Risk Assessment Documentation Research Articles

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

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

EP349 - Use of Pre-operative Risk and Frailty Assessment in patients undergoing Emergency Laparotomy

Abstract Aims Formal preoperative assessment of risk of complications and death in all patients undergoing Emergency Laparotomy is recommended by NELA (National Emergency Laparotomy Audit) in the UK. In addition, frailty assessment in patients who are 65years or older and frail undergoing Emergency Laparotomy is also recommended. In a previous 2018 audit, we had recorded Preoperative Mortality Risk in 77% patients undergoing Emergency Laparotomy and Frailty was not part of our assessment in these patients. In this audit our aim was to evaluate documentation of preoperative frailty and risk assessment in patients undergoing Emergency Laparotomy from 2019 to 2023. Methods Details of all patients who underwent Emergency Laparotomy at a University Hospital under care of one surgical team between January 2019 and December 2023 were obtained from theatre logbooks. Patient notes were retrospectively reviewed to see if frailty assessment and preoperative risk assessment scores were recorded. This data was collected and analyzed using Microsoft Excel. Results During this period, sixty-seven patients were identified. The median age was sixty-seven with an age range from four to ninety-one. Of these 38 (57%) were females. A preoperative p-possum score was documented in 59 (88.1%), 39 (58.2%) patients were 65 years or older of these 26 (66.7%) had frailty assessment carried out. Conclusions Our data suggests that we have over time made progress in the use of Perioperative Risk assessment scores and incorporated frailty assessment in our perioperative practice in patient’s undergoing Emergency Laparotomy. However there remains room for improvement.

Strategies used by nurse leaders to support the delivery of falls prevention practices in hospitals.

Despite prevention efforts, falls in hospital are a common and ongoing safety concern, with older people more likely to fall and experience harm as a result of falls. Clinical guidelines recommend multifactorial falls risk assessment and multidomain, personalised interventions to reduce falls risks in hospitals. This article reflects on findings from a multi-site study on the implementation of multifactorial falls prevention practices that informed the development of actionable guidance. The discussion focuses on strategies used by nurse leaders, at different levels of seniority, that shaped practice on orthopaedic and older person wards. While falls risk assessment documentation was monitored routinely by senior leaders, in practice falls prevention often relied on risk screening and enhanced patient supervision. Findings suggest that nurses need to be empowered to lead practices that modify and mitigate individual falls risks where possible, with greater multidisciplinary and patient and carer involvement.

Evaluation of a Risk Screening Checklist for Venous Thromboembolism Prophylaxis in a Women and Newborn Hospital.

The venous thromboembolism (VTE) risk screening forms were developed to allow for recording identified risk factors for VTE including thrombophilia, history of VTE, postpartum hemorrhage, and cesarean delivery, and documentation of specific actions taken to mitigate these risks and reduce complications due to VTE. Compliance with hospital guidelines in assessing VTE risk and appropriate prescribing of thromboprophylaxis was evaluated prior to the introduction of VTE risk screening forms (March 2022). Efficacy of the new VTE risk screening forms was also assessed (April 2023). Patient discharge summaries and patient medical records including medication charts were used to review the documentation of VTE risk assessments and details of thromboprophylaxis prescribing. Of 74 postnatal patients, 37.8% had VTE risk assessment documented prior to the introduction of VTE risk screening forms. Of 37 patients identified to be at moderate to high risk of VTE requiring pharmacological prophylaxis, 70.3% (n = 26) were appropriately prescribed pharmacological prophylaxis. After the risk screening forms were introduced, a total of 67 antenatal, postnatal, and gynecologic patients were studied. Of these, 32.8% (n = 22) of patients had all required fields completed appropriately. When using the forms, 26.9% (n = 7) of postnatal and 88% (n = 22) of gynecological patients were rated as medium or high risk, and all received medical review within 24 hours. Pharmacological prophylaxis was indicated in 88% (n = 22) of gynecological, 43.8% (n = 7) of antenatal, and 38.5% (n = 10) of postnatal patients, and all were appropriately prescribed. The guideline review and introduction of VTE risk screening forms was valuable to provide guidance in the risk assessment for VTE and to identify patients requiring prophylaxis.

VTE prophylaxis for major abdominal surgery: A hospital audit and nurses' survey for quality improvement

Objective: The objective of this study is to assess and improve VTE prophylaxis practices in major abdominal surgery through a hospital audit and nurses' survey. Primary aims: Evaluate adherence to VTE prophylaxis guidelines in abdominal surgery, identify improvement opportunities in VTE prevention and assess the effectiveness of current prophylactic measures. Nurses’ survey: Evaluate surgical nurses' knowledge and implementation of VTE prophylaxis and identify educational gaps to improve VTE prevention. Secondary aims: Integrate audit and survey insights: Gain insight into VTE management practices, to develop quality improvement programs for better prophylaxis and outcomes. Background: Guidelines for the prevention of venous thromboembolism (VTE) in surgical patients involve risk assessment, followed by chemical and mechanical prophylaxis. Often, VTE risk assessments are not completed which leads to inappropriate or inadequate prophylaxis. The current guidelines suggest that a healthcare provider, such as a nurse or physician, should conduct the VTE risk assessment for each patient. Study design and methods: Initially, a prospective audit was conducted to examine VTE prophylaxis practices at a tertiary hospital. This VTE audit was conducted alongside a nurses' survey to assess current VTE prophylaxis practices. Both measures were taken to review the quality of care provided to surgical patients. Results: The practice of VTE prophylaxis shows high utilisation of all three prophylactic modalities but a lack of risk assessment documentation in the medical records. Nurses, although perceiving it as their responsibility, do not conduct assessments for venous thromboembolism risk. Conclusion: Based on the audit and survey results, the hospital has not fully adopted the guidelines for venous thromboembolism prophylaxis in major abdominal surgery cases. There is a lack of proper risk assessment documentation, and nurses are not consistently engaged in conducting these. Implications for research, policy, and practice: This paper presents valuable insights into the current prescribing practices for VTE prophylaxis after major abdominal surgery, as gleaned from a clinical audit and a survey of nurses. The hospital audit indicates that overall, all three are being used, instead of two. While this approach does not contravene current guidelines, the use of both stockings and compression devices is not needed, instead adding new risks, unnecessary nursing workload and financial cost to health services. Further, this approach may prolong recovery with patients unable to mobilise while wearing compression devices to take part in rehabilitation programs. What this paper adds: This paper adds to the existing literature by highlighting the gap between recommended guidelines and the actual implementation of VTE prophylaxis practices in the context of major abdominal surgery. These results provide meaningful clinical relevance about VTE prophylaxis practice for nurses and surgeons involved major abdominal surgery. The continuing education of Australian nurses should include an emphasis on VTE risk assessment and prevention.

Adherence to evidence-based guidelines for prevention of urinary retention in hip surgery patients: a multicentre observational study.

Urinary retention is a healthcare complication putting patients at risk of unnecessary suffering and harm. Orthopaedic patients are known to face an increased such risk, calling for evidence-based preoperative assessment and corresponding measures to prevent bladder problems. The aim of this study was to evaluate healthcare professionals' adherence to risk assessment guidelines for urinary retention in hip surgery patients. This was an observational study from January 2021 to April 2021 with a descriptive and comparative design, triangulating three data sources: (I) Medical records for 1382 hip surgery patients across 17 hospitals in Sweden were reviewed for preoperative risk assessments for urinary retention and voiding-related variables at discharge; (II) The patients completed a survey regarding postoperative lower urinary tract symptoms, and; (III) data were extracted from a national quality registry regarding type of surgery, preoperative physical status, and perioperative urinary complications. Group differences were analysed with Chi-square/Fisher's exact test, t-test, Wilcoxon rank-sum test, or Mann-Whitney U-test. Logistic regression was used to analyse variables associated with completed risk assessments for urinary retention. Of all study participants, 23.4% (n=323) had a preoperative documented risk assessment of urinary retention. Whether a risk assessment was performed was significantly associated with acute surgery [odds ratio (OR) 3.56, 95% confidence interval (CI) 2.48-5.12] and undergoing surgery at an academic hospital (OR 4.59, 95% CI 2.68-7.85). Acute patients were more often affected by urinary retention and had bladder issues and/or an indwelling catheter at discharge. More than every tenth patient (11. 9%, n=53) completing the survey experienced intensified bladder problems after their hip surgery. The study shows a lack of adherence to risk assessment for urinary retention according to evidence-based guidelines, which negatively affects quality of care and patient safety.

Increasing venous thromboembolism risk assessment through a whole hospital-based intervention: a pre-post service evaluation to demonstrate quality improvement.

Venous thromboembolism (VTE) is a primary cause of morbidity and mortality in hospitalized patients. VTE risk assessment is a crucial part of the VTE prevention guideline. However, VTE risk assessment was not consistently undertaken for admitted patients. The aim of this study was to identify whether a quality improvement project implemented to change documentation of VTE risk assessment for hospitalized patients impacted patient safety by decreasing the rate of VTE incidences. The study was set in a 600+ bed acute hospital that provides medical and surgical services for adult patients during the period October 2018-September 2020. The hospital adopted the American College of Chest Physicians (ACCP) 9th edition VTE prevention guidelines and followed the Modified Caprini risk assessment tool. Following the FOCUS-Plan-Do-Check-Act (FOCUS PDCA) improvement methodology, the improvement team implemented multicomponent interventions over a 3-month period, including conducting educational sessions, sharing VTE documentation compliance results, giving reminders during rounds, assigning a VTE liaison physician within each clinical specialty, and updating and communicating the hospital adopted VTE guidelines. A total of 17 612 patients were included, respectively, 8971 in pre-intervention and 8641 post-intervention period. Documentation of VTE risk assessment upon admission increased significantly in the post quality improvement intervention period (60% vs. 42%, relative increase of 30%, χ2 = 1.43, P < 0.001). The run chart trend analysis demonstrated significant improvement shift and improvement trend after quality improvement project implementation, and it was sustained for 15 months. There was no impact on patient safety with a slight not statistically significant decrease in the VTE incidences rate post intervention period (0.4% vs. 0.5%, relative decrease of 1%, χ2 = 0.82, P < 0.397). The quality improvement project intervention significantly increased the percentage of patients assessed for VTE risk in a hospital setting.

COVID-19 in meat plants: a survey framed within a Target Prevention Plan, in Italy.

During the COVID-19 pandemic, several outbreaks have been recorded worldwide in industrial slaughterhouses and meat-processing plants. Competent Italian health authorities at regional and provincial levels agreed on a risk-oriented control plan. Advocacy actions were activated, targeting meat plant managers and related food business operators. A questionnaire focused on the inventoried risk factors from literature was developed and administered voluntarily to interested stakeholders. In addition, an outbreak questionnaire was proposed to the prevention department of local health units. From 2021 to 2022, 333 advocacy and 24 outbreak questionnaires on 4,765 inventoried plants were collected. The lack of awareness in updating the Risk Assessment Document for COVID-19, non-instrumental body temperature checks at the entrance, working force from different subcontractors, poor hygiene in shared places, and insufficient ventilation were the main critical points recorded. Results provide a post hoc review with an eye toward future zoonotic pandemics.

EGS P32 Audit for evaluation of using the National Emergency Laparotomy Audit (NELA) as risk assessment calculator for high-risk surgical patients undergoing emergency laparotomy

Abstract Background A high-risk surgical operation called an emergency laparotomy has significant mortality and morbidity rate up to 10 times greater than the one performed electively. This entails a significant clinical and financial burden. The National Emergency Laparotomy Audit (NELA) was established in response to the aforementioned data in order to enhance the quality of care for patients having emergency laparotomies and to assist surgeons in reaching the best possible medical choices for their patients. The Emergency, Laparoscopic and Laparotomy Scottish Audit (ELLSA) is an equivalent system in Scotland. However, ELLSA is still not widely used as NELA. Methods This is a single-centre, retrospective audit to evaluate proper risk assessment and NELA registration for patients who had an emergency laparotomy in CEPOD between January 2022 and December 2022. The data was gathered from electronic clinical records via the hospital portal system. This analysis has included the following clinical data (Age, gender, indication of laparotomy, CEPOD form completion, NELA Score, hospital stay, and postoperative surgical outcome). The data was retrieved and analysed using a standard Excel data collection sheet. This audit aims to review and appraise our practise in relation to the NELA guidelines for risk assessment and emergency laparotomy. Results This analysis includes a total of 58 patients.35(60.3%) Males,23(39.7%) females. The included patients had an average age of 62. Almost 48% of these individuals had longer hospital stay more than 10 days. Approximately 21% of CEPOD booking forms had a recorded NELA score. A missing NELA registration form/risk assessment score was found in up to 97% of patient files and operation notes. A retrospective NELA assessment revealed a mortality rate of more than 20% for some included patients. The mortality rate was found to be high, at 21%, for NELA score of &amp;gt;20% mortality and &amp;gt;70% morbidity. Conclusions This Audit has shown that in order to completely comply with NELA guidelines, our practise must be significantly improved. We also need to give risk assessment documentation in patient records more consideration. The high death rate is attributed to patient and family requests for last-ditch surgical interventions, which can be difficult for surgeons to pull off.

Effect of the New Italian Legislative Measures on the Eye Lens Protection of Radioexposed Workers

Introduction: Legislative Decree no. 101, published on 31 July 2020 in the Italian Official Gazette, the official journal of the Italian Government, sets out the provisions of Directive 2013/59/Euratom, which establishes the basic safety rules for protection against the risks arising from occupational exposure to ionizing radiation. Methods: The main purpose of the legislator was to improve the safety of workers exposed to radiation, updating the previous laws adopted by the Italian government 25 years earlier. Many strategies have been attempted in the past to increase the level of protection of these categories of workers. Still, it is too early to evaluate the effectiveness of the proposed measures. Results: Medical professionals play a leading role among other figures involved in the field of occupational radiation protection. To achieve a reliable and detailed evaluation of the risk assessment, which in Italy must be reported in a specific mandatory report called the “Risk Assessment Document”, the legislator has assigned differentiated but coordinated tasks to all the actors involved with different responsibilities in radiation protection. Conclusion: The drastic reduction of the dose limits for the crystalline lens is a tool for more effective protection of workers against exposure to ionizing radiation.

A Retrospective Five-Year Study of Cardiovascular Risk Assessment and Risk-Based Interventions Among Hypertensive Patients in Nairobi Hospital, Kenya.

Introduction Cardiovascular disease (CVD) is a leading cause of global morbidity and mortality. It is projected that the prevalence of CVD will continue to rise in developing countries, largely driven by an increase in the prevalence of potentially modifiable risk factors. Atherosclerotic cardiovascular risk assessment among individuals with risk factors for CVD but without CVD is an inexpensive and viable strategy in CVD risk stratification and prevention. Despite the known benefits of CVD risk assessment, it is not well established whether physicians/ cardiologists in Kenya comply with the guideline-recommended practice of CVD risk stratification as a prerequisite for initiation of primary CVD preventive interventions. Aims and objectives This study was designed to audit the utilization of cardiovascular risk assessment tools in risk stratification of hypertensive individuals and physician provision of risk-based primary CVD prevention interventions. Results A five-year (2017-2022) retrospective study of patients' medical records was conducted in December 2022 at the PrimeCare cardiology clinic in Nairobi Hospital, Kenya. Data were collected from 373 patients' medical records retrospectively. The data were analyzed using IBMSPSSStatistics for Windows, Version 25 (Released 2017; IBM Corp., Armonk, New York, United States). The mean age of the patients was 60 years with the majority being female (54%). The mean BMI was 30.3 kg/m2 while the mean systolic and diastolic pressurewas 140mmHg and 80mmHg, respectively. Only 2.1% of participants were current smokers. The national or alternative guideline-recommended CVD risk assessment tool was used in 0.3% and 2.4%, respectively. The 10-year CVD risk score was documented in only 1.3%. The majority of the participants (93%) had low CVD risk. Half of the patients were taking statins for primary prevention while > 60% of them had been offered therapeutic lifestyle advice. Conclusion The study revealed poor compliance with guideline-recommended CVD risk assessment tools and documentation of the CVD risk level. However, there was above-average adherence to documentation of therapeutic lifestyle measures for primary CVD prevention.

Environmental Land Management and Assessment, in the Context of Resource and Climate-Related Conflict

This paper reviews the growing importance of satellite imagery to provide Normalized Difference Vegetative Index (NDVI) maps, relevant to environmental land management assessment, in the context of resource and climate-related conflict based upon our own humanitarian project-related support. Near real-time space-based monitoring benefits land assessment, human rights observers, and Non-Governmental Organizations (NGOs), in the presence of unstable regimes or socio-economic upheaval. Access to areas to validate claims or allegations with remote sensing tools and digital signal processing techniques is now important. Imagery-based assessment can quantify radiometrically calibrated NDVI, with temporal change indices, may evaluate displacement, to land clearances, and provide metrics on land use change. High-resolution satellite imagery can assess the extent of activities such as open cast mining, and dam construction in inaccessible regions, using semi-automatic orientated methods, generating indices at sub-metric levels derived from satellite data in: Red, Green, Blue, and NIR bands. We discuss the background of space-based applications, and the experimental methodology used. Results and discussion arising from a number of recent cases studies, with specific factors used to help with documentation and formulation of land management risk assessment in the context of climate change threats, e.g. wildfire, are considered. Satellite imagery combined with verified ground data sets of geospatial information and map making, allows external verification of ongoing and planned mining, or construction activities, which impact indigenous communities in such remote geographical regions, for example the controversial Ethiopian Gibe III dam. Seasonal and area change dynamics are observed and discussed.

Evaluation of the Quality and Safety of Venous Thromboembolism Prophylaxis Among Gastroenterology Inpatients at a Tertiary Hospital in Australia.

Background and objective: Hospital acquired venous thromboembolisms (VTEs) are common and preventable. The Queensland Health VTE prophylaxis guidelines, developed in 2018, provide guidance for risk assessment, and prescribing of anticoagulation for prophylaxis and treatment of hospital inpatients. Currently, there are limited recommendations for gastroenterology patients. This study investigated the completion of VTE risk assessments, and the appropriateness of VTE prophylaxis regimens, in accordance with Queensland Health guidelines for gastroenterology patients. The quality and safety of VTE prophylaxis regimens was assessed based on their VTE risk and bleeding risk. Method: A retrospective study was conducted by obtaining a random sample of gastroenterology patients admitted to a tertiary Australian hospital, from 1st May 2019 and 1st May 2020, to determine the compliance of VTE risk assessment and thromboprophylaxis prescribing with state-wide VTE guidelines. The quality and safety of thromboprophylaxis was evaluated using the modified Caprini and HASBLED scores, and subsequent thromboprophylaxis-related complications. Results: Of the 94 patients reviewed, 68 did not have contraindications to thromboprophylaxis. Of these 68 patients, 32 (47%) had no VTE risk assessment recorded in their clinical records and were not prescribed any thromboprophylaxis during the hospitalization. There was no significant difference between thromboprophylaxis prescribing for patients with low VTE risk, compared to moderate to high VTE risk (P = .075). There was a trend for decrease in thromboprophylaxis prescribing as HASBLED bleeding risk score increased, and patients with moderate-high bleed risk were less likely to be prescribed thromboprophylaxis (P = .006). There were no thromboprophylaxis related complications identified. Conclusion: It is essential that all patients have a clearly documented risk assessment and are prescribed thromboprophylaxis according to best practice guidelines. The prescription of venous thromboembolism prophylaxis should continue to be individualized, with each patient assessed holistically.

From hazard identification to risk assessment: The role of the prevention technician in the carcinogenic risk assessment for formaldehyde.

The Prevention Technician in the Environment and Workplaces (PTEW) is a health professional who works in the identification, assessment, and management of risk in living and working places. The PTEW implements specific corrective actions at reducing exposure levels to chemicals such as formaldehyde. The aim of this report was to update the formaldehyde risk assessment document (RAD). The risk assessment process was divided into three steps as follows: (1) preliminary data collection, (2) an on-site visit to identify the use patterns and process, and (3) application of the algorithm to calculate the exposure levels of healthcare workers. In addition, with the introduction of closed-circuit systems, 23 devices were evaluated to identify possible airborne dispersion of formaldehyde. The algorithm was applied in 31 hospital units and the results allowed us to classify the staff in two levels of exposure for each hospital unit; healthcare workers were classified as "exposed" or "potentially exposed." Most of the HCWs are categorized as potentially exposed, and only workers working in laboratories are considered to be exposed. The results showed that devices must be used properly according to the user manual. To increase the level of worker safety, we have proposed to introduce closed-circuit safe handling systems and keeping the duration and intensity of exposure at the lowest possible levels according to the "ALARA" principle. The assignment of the Italian PTEW is to achieve excellence in the levels of health and safety of patients and hospital workers by pursuing a shared mission: improving the quality of public health.

Right needle, right patient, right time? A national flash-mob audit of thromboprophylaxis in palliative care

BackgroundThe prevention of hospital associated thrombosis in palliative care remains controversial yet many countries recommend the documented risk assessment and where appropriate pharmacological prophylaxis of inpatients with advanced cancer. AimTo audit adherence to national guidelines which require hospitalised patients to be risk assessed and receive appropriate thromboprophylaxis. DesignA one day “flash-mob” audit across multiple clinical inpatient sites across the United Kingdom. Setting/participantsInpatients receiving palliative care within hospitals, hospices and specialist palliative care units across the United Kingdom. ResultsData were collected from 1125 patients (514 hospital and 611 hospice/specialist palliative care units). Appropriate thromboprophylaxis was observed in 90 % of hospital and 90 % hospice/specialist palliative care units. Documented risk assessment was only found in 79 % and 71 % of patient notes respectively. Pharmacological thromboprophylaxis was contraindicated in 88 % of hospice/specialist palliative care unit patients due to bleeding risk or receiving end-of-life care. Twenty-four percent of patients in hospital had contraindications due to receiving end of life care, bleeding risk and thrombocytopenia. Patients in hospice/specialist palliative care units were of poorer performance status prior to admission with a history of gradual deterioration. Hospitalised patients were more likely to have been admitted following an acute deterioration of previous good performance status. ConclusionThromboprophylaxis guidelines were followed correctly for the majority of patients. There were considerable differences in the demographics of patients according to place of admission. Patients admitted to hospice/specialist palliative care units were sicker and had more contraindications to prophylaxis than those admitted to hospital. Thromboprophylaxis focused research data conducted in hospices is unlikely to be applicable to the care of palliative care patients admitted acutely to hospital.

Implementation of a pharmacological prophylaxis bundle to prevent obstetric-associated venous thromboembolism.

Venous thromboembolism (VTE) accounts for a significant proportion of pregnancy-related mortality. In response to a series of VTEs at our institution and in accordance with mounting medical evidence for increased assessment, we implemented a universal, standardized obstetric VTE risk assessment process during antepartum and postpartum admissions and corresponding pharmacological thromboprophylaxis, which extends into the postdischarge period to prevent pregnancy-associated VTE in our urban, safety-net population. This quality improvement (QI) project used the Institute for Healthcare Improvement's Model for Improvement. We analyzed data from chart audits, patient and pharmacy outreach, and electronic reports using statistical process control charts. A review of 407 charts showed an increase in the proportion of patients undergoing documented risk assessment from 0% to 80% (average of 61%) from July 2015 to June 2016. The average risk assessment rate increased from 61% to 98% from July 2016 through March 2021 after the screening was integrated into the electronic health record (EHR). Rate of receipt of recommended thromboprophylaxis during admission increased from an average of 85% before EHR integration to 94% after integration. The proportion of high-risk patients receiving prescriptions upon discharge increased from 7% before EHR integration to 87% after integration. We interviewed 117 patients by telephone, of whom 74% continued the medications at home. An interprofessional team can achieve high rates of obstetric inpatient VTE risk assessment, pharmacological thromboprophylaxis initiation, and outpatient continuation using QI methodology.

Tracking the implementation of a risk management process in a public sector organisation – A longitudinal study

This paper presents the results from a longitudinal study of the process of developing and implementing a method for risk assessment in a public sector organisation over a period of 3.5 years. The study explores how people involved in this process viewed factors influencing the implementation and what effects the risk management process gave rise to. While a large share of previous research on this topic has been confined to analysing the final product in terms of the documented risk assessment report, this study explores factors affecting the process leading to such outcome. Data collection was conducted through a questionnaire used on five occasions during the study period. The results from this questionnaire were complemented with an interview study to gain deeper insights and understanding of factors shaping the risk management process. The findings show a maturing process over time where the most clearly visible impact from the risk management process includes an increased risk awareness among persons involved. However, the results also indicate that the outcomes from the risk management process were only to a limited extent spread to the rest of the organisation and persons at the management level showed a declining commitment to the risk management process over the 3.5-year period. Methodologically, the paper underlines the value of adopting a longitudinal research design in the area of risk management to allow for an exploration of trends and patterns arising over time, which contributes to a deeper and more contextualised understanding of a risk management process compared to studies that only rely on capturing snapshots of an organisation's current work practices.

Paediatric Psychosocial Emergencies in Two Inner-City London Hospitals: Review of the Current Management and Critical Evaluation Using NICE Self-Harm Quality Standards (QS34)

AimsThe paediatric wards support many children presenting with psychosocial crises. This has been increasing in recent years. NICE quality standards recommend that children who have self-harmed receive: a comprehensive psychosocial assessment, are assessed within 24 hours of referral if at high risk of suicide, a collaboratively developed risk management plan and monitoring to reduce risk of further self-harm. We aim to measure the number of referrals made by hospitals for acute psychiatric presentations and the adherence to the above quality standards by the Service for Adolescent and Families in Enfield.MethodsWe retrospectively audited inpatients referred by North Middlesex hospital and Barnet hospital. Referral data were collected over 5 years. Data collected between April 2018 and March 2019 were evaluated to review good practice and adherence to the NICE quality standards. For each patient, we collected data on whether they have had a comprehensive psychosocial assessment, if the assessment was completed within 24 hours, 7-day follow-up review and a documented risk assessment.ResultsThere has been a 141% increase in hospital referrals to the service from 2014/15 to 2018/19. The service had 130 referrals between April 2018 and March 2019. 72% of referrals came from North Middlesex hospital and 28% were from Barnet hospital. Ages were between 5 and 18. Girls formed 74% of all presentations. 87% of patients presented with deliberate self-harm, suicidal ideation or suicide attempt. Of all referrals 100% had a comprehensive psychosocial assessment, 93% were seen within 24 hours of being referred, 97% had a documented risk assessment and 92% had a 7-day follow-up review.ConclusionSelf-harm and suicidal ideation in children are rising, especially among girls aged 13 to 16 years (increased by 68% between 2011 and 2014). The gender inequality in our referrals further supports these findings. Higher rates of self-harm have been shown in more deprived areas and could be associated with gang involvement, bullying, abuse, gender identity and family issues. We have developed an assessment protocol and safety plan, are liaising with hospitals daily to arrange assessments and follow-up. Paediatric nurses have been trained in the time to talk programme and a full-time crisis liaison nurse has been employed. This will be re-audited to measure effectiveness of interventions.

'Paper care not patient care': Nurse and patient experiences of comprehensive risk assessment and care plan documentation in hospital.

To explore organisation-wide experiences of person-centred care and risk assessment practices using existing healthcare organisation documentation. There is increasing emphasis on multidimensional risk assessments during hospital admission. However, little is known about how nurses use multidimensional assessment documentation in clinical practice to address preventable harms and optimise person-centred care. A qualitative descriptive study reported according to COREQ. Metropolitan tertiary hospital and rehabilitation hospital servicing a population of 550,000. A sample of 111 participants (12 patients, 4 family members/carers, 94 nurses and 1 allied health professional) from a range of wards/clinical locations. Semi-structured interviews and focus groups were conducted at two time points. The audio recording was transcribed, and an inductive thematic analysis was used to provide insight from multiple perspectives. Three main themes emerged: (1) 'What works well in practice' included: efficiency in the structure of the documentation; the Introduction, Situation, Background Assessment, Recommendation (ISBAR) framework and prompting for clinical decision-making were valued by nurses; and direct patient care is always prioritised. (2) 'What does not work well in practice': obtaining the patient's signature on daily care plans; multidisciplinary (MDT) involvement; duplication of paperwork and person-centred goals are not well-captured in care plan documentation. (3) 'Experience of care'; satisfaction of person-centred care; communication in the MDT was important, but sometimes insufficient; patients had variable involvement in their daily care plan; and inadequate integration of care between MDT team which negatively impacted patients. Efficient and streamlined documentation systems should herald feedback from nurses to address their clinical workflow needs and can support, and capture, their decision-making that enables partnership with patients to improve the individualisation of care provision. The integration of effective MDT involvement in clinical documentation was problematic and resulted in unmet supportive care from the patient's perspective.

579 - Developing a Process Change Control System to Communicate Changes and Document Risk Assessment

579 - Developing a Process Change Control System to Communicate Changes and Document Risk Assessment