal College of Surgeons of England. Pre- and post-intervention audits against an eleven-point dataset pertaining to the handover of acute surgical admissions were undertaken. The results from the two discrete audits periods were compared to examine the impact of intervention. ResultsThere were 137 acute surgical admissions during pre-intervention and 155 admissions in post-intervention audit period. A significant improvement in overall handover practice was observed in post-intervention period. The documentation of patient hospital number (84 (61%) vs. 132 (85%) p < 0.001), past medical history (39 (28%) vs. 75 (48%) p < 0.001) and patient assessment by a senior member of the on-call team (3 (2%) vs. 125 (85%) p < 0.001) all demonstrated significant improvements upon use of structured template. Compliance to effective handover improved following increased awareness of the importance of safe clinical handover among the junior doctors. ConclusionImplementation of a standardised guideline-based structured handover template and training of junior doctors are likely to improve compliance to agreed standards, promote quality of care, and protect patient safety.

Simple approach to improving vancomycin dosing in intensive care: a standardised loading dose results in earlier therapeutic levels

Patients in the Intensive Care Unit (ICU) often have sub-therapeutic vancomycin levels in the initial stages of therapy. Loading doses have been demonstrated to overcome this problem. The aim of this study was to determine the impact of a standardised loading dose and increased clinician awareness of under-dosing on the achievement of early therapeutic vancomycin trough concentrations in the ICU. A pre- and post-intervention observational study was conducted in the ICU following the introduction of a 2-g vancomycin loading dose and demonstration of local under-dosing. All initial vancomycin trough levels were examined, except those from neurosurgical patients. Primary outcome measures were the proportion of patients achieving therapeutic vancomycin levels and mean trough concentrations. A year after introduction, a review was conducted to further assess the impact and sustainability of the intervention. There were 31 courses of vancomycin in the pre-intervention period (no loading doses given) and 21 courses in the post-intervention period, of which 11 had a loading dose. In the pre-intervention group, 13% of courses achieved therapeutic concentrations. This increased to 33% in the post-intervention group (P= 0.08). A statistically significant increase in mean trough concentration, from 9.8 ± 6.6 mg/L to 14.9 ± 6.3 mg/L (P= 0.01), between the pre- and post-intervention groups was observed. During the follow-up period, results were similar to the post-intervention audit. A standardised loading dose is a simple and sustainable intervention that may improve early achievement of therapeutic vancomycin levels in critically ill patients. The clinical significance of this requires further study.

Operational, Quality, and Risk Management in the Transfusion Service: Lessons Learned

For general health care, the difference between quality and safety has been unclear for measurable patient outcomes. In contrast, in the transfusion service (TS), the relationship between quality and safety has been direct and demonstrable. Case studies are summarized to illustrate the relationship between operations, quality management, and risk management in the TS. In blood availability for elective surgery over 3 audited intervals, the incidence of patients undergoing elective surgery without available crossmatched blood that had been requested was 1:333, 1:328, and 1:225 for pre-quality improvement, post-quality improvement, and subsequent postintervention audit assessment, respectively. In event discovery reports (EDRs) over 2 years, incidence of biologic product deviation reports (Food and Drug Administration reportable) was successfully reduced from 60 biologic product deviation reports (12%) of 507 EDRs in 2009 to 42 (12%) of 336 EDRs in 2010. In wrong blood in tube, 102 specimens were identified (by a change in patient's ABO/Rh) from 176,711 type and screen/cross-match specimens received over a 5-year interval, detected either by previous patient record of ABO/Rh or by a second specimen for blood type confirmation implemented in our TS for the last 3 years. No known cases of "mismatched" red blood cell transfusion have occurred during this interval. There is an inverse relationship between resources/time expended on quality and risk management relative to volumes of operations in the TS. Laboratory-based initiatives that improve patient safety and clinical outcomes need to have resources aligned with the personnel and time required for quality management and risk management.

The effect of a dietetic/speech and language therapy assistant practitioner on compliance with nutrition screening targets on an acute stroke unit

Background: Dietetic support on the acute stroke unit (ASU) at Southampton General Hospital (SGH) includes a dietetic/speech & language therapy assistant practitioner (AP). This post offers dedicated time to enable nutrition screening and subsequent care planning. National Institute of Health & Clinical Excellence (NICE) guidance (2006) and Trust policy states that all patients admitted to hospital should be assessed for risk of malnutrition using a validated tool such as the the Malnutrition Universal Screening Tool (MUST). The ASU was not achieving the standard of 100% compliance and intervention was needed to improve performance. The aims of the project were to develop a programme of intervention to improve compliance and to demonstrate any change by pre- and post-intervention audit. Methods: An audit tool was developed and a monthly audit programme commenced. Nursing staff were kept informed of results through posters displayed on the ward. Formal, ward-level teaching sessions were introduced; however, there was limited uptake and so the AP sought a high level of visible presence on the ward and started a programme of 1 : 1 teaching. Ward staff responded well to this more individualised, practical approach: they welcomed the support of the AP and availability for demonstrations when screening patients. This improved screening frequency and referrals to the Dietetic service for ‘high-risk’ patients were actioned quickly. This helped to ensure early nutritional intervention and the positive impact of screening could be seen by ward staff. This fostered an improved attitude to the use of the MUST. Results: Table 1 shows a steady, upwards trend over the 18 month period. Initially, only 11% of patients were being screened for malnutrition. At 6 months, this had risen, and over 60% of patients were being weighed and screened using the MUST. At 9 months, 100% of patients were both weighed and screened. Compliance remained high over the next 6 months. When the project began, compliance was low and nursing staff had not had recent education on nutrition screening. During the last 10 months of data collection, compliance fell below 90% only three times. This was explained by ward closures for infection control reasons and because of the hoist weighing scales being out of order. ‘Appropriate’ patients only were included in the results: those excluded were those who had been on the ward for <24 h, had not been assessed by the physiotherapists and could therefore not be mobilised and those deemed too acutely unwell by the Doctors for Therapist intervention. As a result of this project, discussions around the MUST have increased on the ASU and the MUST now has a place in the initial admission pack. Table 1. Percentage of patients being weighed and assessed with MUST over 18 months Month % Patients weighed % Patients screened August 2009 36 11 February 2010 64 61 May 2010 100 100 June 2010 70 65 July 2010 95 95 August 2010 100 100 September 2010 68 58 October 2010 95 89 November 2010 100 95 Conclusions: The role of the AP on the ASU is a unique one. It allows a practical and individual focus that has improved MUST-related awareness and skills amongst ward staff and supported a significant improvement in compliance with national and local standards of good clinical practice on the ASU. Reference: NICE (2006) Nutrition Support for Adults: Oral Nutrition Support, Enteral Tube Feeding and Parenteral Nutrition (Clinical Guideline 32). http://www.nice.org.uk.

Color-Coding and Human Factors Engineering to Improve Patient Safety Characteristics of Paper-Based Emergency Department Clinical Documentation

Investigators studied an emergency department (ED) physical chart system and identified inconsistent, small font labeling; a single-color scheme; and an absence of human factors engineering (HFE) cues. A case study and description of the methodology with which surrogate measures of chart-related patient safety were studied and subsequently used to reduce latent hazards are presented. Medical records present a challenge to patient safety in EDs. Application of HFE can improve specific aspects of existing medical chart organization systems as they pertain to patient safety in acute care environments. During 10 random audits over 5 consecutive days (573 data points), 56 (9.8%) chart binders (range 0.0-23%) were found to be either misplaced or improperly positioned relative to other chart binders; 12 (21%) were in the critical care area. HFE principles were applied to develop an experimental chart binder system with alternating color-based chart groupings, simple and prominent identifiers, and embedded visual cues. Post-intervention audits revealed significant reductions in chart binder location problems overall (p < 0.01), for Urgent Care A and B pods (6.4% to 1.2%; p < 0.05), Fast Track C pod (19.3% to 0.0%; p < 0.05) and Behavioral/Substance Abuse D pod (15.7% to 0.0%; p < 0.05) areas of the ED. The critical care room area did not display an improvement (11.4% to 13.2%; p = 0.40). Application of HFE methods may aid the development, assessment, and modification of acute care clinical environments through evidence-based design methodologies and contribute to safe patient care delivery.

Venous thromboembolism prophylaxis guideline implementation is improved by nurse directed feedback and audit

BackgroundVenous thromboembolism (VTE) is a major health and financial burden. VTE impacts health outcomes in surgical and non-surgical patients. VTE prophylaxis is underutilized, particularly amongst high risk medical patients. We conducted a multicentre clinical audit to determine the extent to which appropriate VTE prophylaxis in acutely ill hospitalized medical patients could be improved via implementation of a multifaceted nurse facilitated educational program.MethodsThis multicentre clinical audit of 15 Australian hospitals was conducted in 2007-208. The program incorporated a baseline audit to determine the proportion of patients receiving appropriate VTE prophylaxis according to best practice recommendations issued by the Australian and New Zealand Working Party on the Management and Prevention of Venous Thromboembolism (ANZ-WP recommendations), followed by a 4-month education intervention program and a post intervention audit. The primary endpoint was to compare the proportion of patients being appropriately managed based on their risk profile between the two audits.ResultsA total of 8774 patients (audit 1; 4399 and audit 2; 4375) were included in the study, most (82.2% audit 1; and 81.0% audit 2) were high risk based on ANZ-WP recommendations. At baseline 37.9% of high risk patients were receiving appropriate thromboprophylaxis. This increased to 54.1% in the post intervention audit (absolute improvement 16%; 95% confidence interval [CI] 11.7%, 20.5%). As a result of the nurse educator program, the likelihood of high risk patients being treated according to ANZ-WP recommendations increased significantly (OR 1.96; 1.62, 2.37).ConclusionUtilization of VTE prophylaxis amongst hospitalized medical patients can be significantly improved by implementation of a multifaceted educational program coordinated by a dedicated nurse practitioner.